Survey of acupuncturists: practice characteristics and pediatric care

OBJECTIVE

To describe the practice characteristics and pediatric care provided by licensed acupuncturists.

DESIGN

Cross-sectional survey.

SETTING

Boston metropolitan area.

SUBJECTS

227 licensed acupuncturists were surveyed; 140 (62%) responded.

MAIN OUTCOME MEASURES

(1) DEMOGRAPHICS, (2) practice characteristics, (3) pediatric care, (4) recommendations of peers recognized as experts in pediatric acupuncture.

RESULTS

(1) DEMOGRAPHICS: 70% Caucasian, 61% female; (2) practice characteristics: average of 39 visits weekly with an average charge of $54 for a 57-minute visit; patients were typically scheduled for follow-up once or twice weekly; only 5% of fees were covered by insurance; 80% recommended herbal remedies and 66% dispensed herbs in the office; (3) few acupuncturists treated more than one child per week; most used non-needle techniques or Japanese-style acupuncture to stimulate points in children; 85% would refer a febrile two-week-old infant immediately to a physician; (4) only 17 acupuncturists were recommended by three or more peers and saw three or more patients weekly; their practices were all in wealthy suburban areas.

CONCLUSIONS

Most acupuncturists in the Boston area are Caucasian and female. Compared with physicians, they schedule patients for more frequent follow-up, allocate more time, are less likely to be reimbursed by insurance, and treat fewer children. Additional studies are needed to assess effectiveness, quality, and access to acupuncture services for adults and children.

Late ophthalmological complications after total body irradiation in non-human primates

PURPOSE

To investigate the long-term effects of total body irradiation (TBI) on the incidence and time course of ocular complications.

MATERIALS AND METHODS

Rhesus monkeys treated with TBI photon doses up to 8.5 Gy and proton doses up to 7.5 Gy were studied at intervals up to 25 years post-irradiation. They were compared with control groups with a similar age distribution. Cataract formation and ocular fundus lesions were scored according to a standardized protocol. Fluorescein angiography and histopathology was performed in selected animals.

RESULTS

Cataract formation occurred after a latent period of 3-5 years. Significant cataract induction was observed for photon-doses of 8 and 8.5 Gy and beyond 20 years after proton irradiation. The severity of the lesions represents significant impairment of vision and would require cataract surgery if similar results occurred in human bone marrow transplant patients. Fluorescein angiography demonstrated a normal pattern of retinal vessels in 13 out of 14 animals (93%) from the irradiated group and in eight out of nine animals (89%) from the control group. No additional lesions apart from age-related degenerative changes could be demonstrated. Histological evaluation revealed no radiation-associated vasculopathy.

CONCLUSIONS

Radiation alone for doses up to 8.5 Gy of photons does not carry a potential risk for fundus pathology, whereas clinically important cataract induction should be anticipated within 5 years after photon doses of 8.0 and 8.5 Gy and proton doses in excess of 2.5 Gy.

Ras proteins induce senescence by altering the intracellular levels of reactive oxygen species

Human diploid fibroblasts eventually lose the capacity to replicate in culture and enter a viable but nonproliferative state of senescence. Recently, it has been demonstrated that retroviral-mediated gene transfer into primary fibroblasts of an activated ras gene (V12ras) rapidly accelerates development of the senescent phenotype. Using this in vitro system, we have sought to define the mediators of Ras-induced senescence. We demonstrate that expression of V12Ras results in an increase in intracellular and in particular, mitochondrial reactive oxygen species. The ability of V12Ras to induce growth arrest and senescence is shown to be partially inhibited by coexpression of an activated rac1 gene. A more dramatic rescue of V12Ras-expressing cells is demonstrated when the cells are placed in a low oxygen environment, a condition in which reactive oxygen species production is inhibited. In addition, in a 1% oxygen environment, Ras is unable to trigger an increase in the level of the cyclin-dependent kinase inhibitor p21 or to activate the senescent program. Under normoxic (20% O2) conditions, the V12Ras senescent phenotype is demonstrated to be unaffected by scavengers of superoxide but rescued by scavengers of hydrogen peroxide. These results suggest that in normal diploid cells, Ras proteins regulate oxidant production and that a rise in intracellular H2O2 represents a critical signal mediating replicative senescence.

