The correct answer is 1. The anticholinergic can be administered intravenously and also intramuscularly if I am not mistaken. The occurrence of dystonia as a side effect is common in children and is one of the main reasons why pediatricians do not usually prescribe some antiemetics in children.

[HIDDEN] The anticholinergic can be administered intravenously and also intramuscularly if I am not mistaken. The occurrence of dystonia as a side effect is common in children and is one of the main reasons why pediatricians do not usually prescribe some antiemetics in children.

A 10-year-old boy is brought to the Emergency Department because for the last 2 hours he has been involuntarily turning his neck to the right associated with marked cervical pain at each turn. The grandmother subsequently tells us that he has been vomiting since yesterday, so she gave him a syrup; what would be the most appropriate therapeutic approach?

Do not treat until an electroencephalogram is performed in the following days.

Do not treat until the result of the cerebrospinal fluid culture is known in the next few days.

Start an intravenous antibiotic after obtaining a pharyngeal swab.

Kay's Tutor v Ayrshire & Arran Health Board

"Meningitis is a disease which causes inflammation of one or more of the three membranes which envelop the central nervous system consisting of the brain and spinal chord. The three membranes are the dura mater, the arachnoid and the pia mater. Between the arachnoid and the underlying pia mater is the subarachnoid space, which is filled with cerebro-spinal fluid (CSF). The general practitioner had treated the respiratory infection with ampicillin administered orally, but due to vomiting its therapeutic effect may have been to some extent frustrated. On admission to hospital Andrew was found to be seriously ill. He was treated with benzyl penicillin and sulphadiazine administered intravenously. A specimen of CSF was taken and sent for analysis. On the following day, 29 November, the laboratory reported that two cultures of pneumococci had been cultivated from the specimen. This led to a confirmed diagnosis of pneumococcal meningitis, a most virulent form of the disease. The consultant

Pearls and oy-sters: tuberculous meningitis: not a diagnosis of exclusion.

A 21-year-old man presented to his local emergency department with 5 days of headache, which was dull, occipital, bilateral, nonthrobbing, and progressively worsening. It was associated with mild fever, photophobia, and neck pain and stiffness. He had no history of headache, chronic illness, recent vaccinations, cutaneous rash, cough, diarrhea, arthralgia, or myalgia. He was from Ecuador and had been living in the United States for less than 1 year. He had been incarcerated while in Ecuador. Sublingual temperature on admission was 102.6°F. Other vital signs were within normal limits. On physical examination, he appeared thin but not cachectic. He had meningismus and photophobia, but no papilledema and his mental status was alert and attentive. There were no focal neurologic deficits. CSF contained red blood cells: 24 × 10(3)/μL; white blood cells: 85/μL (lymphocytic predominant); protein: 128 mg/dL; and glucose: 48 mg/dL (CSF/serum glucose ratio = 0.53). CSF Gram stain and cultures, PPD test, and blood and urine cultures were all negative. CT scan of the head on day of admission was entirely normal. MRI without gadolinium contrast showed a single punctate T2 hyperintensity in the left frontal periventricular white matter. Chest radiograph was clear. He received empiric vancomycin, ceftriaxone, and acyclovir. Corticosteroids were not given. The patient did not improve with antibiotics and continued to be intermittently febrile. On day 5, he became abruptly more somnolent, then comatose, opening eyes only to pain, his pupils were 5 mm and reactive, he had intact brainstem reflexes, withdrawing both arms and legs. Emergent head CT showed development of hydrocephalus and a ventriculoperitoneal shunt was emergently placed. The neurologic examination did not improve after shunt placement, and repeat head CT showed increased hydrocephalus with bilateral cerebral infarcts. On day 11, he was transferred to Columbia University Medical Center for intensive care. He was febrile and comatose. He did not open his eyes to pain, pupils were 7 mm minimally reactive, brainstem reflexes were intact, and he exhibited extensor posturing to pain. Mannitol was given, corticosteroid therapy was started, and an extraventricular drain was placed. The next day, his right pupil was 8 mm and nonreactive. MRI showed diffuse contrast enhancement of the arachnoid, extensive infarction of basal ganglia, midbrain, and pons, and small ring-enhancing lesions in the cerebellum (figure 1, A-D). Repeat lumbar puncture showed red blood cells: 550 × 10(3)/μL; white blood cells: 250/μL (14% neutrophils, 80% lymphocytes, 6% monocytes); protein: 65 mg/dL; and glucose: <10 mg/dL (CSF/serum glucose ratio = 0.08). CSF testing for Cryptococcus and toxoplasmosis was negative. CSF acid fast bacilli (AFB) smear was negative ×2, and CSF nucleic acid amplification test was also negative for tuberculosis. Serum HIV test was negative. Not until 14 days after initial presentation and 3 days after transfer to the intensive care unit was antituberculosis therapy finally started, because the pattern of infarcts on the MRI suggested basilar meningitis and he had not improved on broad-spectrum antibiotics. That same day, the first sputum AFB smear was positive, as were all succeeding daily sputum AFB smears. Tuberculosis nucleic acid amplification was positive from the sputum, but persistently negative from the CSF. Daily portable chest radiographs had been normal (read as likely atelectasis), but chest CT showed dense consolidations in the left lung and diffuse micronodular opacities throughout both lungs. Two days later, only 21 days after the onset of his headache, the patient died of cardiopulmonary arrest secondary to transtentorial cerebral herniation. Thirteen days later, the CSF culture became positive for Mycobacterium tuberculosis sensitive to streptomycin, isoniazid, ethambutol, rifampin, and pyrazinamide.

[Acute meningococcemia in a 4-month-old infant].

