Cyclic vomiting syndrome in adults.

Cyclic vomiting syndrome (CVS) was initially described in children but can occur in all age groups. Cyclic vomiting syndrome is increasingly recognized in adults. However, the lack of awareness of CVS in adults has led to small numbers of diagnosed patients and a paucity of published data on the causes, diagnosis and management of CVS in adults. This article is a state-of-knowledge overview on CVS in adults and is intended to provide a framework for management and further investigations into CVS in adults.

Mask fear in children presenting for anesthesia: aversion, phobia, or both?

BACKGROUND: Anesthesia induction in children is commonly accomplished by introducing volatile agents by mask. Occasionally a child describes an excessive fear of the anesthesia facemask. Little is known of the cause of the fear or of the quality or magnitude of the feelings the child is experiencing. The purpose of this study was to allow children who have established mask fear as demonstrated by volunteering the presence of fear and requesting no mask be placed on the face during the induction of anesthesia and their parents to describe and compare the distress from the mask to the alternative intravenous anesthesia induction. METHODS: Eight children describing mask fear on the preanesthetic examination were studied. An Anesthesia Mask Fear questionnaire developed by the investigators was answered by the children and their parents. RESULTS: Six children and their parents completed the study. The age at presentation of mask fear ranged from 1.4 to 14 years. There were one to 16 anesthetic exposures prior to reporting mask fear. One child described an aversion to the odor of the mask. Another boy developed mask fear after a single anesthetic exposure. He was subsequently diagnosed with a generalized anxiety disorder. Four female children developed mask fear after repeated anesthetic exposures. These children rated mask fear with the greatest discomfort possible while venous cannulation was scored at half or less that of the mask discomfort. CONCLUSIONS: Care must be taken when developing a plan for anesthesia induction in children requiring multiple procedures. Children may develop an aversion to the odor or feel of the mask, or have a true phobia (irrational fear) of the mask. Those children with a phobia might also have other underlying anxieties.

Parental psychosocial outcomes in pediatric liver and/or intestinal transplantation: pretransplantation and the early postoperative period.

Although liver transplantation has become an effective treatment for end-stage liver disease and liver/intestine transplantation is becoming an increasingly viable procedure for end-stage short-gut syndrome in children, little is known about the impact of these procedures on the child's family. Examination of the impact of these transplantations on the family is needed to identify psychosocial factors that may adversely affect the child's physical and emotional health and to plan for preventive interventions. The psychosocial impact of pediatric liver and/or intestine transplantation on parents was assessed in a cross-sectional sample of 41 mothers and 20 fathers evaluated pretransplantation and 2 months posttransplantation. Parental mental health, parenting stress, and quality of life were assessed, as well as demographic, child, and family characteristics as they related to parental outcomes. Parent adjustment did not differ with regard to time of assessment. A majority of parents (n = 31) reported elevated psychological symptoms on the Brief Symptom Inventory (BSI), with fathers showing greater distress than mothers (P < .05). Parents' total scores on the Parenting Stress Index and the Parent and Child Domain subscales were in the normal range. Quality of life was assessed by the Physical Health, General Health Perception, and Vitality subscales of the SF-36. Parents reported better physical functioning (P = .02) but lower vitality ratings than a normative population (P < .01). Family conflict was associated with higher psychological distress on the BSI (P = .02), whereas demographic factors, including the child's age, sex, and number of people in the household, proved most useful in predicting parenting stress and quality of life. These findings of significant psychological distress in parents of children undergoing liver and/or small-intestine transplantation have implications for the child's adaptation and underscore the need for psychosocial assessment of both parents in the perioperative period. Early identification of families at psychosocial risk and the development of interventions that may prevent or reduce psychological distress are indicated to ensure the best possible outcomes for these children and their families.

Brief report: behavioral correlates of postoperative pain in toddlers and preschoolers.

OBJECTIVE: To investigate the association between preoperative parent and child behaviors and postoperative pain in toddlers and preschoolers. METHOD: Participants were 74 pediatric patients (59 boys, 15 girls), scheduled for inguinal hernia or hydrocele repair, and their parents. Children ranged in age from 12 to 64 months (M = 33.7 months, SD = 14.7 months). Child and parent behaviors were assessed 30 minutes prior to surgery using the Behavioral Observation Scale (BOS), a modified version of the Dyadic Prestressor Interaction Scale (Melamed & Bush, 1985. Postoperative pain was assessed using an observational measure, the Toddler-Preschooler Postoperative Pain Scale (TPPPS) (Tarbell, Cohen, & Marsh, 1992). RESULTS: Postoperative pain was negatively related to parents' provision of surgery-relevant information during the preoperative observation period. CONCLUSIONS: Preoperative interventions for young children should include information about the surgery experience.