Mortality in beagles irradiated during prenatal and postnatal development. I. Contribution of non-neoplastic diseases

To evaluate the lifetime health effects of exposure to ionizing radiation during development, 1,680 beagles received whole-body exposures to 60Co gamma rays or sham exposures. Eight groups of 120 dogs each received mean doses of 15.6-17.5 or 80.8-88.3 cGy in early, mid- or late gestation, at 8, 28 or 55 days after breeding, or at 2 days after birth. Another group of 120 dogs received a mean dose of 82.6 cGy as 70-day-old juveniles and one group of 240 dogs received a mean dose of 81.2 cGy as 365-day-old young adults. Sham irradiations were given to 360 controls. Sexes were equally represented. There was no significant effect of irradiation on mean survival times in any groups. In 1,343 dogs allowed to live out their life span, chronic renal disease was a common cause of mortality, and irradiation in the late fetal or juvenile periods potentiated this disease, resulting in increased mortality due to renal failure. This was consistent with earlier findings of the high radiosensitivity of the kidney in the perinatal period. Hypothyroidism associated with atrophic thyroiditis was decreased by irradiation, a finding contrary to expectation and not easily explained. Diabetes mellitus was increased by irradiation in the mid- and late gestation and juvenile periods, a finding which is intriguing based on early reports of a similar finding in atomic bomb survivors. Though convulsive seizures were a common cause of mortality in the dogs, there was no evidence for increased risk associated with prenatal irradiation as has been reported in humans. Genetic analyses indicated that renal disease, hypothyroidism, diabetes mellitus and convulsive seizures all had a heritable component, but that this did not influence or bias the radiation responses evaluated.

Mortality in beagles irradiated during prenatal and postnatal development. II. Contribution of benign and malignant neoplasia

To evaluate the lifetime carcinogenic hazards of exposure to ionizing radiation during development, 1,680 beagles received whole-body exposures to 60Co gamma rays or sham exposures. Eight groups of 120 dogs each received mean doses of 15.6-17.5 or 80.8-88.3 cGy in early, mid- or late gestation, at 8, 28 or 55 days postcoitus or at 2 days after birth. Another group of 120 dogs received a mean dose of 82.6 cGy as 70-day-old juveniles and one group of 240 dogs received a mean dose of 81.2 cGy as 365-day-old young adults. Sham irradiations were given to 360 controls. Sexes were equally represented. In 1,343 dogs allowed to live out their life span, neoplasia was a major disease, contributing to mortality in 40% of the dogs. There was a significant increase in benign and malignant neoplasms occurring in young dogs (<4 years old), including fatal malignancies, after irradiation in the perinatal (late fetal and neonatal) periods. The lifetime incidence of fatal neoplasms was also increased in dogs irradiated perinatally. Three malignancies-lymphomas, hemangiosarcomas and mammary carcinomas-accounted for 51% of all fatal tumors. There was an apparent lifetime increase and earlier onset of lymphomas in dogs exposed as fetuses. Fatal hemangiosarcomas were increased in dogs irradiated early and late in gestation. Fatal mammary carcinomas were not increased by irradiation, although non-fatal carcinomas were increased after perinatal exposure. Myeloproliferative disorders and central nervous system astrocytomas appeared to be increased in perinatally irradiated dogs. These data suggest that irradiation in both the fetal and neonatal periods is associated with increased early onset and lifetime cancer risk.

Penetrating pencil injury: an unusual case of child abuse

OBJECTIVE

We report an unusual case of penetrating pencil injury in a young child that turned out to be a case of physical abuse.

METHOD

This is a case report with review of the literature.

RESULTS

A 4-year-old boy was brought by his mother to the accident and emergency department for a penetrating wound of the right hand. He was said to have injured himself during a fall at home while holding a sharpened lead pencil. The pencil broke after penetrating the hypothenar eminence, leaving the graphite tip embedded in the palm. On surgical exploration, a piece of graphite measuring 1.3 cm was removed. The injury was actually inflicted by his mother because he failed to complete his homework properly. Deep penetrating injuries associated with the lead pencil are uncommon events in the medical literature. They are often reported as accidental and usually involve the oropharynx and the orbit.

CONCLUSION

Deep penetrating injury with a pencil is unusual in childhood and the public should be made aware of the possibility of nonaccidental injury.