What causes meningococcial diseases (MD) is a Gramm-negative diplococcus Neisseria meningitidis (meningococcus). Most frequently it manifests itself in the form of meningitis and meningococcemia. The mortality rate of those suffering from MD has not significantly changed for three decades and ranges from 7% to 19%, and for meningococcemia from 18% to 53%. According to the data presented by domestic authors, of the total of the diseased with bacterial meningitis 75% are children with mortality rate from 6% to 15%. Severe forms of meningococcemia sometimes have extremely rapid development and lethal outcome within a few hours. Key elements for establishing the diagnosis of meningococcemia are presence of hemorrhagic rash with high fever, loss of interest in the environment, loss of consciousness and paleness. The boy was admitted to hospital as an emergency case on 29 December 1988 at 11:45. The disease manifested abruptly the day before. He burst into tears easily, would take very little food and in the evening his temperature rose T degree 40.8 degrees C. Before midnight, in the village he was given injections of: lincomycin 300 mg and lasdol 250 i.m. During admittance the infant was agitated, kept moaning. His skin was pail gray with dot-like and spot-like hematoma which were more numerous and intense on the left ear, lower part of the body, scrotum and legs. The infant breathed heavily and fast (FR: 100/min) Cardiologist's finding showed: tahicardia over 200/min, buffled tones, gallop rhythm, pulsating neck veins and edema point to acute heart failure. Large fontanelles remained swollen even after lumbar puncture (LP) and extraction of 15 ml of clear cerebro-spinal fluid. Soon after admittance the boy stopped moaning but didn't cry when pricked and slipped deeper into coma. During the third hour of treatment generalized convulsions began which lasted approximately 10 minutes and stopped after i.v. administered diazepam. The boy remained in coma the second day in lethargy and with swollen fontanelles on the third day, so the first subdural puncture was then performed bilaterally. On that occasion only from the right side 8 ml of reddish liquid was obtained. Right after he was admitted we began permanent transfusion, which lasted 17 days. On the first day he received fresh blood transfusion. He was administered benzinpenicilline, chloramphenicol-succinate, lanatoside, human albumins, dexamethasone.... Blood oxygenation was carried out in the first few days of illness during the exhibited cardio-respiratory failure. Among risk factors, which contribute to occurrence of meningococcemia, is also artificial infant food. The reported boy was incorrectly fed with overdiluted cow milk. That and apparent hemostasis brake-down only worsened anemia and increased susceptibility to infections. Although LP was performed when the boy was admitted and the nutritious foundation was soaked with cerebro-spinal fluid, no bacteria were isolated or their presence confirmed in cerebro-spinal fluid colored after Gramm's method, because the child was given linkomycin the previous night. On the basis of clinical findings, hemorrhagic rush, convulsions, coma and acute heart failure as well as the laboratory findings it was concluded that it was a case of severe meningococcemia, meningitis and subdural effusion. Listed therapy and six subdural punctures led to full recovery of the patient. Further examination by a pediatrician and a psychologist eliminated the possibility of mental deficiency. The boy is now a good fifth grade elementary school pupil.

Maintaining Safety and Planning for the Future.

Kevin is a 12-year-old boy with autism spectrum disorder, intellectual disability (nonverbal IQ scores in mid-40s), and attention-deficit/hyperactivity disorder who has been followed up by a developmental-behavioral pediatrician (DBP) and a child psychologist for medication and behavioral management since he was 4 years old. Kevin was placed in the care of his great-great-aunt shortly after he turned 2 years of age because of concerns of neglect. She is now his legal guardian.Kevin is predominately nonverbal but does use a few single words to make requests or label items. He attends a public school and receives full-time special education support. He has a personal care assistant (PCA) who provides in-home support 5 to 6 days/wk for 3 to 4 hours at a time. The PCA is working on toilet training, using a "clock-training" approach, and also takes Kevin outdoors to play or on short outings during her visits. In his free time, Kevin prefers to watch cooking shows on television.Over the past year, Kevin's behaviors have become more concerning. There have been several episodes of Kevin waking up during the early morning hours and going to the kitchen to "cook." After one of these episodes, his guardian was not aware that Kevin had woken up until the next morning when she found a concoction of corn starch, coffee grounds, cottage cheese, and powdered drink mix in the blender. Kevin had also woken up during the night and ventured out of the house into the back yard. His guardian had woken up immediately as the alarm system sounded when he opened the outer door from the house to the yard.A door alarm was added to Kevin's bedroom door so that his guardian would be alerted when he leaves his bedroom; however, the alarm is not used consistently because there are times when the alarm cannot be found at bedtime. Kevin's guardian was able to obtain a GPS device for him to wear on his shoe from the local police department. He wears this without resistance every day.Kevin's guardian is in her mid-70s, and she has had several health issues over the past 2 to 3 years. There are no other family members who are willing or able to care for Kevin if his guardian were no longer able to. The DBP and child psychologist have encouraged Kevin's guardian to explore long-term residential care options with the state agency that provides support for individuals with intellectual disabilities and with Kevin's insurance provider, but the guardian is very reluctant to do this. She fears that Kevin will be removed from her care or placed in a "home" where someone will "do bad things to him."What else would you recommend or actions would you take to support Kevin's guardian in ensuring Kevin's safety and planning for his future care?

History of head trauma in a 6-year-old boy: maybe more than meets the eye (and head).

It is spring and you are meeting for the first time, Eddie, a recently turned 6-year-old boy who moved to the area in September of the previous year and is here for his 6-year-old health maintenance visit. Eddie's mother is concerned that although he is "only" in kindergarten, he is not retaining any information at school. His mother reports he knew some of his letters before kindergarten. Currently, when he is trying to write a word, for example, "daddy" he will need to ask his mother: "what letter is the letter D?" Before kindergarten, he knew his numbers 1 to 10. At times now, Eddie will forget these numbers. For example, "if he is counting he will forget what comes after 4 and what comes after 9." Mother reports he will start crying for no apparent reason and if she asks why, he will say "I don't know why." Mother is worried that Eddie is sad, although she denies suicidal ideation. She reports he used to like making noise with other kids, and now he cannot stand when the children are noisy. Eddie will comment he does not want to go to school because the kids make lots of noise and his head hurts. He complains of headaches as often as 2 to 3 times a month. She next states, "This was not an issue before his head trauma." At this point, she reveals to you that in August, before the family relocated, Eddie fell from a 7-foot deck onto concrete while playing. He struck his head on the left side and lost consciousness for several seconds until shaken awake. He was nauseous and disoriented initially but without emesis or incontinence. He was taken to the local emergency department where he was admitted for 1 day and diagnosed with closed head injury, left frontal epidural hematoma, and question of postconcussive syndrome. Eddie has gone back to see the neurosurgeon twice over the last 6 months for scheduled visits and since the accident has had no further treatment.Eddie's mother reports that before the accident, if she read him a story from a book, he could remember the details from the story. Currently, he does not have good memory recall. Before the trauma, he did not attend a preschool program but stayed home with his mother full time. Eddie's first formal schooling has been kindergarten this year. When they moved, the neurosurgeon recommended he start school at the end of September given his head trauma in August. He had a recent computed tomography completed 3 months ago showing the epidural hematoma had completely resolved and the study was otherwise normal. His mother reports he had an evaluation the spring before the accident for a kindergarten screening test and was reported as "excellent." Eddie's birth and medical history are otherwise unremarkable except for some seasonal allergies. He has not had a loss in language skill, although his mother reports he did not speak during his hospitalization. He would just stare and nod his head if someone would ask him a question. No family history of any learning or behavioral difficulties on either side of the family. Eddie has 2 older brothers, 10 and 7 years of age, with no learning issues.What would you do next?

