Respiratory depression in a child unintentionally exposed to transdermal fentanyl patch.

A 2-year-old boy was found unresponsive after sleeping in bed with his grandmother. After the patient was intubated and ventilated, paramedics discovered a transdermal fentanyl patch on the victim's back. Removal of the patch and treatment with naloxone resolved symptoms. This is the first reported case of secondary exposure to a fentanyl patch causing clinically significant respiratory depression in the pediatric population, and it emphasizes a new hazard of such drug use.

[The use of osteointegrated implants in plastic surgery. Ear reconstruction]. / L'impiego degli impianti osteointegrati in chirurgia plastica. Ricostruzione del padiglione auricolare.

The authors present the case of a 14-year-old patient suffering from first branchial arch syndrome with agenesia of the auricle in which the auricle was reconstructed using osteointegrated implants. The patient had previously undergone numerous attempts at reconstruction using traditional methods, all of which had failed. In order to ensure an accurate preoperative evaluation, the patient was studied using CT with a standard technique and three-dimensional image reconstruction for a qualitative and quantitative evaluation of bone thickness so as to allow the optimal positioning of fixtures. This test also revealed the existence and good degree of development of the middle and internal ear. The Authors then proceeded to implant 4 titanium fixtures into the mastoid process of the temporal bone, three of which were used for fixing the auricle prosthesis and one for the insertion of a bone anchored hearing aid. The epithesis, in soft silicon, was modelled to match the contralateral ear with excellent aesthetic results.

Urban/rural differences in child passenger deaths.

Motor vehicle crashes are the leading cause of death for Alabama children. This fact persists despite a child restraint law and an amendment designed to prevent such deaths in preschoolers. This study compared cumulative motor vehicle-passenger death rates by county and by urban and rural residence. Rural children had twice the rate of death of urban children. Additionally, these death rates demonstrated a sharp negative gradient when residence areas were ordered by increasing population densities (rural agricultural, rural manufacturing, suburban, and urban, respectively). Because child passenger death rates are significantly higher among rural children, future research should focus on hazards associated with the rural environment. A list of key study elements is provided.

Albuterol overdose: a case report and differential diagnosis.

The increase in the use of selective beta 2 agonists as first-choice agents in the therapy of asthma has resulted in a concomitant increase in overdoses and other therapeutic misadventures. This case describes a 22-month-old child who ingested a large overdose of albuterol, resulting in an acute syndrome consisting of agitation, tremulousness, marked hyperglycemia of > 320 mg/dl (17.8 mmol/L), ketonuria, and hypokalemia. Such toxicity has generally been reported only in diabetics or pregnant patients. These findings and a brief review of the pharmacology and toxicology of beta 2 agonists are detailed, with special emphasis on the differential diagnosis of overdoses characterized by hyperglycemia, hypokalemia, agitation, and tremulousness. A system of ordering the relative toxicity of these (and other) drugs is proffered using the exposure-case fatality rate (ECFR) as a crude measure of clinical toxicity (while delineating its shortcomings). Applying the ECFR (using American Association of Poison Control Centers' data base) to beta 2 agonist overdoses indicates that the resulting clinical syndrome, while troublesome, generally results in a benign outcome.

Racial differences in childhood hospitalized pedestrian injuries.

This research provides an epidemiologic analysis of pedestrian-related injury discharges from The Children's Hospital of Alabama in Birmingham, utilizing a case-control design. Evidence is provided supporting the racial disproportionality of serious, nonfatal pedestrian injuries in children. These data indicate that pedestrian injuries resulting in hospitalization are more common among black children than among white children (odds ratio = 2.95) when compared with an age- and gender-matched control group of other hospitalized injuries. This racial association with pedestrian injury remained significant when the data were stratified by payment class, a proposed surrogate measure of socioeconomic status (adjusted odds ratio = 2.59). A catalog of harmful environmental factors that may be pervasive in black children's lives is provided as an aid in planning intervention programs and their evaluation.

Poison control centers: can their value be measured?