Prevention of beta-thalassemia major by antenatal screening in Hong Kong

The thalassemias are common in Hong Kong. One of the severe forms, beta-thalassemia major, has been preventable locally by antenatal screening since 1983. Yet new patients are still being diagnosed. In this retrospective study, 34 children with severe beta-thalassemia syndromes were diagnosed in two major public hospitals between 1990 and 1996. They included one pair of identical twins and two pairs of siblings. Twenty-seven (79%) had homozygous beta-thalassemia and seven (21%) had beta E thalassemia. All but four (12%) were transfusion dependent. Fifty-five (89%) parents had been evaluated for their thalassemia status. Forty-eight had beta-thalassemia traits and seven were hemoglobin E carriers. The reasons for the birth of these children with severe beta-thalassemia syndromes were (1) late or no antenatal visit (n = 8, 24.2%), including three cross-border deliveries in which the pregnant mothers came from mainland China to Hong Kong for confinement, (2) lack of maternal screening (n = 13, 39.4%), (3) lack of paternal screening (n = 7, 21.2%), (4) parental refusal (n = 3, 9.1%), and (5) unknown (n = 2, 6.1%). These findings suggest that several factors undermine the effectiveness of antenatal screening for prevention of thalassemias. Many medical practitioners and the general public are still not aware of the screening procedures. The migration of population from mainland China to Hong Kong may result in the birth of many more children with beta-thalassemia major.

The role of yeast VDAC genes on the permeability of the mitochondrial outer membrane

In addition to the POR1 gene, which encodes the well-characterized voltage dependent anion-selective channel (YVDAC1) of the mitochondrial outer membrane, the yeast Saccharomyces cerevisiae contains a second gene (POR2) encoding a protein (YVDAC2) with 50% sequence identity to YVDAC1. Mitochondria isolated from yeast cells deleted for the POR1 gene (delta por1) had a profoundly reduced outer membrane permeability as measured by the ability of an intermembrane space dehydrogenase to oxidize exogenously added NADH. Mitochondria missing either YVDAC1 or both YVDAC1 and YVDAC2 showed a 2-fold increase in the rate of NADH oxidation when the outer membrane was deliberately damaged. Mitochondria from parental cells showed only a 10% increase indicating that the outer membrane is highly permeable to NADH. In the absence of YVDAC1, we calculate that the outer membrane permeability to NADH is reduced 20-fold. The low NADH permeability in the presence of YVDAC2 was not due to the low levels of YVDAC2 expression as mitochondria from cells expressing levels of YVDAC2 comparable to those of YVDAC1 in parental cells showed no substantial increase in NADH permeability, indicating a minimal role of YVDAC2 in this permeability. The residual permeability may be due to other pathways because cells missing both genes can still grow on nonfermentable carbon sources. However, YVDAC1 is clearly the major pathway for NADH flux through the outer membrane in these mitochondria.

Impairments of mental rotation in Parkinson's disease

It is controversial whether parkinsonian patients are impaired on visuospatial tasks. In the present study, patients and normal control subjects judged whether pairs of wire-frame figures in different orientations were the same or different. The orientation difference between the figures was either in the picture plane (around the z-axis, or two-dimensional) or in depth (around the y-axis, or three-dimensional). Reaction times and error rates were measured. For the two-dimensional task, there were no significant differences in errors between the two groups, though Parkinsonian subjects were significantly slower to respond than the control group. In the three-dimensional task, patients had a different pattern of reaction times from the controls and made significantly more errors, which were systematic at large angular differences. The results suggest a visuospatial deficit in Parkinson's disease, which reflects problems in some aspect of the perception of extra-personal space.

Epidural haematoma and stroller-associated injury

We present a severe case of head injury in an infant associated with stroller use and review similar reports from the literature. A case report and a literature search of the Medline database from 1966 to 6/1996 using the terms 'perambulator', 'parm', 'stroller', or 'baby carriage'. Reports in English describing injuries associated with their use are reviewed. We report a case of epidural haematoma in a 10 months old girl who sustained the injury after falling from a stroller. Safety harnesses were not worn during the incident. There was no skull fracture. Complete recovery followed surgical evacuation of the blood clot. Five reports describing stroller-related injuries were found in the English literature. Most injuries were mild. Three cases of death were reported of which two were classified as child abuse. The prevalence of unintentional stroller-associated injury is not clear. Mild injury, mostly to the head region, is probably common. Life-threatening injuries are rare but these are potentially preventable if strollers are properly designed and safety recommendations are followed.