[Rational use of antibiotics in pediatrics: impact of a rapid test for detection of beta-haemolytic group A streptococci in acute pharyngotonsillitis].

To assess the reliability and validity of a rapid test for the identification of Streptococcus pyogenes in the pharyngeal exudate of children presenting with pharyngotonsillitis. To evaluate the impact of its use in outpatient clinics on antibiotic use, on the incidence of second medical visits and complications, and on the degree of parental satisfaction. After a clinical diagnosis of acute pharyngitis was established and written informed consent obtained from the parents, dual throat swabs were collected from 430 children who attended the emergency department of our hospital or the pediatric offices of three health centers in our area. The first specimen was examined by the rapid test, QuickVue Flex Strep A, and the second one was sent to the laboratory for conventional culture. As a rule, antibiotics were indicated only when the rapid test was positive. Special emphasis was placed on explaining to parents that treatment was not necessary when the test was negative. Telephone follow-up was provided to the family during the next four weeks, after which a satisfaction survey was carried out. The sensitivity of the investigated rapid test was 91.2% (negative predictive value: 96.5%) and specificity was 96.2% (positive predictive value: 90.4%). Antibiotics were given to 41.9% of the patients, approximately half the expected rate in the absence of the rapid test. There was no significant difference in the number of second visits or hospitalizations between the groups of treated and non-treated subjects. Clinical evolution was good in all cases. The degree of parental satisfaction was very high, independent of the treatment given to the patients. The rapid test for the detection of group A streptococci is a reliable tool for the selection of patients able to benefit from antibiotic treatment. It is easy to handle and apply and its use allows a significant reduction in the administration of antibiotics in pharyngotonsillitis. Most users accept and are satisfied with this novel diagnostic and therapeutic procedure.

Toddler Sleep Challenges: All in a Day's Work.

Leo is a 26-month-old boy who you are seeing for an urgent care visit due to "sleep difficulty," particularly sleep onset. Since age 1, he screams, hits, and kicks his mother every day, starting after she gets home from work at 5 PM (or before the family's dinnertime on her days off) and escalating over the course of the evening until he "wears himself out" and falls asleep in a crib in his own room around 9 to 10 PM Once asleep, he sleeps well through the night and wakes easily around 7 AM in a pleasant mood; his mother leaves for work soon after he awakens. He naps after lunch for 2 to 3 hours on weekdays at an in-home child care with 1 to 2 adult caregivers and 5 other children aged 0 to 5 years. He refuses to nap at home.Leo goes to bed easily when his father puts him to bed if his mother is not at home, but his mother feels that evenings are the only time she can spend with Leo, and so, she tries to put him to bed most nights. However, because of Leo's behaviors at bedtime with her, she feels inadequate, depressed, and guilty; when she tries to disengage or allow her husband to help, Leo screams, "Mommy, mommy!" and tries to gain access to her and resists his father putting him to bed until his mother returns. Both parents worry that "he would not grow out of this," and his mother now avoids coming home from work for fear of Leo's behavior. Both parents feel that this situation is causing marital strain.Leo was born healthy at full-term and is an only child; pregnancy was complicated by hyperemesis gravidarum. Leo has been healthy and meeting developmental milestones. His parents describe his temperament as "like his father at that age," "easy, but never able to self-soothe," "intense" in his emotional reactions, persistent, "strong-willed and serious," and "shy and observant, withdrawn at first and then getting more pleasant after a while" in novel situations. Behaviorally, he engaged in noninjurious head-banging at home when upset between 12 and 15 months; bit children a few times at child care between 20 and 24 months; and lately refuses to share or will push other children at child care every few weeks. His parents recently read a book about parenting "spirited" children but did not find it helpful. What would you do next?

Where do out-of-hours calls to a consultant microbiologist come from?

There is little in the literature about out-of-hours calls to medical microbiologists. The calls taken by a consultant medical microbiologist over a five-year period in an Irish tertiary referral hospital were reviewed. Excluding calls on weekend mornings and significant evening positive blood cultures, the mean annual number of calls on a one-in-four rota was 89 (range 70-111). Over 90% of calls were received before midnight and 51% were from specialist registrars. Medical specialties, neurosurgery and intensive care were the most common departments seeking advice. Two-thirds of calls related to the management of an individual patient, but advice on infection prevention and control is increasingly requested. Calls out-of-hours are not insignificant but little is known about how these vary between hospitals and what contribution they make to patient care.

An evidence-based approach to managing the anticoagulated patient in the emergency department.

You start another busy shift with a double row of charts waiting to be seen. Your first patient is an elderly man who fell 1 hour prior to presentation. He did not lose consciousness, but he was dazed for a few minutes. He complains of a mild headache but denies any neck pain. He takes warfarin for valvular heart disease. He looks good and has no focal neurological complaints. His mental status is normal, he has a negative head CT scan, and his INR is 3.9. His family wants to take him home, which would help relieve some of the congestion in the ED, but you wonder what would be best. To observe and repeat imaging? Reverse his anticoagulation? Change his dosing regimen of warfarin? In the next room, you quickly evaluate a 51-year-old obese woman with nonspecific back and abdominal pain that started 24 hours before and has slowly progressed to become intolerable. She denies fever, chills, nausea, or vomiting. She is on the last day of a 5-day course of ciprofloxacin for a UTI. She takes warfarin for a pulmonary embolus that occurred 2 months prior. Her hematocrit is mildly decreased, and her white blood count is normal; however, the INR is 6.8. You wonder if her abdominal pain is related to the UTI, or if it could be somehow related to the prolonged INR. In fact, you wonder why her INR is so prolonged...

