Extradural haematoma after temporomandibular joint arthroscopy. A case report

A case report of an extradural haematoma (EDH) after temporomandibular joint arthroscopy is presented. The possible cause of this unusual occurrence is discussed.

Anaplastic astrocytoma with granular cell differentiation: case report and review of the literature

In contrast to the relatively common soft tissue form of granular cell tumor (GCT), intercerebral GCTs are rare neoplasms. The Schwann cell is the accepted cell of origin for soft tissue GCTs. However, the origin of intracerebral tumors is controversial. We report a case of a GCT intimately associated with an anaplastic astrocytoma. Immunohistochemical staining with glial fibrillary acidic protein demonstrated focal positive staining within the granular cells. Six GCTs from other body sites were stained with glial fibrillary acidic protein for comparison and all were negative. The granular cell component was diffusely positive for S-100 and negative for epithelial membrane antigen and cytokeratin. Ultrastructurally, filaments characteristic of astrocytic cells were demonstrated within some granular cells. Based on our light microscopic, electron microscopic, and immunohistochemical findings, the granular cell component of this anaplastic astrocytoma is likely astrocytic in origin. We propose that these tumors be designated astrocytic neoplasms with granular cell differentiation and their prognoses dictated by the grade of the glial component.

An epithelial cyst of the suprasellar region

A case of a 26 year old woman with increasing headaches due to a suprasellar cyst is described. Histology was consistent with an epithelial cyst with features resembling both Rathke's cleft cysts and enterogenous cysts. The differential diagnosis and treatment of suprasellar cysts is discussed.

Neurogenic claudication secondary to vascular disease

Neurogenic claudication is characterized by sensory symptoms which appear during exercise or while maintaining a fixed posture. They are paraesthetic in quality, may be associated with 'march' phenomena, and patients may have bowel and bladder disturbance. The problem is most commonly secondary to lumbar canal stenosis (LCS) but rarely due to aortic disease, as shown in this case report. This report concerns a 66 year old woman who presented with symptoms of paraesthesia radiating from the buttocks to the thigh and, intermittent loss of bladder and bowel function, all associated with walking. There were no associated symptoms of vascular claudication. Clinically, there was evidence of aorto-iliac obstruction with absence of femoral pulses and a vascular index of 0.4 at both ankles. Neurological examination was normal at rest but the left ankle jerk was absent immediately after exercise. Myelogram and computerized tomographic (CT) scan were normal. An aortogram revealed a very tight irregular stenosis of the aorta at the level of the renal and mesenteric arteries. Very few lumbar vessels were seen. An aortic endarterectomy via a thoraco-abdominal approach was performed and an aortobifemoral graft inserted. The patient's symptoms resolved following this procedure. We postulate that her symptoms were caused by a 'steal' from the blood supply to the cauda equinda due to the severe athromatous disease of her upper abdominal aorta.

Attention deficit hyperactivity disorder in children: diagnosis, treatment, and follow-up

Hyperactive, and fidgeting behavior in children, is not a new syndrome, but has been present in children for centuries. Only in recent years have health providers begun to observe these features and behaviors in children and recommend some therapies. Children labeled with Attention Deficit Hyperactivity Disorder (ADHD) display the symptoms of inattention, impulsivity, and hyperactivity; however, these behaviors are seen in a variety of conditions. This article describes some of the symptoms associated with ADHD, as well as the evaluation, therapeutic modalities (behavioral, psychodynamic and pharmacological), and the follow-up of children with ADHD.

Thoracic intramedullary haematoma as a complication of warfarin: case report and literature review

Spontaneous intraspinal haematomas due to anticoagulants are uncommon, and usually extradural or subdural. Intramedullary haematomas are particularly rare, and only two case reports were found in the literature. We report a case of a thoracic intramedullary haemorrhage in a 61 year old man who had been commenced on warfarin 1 month previously, following aortic valve replacement. The literature is reviewed and reversal of warfarin effects, imaging and recommendations for treatment are discussed.

A new method for assessment of cultured cardiac myocyte contractility detects immune factor-mediated inhibition of beta-adrenergic responses

BACKGROUND

Potentially reversible congestive heart failure accompanies disease states associated with an immune cell myocardial infiltrate such as cardiac allograft rejection and inflammatory myocarditis. We therefore examined the hypothesis that immune cells can produce noncytotoxic alterations in cardiac function.