Making the female condom a "reality" for adolescents

Alarming rates of pregnancy, sexually transmitted diseases, and human immunodeficiency virus infection among adolescents point to the need for expanding contraceptive options for adolescents. The female condom-a female-controlled barrier method that protects both partners from sexually transmitted diseases-marks an important breakthrough in contraceptive technology. This report reviews current research on the efficacy and acceptability of the female condom and considers the feasibility of its use in the adolescent population. Specifically, the authors first consider the factors that affect teenage condom (and other contraceptive) use (efficacy, cost and availability, and acceptability) and then apply the mechanics of the female condom to these issues. Based on this analysis, recommendations for future steps to be taken by researchers, adolescent health practitioners, and the manufacturer of the female condom are presented.

Intrathecal methotrexate overdose

We report two cases of intrathecal methotrexate overdose. A 3-y-old girl with acute lymphoblastic leukaemia and a 4-y-old boy with Burkitt's lymphoma were to receive an intrathecal injection of methotrexate after completion of intravenous methotrexate infusion. Instead of 12.5 mg, they both received a dose of 125 mg. Both children developed generalized convulsion 3 h after the overdose, but afterwards recovered completely. Intravenous folinic acid and dexamethasone rescue were employed, but no attempt was made to exchange the cerebrospinal fluid. In addition to the staff's failure to check the drug label carefully, the marked resemblance of the two dose preparations of methotrexate (50 mg/5 ml and 500 mg/5 ml) may have been contributory.

Non-neoplastic and neoplastic thyroid disease in beagles irradiated during prenatal and postnatal development

To evaluate the lifetime hazards of exposure to ionizing radiation, 1,680 beagles received whole-body exposures to 60Co gamma rays or sham exposures during development. Eight groups of 120 dogs each received mean doses of 16-18 or 81-88 cGy at 8, 28 or 55 days of gestation, or at 2 days after birth. One group of 120 dogs received a mean of 83 cGy at 70 days of age and one group of 240 dogs received a mean of 81 cGy at 365 days of age. Sham irradiations were given to 360 controls. Sexes were equally represented. In 1,343 dogs allowed to live out their life span, heritable lymphocytic thyroiditis with hypothyroidism was a major contributor to mortality. Irradiated dogs had a decreased risk for hypothyroidism, a finding that was surprising and not easily explained. Of the 1,343 life-span dogs, those exposed as neonates at 2 days of age or as juveniles at 70 days of age had evidence for an increased risk for thyroid follicular cell neoplasia. Hypothyroid dogs had a significantly increased risk for thyroid neoplasia, including greater risk for carcinomas, but no evidence of a greater sensitivity to radiation-induced tumors. In dogs with normal thyroid function irradiated at 2 or 70 days of age there was increased risk for benign and malignant follicular cell neoplasms, including multiple neoplasms. No difference between sexes was noted. These findings related to age sensitivity in the dog were consistent with the high risk for radiogenic thyroid neoplasia in humans after exposure during early childhood.

The role of pyridine dinucleotides in regulating the permeability of the mitochondrial outer membrane

Both NADH and NADPH reduce the permeability of the mitochondrial outer membrane to ADP. This is specific for the outer membrane and uncorrelated with the respiratory control ratio. This could result in a 7-fold difference between the concentration of ADP in the intermembrane space and that in the external environment (at 5 microM ADP). In both cases the permeability declines by a factor of 5, but NADH is more potent: KD = 86 microM for NADH versus 580 microM for NADPH. The lower apparent affinity for NADPH is partly explained by Mg2+-NADPH being the active species, and under our conditions only 30% of the NADPH is in this form. The corrected KD is 184 microM. Free NADH has the same charge as the Mg2+-NADPH complex, and thus both likely bind to the same site. The ability of NADH and NADPH to induce the closure of reconstituted VDAC channels is consistent with VDAC being the main pathway for metabolite flow across the outer membrane. Oncotic pressure, effective at inducing VDAC closure, also decreases the outer membrane permeability. Thus, in the presence of cytosolic colloidal osmotic pressure NAD(P)H may inhibit mitochondrial catabolic pathways and divert reducing equivalents to anabolic pathways.