[Meningococcemia and meningitis due to Neisseria meningitidis W135 developed in two cases vaccinated with bivalent (A/C) meningococcal vaccine].

Meningococcal infections may develop as episodic or endemic cases particularly among children attending day-care centers, boarding schools or among military personnel. Bivalent (A/C) meningococcal vaccine is applied to all new military stuff since 1993 in Turkey. In this report two cases of meningococcemia and meningitis, developed in two soldiers vaccinated with meningococcal vaccine, were presented. The first case was a 21 years old male patient who was admitted to the emergency service with the complaints of high fever, headache, fatigue and vomiting. He was conscious, cooperative and oriented with normal neurological findings. Maculopapular exanthems were detected at the lower extremities. The patient was hospitalized with the initial diagnosis of sepsis or meningococcemia and empirical treatment was initiated with ceftriaxone and dexamethasone. Cerebrospinal fluid (CSF) examination yielded 10 cells/mm3 (lymphocytes) with normal CSF biochemical parameters. A few hours later skin rashes spread over the body rapidly, the symptoms got worse, confusion, disorientation and disorientation developed, and the patient died due to cardiac and respiratory arrest at the seventh hour of his admission. The second case was also a 21 years old male patient who was admitted to the hospital with the complaints of fever, headache, painful urination, confusion and agitation. He was initially diagnosed as acute bacterial meningitis due to clinical (stiff neck, positive Kernig and Brudzinsky signs) and CSF (8000 cells/mm3; 80% polymorphonuclear leukocytes, increased protein and decreased glucose levels) findings. Empirical antibiotic therapy with ceftriaxone was initiated and continued for 14 days. The patient was discharged with complete cure and no complication was detected in his follow-up visit after two months. The first case had an history of vaccination with bivalent (A/C) meningococcal vaccine three months ago and the second case had been vaccinated one month ago. The bacteria isolated from the blood culture of the first case and the CFS culture of the second case, were identified as Neisseria meningitidis by conventional and API NH system (BioMerieux, France). The isolates were serogrouped as W135 by slide agglutination method (Difco, USA), and both were found to be susceptible to penicillin and ceftriaxone. As far as the last decade's literature and these two cases were considered, it might be concluded that N.meningitidis W135 strains which were not included in the current bivalent meningococcal vaccine, gained endemic potential in Turkey. Since N.meningitidis W135 strains may lead to serious diseases, vaccination of the risk population with the conjugate tetravalent meningococcal vaccine (A/C/Y/W135) should be taken into consideration in Turkey.

Electrocardiogram before starting stimulant medications: to order or not?

D is an 8-year-old boy brought to his paediatrician for evaluation. His mother is concerned as his teacher has been frequently complaining that he is very restless and often disturbs the rest of the class by getting up on some pretext or the other. He is unable to concentrate on his work and gets distracted very easily. He makes many careless mistakes and can hardly finish his tasks on time. He is frequently reprimanded for talking during class. He often answers out of turn or before the question has been completed; however, so far, he has been managing to get passing grades. At home, he is constantly on the go while he is awake. If he is forced to sit, like at mealtimes, he fidgets a lot. He also needs to be constantly nagged to do everything, even his daily activities such as brushing his teeth, or he forgets to do them or leaves them incomplete. He takes ages to finish his food. It is a major job to get him to do his homework. His mother says that at home he has been like that since the last 2 to 3 years, but now she is concerned because of the difficulties he is experiencing at school as well. After obtaining his medical history, examination, and getting response from parents and teachers--using Vanderbuilt Assessment Scales--the paediatrician diagnoses him to have attention deficit hyperactivity disorder. Besides behavioural interventions, he considers medications for his management. The paediatrician is debating the merits of performing electrocardiogram and/or referring the boy to a cardiologist before starting stimulant medications. If you were caring for this patient, how would you proceed?

A proactive, data-based determination of the standard of medical care in pediatrics.

A 3-week-old infant awoke with a fever. He was taken to the doctor who noted that the child was irritable. The doctor took him to the hospital where a resident performed a spinal tap, started an intravenous (IV) line, and ordered antibiotics. The entire drama, from entering the doctor's office to infusion of ampicillin, took 2 hours. The doctor was sued for malpractice. Expert witnesses for the plaintiff testified that he had deviated from the standard of medical care by taking too long to administer antibiotics, which, in their view, ought to have been given within 30 minutes. Expert witnesses for the defense testified that 2 hours to administer antibiotics in this case was within the standard of care. What ought to be the response of the pediatric community to discrepant expert testimony such as this? One possible response is nothing. Lawyers from both sides will find expert medical witnesses who articulate positions favorable to their clients (as they did in this case), and the truth will emerge after vigorous cross-examination. This, we suggest, is inadequate. We believe that some expert opinions can be viewed as better than others. That is, some opinions describe the standard of medical care correctly while other expert opinions are (to put it charitably) idiosyncratic, failing to depict accurately the skill and care ordinarily administered in comparable situations. Currently, jurors are informed about the standard of care by expert witnesses, who rely on their own medical knowledge and experience. However, a huge body of literature demonstrates that recollections of individual experience are inevitably flawed, and flawed in a nonrandom direction (the Monday morning quarterback phenomenon). Consider the infant with meningitis. When experts in pediatric emergency medicine and pediatric infectious diseases (ID) were asked about the median time from emergency room (ER) presentation to administration of antibiotics in a child with suspected meningitis, their opinions were wrong and slanted toward the outcome known to be desired (namely, a shorter elapsed time). ER physicians (median estimated time to antibiotic administration [AB-TIME] = 46 minutes) and ID physicians (median estimated AB-TIME = 80 minutes) consistently underestimated the actual median value of AB-TIME determined by chart review (120 minutes). From the judicial perspective such potential flaws in expert testimony are assumed to be equally distributed among experts. All admissible evidence is a priori of equal weight until a jury decides otherwise. The standard of medical care is created anew by expert testimony in each individual case, disappearing, like Brigadoon, upon resolution of the dispute. However, to anyone but a lawyer, the standard of medical care must exist as something outside the courtroom testimony of experts, and if it does exist, it should be easily described so that expert testimony can be judged more (or less) accurate in depicting it. We contend that medical care is not a single behavior that conforms to or deviates from an idiosyncratic and retrospectively determined standard, but rather a distribution of behaviors in response to a variety of medical circumstances. For a given scenario, each of several possible responses can be ascribed a relative frequency based on empirical data, and the consequent normal curve depicts the totality of medical care. Substandard care then falls out neatly as behaviors lying outside the large majority of cases. Juries would be empowered (as they are currently) to determine exactly where on this curve substandard care lies, but at least the debate would share the same description of reality. Recent US Supreme Court guidelines regarding expert testimony provide an opportunity to expand the use of databases in medical negligence cases. The Court restricted expert testimony to "scientific knowledge ... based on generating hypotheses and testing them to see if they can be falsified ... (ABSTRACT TRUNCATED)

When to Raise Our White Flag-A Discussion of Scope of Practice in a Resource Scarce World.

