Complications of labor and delivery: shoulder dystocia.

This article reviews one of the less common but most dreaded complications of labor and delivery, shoulder dystocia, an infrequent but potentially devastating event that results from impaction of the fetal shoulders in the maternal pelvis. Shoulder dystocia occurs most commonly in patients without identified risk factors, and can result in both maternal and fetal morbidity. Because the vast majority of cases of shoulder dystocia are unpredictable, obstetric care providers must be prepared to recognize dystocia and respond appropriately in every delivery. Detailed documentation is essential after any delivery complicated by shoulder dystocia.

Comfort, satisfaction, and anxiolysis in surgical patients using a patient-adjustable comfort warming system: a prospective randomized clinical trial.

Comfort warming systems aim to produce a comfortable local environment over which the individual patient has control. We studied a patient-adjustable comfort warming system using the Bair PAWS (Patient Adjustable Warming System) (Arizant Healthcare, Inc, Eden Prairie, MN), specifically to study comfort warming rather than therapeutic warming. One-hundred thirty patients were enrolled in this prospective randomized clinical trial, with 58 patients randomized to the patient warming gown, and 72 randomized to the warm blanket group. Groups were similar for gender, age, height, weight, surgical time, body surface area, and body mass index. The patient-adjustable warming system group had perceived greater control and satisfaction at 30 minutes after treatment was initiated compared with the warmed blanket control group. However, there were no differences in satisfaction levels with thermal comfort among those patients contacted one day postoperatively. Additional research is needed to improve external validity of study findings. Further refinement of a nursing definition of thermal comfort should be explored.

Acute necrotizing encephalopathy in 3 brothers.

Acute necrotizing encephalopathy (ANE) is a devastating and rapidly progressive neurologic disorder that occurs in healthy children after common viral infections. Typically, ANE is sporadic and does not recur. However, familial (ANE1) and recurrent cases have been reported and were recently linked to mutations in RANBP2 (RAN-binding protein 2). We report here a multiply affected kindred with recurrent familial ANE. These affected male siblings (a set of twins and their older brother) all presented with prodromal fever and upper respiratory tract infection that progressed within 72 hours to seizures, coma, and ultimately death, a course that is typical of ANE. It should be noted that 1 brother was treated with early aggressive management, including corticosteroids, and he survived for an additional 5 years. This represents the second reported case of familial ANE in the United States and the only case of male siblings with consanguineous parents. We hope that early recognition and growing awareness can lead to more effective treatment and better outcomes in the future.

Back pain as the only presenting symptom of intussusception: a case report.

Intussusception can often be a difficult diagnosis as many children do not present with the typical findings of abdominal pain, vomiting, and hematochezia. The authors report the case of a young child who presented with back pain as the only symptom of intussusception. We encourage pediatricians to consider this diagnosis in any child with episodes of intermittent abdominal or back pain.

Venous hum causing tinnitus: case report and review of the literature.

Hearing one's own heart murmur has been reported in adults, but has not been reported in the pediatric literature. This study reports the case of a young child who clearly heard her own venous hum, causing her to complain of pulsatile tinnitus. This entity should be included in the differential diagnosis of pulsatile tinnitus and by doing so pediatricians and cardiologists may avoid ordering unnecessary diagnostic procedures.

An electrophysiological investigation of the effects of coreference on word repetition and synonymy.

In two experiments the effects of word repetition, synonymy, and coreference on event-related brain potentials during text processing were studied. Participants read one (Experiment 1) or two sentence (Experiment 2) texts in which critical nouns were preceded by the definite (the) or indefinite (a) articles. Experiment 1 was run as a control to verify that differences in article processing in the second sentences of Experiment 2 would not contaminate the ERPs to critical noun items. They did not. In Experiment 2, an initial sentence was used to set up a context and contained either a first presentation or synonym of the critical word from the second sentence. N400 (but not Late Positive Component; LPC) priming effects were found for repetitions and synonyms (larger for repetitions) in second sentences. This extends observations of priming in word lists and single sentences to two-sentence texts. There was also a greater left anterior negativity or "LAN" for coreferential critical nouns (those following the article "The") compared to non-coreferential critical nouns (those following the article "A") suggesting that ERPs are sensitive to working memory processes engaged during referential assignment. In response to the articles themselves, there was a greater N400-700 elicited by the article "A" vs. "The." Finally, there was a greater N400-like negativity to the final words of non-coreferential sentences implying that the meanings of these sentences were difficult to integrate with the discourse level representation established by the prior sentence.

Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding.