METHODS AND RESULTS

A novel system to evaluate cultured cardiac myocyte contractility was developed using neonatal rat cardiocytes grown on human amniotic membrane segments. Spontaneous synchronous cell beating produced macroscopic distortion of these membranes. Movement of free-floating membranes anchored within a perfusion chamber was visualized under low-power microscopy and measured from recordings of the rhythmic displacement of membrane-adherent markers. Additions of graded concentrations of isoproterenol to the perfusate produced up to threefold increases in the initial contractile phase velocity (contractile index), with an EC50 of 10(-7) M. When the extracellular Ca2+ concentration was increased from 0.9 to 3.6 mM, 2.43-fold increases in this index occurred. Myocytes incubated for 72 hours in the presence of dilutions of medium conditioned by activated rat splenic macrophages and lymphocytes exhibited an isoproterenol contractile index inhibited by 62% compared with control cells. In contrast, responses of supernatant-exposed and control cells to increased extracellular Ca2+ concentrations were not significantly different. Parallel studies of increases in myocyte intracellular adenosine 3':5'-cyclic monophosphate concentrations in response to isoproterenol stimulation demonstrated correlative inhibition that was specific for exposure to medium conditioned by immune cells.

CONCLUSION

Thus, a new method of in vitro cardiac contractility assessment that has significant advantages over existing systems has been developed and characterized. This new method has enabled description of an inhibitor of cardiac contractile function produced by activated immune cells.

A prospective analysis of a two-year experience using computed tomography as an adjunct for cervical spine clearance

The role of CT scanning as an adjunct to plain roentgenograms of the cervical spine was reviewed in acutely injured blunt trauma patients. Following institution of a protocol to evaluate the cervical spine in all blunt trauma patients, 179 patients underwent CT scanning of their cervical spine. This was performed for patients whose x-ray findings were positive, for patients with plain x-ray films suggestive of a pathologic condition, for patients with plain x-ray films that did not reveal all of the cervical vertebrae, and for patients who had persistent pain or neurologic deficits despite normal plain x-ray films. Of 123 patients not able to have their cervical spine cleared by normal roentgenograms, 93% were cleared within 24 hours of admission based on CT scans. There were no missed injuries in this setting. A false-positive rate of 28% and a false-negative rate of 1.5% were found for plain roentgenograms. Computed tomographic scans detected 98% of the injuries in our study and when combined with a three-view plain x-ray series of the cervical spine, 100% of cervical spine injuries were detected. Computed tomographic scanning as an adjunct to plain x-ray films of the cervical spine is a highly accurate and expedient modality to clear the cervical spine of blunt trauma patients.

Intracranial metastasis from carcinoma of the paranasal sinus

Carcinomas of the paranasal sinuses are locally invasive tumors that only occasionally metastasize. The tumor may spread intracranially by local invasion through the dura into the frontal lobes and extension along the vidian nerve. We describe two cases of cerebellar metastasis in patients with local recurrence and discuss the mechanism of spreading. It is possible that more aggressive treatment of these tumors, which results in longer survival, may be associated with an increased incidence of intracranial metastasis.

A brief history of pediatric nurse practitioners and NAPNAP 1964-1990

The pediatric nurse practitioner movement began in 1964 and is now 25 years old. Anniversaries are a good time for pausing to look backward and look forward. This brief history reports some early pediatric nurse practitioner adventures and a few of the beginning episodes of the National Association of Pediatric Nurse Associates and Practitioners. These special highlights make a remarkable statement about an elite cohort of nurses.

Implantation metastasis of pineoblastoma after stereotactic biopsy. Case report

A case is reported of implantation metastasis occurring 2 months after stereotactic biopsy of a pineoblastoma was performed in an 18-month-old child. Although implantation metastasis is well recognized after needle biopsy of solid tumors, it has not been described following stereotactic biopsy of a brain tumor. Implications for the role of stereotactic biopsy in the management of brain tumors is discussed.

Authoring systems. Finding the right tool for your courseware development project

Many factors must be considered when selecting an appropriate tool for courseware development. An overview of development tools is provided. Based on the authors' experience in selecting an authoring system for a recent courseware development project, a practical process for selecting the appropriate tool is described. Considerations when determining the general needs for an authoring system and evaluating specific authoring systems' features are outlined. Selection considerations are also discussed.

