Lymphoid hypophysitis with selective adrenocorticotropic hormone deficiency.

This report describes a 31-year-old woman with evidences of selective adrenocorticotropic hormone deficiency associated with a remarkable pituitary lesion, lymphoid hypophysitis. Clinical manifestations of secondary hypocortisolism, which first appeared during the immediate postpartum period following normal pregnancy, included progressive weakness and mental aberrations, fasting hypoglycemia, transient hypercalcemia, and striking ECG changes. Sudden death resulted from cardiorespiratory collapse. Microscopic examination of the anterior pituitary disclosed focal fibrosis and extensive lymphocytic infiltrations with a marked reduction of basophils; immunostaining techniques demonstrated a selective loss of corticotropin-secreting cells. The histopathology of the pituitary and its association in this case with lymphoid thyroiditis suggest that selective damage to corticotrophs was due to an autoimmune process.

Kerion caused by Trichophyton verrucosum.

A 12-year-old girl developed a severe inflammatory fungal infection of the scalp caused by Trichophyton verrucosm. The infection resulted in scarring alopecia. The natural history, differential diagnosis, pathogenesis, and treatment of this infection of the skin are reviewed.

American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health. The child in court: a subject review.

When children come to court as witnesses, or when their needs are decided in a courtroom, they face unique stressors from the legal proceeding and from the social predicament that resulted in court action. Effective pediatric support and intervention requires an understanding of the situations that bring children to court and the issues that will confront children and child advocates in different court settings.

Buffered lidocaine for skin infiltration prior to hemodialysis.

This study compared the effects of buffered versus unbuffered lidocaine when used as local anesthetic in preparation for cannulation of the arterial and venous sites of children requiring hemodialysis. The subjects for this study were seven children, ages 6-18 years, observed during 101 dialysis treatments. For each subject undergoing hemodialysis on a given day, one syringe containing 1% lidocaine (L) and one containing buffered lidocaine (BL) were prepared. The BL solution was prepared by adding 2 mL of 8.4% sodium bicarbonate to 20 mL of 1% lidocaine just prior to use. The choice of local anesthetic used for cannulation of the arterial or venous site was randomly assigned to be either L or BL. Nurses, raters, and subjects were blind to contents of the syringe. The procedures for piercing the skin, pausing, and infiltrating were standardized, as was the volume administered. Speed of injection was not controlled. Comparisons of self-reported pain and behavioral observations for L versus BL revealed no significant differences for pain of infiltration or pain of cannulation. Technique variables such as the speed of injection, which tended to be very slow for these children, appear to significantly influence infiltration pain and the relative merits of buffering.

Benzodiazepines for acute pain in children.

When pediatric pain is refractory and unresponsive to appropriate use of analgesic agents, there might be additional physical or psychologic dimensions of the pain that are not addressed by the analgesics. In addition to appropriate analgesic therapy, the psychologic needs of the child should be directly addressed and appropriate adjunctive physical modalities employed. Although benzodiazepines lack direct analgesic effects, they can reduce the distress associated with acute pain states by decreasing anxiety, insomnia, and muscle spasms that can be associated with acute pain. Intermediate or long-acting benzodiazepines in modest doses can be useful adjunctive agents when used short term for the treatment of selected acute pain complaints. In the highly distressed school-age child or adolescent with pain complaints relatively unresponsive to appropriate care, judicious use of benzodiazepines is worthy of consideration.

Parental anxiety and minor illness.

Anxious parents can present a challenge to pediatricians. This study examines the relationship of the anxiety of parents seeking pediatric care for minor conditions to parental perceptions of the child's present condition, worries about the child not related to the present condition, and other personal worries. Assessments of 150 parents were made regarding parental anxiety, perceptions, and worries before and after a pediatric visit. A high-anxiety group (HAG) and low-anxiety group (LAG) were derived from the 25% most and 25% least-anxious parents. A 2 x 2 repeated-measures analysis of variance revealed that both before and after the pediatric visit, parents in the HAG reported significantly poorer understanding of the child's condition and reported more worry about the reason for the visit, the child's behavior, finances, school or day care, relationships, employment, and future and past events than parents in the LAG (p < .003). The results suggest that factors unrelated to the child influence the anxiety of highly anxious parents of a child with a minor ailment. Actions that focus solely on the child and the child's condition could have a limited impact on anxiety. When faced with an anxious parent of a child with a minor condition, it appears sensible not only to be aware of perceptions and worries related to the child, but also other personal life concerns for that parent, the parent's general tendency to worry or become anxious, and how that parent is processing information.