Thomas is a 13-year-old boy with autism spectrum disorder, attention deficit hyperactivity disorder (ADHD), generalized anxiety disorder, separation anxiety disorder, and major depressive disorder who presented for a follow-up to his developmental and behavioral pediatrician (DBP). His mother describes an increase in symptoms of anxiety and depression for the last 6 weeks, accompanied by suicidal ideation and thoughts of self-mutilation.Before this increase in symptoms, he had been doing well for the last several months with the exception of increasing weight gain, and Abilify was decreased from 5 mg to 2.5 mg at his last visit. Other medications at that time included Zoloft 100 mg twice daily, Focalin XR 40 mg every morning, and Focalin 5 mg every night. Without seeking the guidance of our developmental and behavioral pediatrics clinic, his mother increased his intake of Zoloft to 150 mg each morning and continued 100 mg each evening because of worsening anxiety and depression.Religion is very important to Thomas and his family. He acknowledges that he does not want to die and feels badly because "suicide is against our religion."Helping Thomas receive appropriate care has been a challenge. He was diagnosed with ADHD and Asperger disorder at the age of 5. Thomas is homeschooled and is very attached to his mother. His parents have very different parenting styles, with his mother being more permissive and his father more authoritarian. At the time of initial diagnosis, the behavioral health services (BHS) in Thomas' community, which is about an hour away from the DBP, were limited to older children, and he was followed by a DBP for ADHD medication management. At the age of 11, he expressed passive suicidal ideation and described that he imagined his mother as "the devil with fire coming out of her eyes" when she corrected him. He was evaluated by BHS, diagnosed with anxiety disorder, and started on Lexapro. BHS linked to the DBP were out of network for his insurance. The family was unable to pay out of pocket, so care was subsequently transferred to a DBP clinic that was in network. Soon after, Thomas developed auditory hallucinations, and Abilify was added after consultation with BHS.Over the last few years, Thomas' symptoms have waxed and waned. He did well for a short time and then again developed auditory hallucinations, worsening symptoms of anxiety and depression, and increasing somatic symptoms including vomiting and penile pain. Medications were adjusted with input from BHS, and further attempts were made to link him to local BHS but were unsuccessful. With his current concerns of suicidal ideation and self-mutilation, what would be your next steps?

Neurology_Adams

Duration of therapy Most cases of bacterial meningitis should be treated for a period of 10 to 14 days except when there is a persistent parameningeal focus of infection (otitic or sinus origin), in which cases longer treatment may be needed. Antibiotics should be administered in full doses parenterally (preferably intravenously) throughout the period of treatment. Treatment failures with certain drugs, notably ampicillin, may be attributable to oral or intramuscular administration, resulting in inadequate concentrations in the CSF. Repeated lumbar punctures are not necessary to assess the effects of therapy as long as there is progressive clinical improvement. The CSF glucose may remain low for many days after other signs of infection have subsided and should occasion concern only if bacteria are present in the fluid and the patient remains febrile and ill.

Chronic hip pain in a boy with mental retardation and cerebral palsy.

Jonny is a 13 year old boy with spastic quadriparesis and severe mental retardation following Haemophilus influenza type B (HIB) meningitis at 2-months of age. Signs of meningitis started on the evening of his 2-month immunizations that included the HIB vaccine. He presented to his pediatrician with left hip pain that occurred intermittently for a few years and more frequently in the past six months. His parents initially attributed the pain to whizzing around the back yard in a motorized wheelchair. An earlier evaluation of hip pain led to bilateral femoral osteotomies for hip dysplasia. Obesity, associated with inactivity and a tendency to consume fatty foods, complicates Jonny's disabilities. His only activity is a modest amount of physical therapy at school and "floor time" for about one hour each day at home. In the office of his pediatrician, Jonny is friendly, smiling, and verbalizing a few words with his limited expressive vocabulary. He is resistant to a hip examination and grimaces with manipulation of his left hip. Spasticity of the left leg appears increased compared to previous examinations. He has nonpitting edema of his lower legs and feet, a cryptorchid left testicle, and a somewhat tender left inguinal area. Jonny lives with his mother and father in a small house on a busy street less than one-half mile from the pediatrician's office. Jonny's pediatrician often sees him in his wheelchair, accompanied by his mother or grandmother, and waves or stops to chat. He has van services to school, and there is a Hoyer lift in the home, but his parents do not own a van. Recently, Jonny's father finds it more difficult to lift him. The family has also been challenged by the mental health problems of Jonny's two older brothers, and a serious eye injury suffered by his middle brother in a motor-vehicle accident. Jonny's pediatrician has cared for him and his two brothers since birth. Although the parents continue to believe that the HIB vaccine caused his catastrophic illness, they remain with the pediatrician. In general, they are satisfied with the individualized educational plan at a local public school. When he was 6.5 years old, Jonny's school aid reported that he attempted to touch her in the genital area. The pediatrician attended the meeting to review this incident and successfully advocated for Jonny by pointing out that this was an isolated incident; it did not occur again. At 6 years old Jonny functioned in the 1.5-2.5 year old range with motor skills in the 6-12 month level according to the Bayley Scales of Infant Development and the Vineland Adaptive Behavior Scales. In the past a neurologist and a physiatrist saw Jonny, but both of these individuals moved from the community. He had prior evaluations at a children's orthopedic clinic at a small community hospital and at the local Shriner's hospital. He had a tonsillectomy and adenoidectomy at 7 years old. He is currently treated for constipation and receives dental care at a clinic for people with disabilities. His pediatrician has always respected the parents for their care and obvious love for their disabled child. However, parental resistance to addressing major issues such as obesity has frustrated his pediatrician. When the pediatrician suggested that Jonny was eligible for the state's managed care program, which would convert Medicaid coverage to a state sponsored program with more extensive services and case management, Jonny's mother repeatedly said that she would "think it over." At the current visit, the pediatrician recommended an adjustment of Jonny's wheelchair, a hip x-ray, a referral to Shriner's Hospital, and an appointment with a pediatric surgeon to address the undescended testicle and possible hernia. Jonny's mother mentioned that he had been to Shriner's Hospital for hip pain two years earlier but was told nothing could be done "because nothing was wrong with his bone." The hip x-ray was normal as well as a complete blood count and a C-reactive protein. The pediatric surgeon did not find a hernia and deferred treatment of the cryptorchid testicle. His parents contacted the wheelchair company to arrange adjustments. The pediatrician called the medical director at the Shriner's Hospital to discuss Jonny's case, but 2 months after the initial visit, the parents had not arranged for an appointment at the Shriner's Hospital. Jonny's hip pain persisted. The pediatrician now wonders how he can more effectively address Jonny's current problems and improve overall care for him and his family.

