Audiological deficits in brain-injured children and adolescents.

A retrospective chart review of 62 children aged 2 to 18.5 years admitted over a 4-year period to a brain injury rehabilitation unit was performed. Glasgow Coma Scales were not always recorded at the referring institutions, but all but three of the children in the series experienced a period of unresponsiveness to the environment for a period of at least one hour. Available Glasgow Coma scores at the time of injury ranged from 3 to 13. Maximum coma duration was 3 months. All children received an audiological evaluation. Sixteen per cent of the children had conductive hearing losses, 13% had sensorineural hearing loss, and 16% had central auditory processing problems. Three of these children were found to have combined losses, one with both conductive and sensorineural hearing loss, and two with sensorineural hearing loss and central auditory processing problems. Of the five patients with the most severe injuries and prolonged comas, none had hearing deficits. Twenty-five of the 62 patients, or 40%, had hearing deficits, of which 15 are known to persist.

Safety and efficacy of oral flecainide therapy in patients with atrioventricular re-entrant tachycardia.

OBJECTIVE: To assess the short- and long-term safety and efficacy of oral flecainide therapy in patients with symptomatic tachycardia and an extranodal accessory pathway. DESIGN: Open-label, uncontrolled trial with a mean follow-up of 24 months. SETTING: Referral-based, teaching medical center. PATIENTS: Sixty-three patients with symptomatic tachycardia and an extranodal accessory pathway. INTERVENTIONS: Patients had electrophysiologic testing before and after the initiation of oral flecainide therapy and were followed long-term for the presence of symptoms, new physical limitations, and adverse effects of therapy. MEASUREMENTS AND MAIN RESULTS: Flecainide therapy prevented or slowed (324 +/- 59 ms to 398 +/- 55 ms; P less than 0.001) inducible sustained atrioventricular reciprocating tachycardia in 44 of 63 patients (70%). Of the 44 patients discharged from the hospital, 33 (75%) have continued to receive flecainide therapy and have shown no adverse effects (mean follow-up, 24 +/- 10 months). Adverse cardiac reactions (proarrhythmia or sinus node suppression) attributable to flecainide occurred in 11 of 63 patients (17%); in 9 (82%) of these 11 patients, events were detected during either in-hospital monitoring or the electrophysiologic study done before discharge. Structural heart disease was detected by two-dimensional echocardiography in 8 of 11 patients who had adverse cardiac events and in 6 of 52 patients who did not have such events (P less than 0.001). Isoproterenol reversed the effects of flecainide therapy in 11 of 21 patients; 7 of the 11 patients had spontaneous clinical recurrences of tachycardia or palpitations during the follow-up period, but these symptoms occurred in only 1 of 10 patients who did not show isoproterenol-induced reversal (P = 0.02). CONCLUSIONS: Oral flecainide therapy was effective in 33 of 63 patients who had tachycardia and an extranodal accessory connection. Hospital monitoring during initial therapy is recommended, and flecainide should be used with caution, if at all, in patients with structural heart disease. An isoproterenol challenge appears to be helpful in predicting late recurrence of tachycardia.

Patterns of PRN analgesic drug administration in children following elective surgery.

Conducted chart review study of 114 4- to 14-year-olds hospitalized for elective surgery to investigate analgesic medication patterns. Correcting for body weight and different drug potencies, correlations were examined between analgesics, child age, painfulness of recovery, and seriousness of surgical procedure. Weight-adjusted analgesics prescribed and delivered PRN were unrelated to painfulness of procedure and age. Expert ratings of the seriousness of anticipated sequelae were found to be a modest but significant predictor of analgesics. Results suggest that PRN prescription of analgesics in children essentially guarantees very low drug delivery without achieving individualized pain management. Possible interpretations and suggestions for research into effects of practitioner attributions of seriousness on clinical decision making are discussed, along with implications for other explanations of inadequate analgesic practices.

Upon-admission adrenal steroidogenesis is adapted to the degree of illness in intensive care unit patients.

Adrenal function was studied in 2 groups of intensive care unit (ICU) patients with varying degrees of illness, as determined by Acute Physiological and Chronic Health Evaluation (APACHE). The 15 seriously ill patients with high APACHE scores (greater than or equal to 25) had elevated Therapeutic Intervention Scores and increased mortality compared to the 15 ill patients (APACHE, less than or equal to 10; 67% vs. 27%). Plasma cortisol, aldosterone, and androstenedione concentrations were increased in the ICU patients compared to those in normal subjects (n = 23), being greater in the seriously ill patients. Plasma dehydroepiandrosterone sulfate (DHEAS) concentrations were low in both groups of ICU patients. The ratios of aldosterone or androstenedione to cortisol were not altered, whereas the DHEAS to cortisol ratios were reduced in the ICU patients. ACTH injection elicited increases in plasma cortisol, aldosterone, and androstenedione concentrations in both groups of ICU patients, and the ratios of aldosterone and androstenedione to cortisol did not change. In the seriously ill patients, plasma DHEAS increased, so that the DHEAS to cortisol ratio did not change, whereas in less ill patients plasma DHEAS did not increase, so that the DHEAS to cortisol ratio was reduced. In this study of patients admitted to an ICU, impairment of adrenal steroid secretion appears to be specific for DHEAS. Although plasma cortisol was elevated in ill patients proportional to the degree of illness, the contribution of the concomitant decrease in DHEAS to this increase is not clear.

