Levonorgestrel-Releasing Intrauterine System Utilization in Patients with Developmental Delays.

INTRODUCTION: Adolescent females with developmental delays (DDs) experience unique physical and emotional challenges related to menstruation. Providers often recommend hormonal medication for menstrual management. The objective of our study was to describe the utilization and safety of the levonorgestrel-releasing intrauterine system (LNG-IUS) in adolescents with DDs. METHODS: We utilized the Pediatric Health Information System to identify females aged 10-25 with DDs who underwent an LNG-IUS insertion between 2011 and 2020. Using a gynecologic procedure and diagnosis codes, we assessed indications for and complications of LNG-IUS use. We also evaluated early LNG-IUS removal. RESULTS: One thousand five hundred and sixty female patients with DDs underwent LNG-IUS insertion. LNG-IUS insertion under anesthesia was most commonly performed in patients with autism and Down syndrome, and unspecified menstrual issues were documented for 40% of the cohort. Perforation was observed in 11 patients (1%), and mechanical complications (malpositioned IUS or lost threads) were observed in 23 patients (1%). DISCUSSION: This is the largest analysis of LNG-IUS use in patients with DDs to our knowledge and shows the utilization of LNG-IUS in patients with DDs. We provide descriptive information that providers can use to accurately advise their patients with DDs on the risks and benefits of LNG-IUS use for menstrual management.

Comparison of UK paediatric cardiac surgical performance by analysis of routinely collected data 1984-96: was Bristol an outlier?

BACKGROUND: Reports of high mortality after paediatric cardiac surgery at the Bristol Royal Infirmary, UK, led to the establishment of an independent public inquiry. A key question was whether or not the mortality statistics in Bristol were unusual compared with other specialist centres. To answer this question, we did a retrospective analysis of mortality in the UK using two datasets. METHODS: Data from the UK Cardiac Surgical Register (CSR; January, 1984, to March, 1996) and Hospital Episode Statistics (HES; April, 1991, to December, 1995) were obtained for all 12 major centres in which paediatric cardiac surgery is done in the UK. The main outcome measure was mortality within 30 days of a cardiac surgical procedure. We estimated excess deaths in Bristol using a random-effects model derived from the remaining 11 centres. Additionally, a sensitivity analysis was done and case-mix examined. FINDINGS: For children younger than 1 year, in open operations, the mortality rate in Bristol was around double that of the other centres during 1991-95: within the CSR, there were 19.0 excess deaths (95% interval 2-32) among 43 deaths; and in HES, there were 24.1 excess deaths (12-34) among 41 deaths recorded. There was no strong evidence for excess mortality in Bristol for closed operations or for open operations in children older than 1 year. INTERPRETATION: Our results suggest that Bristol was an outlier, and we do not believe that statistical variation, systematic bias in data collection, case-mix, or data quality can explain a divergence in performance of this size.

Thoracic and abdominal blastomycosis in a horse.

A 5-year-old Quarter Horse mare was examined because of lethargy, fever, and weight loss of 1 month's duration. Thoracic auscultation revealed decreased lung sounds cranioventrally. Thoracic ultrasonography revealed bilateral anechoic areas with hyperechoic strands, consistent with pleural effusion and fibrin tags. A large amount of free fluid was evident during abdominal ultrasonography. Abnormalities included anemia, hyperproteinemia, hyperglobulinemia, hyperfibrinogenemia, and hypoalbuminemia. Thoracic radiography revealed alveolar infiltrates in the cranial and caudoventral lung fields. A cavitary mass, consistent with an abscess, could be seen caudodorsal to the crura of the diaphragm. Ultrasonographic evaluation of this area revealed a hypoechoic mass with septations. Bilateral thoracocentesis was performed. Bacterial culture of the pleural fluid did not yield growth, but Blastomyces dermatitidis was isolated from pleural fluid, abdominal fluid, and an aspirate of the abscess. The mare was euthanatized, and a diagnosis of thoracic and abdominal blastomycosis was confirmed at necropsy.

Quantification of primary and secondary lesions in severe head injury.

The current trend is to classify brain damage due to non-missile head injury as focal or diffuse. Quantitative findings will be discussed and reference will be made to both human and experimental non-human primate.

Ischaemic brain damage is still common in fatal non-missile head injury.