Amyloidosis of the nervous system

Various types of amyloid fibril deposits occur in the nervous system with unique clinical characteristics and pathogeneses. Genetic mutations cause the familial amyloidotic polyneuropathies and acquired polyneuropathies occurring particularly in patients suffering from hypernephromas and myelomas also result from the production of abnormal proteins. Amyloid fibril deposits in cerebral plaques and vessels consisting of beta-protein are seen in acquired and familial Alzheimer's disease and in Down's syndrome individuals over 40 years of age. This amyloid fibril deposition could result from a mutational, transcriptional or post-translational alteration in these pathologic processes with most evidence supporting the latter. Other diseases including hereditary cerebral hemorrhage of the Dutch type and Batten's disease involve beta-amyloid deposition. The features of the familial and transmissible forms of the spongiform encephalopathies are associated with the prion protein which comprises the amyloid fibril deposits in these conditions. This wide variety of nervous system disorders having amyloid deposits as their primary or subsidiary characteristic make studies of these conditions intriguing models for research workers in clinical, pathologic and molecular biologic fields.

Psychological coping and the management of pain with cognitive restructuring and biofeedback: a case study and variation of cognitive experiential therapy

Pain is generally recognized as being influenced by multiple psychological factors. Cognitive experiential therapy may use cognitive restructuring with imagery and hypnosis. The restructuring of negative cognitive, affective, behavioral, and physiological states occurs through six stages. This case study illustrates the use of cognitive restructuring and biofeedback with a woman hospitalized for depression and a chronic pain syndrome consisting of tension headache pain. Measures of headache pain (frequency, intensity), skin temperature, and assessment with the Millon Behavioral Health Inventory consisting of broad categories and scales were taken at pretest, posttest and follow-up. The biofeedback treatment alone showed some physiological improvement. Cognitive restructuring and biofeedback resulted in improvements on the Millon, and reduction of headache symptoms at the posttest. Gains on the Millon broad categories of personality coping styles and psychosomatic correlates were maintained at follow-up and chronic headache pain was not reported. Self-report headache frequency and intensity decreased over time with the cognitive restructuring and biofeedback approach.

Effects of nearpoint visual stress on psycholinguistic processing in reading

To date, there have been few studies to evaluate directly the relationship between binocular visual stress and reading performance. This study employed the cloze procedure to demonstrate the effects of nearpoint stress on performance and efficiency in reading comprehension. Using 19 third year optometry students as subjects, binocular stress was simulated by -2.00 D lenses. Performance, as determined by the time to complete the task, was significantly reduced (p less than .03), but no significant differences in accuracy scores were measured.

Clinical spectrum of primary empty sella turcica

Over recent years empty sella turcica has become more frequently diagnosed with high resolution computerized tomography and the associated clinical abnormalities have been better described. In this article the spectrum of clinical presentation is based on a review of 26 cases with six illustrative case reports. Recommendations for management and further assessment are presented. It is important for clinicians to be aware of the varying presentations of this syndrome, since it should not be considered simply as an incidental finding. A patient diagnosed with empty sella syndrome requires clinical and endocrine evaluation, and appropriate follow-up as determined by initial test results.

A controlled trial of stimulant medication in children with the fragile X syndrome

Attentional deficits and hyperactivity frequently are major problems for fra(X) boys. This study evaluated the effectiveness of 2 stimulant medications, methylphenidate and dextroamphetamine compared to placebo in 15 children (13 males, 2 females) with the fra(X) syndrome. A double-blind crossover design was used with outcome measures which included parent and teacher behavior checklists, a controlled observation period, continuous performance tasks and an actometer measure of movement. When the children were treated with methylphenidate only, improvement was seen in socialization skills and attention span according to teacher checklists. Ten children were clinically considered responders and treatment was continued after the study was completed.

Note on the factor structure of the Millon Behavioral Health Inventory

The factor structure of the Millon Behavioral Health Inventory was examined. Millon, Green, and Meagor in 1982 factor analyzed the responses to the inventory using a principal component analysis which gave four factors. Here procedures used by Millon, et al. were replicated. Principal components analysis ( N = 26 pain patients and 37 graduate students in counseling) with a varimax rotation resulted in four factors which essentially replicated the earlier findings. However, further study of the inventory should determine the stability of these factors with larger samples.

Typological analysis of MMPI personality patterns of drug dependent men

This study replicated Types I and II of Berzins, Ross, English and Haley's (1974) initial typological research with a drug dependent sample. In this research, Minnesota Multiphasic Personality Inventory (MMPI) profiles of 447 drug dependent men were submitted to Johnson's (1967) hierarchical clustering procedure. The hierarchical clustering procedure yielded nine small but clinically meaningful personality subtypes. These types were compared to Berzin's (Berzins et al.) profiles and categorized into three diagnostic classes: character disorder, 42% of the sample; neurotic characters, 35% of the sample; and borderline disorder, 23% of the sample. The profiles were discussed with respect to the scale similarity and differences within the diagnostic class. The results were discussed, with implications for treatment and further research efforts with the drug dependent population.