"Munchausen by proxy" syndrome in a small bowel transplant recipient.

Munchausen by Proxy is potentially one of the most harmful forms of child abuse with a reported mortality rate of nearly 10% and may be a secondary cause of chronic intestinal pseudo-obstruction. If MBP is suspected, prompt action should be taken to separate the mother and child to determine if the symptoms are legitimate or fabricated. Successful treatment depends on the collaboration between disciplines and cooperation of all staff members. It is important that MBP be ruled out in cases of CIP when these children are evaluated for transplant to prevent needless morbidity.

Consequences of worksite hypertension screening. Changes in absenteeism.

To confirm reports of increased absenteeism after worksite hypertension screening, we performed a three-stage blood pressure screening among 5888 self-selected heterogeneous workers at 11 electronics plants using standardized screening and labeling procedures. A total of 296 subjects with mean systolic blood pressure of 140 mm Hg or greater or diastolic blood pressure of 90 mm Hg or greater on all three occasions were considered to have sustained hypertension. From the untreated normotensive subjects matched for eight sociodemographic and occupational variables, we prospectively selected one to three controls for each sustained hypertensive subject. Uncorrected absenteeism rates for sustained hypertensive subjects increased 22% from baseline in the postscreening year. Correction by logarithmic transformation for skewed distributions and by rates for matched controls for temporal trends reduced these changes to statistical insignificance with high statistical power. Several subgroups exhibited trends to increased absenteeism. At 12-month follow-up, the blood pressure of the sustained hypertensive subjects showed mean decreases of 12.6/6.7 mm Hg (p less than 0.0001) after the majority had received pharmacological antihypertensive treatment. These results suggest that worksite hypertension screening and labeling produce insignificant absenteeism change overall among self-selected heterogeneous work force populations.

Consequences of worksite hypertension screening. Differential changes in psychosocial function.

To evaluate reports of psychosocial dysfunction after worksite screening, a three-stage blood pressure screening was performed using standardized screening and labeling procedures. Of a heterogeneous group of 5,888 workers, 296 with sustained hypertension were identified and randomly assigned to traditional arousal or reassurance debriefings, matching each hypertensive subject with one to three normotensive control subjects on eight sociodemographic and occupational variables. Subjects exhibiting absenteeism increases or persistent hypertension six months after screening were randomly assigned to worksite health education programs or no intervention. After adjustment for values among matched control subjects, previously unaware hypertensive subjects had significant post-screening decreases in anxiety that were significantly associated with specific worksites and with reassurance rather than traditional debriefing (p less than 0.05). The health education program did not significantly affect anxiety, blood pressure, or absenteeism. Increased absenteeism was associated with higher baseline anxiety levels (p less than 0.05). It is concluded that worksite hypertension screening produces minimal adverse psychosocial changes, reassurance debriefing may be beneficial, and unspecified worksite characteristics may determine consequences of similar preventive medicine efforts.

The clinical judgement process in the prescribing of psychotropic drugs.

The primary objective of this study was to assess the strategies used by general practitioners in prescribing psychotropic drugs. Twenty-four physicians associated with the University of Toronto were presented with 63 vignettes, each describing a patient with a different combination of symptoms for which psychotropics are prescribed, and asked to choose the most appropriate drug for each patient. A mathematical model for each physician's prescribing pattern was developed from the information provided by his/her responses to the case descriptions. The physicians' prescribing strategies were found to be highly idiosyncratic, and were not related to their medical experience nor to the type of private practice in which they engage. The decision-making processes the physicians used to prescribe major tranquilizers and antidepressants were adequately modeled by a multiple linear regression equation, with very few of the predictor variables accounting for a substantial portion of the variance in prescription choice. Policies for prescribing minor tranquilizers were less successfully captured by this technique. Implications for the use of such models for improving prescribing techniques for their potential utility in clinical training are discussed.