A detailed neuropathological examination has been undertaken on a consecutive series of head injuries dying in the Institute of Neurological Sciences, Glasgow, between 1968-72 (151 cases) and 1981-82 (112 cases) in order to determine the frequency and distribution of any ischaemic brain damage. Ischaemic damage was found in the brains of 92% of the 1968-72 cases and in 88% of the 1981-82 cases: there was no statistical difference in the amount of moderately severe and severe ischaemic damage in the two groups, 55% and 54% respectively. There was evidence, however, that an increased number of patients with severe ischaemic brain damage was admitted in 1981-82 as a result of a changed admission policy of the Department of Neurosurgery that resulted in an increased detection of intracranial haematomas. It is concluded that ischaemic brain damage is still common after severe head injury, and it seems likely that it remains an important cause of mortality and morbidity.

Fatal head injury in children.

A comprehensive neuropathological study was undertaken on 87 children aged between 2 and 15 years with fatal head injuries to identify those features which occurred at the time of head injury (fractured skull, contusions, intracranial haematoma and diffuse axonal injury) and those which were subsequently produced by complicating processes (hypoxic brain damage, raised intracranial pressure, infection and brain swelling). The types of brain brain damage identified were remarkably similar to those seen in adults. The only difference was the prevalence of diffuse brain swelling in children.

Brain damage in fatal non-missile head injury without high intracranial pressure.

As part of a comprehensive study of brain damage in 635 fatal non-missile head injuries, the type and prevalence of brain damage occurring in the absence of high intracranial pressure were analysed. Of 71 such cases, 53 sustained their injury as a result of a road traffic accident; only 25 experienced a lucid interval. Thirty eight had a fractured skull, a mean total contusion index of 12.9 and diffuse axonal injury in 29: severe to moderate ischaemic damage was present in the cerebral cortex in 25, brain swelling in 13, and acute bacterial meningitis in nine. The prevalence and range of brain damage that may occur in the absence of high intracranial pressure are important to forensic pathologists in the medicolegal interpretation of cases of fatal head injury.

Pulmonary abscess caused by a Mycoplasma sp in a cat.

A Mycoplasma sp was isolated from an abscess of the right cranial lung lobe in a 6-year-old Persian cat. The cat responded well to resection of the affected lung lobe and to a 2-week course of tylosin treatment.

Brain damage in non-missile head injury secondary to high intracranial pressure.

A comprehensive neuropathological analysis was undertaken on 434 patients who died as a result of a non-missile head injury in order to determine the frequency and extent of brain damage secondary to high intracranial pressure (ICP) in head injury. Using the criterion of pressure necrosis in the parahippocampal gyrus as evidence of high ICP due to a supratentorial expanding lesion, it was established that the ICP had been high in 324 cases. In 42 of these there was no other brain damage attributable to a high ICP. There was evidence of secondary brain stem damage in 221 cases and in 44 of these the damage could be seen only microscopically. In 54 cases there was a contralateral peduncular lesion. Other abnormalities were infarction in the territories of various arteries and in the anterior lobe of the pituitary. There was a supracallosal hernia in 80 cases and haemorrhage in the oculomotor nerves in 48 cases. These results further emphasise the frequency and range of brain damage due to secondary vascular factors brought about by high ICP in a patient who has sustained a head injury.

Deep intracerebral (basal ganglia) haematomas in fatal non-missile head injury in man.

Deep intracerebral (basal ganglia) haematomas were found post mortem in 63 of 635 fatal non-missile head injuries. In patients with a basal ganglia haematoma, contusions were more severe, there was a reduced incidence of a lucid interval, and there was an increased incidence of road traffic accidents, gliding contusions and diffuse axonal injury than in patients without this type of haematoma. Intracranial haematoma is usually thought to be a secondary event, that is a complication of the original injury, but these results suggest that a deep intracerebral haematoma is a primary event. If a deep intracerebral haematoma is identified on an early CT scan it is likely that the patient has sustained severe diffuse brain damage at the time of injury. In the majority of head injuries damage to blood vessels or axons predominates. In patients with a traumatic deep intracerebral haematoma, it would appear that the deceleration/acceleration forces are such that both axons and blood vessels within the brain are damaged at the time of injury.

Gliding contusions in nonmissile head injury in humans.

"Gliding" contusions, ie, hemorrhagic lesions in the parasagittal white matter, were analyzed in 434 fatal nonmissile head injuries in humans. It is concluded that gliding contusions are a type of diffuse brain damage occurring at the moment of injury. Gliding contusions are significantly associated with road-traffic accidents, with the absence of a skull fracture or a "lucid interval," and with the presence of diffuse axonal injury and deep hemispheric traumatic hematomas.

Clinical evaluation of two methods of subdural pressure monitoring.