The X-Files (season 2)

Scully turns up comatose in a hospital four week later with no explanation about how she got there. X provides Mulder with information allowing him to take revenge on her captors, but Mulder is instead convinced by Scully's sister Melissa to visit her bedside. Scully recovers and returns to work shortly thereafter. The agents later investigate a case involving alien biology being injected into teenagers in Wisconsin, and once again they encounter Deep Throat's killer, who is killed by the local sheriff.

Discovering gifted children in pediatric practice.

Casey is a first grader who is brought to the pediatrician for consideration of ADHD. His mother is concerned that he is very difficult to focus at home when asked to do anything and gets so distracted at meals that he eats very little. The teachers last year and this year say that Casey is very distracted, always "in a fog" and just can't seem to get his work done. "He's in his own world." His report card has several unsatisfactory marks because of poor completion of work, doing things other than the assignment and talking too much to the kids around him. The parents are very upset as they see their son as very bright. His advanced vocabulary, early reading skills and his extensive knowledge of engines, machines and aircraft were all noted in his medical chart in the past as part of his health supervision visits. He has lots of friends, mostly third graders and plays soccer with moderate success. The paternal grandmother says Casey is just like his dad who is now a biochemical geneticist. He too had a hard time getting his work in as a child and "always talked back" to the teacher. Casey's mother would like him on medication before the Iowa Basics come around. The Vanderbilt rating scales by both teacher and parent are positive for inattention and borderline for hyperactivity. Casey took it upon himself to speak to the principal about how bored he was with the classroom work. She agreed that he could have some special assignments. In the pediatrician's office, Casey is a delightful, verbal, thin boy who has about 100 things to talk about, from train engines to the sports scores, acquired from the television sports channel, to what should be done to "fix" his school. He said he was bored and knew more about volcanoes than the science teacher. He just wanted to get home each day and work on his elaborate train setup. He doesn't seem overly active, distractible, anxious, inattentive or oppositional. Testing by the school psychologist showed him to have an IQ of 138 with an even verbal/performance profile. Sam is a 4-year old whose parents brought him to the local private school for application to kindergarten. The admission requirements consisted of a group "developmental" test, given to groups of 20 youngsters at a time. Sam failed the test. The report said that he was too immature, talked out of turn and generally wasn't ready for the vigorous academic program planned at that school. He asked too many questions and argued with the admissions person. They suggested he might need medication before he attempted school. His parents asked their pediatrician for an opinion on the school report. They asked for a referral for testing as they could not believe their son was a preschool failure. The psychologist reported that his IQ was 142 (verbal 146 and performance 136).

[An infant less than three months of age at emergency call service].

Examination and treatment of an infant less than three months of age requires different action at the emergency department as compared with bigger children. Even slight cough and vomiting may be indications of a severe disease in this age group. In addition, symptoms in small infants are often diffuse and sometimes difficult to observe and analyze. A general assessment by the physician constitutes the basis for diagnostics. Of the severe diseases, most are infections.

Spiritual Assessment in a Patient With Lung Cancer.

CASE STUDY  Mr. G., an 82-year-old retired European man, was diagnosed with stage 4 non-small cell lung cancer (NSCLC) and recently enrolled on a phase II clinical trial. He is married and has two adult children, who are very supportive. He and his wife described themselves as nonpracticing Catholics. He had never smoked, and there was no personal or family history of cancer. Fatigue was the main side effect from the clinical trial drugs, necessitating frequent periods of rest throughout the day and ultimately requiring dose reduction. His left leg was edematous and painful, and he was diagnosed with and treated for deep-vein thrombosis. Over time, these symptoms resolved, and Mr. G. enjoyed a fairly normal quality of life (QOL). He continued to do well for almost a year, but then his cancer progressed and his performance status began to decline. When offered treatment options, he elected to discontinue the clinical trial, take a break, and then initiate single-agent chemotherapy. Mr. G. was enrolled in a palliative care research study that provided patient-tailored education by an advanced practitioner (AP). The education addressed each QOL domain: physical, psychological, social, and spiritual. When the AP connected with Mr. G. during one of his clinic appointments, he appeared very concerned. He shared that he previously had lived in a communist country and now that he was in the United States, he was afraid of losing his insurance and having to stop treatment. The conversation was interrupted as he was called in for his appointment, yet he consented to talk about the matter further by telephone. The AP contacted Mr. G. the next day. He shared a glimpse of his childhood and experience in his homeland to try to explain his current fears. After reassuring him that his insurance would not be withdrawn, the AP asked whether he would be willing to talk about his life before coming to the United States more than 50 years ago. She wanted to assess where he was spiritually as a self-described nonpracticing Catholic. Mr. G. began by stating that he knew he was going to die of his lung cancer. He added that he did not know whether he was afraid of dying or believed in an afterlife, as he felt ambivalent about faith and religion. The AP learned that what gave his life meaning was his family. His "boys" were everything to him, and he did not want to be a burden to them or his wife. The AP listened and then encouraged Mr. G. to tell his whole story. As a child, he had lived in an occupied country in Eastern Europe during World War II. Mr. G. and his family spent over a year in a concentration camp. They slept on straw, their heads were shaved, and they all had lice. Men aged 18 to 40 were shipped to Russia to work in the copper mines, where many died of exhaustion. Most older men were killed, and he watched his grandfather die beside him. Horse-drawn buggies took dead bodies to mass graves, where lime was poured over them. Mr. G. had boils over his entire body from lack of nutrition. Though technically Catholic, Mr. G. did not ask God to save him; he had seen too much to believe that God would be involved. One day, he escaped with two other boys. With the help of a stranger, they crossed at night into Romania. They walked for miles into Hungary, where they found shelter in a convent for several weeks. The Mother Superior collected money so he could take the train to Budapest and arranged for him to stay in a Catholic home. From Budapest, he went to Austria, living in refugee camps until moving into an apartment of his own. Mr. G. attended college in Austria and later moved with his wife to the United States, where they raised two boys and owned a successful business.