Associations between lymphocytic thyroiditis, hypothyroidism, and thyroid neoplasia in beagles

The thyroids were evaluated in 276 control Beagles that were allowed to live out their full life span (mean = 12 years) in a closed breeding colony. Lymphocytic thyroiditis was found in 26.3% of the dogs. This lesion was characterized by lymphoplasmacytic inflammation accompanied by follicular destruction. The thyroiditis was progressive, resulting in severe atrophy of follicular tissue, and 44 dogs (15.9%) were diagnosed as hypothyroid at the time of death. In accordance with the experimental protocol, hypothyroid dogs were not given thyroxine replacement therapy. There was a high degree of heritability for the hypothyroidism. Hypothyroid dogs had an increased risk for thyroid follicular epithelial neoplasia and, in particular, for follicular adenocarcinomas. Twenty-four of the 44 hypothyroid dogs (54.5%) had one or more follicular thyroid neoplasms, whereas only 53 of the 232 (22.8%) clinically euthyroid dogs had similar tumors. Multiple thyroid tumors were present in 14 of the 44 (31.8%) hypothyroid dogs but in only 12 of the 232 (5.2%) euthyroid dogs. One or more follicular adenocarcinomas were present in 15 of the 44 (34.1%) hypothyroid dogs but in only 16 of the 232 (6.9%) euthyroid dogs. There was no difference in prevalence of hypothyroidism or tumors between the sexes. The strong association between progressive lymphocytic thyroiditis, hypothyroidism, and thyroid follicular neoplasia in these Beagles probably relates to promotion of residual follicular epithelium by chronic excess thyrotropin stimulation.

The use of fiberoptic endoscopy in anesthesia

The fiberoptic bronchoscope has contributed greatly to the practice of anesthesiology over the past 30 years. It has become an indispensable tool in the approach to the difficult airway, as well as the placement and positioning of double-lumen tubes for thoracic surgery. The equipment, preparation, and methods for using the endoscope in anesthesia, are presented here.

Plesiomonas shigelloides septicemia: case report and literature review

A 13-year-old girl with Plesiomonas shigelloides septicemia is reported. The infection occurred while she was receiving an allogeneic bone marrow transplantation for acute promyelocytic leukemia. Treatment with ciprofloxacin was successful. Twenty-one cases of Plesiomonas septicemia have been reported in the literature. Immunocompromised hosts, especially neonates, are commonly affected. The case mortality rate is high, with 13 of the reported patients dying of the infection. Successful treatment relies on the early identification of the organism and implementation of effective antibiotics.

Malignant peripheral neuroectodermal tumor in an infant with neurofibromatosis type 1

A case of multifocal malignant peripheral neuroectodermal tumor (PNET) arising from a plexiform neurofibroma in a 4-month-old Chinese boy with neurofibromatosis type 1 (NF-1) is described. Cytogenetic culture demonstrated hypotriploid karyotype with an abnormal clone characterized by 59-60, XY, +2, +3, +6, +8, +8, +12, +i(13)(q10), +der(14)t(1;14)(q21;q32), +16, +19, +20, +mar[cp3] with no apparent abnormality of chromosome 17. The child was treated with combination chemotherapy comprising ifosphamide, vincristine and doxorubicin. Despite initial partial response the child finally died of tumor progression and pulmonary metastases 8 months after diagnosis. We believe this is the first reported case of PNET in a child with NF-1 and may support an association between these two disorders of neural crest origin.

High spinal anesthesia after epidural test dose administration in five obstetric patients

BACKGROUND AND OBJECTIVES

A commonly used test dose in parturients receiving continuous lumbar epidural analgesia for labor consists of 3 mL of dextrose-free 1.5% lidocaine with 1:200,000 epinephrine.

METHODS

of 1,962 obstetric epidural anesthetics administered over a 17-month period, unintentional subarachnoid placement of the epidural catheter was detected by injection of the test dose in five laboring patients. The characteristics of the resulting subarachnoid blocks were studied.

RESULTS

After negative aspiration for cerebrospinal fluid in each case, test dose injection resulted in the rapid onset of high sensory block with associated motor and sympathetic block, accompanied by significant hypotension requiring aggressive treatment.

CONCLUSIONS

While this test dose appears to be a sensitive indicator of an unexpected subarachnoid catheter, the resulting excessive spinal blocks in these laboring patients raise the question of its safety.