Preparing faculty to use and develop computer-based instructional materials in nursing

This paper identifies the need for more specific guidelines in preparing faculty to use and develop computer-based instructional materials. Cory's model for faculty development is described and planning considerations are outlined. Finally, components of this multifaceted approach to faculty development--identifying available resources, emphasizing the current uses of computers, providing computer literacy/faculty awareness sessions, focusing on the instructional use of microcomputers, collaboration, and communication--are discussed.

Effects of exposure to salty drinking water in an Arizona community. Cardiovascular mortality, hypertension prevalence, and relationships between blood pressure and sodium intake

A high level of sodium (440 mg/L) in the water supply of Gila Bend, Ariz, caused concern because of apparently elevated rates of hypertension in Gila Bend Papago Indians. We surveyed 342 Gila Bend Papago Indians and 375 non-Indians from July to September 1983. Participants 25 years of age and older were interviewed for health risk factors, water consumption, and dietary sodium and calcium intake and had height, weight, blood pressure, and urinary sodium and potassium levels measured. No consistent associations were found between any of the sodium values and systolic or diastolic blood pressure. Mean blood pressures for the Gila Bend whites were lower in most age groups than in comparison US white populations. The prevalence rates of hypertension in Gila Bend were not significantly higher than national rates.

The health and educational status of adolescents with congenital rubella syndrome

As part of a longitudinal study of children with congenital rubella syndrome, 53 adolescents between 16 and 18 years of age were surveyed to determine their health and educational status. The findings were compared with those at the 18-months evaluation. At 16 to 18 years neurosensory impairments, cerebral dysfunction and organic behaviour syndromes were predominant, but the majority of children had multiple handicaps. A higher proportion had hearing loss. Although all the hearing-impaired children were begun in oral-based educational programs, 90 per cent of those with severe to profound hearing-loss diagnosed before the age of 18 months had changed to total or manual communication. Those with mild to moderate hearing-loss diagnosed after 18 months primarily communicate orally. The educational implications of these findings are discussed.

Looking out from the isolator: David's perception of the world

David, who from September 1971 to February 1984 actively lived his life in a sterile isolator, was severely deprived of experience of the physical world. His difficulty with the concepts of space, depth, and size related clearly to his limited experience rather than to cognitive or visual-motor-perceptual deficits.

Long-term sequelae of group B streptococcal meningitis in infants

The long-term outcome and admission features predictive of outcome were determined for 61 patients with group B streptococcal meningitis treated between 1974 and 1979. Infection was rapidly fatal in 13 patients (21%). Among the 48 survivors, 38 (79%) 3 years of age or older were available for comprehensive evaluation. Excluding five who had died before age 3 years, the mean age at evaluation was 6.0 years (range 3.3 to 9.0 years). Among survivors, 11 (29%) had severe neurologic sequelae, eight (21%) had mild to moderate deficits, and 19 (50%) were functioning normally. Analysis of predictive features revealed a significant risk of death or severe impairment among infants who at hospital admission were comatose or semicomatose, had decreased perfusion, total peripheral WBC less than 5,000/mm3, absolute neutrophil count less than 1000/mm3, and CSF protein greater than 300 mg/dl (P less than or equal to 0.05). These data indicate that, although mortality from group B streptococcal meningitis has declined, approximately half of the survivors of acute infection have some degree of morbidity when evaluated at ages permitting the detection of language delay and borderline or mild mental retardation.

Standard curves for birth weight

The standard curves based on data from Denver are used to determine whether birth weights are appropriate. Several reports note differences between their birth weights and those from the Denver report and ascribe them to climatic and socioeconomic conditions. This study analyzed the data for a middle-class city near sea level. The birth weights for two years (1970 and 1982) were analyzed. The 10th, 50th and 90th percentiles were provided for 36-44 weeks of gestation for the 1982 data. The birth weights increased significantly over time. A statistical analysis of proportions gave significance to the birth weight differences in terms of sex and parity. Part of the increase in cesarean sections might have been the result of the increase in birth weights. Standard curves for birth weights should be based on regional data and updated periodically.

The hospital nurse practitioner in pediatrics. A new expanded role for staff nurses

The Hospital Nurse Practitioner Program in Pediatrics at the University of Colorado Health Sciences Center, Denver, prepared staff nurses for a new and expanded role as health care providers in hospital settings. With the use of their increased skills and greater decision-making responsibilities, hospital nurse practitioners admitted patients to the hospital, assessed both the initial clinical status and subsequent changes in the patient's condition, wrote relevant orders, performed a variety of technical procedures (including many previously reserved to house staff and other physicians), ordered and interpreted laboratory studies, counseled patients and families, discharged patients, and provided other traditional nurse practitioner skills. Hospital nurse practitioners had an improved collaborative relationship with physicians. This program showed that hospital nurse practitioners can be as significant in affecting the health care that patients receive on the general units of hospitals, as are nurse practitioners who deliver care and services to ambulatory patients.