Spectrum of serum cortisol response to ACTH in ICU patients. Correlation with degree of illness and mortality.

Recent reports suggest adrenal insufficiency in critically ill patients is common. We found only one case of de novo adrenal insufficiency using admission ACTH injection in 70 selected intensive care unit (ICU) patients. Random serum cortisol levels correlated positively with illness severity in ICU patients using proven methods for assessing illness severity. Those with the highest random serum cortisol levels (greater than 60 micrograms/dl) had the greatest mortality, while those with lower random cortisol levels which stimulated to more than 18 micrograms/dl after ACTH injection had improved outcomes. Based on our results, routine screening for adrenal insufficiency in ICU patients is not warranted. If it is suspected, the cosyntropin test should be performed since low random cortisol levels (even to 5 micrograms/dl) are not diagnostic of adrenal insufficiency.

Acute hallucinogenic reaction to carbinoxamine maleate.

A reaction to Rondec is reported. The patient presented with agitation and hallucinations and responded promptly to a trial of physostigmine. The clinical picture and prompt resolution of symptoms with physostigmine strongly suggest that the reaction was to the antihistamine component of the medication.

Premature adrenarche. Clinical and diagnostic features.

Premature adrenarche (PA) or isolated growth of sexual hair in young children, is a benign condition that may initially be confused with true precocious puberty or pathologic virilizing disorders. The clinical findings, family history, and serum concentrations of dehydroepiandrosterone sulfate (DHEA-S) were compared in 24 children with PA (79% black females) seen in a 2-year period and in an age-matched control group of 17 black females. Twenty three of 24 patients, but none of the controls, had an adult-type axillary odor. There was a positive family history of PA in only three of 24 children with PA, and in one of 17 controls. The mean serum DHEA-S was significantly higher in the PA children than in the controls, but there was a broad range of concentrations (10-143 micrograms/dl), with values in 10 of 24 cases falling within the control range for age. We conclude that: (1) PA is a relatively common finding in black females between ages 3 and 8, (2) an axillary odor is almost always present in children with PA, and (3) determination of serum DHEA-S may be of some help in confirming the clinical impression of a modest increase in adrenal androgen secretion and in ruling out a more serious disorder. In most cases, however, the diagnosis of PA can be made on the basis of the history, physical examination, and lack of rapid progression over time; the use of laboratory tests to rule out a pathologic virilizing process may best be reserved for those children with very early onset, increased linear growth, or other signs of virilization.

Anaphylactoid purpura: hypertension with minimal urinary abnormalities.

We wish to draw attention to a case of hypertension in a child with anaphylactoid purpura, but with minimal urinary findings. Early recognition and effective antihypertensive therapy for short periods of time prevent potential complications. The wide spectrum of presentations, the epidemiological features, the diagnostic work-up and the role of the primary care physician are also reviewed.

Lorcainide for high-frequency ventricular arrhythmia: preliminary results of a short-term double-blind and placebo-controlled crossover study and long-term follow-up.

Lorcainide, 100 mg twice daily was compared with placebo in 39 patients with frequent ventricular arrhythmias in a randomized double-blind crossover trial. A mean frequency of ventricular premature beats (VPBs) of at least 30 VPBs/hour was required during a drug-free period of 48 hours. Holter monitoring and a maximal symptom-limited exercise test were performed at the end of each of the 2-week double-blind treatment phase. The group averaged 350 +/- 361 (standard deviation) VPBs/hour. Lorcainide decreased the mean VPB frequency of the group by 46% (p less than 0.01), with VPB reduction beyond the expected variation in 22 of 39 patients. In 13 patients VPBs were unchanged and in 4 they increased. Eight additional patients responded during drug titration, for an overall response rate of 77% (30 of 39). Lorcainide did not significantly reduce the exercise-related VPB frequency. At 6 months 61% of patients had significant VPB suppression. Thus, lorcainide was effective in reducing the frequency and grade of spontaneous ventricular arrhythmias during short- and long-term evaluation.

Negative pressures during swing phase in below-knee prostheses with rubber sleeve suspension.

Negative pressures in the small space between the distal stump and the below-knee prosthetic socket were measured during swing phase for a series of nine subjects. A molded rubber sleeve connecting the prosthesis and the thigh was found to enhance this effect so that suction suspension occurred during the entire swing phase. Deterioration of the suction occurred when the sleeve was intentionally pierced, and when other suspensions such as a suprapatellar cuff or thigh band were tested. The findings indicate that the total-contact socket, gel liner and elastic sleeve combine to create suction in the below-knee socket which improves overall comfort and function for the patient in using the prosthesis.