Most regions of the United States are served by poison control centers that provide 24-hour toxicologic guidance resulting in the home management of most poison exposures. It has been suggested that without public access to a poison control hotline the majority of poison-exposed patients would seek medical care in emergency departments or other outpatient visits. This study compares the patterns of community response to poison exposure in Louisiana before and after the discontinuance of the state poison control service, and also compares these patterns to the situation in Alabama, which maintained poison center services throughout the study period. After discontinuance of the poison control service in Louisiana, poison exposure cases had up to four times the rate of "self-referral" to health care facilities and less than half the rate of home management when compared to Alabama cases. Before the closing of the Louisiana center, Alabama and Louisiana triage patterns for poison exposures were nearly identical. The maximum annual cost attributable to unnecessary outpatient service utilization in Louisiana was estimated to be $1.4 million, an amount more than three times the annual poison control center state appropriation.

Ingestion of prescription drugs by children: an epidemiologic study.

Although the Poison Prevention Packaging Act of 1970 has resulted in a 65% decline in ingestion of products packaged in child-resistant containers, ingestion of prescription drugs by children has declined by only 36%. Since ingestion of solid prescription drugs remains an important cause of ingestion-related morbidity in children, this descriptive epidemiologic study of cases reported to a poison control center was done with the hope of identifying factors responsible for this continuing problem. The study provides an epidemiologic perspective of this unnecessary risk to child health, and also proposes interventions targeted to high-risk caregivers.

The effects of commercial coaching or the NBME Part I Examination.

A total of 55 second-year medical students from the University of Alabama in Birmingham utilized the services of a commercial test-coaching company to assist them in preparations for the June 1977, 1978, and 1979 National Board of Medical Examiners Part I examination. These students scored significantly higher on the examination than students with comparable basic science grade-point averages. Students were surveyed to determine the nature of the course and to identify the salient points which they believed contributed to higher Part I scores. The study raises questions concerning the impact of commercial coaching on the licensure process for both domestic students and students of foreign medical schools entering the U.S. medical profession.

Hospitalization as a measure of clinical toxicity.

Acute animal toxicity data are useful in comparing a series of compounds with regard to a given toxic endpoint. Such information is not obtainable from human populations, and clinicians must often be guided by empiric judgement in treating acute ingestions. This experimental survey compared the calculated percent of cases hospitalized for 12 common substances ingested by young children as reported by the National Clearinghouse for Poison Control Centers for 1975-1976. Such ratios are offered as measures of clinical toxicity and as helpful modes of input in guiding patient management.

Enuresis: causes, cures and cautions.

Enuresis is a common benign condition that affects up to 10 percent of school children. Innumerable causes have been proposed: emotional disturbances, small bladders, infections, allergies, polyuria and deep sleep. In an effort to modify abnormal sleep, drugs such as amphetamine or imipramine are frequently prescribed. Imipramine is often very effective but its acute toxicity is not fully appreciated by many patients or their parents. Since accidental imipramine overdose is a serious matter, strict rules regarding its storage and use must be enforced.

[Klobusitsky's hemocoagulase in plastic surgery]. / L'emocoagulasi Klobusitzky in chirurgia plastica

Klobusitzsky haemocoagulase, a haemostatic drug obtained from snake poison, was administered prior to surgery in 35 cases of harelin, cleft palate, hypospadias and deviation of the nasal septum. Treatment was carried out from 2 to 6 days, doses and i.m. or i.v. administration being determined on the basis of age. Objective and subjective results were good, particularly in cases of cleft palate and septum deviation. In all cases, there was a significant shortening of bleeding time after treatment with the drug.

Central nervous system salicylate.

The poor correlation between clinical salicylate toxicity and serum blood levels is reapproached in light of recent evidence linking clinical severity with initial volume of distribution (Vd). It is recognized that two variables alter salicylate Vd in such manner that serum salicylate levels are misleading (thus, the change in Vd is not detected by present methods). These variables are serum protein binding and the pH-dependent ionized/un-ionized ratio in the unbound salicylate fraction. Measurements of salicylate concentration in the cerebro spinal fluid (CSF) would circumvent these variables, but would be clinically impractical. Thus, an alternative is sought to the inexact total serum salicylate levels and the impractical CSF salicylate levels for assessment of the severity of salicylate poisoning. This study indicates that, in dogs, serum unbound salicylate levels closely reflect CSF salicylate levels, even as a decrease in serum protein binding is in progress. However, serum unbound salicylate concentration does not reflect CSF salicylate concentration as a decrease in serum pH is elicited (CSF salicylate actually increased as serum unbound salicylate decreased). On the other hand, serum unbound salicylate measurement would seem preferable to total serum salicylate measurements now used in that the total value decreased markedly as either protein binding change or acidosis produced a change in distribution and the resultant increase in CSF salicylate.