InternalMed_Harrison

Administration of hypotonic intravenous solutions should be monitored carefully in any serious acute brain illness because of the potential for exacerbating brain swelling. Cervical spine injuries must not be overlooked, particularly before attempting intubation or evaluation of oculocephalic responses. Fever and meningismus indicate an urgent need for examination of the CSF to diagnose meningitis. If the lumbar puncture in a case of suspected meningitis is delayed, an antibiotic such as a third-generation cephalosporin may be administered, preferably after obtaining blood cultures. The management of raised ICP is discussed in Chap. 330.

A curious cause of appendicitis.

A previously healthy 10-year-old boy presented to the emergency department with central abdominal pain, loose stool and vomiting. He was diagnosed with gastroenteritis, but was well enough to be discharged. The next day he reattended with ongoing diarrhoea and vomiting, with the pain now localised to the right iliac fossa (RIF). Acute appendicitis was suspected, and he was taken for laparoscopic appendicectomy. At surgery, a gangrenous appendix was found, with pus extending from the pelvis up to the liver. The appendix was excised and thorough peritoneal washout performed. Postoperatively, he received 48 hours of intravenous antibiotics and was discharged home. Unfortunately the boy presented again 11 days later with right lower quadrant pain and fever. Ultrasound revealed a collection in the RIF, and he returned to theatre for washout. His recovery was slow until the peritoneal pus sent for bacterial culture grew Salmonella enteritidis, identification of which facilitated appropriate antibiotic treatment.

261st Medical Battalion

The data demonstrates that for the first week the battalion averaged 1035 admissions each day. Then the rate fell and the average daily admission rate for the first two months was 571.6 patients. After that the rate became much lower - the breakthrough at St. Lo occurred on 25 July 1944, and the front moved in all directions requiring new evacuation points, accounting for the drop in patient load in the 261st's treatment facilities.

Interoception in Practice: The Gut-Brain Connection.

Tony is a five and a half-year-old boy who has been a patient in your primary care practice since he was adopted at birth. He has been treated by a child and adolescent psychiatrist for behavioral concerns starting at age 3 years and has been diagnosed with autism spectrum disorder, attention-deficit/hyperactivity disorder (ADHD) combined type, anxiety disorder, and insomnia. He presents today with complaints of repeated emesis and refusal to eat or drink over the past 2 weeks and is now dehydrated. Tony was born at 30 weeks' gestational age by vaginal delivery with a birth weight of 4lbs 15oz and was described as minimally responsive at birth. There was known prenatal exposure to tobacco and methamphetamine and inadequate prenatal care. The maternal history is notable for a reported diagnosis of bipolar affective disorder, prostitution, and being unhoused at the time of delivery. Tony received antibiotics after delivery for presumed newborn infections. As an infant, he had kidney reflux, low serum ferritin, insomnia, and failure to thrive. Regarding developmental milestones, Tony was sitting up at 7 months, walking at 14 months, talking at 18 months, and speaking in full sentences by 24 months. When he presented to the psychiatric service at age 3 years, behavioral problems included irritability with destructive rages, excessive fears, separation anxiety, hyperactivity, and impulsivity with a lack of awareness of danger to the extent that he required a safety harness when in public and security locks in the home because of repeated elopements. Tony also had at the time of his initial presentation significant defiance, extreme tantrums, violent aggressive outbursts, cognitive rigidity, repetitive behaviors, resistance to change, frequent nondirected vocalizations, and self-injurious behaviors including slapping himself on the head and biting of his hands and feet. Review of systems includes complaints of frequent abdominal and neck pain, persistent insomnia, night terrors, restrictive eating habits with poor weight gain, and reduced sensitivity to pain. Treatment history included gabapentin and subsequently divalproex for seizure-like episodes (despite negative EEG) described as frequent staring spells with repetitive biting of his lips. Psychotropic medications were risperidone for irritability associated with autism and clonidine extended release for ADHD. He also took melatonin for sleep. During his well-child check at the age of 5 years, Tony is making good progress from a developmental standpoint, has age-appropriate expressive and receptive language skills, is fluent in both English and Spanish, is able to recite the alphabet, counts to 20, has learned to swim, and is demonstrating interest in planets and astrology. He is reported to have a secure attachment to his adoptive parents and is described as emotionally sensitive, caring, kind, considerate, and empathetic. He has good eye contact and can read facial expressions. He is affectionate and protective of his infant sibling, his biological sister, who is also adopted by his parents and now living in the home. Tony made an excellent adjustment to the start of kindergarten and up until this point was responding positively to his psychotropic medication regimen. But then at age five and a half, Tony experienced sudden and unexplained behavioral worsening, which was followed by the onset of recurrent vomiting and refusal to eat or drink. Comprehensive medical workup including upper endoscopy and biopsy resulted in a diagnosis of eosinophilic esophagitis (EoE). What would be your next step?

Rapid throat-culture as diagnostic aid: ineffective in decreasing antibiotic prescriptions.

An overnight slide-culture for the detection of group A streptococci was introduced in a Finnish health centre. The number of patients from whom a throat culture was obtained increased from 55% to 70% with the new method. Despite this increase, the prescribing habits of primary care physicians did not change. Treatment was in most cases (84-90% of those treated) still initiated before culture results were available, and antibacterial medication was discontinued only occasionally (1-3%). Physicians usually decided the treatment during the first consultation. These findings contradict earlier studies where prescriptions decreased during rapid culture. Use of throat cultures as diagnostic aid should be reconsidered, especially when more rapid methods now are available.