Individual interviews of children with unexplained symptoms.

Individual interviews were conducted with 24 children (ages, 5 to 12 years) as part of an evaluation of unexplained physical symptoms. All of the children had refractory symptoms that had resulted in multiple medical evaluations and considerable disability. At the time of referral, all of the families suspected an organic cause and denied a major impact of psychological influences on the symptoms. Interviews with the children alone disclosed major sources of anxiety in 18 of the 24 children. The newly exposed anxieties were dealt with in a family context. Therapeutic strategies concerning the anxieties led to rapid symptom improvement in 15 of the 18 patients in whom the individual interview revealed specific sources of anxiety.

Somatic symptoms as family myth.

Three children were treated for persistent somatic complaints for which no organic explanation could be found. Psychosocial factors were largely responsible for the disorders, but the families resisted any consideration of psychosocial influences. An understanding of the families' involvement in the children's symptoms leads to the diagnosis of "family myths." It is important to understand and respect the meaning of the symptoms for the proper diagnosis and treatment in such children.

Parental anxiety and response to symptoms of minor illness in infants.

Examined the relationship between parental anxiety and parental contact with the clinic following a child's initial DPT immunization. The subjects were 80 volunteer mothers who brought their 8-week-old infants to an outpatient clinic for a well-child visit. At the time of the visit, maternal anxiety, anxiety proneness, perception of the infant as fussy or difficult, and demographic information were assessed. Seventy-two hours after the immunization, subjects reported DPT side effects and physician contacts. Discriminant function analysis found that mothers who were anxious prior to DPT administration and who had infant girls were more likely to contact the clinic by telephone. This relationship was independent of prior maternal experience with DPT immunization, maternal perception of the infant's general fussiness, and maternal Trait anxiety.

The role of social modeling in unexplained pediatric pain.

Interviewed 20 children with recurrent unexplained pain (UP) and 20 children with recurrent explained pain (EP) secondary to sickle cell anemia and their parents to determine the presence of models of pain or illness behavior in the child's environment. The location, intensity, frequency, and environmental consequences of the children's and the models' pain were also assessed. The hypothesis that UP Ss would identify more models was supported. In addition, UP Ss identified more positive consequences of the child's pain behavior while EP Ss identified more negative consequences. Children perceived the frequency and intensity of their pain to be similar to their models', while parents did not report such a relationship. Body location data suggest that children may model either general illness behavior or exact symptoms. Implications for future research are discussed.

Anxiety in parents seeking pediatric care.

Interviewed parents of 103 children brought to a pediatric walk-in clinic, before and after seeing a physician. Previsit state anxiety was minimally related to parent perceptions of child's condition or the hospital. Anxiety, perception of child's discomfort, and perception of illness severity decreased while perceived understanding of child's illness increased postvisit. Parent perceptions of their child's condition and of the visit contributed little to the prediction of postvisit anxiety. Parent perceptions of their child's illness and the hospital were minimally related to their level of state anxiety when they brought their child to an acute care service. The visit with the physician decreased parent anxiety and improved parent perceptions of their child's condition, but these effects had little relationship to postvisit anxiety.

The non-psychiatric physician's responsibilities for the suicidal adolescent.

Pediatricians, internists, emergency-room physicians, family practice physicians, and other non-psychiatric physicians, often trusted allies of the child and family, are in an excellent position to assess, manage, and even prevent suicidal behaviors in their younger patients. This is not to suggest that these physicians should necessarily undertake extensive counseling or therapy with self-destructive children and adolescents; rather, they can help to screen and coordinate appropriate referrals and reinforce and/or support corrective efforts.

A multidisciplinary approach to pediatric pain: an empirical analysis.

A comprehensive assessment and multidimensional approach are critical for optimal outcomes in pediatric pain management. The purpose of this article is to describe the structure, function, and results of a multidisciplinary pain team composed of individuals from nursing, pediatric medicine, and pharmacology. The team's activities, including individual consultation on a school age/adolescent unit, are described.

How pediatricians can respond to the psychosocial implications of disasters. American Academy of Pediatrics. Committee on Psychosocial Aspects of Child and Family Health, 1998-1999.

Natural and human-caused disasters, violence with weapons, and terrorist acts have touched directly the lives of thousands of families with children in the United States.1 Media coverage of disasters has brought images of floods, hurricanes, and airplane crashes into the living rooms of most American families, with limited censorship for vulnerable young children. Therefore, children may be exposed to disastrous events in ways that previous generations never or rarely experienced. Pediatricians should serve as important resources to the community in preparing for disasters, as well as acting in its behalf during and after such events.