Recordings from two different types of subdural pressure monitor with simultaneous intraventricular pressure (IVP) tracings are compared in 20 head-injured patients. In the first 10 patients a fluid-filled catheter was placed subdurally and connected to an external transducer, and in the second 10 the Gaeltec model ICT/b solid state miniature transducer was used. The latter system has the advantage that both zero and calibration checks can be carried out after insertion. Only 44% of the fluid-filled catheter readings corresponded with IVP in series of 10-mm Hg ranges, while 53% of readings were lower; this tendency was more marked at higher pressures. With the Gaeltec transducer, 72% of subdural pressure readings corresponded with IVP, while only 9% were lower and 19% were higher than IVP. The differences may have been due to technical causes or to true pressure differentials. The subdural catheter appears too unreliable for routine clinical use, but the Gaeltec transducer may be a satisfactory alternative to ventricular pressure monitoring.

The contusion index: a reappraisal in human and experimental non-missile head injury.

A previously described method of quantifying cerebral contusions in man (the contusion index) caused by non-missile head injury has been modified and applied to a larger series of cases, and used to assess contusions in experimental head injuries. The initial findings in man have been confirmed, viz. that contusions are most severe in the frontal and temporal lobes; that contusions may be entirely absent in a patient dying as a result of a head injury; that there is no correlation between the severity of contusions and the nature of the injury; that the concept of contrecoup must continue to be questioned; that contusions are more severe in patients who have a fracture of the skull in comparison to those who do not; that contusions are more severe in patients who do not experience a lucid interval than in those who do; and that contusions are less severe in patients with diffuse axonal injury than in those who do not have diffuse axonal injury. The distribution of contusions in subhuman primates is similar to that seen in man, and they occur more frequently with short duration than with long duration acceleration.

Diffuse axonal injury in head injuries caused by a fall.

82 cases of diffuse axonal injury were found at necropsy in 635 patients with fatal nonmissile head injuries. 13 of these injuries were attributable to falls, and in all the patients fell from a considerable height. Diffuse axonal injury was not found in those with head injuries caused by a simple fall--ie, a fall from not more than the person's own height--but there was a statistically significant association between the presence of diffuse axonal injury and falls from a considerable height. These results indicate that diffuse axonal injury rarely, if ever, occurs as a result of a fall unless the patient has fallen some distance.

Age-related changes in function of transfer ribonucleic acid of rat livers.

Changes in transfer ribonucleic acids during aging could be caused by alterations in regulation or mutation and give rise to slower and less accurate protein synthesis. Rodent liver parenchymal cells, purified from disaggregated livers, do decrease in ability to incorporate labeled amino acids during aging. Moreover, old rodents have a rapidly degraded fraction of liver soluble RNA which is absent from middle-aged animals. In addition, tRNAs purified from old unfractionated liver cannot be acylated as well as from young. High speed supernatant tRNAs from old and young liver are quite similar in acylation capacity. Analysis indicates that a defective subfraction of tRNA may be bound to the ribosomal fraction of the liver cell. Some evidence indicates that base modification levels differ in young and old rodent liver. Shifts in the proportions of lysine and serine isoacceptors during aging are consistent with this idea. One isoacceptor change is an increase in tRNAlys4, which is correlated with cell division capacity in other systems.

5,6,7,8-Tetrahydroguinolines. 4. Antiulcer and antisecretory activity of 5,6,7,8-tetrahydroquinolinenitriles and -thioamides.

A number of 5,6,7,8-tetrahydroquinoling-8-nitriles and -8-thioamides and related compounds have been found to be potent inhibitors of basal gastric secretion in the pylorus-ligated rat and to afford protection against gastric erosions induced in rats by cold-restraint stress. Molecular manipulation has proved useful in determining factors necessary for such activity and structure-activity relationships are discussed. It has been shown that the most necessary requirements for activity are a pyridine nitrogen with its available lone pair and a primary or secondary thioamide. Also desirable is a six-membered carbocyclic ring with relative freedom from steric hinderance around the 8 position.

5,6,7,8-Tetrahydroquinolines. 5. Antiulcer and antisecretory activity of 5,6,7,8-tetrahydroquinolinethioureas and related heterocycles.

A series of thioureas derived from 5,6,7,8-tetrahydroquinoline, 1,5-, 1,6-, and 1,8-naphthyridiness, pyrido[2,3-b]azepine, and 7-azaindoline has been prepared and tested for antisecretory activity in the pylorus-ligated rat and protective activity against gastric erosions caused by cold-restraint stress. The thioureas exhibit different structure-activity relationships from the corresponding 5,6,7,8-tetrahydroquinoline-8-thiocarboxamides and these relationships are discussed. The activity of the thioureas is less affected by structural differences than the corresponding thioamides although they probably have the same mode of action.