Maurice Raynaud first described the vasospasm of arterioles in 1862, and Raynaud's phenomenon is now felt to be common, affecting up to 20% of women of childbearing age. Raynaud's phenomenon has been reported to affect the nipples of breastfeeding mothers and is recognized by many lactation experts as a treatable cause of painful breastfeeding. In 1997, Lawlor-Smith and Lawlor-Smith reported 5 women with Raynaud's phenomenon associated with breastfeeding, but there are few other case reports, and none report the possible relationship between Raynaud's phenomenon of the nipple and previous breast surgery. We report 12 women who breastfed 14 infants, all of whom were seen in 1 pediatric practice and 1 lactation consultation center in San Francisco, California, within the past 3 years. Of the 12 women, 11 were seen between June 2002 and May 2003. All women suffered from extremely painful breastfeeding, with symptoms precipitated by cold temperatures and associated with blanching of the nipple followed by cyanosis and/or erythema. Poor positioning and poor attachment or latch may cause blanching of the nipple and pain during breastfeeding, but 10 of the 12 mothers were evaluated by experienced lactation consultations, who were sure that inappropriate breastfeeding techniques were not contributing factors. Because the breast pain associated with Raynaud's phenomenon is so severe and throbbing, it is often mistaken for Candida albicans infection. It is not unusual for mothers who have Raynaud's phenomenon of the nipple to be treated inappropriately and often repeatedly for C albicans infections with topical or systemic antifungal agents. Eight of our 12 mothers and their infants received multiple courses of antifungal therapy without relief before the diagnosis was made. To diagnose Raynaud's phenomenon accurately, additional symptoms such as precipitation by cold stimulus, occurrence of symptoms during pregnancy or when not breastfeeding, and biphasic or triphasic color changes must be present. All our mothers experienced precipitation of symptoms by cold stimuli and demonstrated biphasic or triphasic color changes, and 6 of the 12 experienced symptoms during pregnancy. Interestingly 3 of 12 mothers also reported a history of breast surgery, including 1 mother who had a fibroadenoma removed and 2 who had breast-reduction surgery. The association between breast surgery/implants and autoimmune disease, including Raynaud's phenomenon, has been discussed extensively, but the association of Raynaud's phenomenon of the nipple during breastfeeding has not been reported previously. Given the small numbers in the study, it is uncertain as to whether this may be a precipitating factor in developing Raynaud's phenomenon. Treatment options include methods to prevent or decrease cold exposure, avoidance of vasoconstrictive drugs/nicotine that could precipitate symptoms, and pharmacologic measures. There are reports in the lay press of the use of herbal medicines, aerobic exercise, and dietary supplements, but because most women with painful breastfeeding require immediate relief of the pain to continue breastfeeding successfully, it is important to offer a treatment plan that will alleviate the pain quickly. Nifedipine, a calcium channel blocker, has been used to treat Raynaud's phenomenon because of its vasodilatory effects. Very little of the medication can be demonstrated in breast milk and thus is safe to use in breastfeeding mothers. Of the 12 mothers in our series, 6 chose to use nifedipine, and all had prompt relief of pain. Only 1 mother developed side effects from nifedipine. Pediatricians and lactation consultants should be aware of this treatable cause of painful breastfeeding and should specifically question their patients, because most mothers will not provide this information to the breastfeeding consultant. Prompt treatment will allow mothers to continue to breastfeed pain free while avoiding unnecessary antifungal therapy.

An MRI study of temporal lobe abnormalities and negative symptoms in chronic schizophrenia.

Previous magnetic resonance imaging (MRI) studies have reported various subtle brain abnormalities in schizophrenic patients, including temporal lobe abnormalities, which are of particular interest given the role of this brain region in auditory and language processing, and the characteristic deficits in these processes in schizophrenia. Subjects in this study were 16 male patients diagnosed with chronic schizophrenia and 15 healthy male comparison subjects. These patients were characterized by negative symptoms. High spatial resolution coronal MRI 1.5-mm-thick slices were used to measure the gray matter volume of the superior temporal gyrus, anterior and posterior amygdala/hippocampal complex, and parahippocampal gyrus. Patients, relative to normal comparison subjects, evinced a reduction of gray matter volume in bilateral superior temporal gyri and anterior amygdala/hippocampal complex. The reduction in gray matter of the superior temporal gyrus in patients with schizophrenia is consistent with previous findings, and is noteworthy in that it was found in this group of patients with predominantly negative symptoms. The reduction in the anterior amygdala/hippocampal complex was an additional temporal lobe finding. These results underscore the role of temporal lobe structures in the pathophysiology of schizophrenia.

Treating tobacco use and dependence: an evidence-based clinical practice guideline for tobacco cessation.

The prevention of tobacco-related morbidity and mortality through smoking cessation intervention is among the most vital missions of the chest clinician. This article summarizes the major findings and clinical recommendations of the US Department of Health and Human Services/Public Health Service Guideline, Treating Tobacco Use and Dependence, which is a comprehensive, evidence-based blueprint for smoking cessation. By becoming fluent in the clinical interventions and by implementing the simple institutional changes described in this article and in the guideline, chest clinicians can more effectively intervene with their patients who smoke.