Heterogeneity among alveolar macrophages in humoral and cell-mediated immune responses: separation of functional subpopulations by density gradient centrifugation on Percoll

Rabbit alveolar macrophages (AM) were separated into four subpopulations by centrifugation on discontinuous density gradients of Percoll. The subpopulations were compared to unseparated AM populations for their ability to provide accessory function to adherent cell-depleted splenocytes for antigen-stimulated lymphoproliferation and for the production of lymphokine. They were also tested for their ability to modulate in vitro plaque-forming (PFC) responses. AM subpopulations that provided accessory function for the production of migration inhibitory factor (MIF)-containing culture supernatants were recovered from the least dense fractions of the Percoll gradients. These cells were cytochemically characterized as mature cells. AM that suppressed the in vitro PFC response and augmented the antigen-stimulated lymphoproliferative response to the greatest degree were recovered from the most dense fractions of the Percoll gradients and were characterized as immature cells. These results suggest that there are distinct subpopulations of AM, the function of which may represent different stages of maturation (or differentiation).

Survival of low-birth-weight infants with neonatal intraventricular hemorrhage. Outcome in the preschool years

Twenty-nine low-birth-weight infants who survived neonatal intraventricular hemorrhage (IVH) were followed up prospectively and were last examined at a mean age of 3 1/2 years. The mean gestational age (+/- SD) of the group was 28.9 weeks (+/- 2.4 weeks), and the mean birth weight (+/- SD) was 1,167 g (+/- 292 g). Ten patients (34%) had normal neurologic outcome, and four (14%) had minimal abnormalities. Nine children (31%) were categorized as moderately abnormal, and six (21%) had severe abnormalities on neurologic examination. Intellectual performance was normal for 14 patients (48%), mildly delayed for seven (24%), and in the retarded range for eight (28%). Twelve children (41%), at 3 years of age, had handicapping conditions severe enough to warrant admission to special education programs in the public school. The grade of IVH was related significantly to neurologic outcome; both grade of hemorrhage and birth weight were correlated significantly with need for special education. Intellectual performance was related not only to grade of hemorrhage and birth weight, but also to paternal social class.

Human insulin and porcine insulin in the treatment of diabetic children: comparison of metabolic control and insulin antibody production

Semisynthetic human insulin and highly purified porcine insulin were compared in a double blind crossover study in 21 diabetic children. Glycosylated haemoglobin values at the end of four month treatment periods were higher after treatment with human insulin than after treatment with porcine insulin (mean 15.7% (SD 2.3%) v 14.2% (2.3%); p less than 0.01). Higher fasting blood glucose concentrations occurred during treatment with human insulin than with porcine insulin (mean 12.0 (SD 2.1) v 11.0 (2.4) mmol/1; mean 216 (SD 38) v 198 (43) mg/100 ml; p less than 0.05), but there were no significant differences at other time points during the day. The incidence of hypoglycaemia was similar for both treatment groups. Concentrations of antibody reactive with porcine and human insulins were similar for the two treatment groups, although greater fluctuation was observed in the amount of antibody reactive with human insulin. Semisynthetic human insulin is safe and effective in diabetic children, although further work is needed to devise regimens which achieve optimal blood glucose control.

The family with a handicapped child: a review of the literature

Research is reviewed on the impact of a handicapped child on the family. While most authors agree that the presence of such a child is a family stressor, there have been few studies using control groups, analytical methods, representative samples, or adequate numbers. The wide age range of the children within and across studies and the diversity of populations confuse some issues and leave others unresolved. In addition, no instrument has been designed to measure specifically the stress in families of a handicapped child. Most authors have not taken into account the dynamic process of rearing a handicapped child, nor have they addressed the problems of having a mildly handicapped child.

The selection of patients for excretory urography

Symptoms, signs, and laboratory findings that indicated excretory urography in 1,622 patients, were compared with the radiographs. The chance that an indication would be associated with demonstrable disease was calculated. No "low-likelihood" indications could be identified. Elimination of the urograms obtained for any of the indications would not have been possible without simultaneously precluding detection of many diseased patients. The monetary cost of case-finding was low, and the efficacy of patient referral high.