Management of cryptococcal meningitis in patients with AIDS.

A case of cryptococcal meningitis in a patient with the acquired immunodeficiency syndrome (AIDS) is described, as well as the epidemiology, pathogenesis, clinical manifestations, diagnosis, and therapeutic management of the disease. In July 1987 a 38-year-old white man was admitted to the hospital because of confusion, disorientation, and headache. His medical history was notable for a positive human immunodeficiency virus test. Culture of the cerebrospinal fluid was positive for Cryptococcus neoformans. The patient was started on amphotericin B 16 mg/day (0.3 mg/kg/day) intravenously and flucytosine 2 g every six hours (150 mg/kg/day) orally. Despite premedication with diphenhydramine and acetaminophen, he experienced rigors that were treated with hydrocortisone and meperidine. Three weeks later he was discharged on flucytosine 2 g orally every six hours and amphotericin B 50 mg intravenously every other day. One week later the patient developed fever and chills; blood cultures were positive for methicillin-sensitive Staphylococcus aureus, and his peripheral leucocyte count was 1.8 X 10(3)/cu mm. Flucytosine was discontinued, and he was treated with intravenous nafcillin while remaining on amphotericin B. In October the patient complained of nausea, vomiting, weakness, and agitation. A CSF latex agglutination titer for cryptococcal antigen was 1:32. He was treated with amphotericin B 50 mg daily until symptoms resolved and then continued on amphotericin B 50 mg twice weekly. Cryptococcosis is the most common life-threatening fungal infection among AIDS patients. In contrast to immunocompetent hosts, this population invariably develops disseminated disease, with 85% having meningeal involvement. The most effective therapy for cryptococcal meningitis in patients with AIDS has not been established.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of sphenoid sinusitis which could be diagnosed by orbital computed tomography after detected Strepotococcus pneumoniae from blood culture].

We report a case of sphenoid sinusitis which could be diagnosed by orbital CT after detecting Strepotococcus pneumoniae from blood culture. A previously healthy 47 year-old Japanese male was admitted to our hospital with severe left-sided headache of 2 days duration. From 9 days before hospitalization (1st day), the patient complained of cough and sputum. On physical examination, his neck was supple and his temperature was 38.3 degrees C. The rest of the examination was normal. A chest radiograph, sinus radiograph, and head computed tomographic (CT) scan without contrast material disclosed no abnormalities. Lumbar puncture was done and cerebrospinal fluid was clear and cell counts and the levels of glucose and protein were normal. The peripheral white blood cell count was 14,400/fl, and the C-reactive protein level was 9.6 mg/dl. After blood, urine, pharyngeal mucus and cerebrospinal fluid cultures were obtained, empirical antibiotic therapy with 2 gms of piperacillin twice daily was begun. He complained sever left-sided retro-orbital headahe on the next day too. The lumbar puncture and head CT scan with contrast material was done again but gave no diagnostic clues. The examinations by the otolaryngologist, ophthalmologist and dentist found no abnormal findings. On the 3rd hospitalized day, Strepotococcus pneumoniae was detected from the blood culture taken on the 1st hospitalized day. A CT scan focused on orbita was done and revealed a low density area of the left sphenoid sinus. The dose of piperacillin was increased to 4 gms twice daily and continued for 24 days. The patient's headache improved and piperacillin was changed to oral levofloxacin 100 mg, three times daily on the 26th day. The medication was stopped on the 73th day. Isolated sphenoid sinusitis is rare, but crtitical complications such as cranial nerve involvement, brain abscess, and bacterial meningitis may happen. It is necessary to also think of sphenoid sinusitis in practices of patients with severe headache.

Severe sepsis caused by Arcanobacterium haemolyticum: a case report and review of the literature.

To describe a case of severe sepsis, cavitary pneumonia, and pyomyositis caused by Arcanobacterium haemolyticum. An 18-year-old male with a medical history significant for mild asthma presented to the emergency department complaining of a 7-day history of fever, diffuse myalgias, nausea, vomiting, diarrhea, and pain in his right upper quadrant, right shoulder, and left thigh. Cultures of blood, bronchoalveolar fluid, and surface and surgical swabs from the patient's left lower extremity grew A. haemolyticum. The patient was successfully treated with intravenous penicillin G 4 million units every 4 hours and azithromycin 500 mg once daily for 14 days. Within 36 hours after initiation of focused therapy, he became afebrile, pain decreased, and pulmonary symptoms abated. Oral azithromycin 500 mg/day for an additional 3 weeks was prescribed on discharge, and the patient showed no relapse at 2-month follow-up. A. haemolyticum is a weakly acid-fast, branching gram-positive bacillus most commonly implicated in pharyngitis in healthy adolescents and skin and soft-tissue infections in older, immunocompromised patients. Systemic infections are rarely reported in the literature. This organism remains susceptible to most classes of antimicrobials, including penicillins, cephalosporins, carbapenems, macrolides, tetracyclines, clindamycin, and vancomycin. Routine resistance has been reported only with trimethoprim/sulfamethoxazole. To our knowledge, there are no published case reports of severe sepsis caused by A. haemolyticum. While treatment options are numerous, we recommend the use of intravenous penicillin or a cephalosporin as first-line pharmacologic management of deep-seated infections caused by this rare organism.

Johnny Weeks

While in the hospital for that beating, Johnny discovers he is HIV positive; he also undergoes a colostomy operation. Season 2 Johnny is first seen by Detective Jimmy McNulty, stealing from a shopping centre with Bubbles. McNulty catches Johnny and Bubbles, but instead of arresting them asks them to find stick up artist Omar Little. At the end of Season 2, Officer Santangelo arrests Bubbles and Johnny stealing morphine from an ambulance. They are released because Bubbles gives information about Proposition Joe's dealers at the projects, when Cheese is shot in the shoulder by Brother Mouzone. Season 3 Johnny and Bubbles continue to steal from scrapyards. Bubbles would rather make money by continuing to inform detectives McNulty and Greggs. Johnny finds out that Bubbles is a police informant and the two men quarrel and split up. Without Bubbles looking after him, Johnny overdoses and his body is discovered in a vacant house in Major Colvin's "Hamsterdam" free zone.

Attention deficit hyperactivity, fetal alcohol spectrum disorder, or something else: the broad differential of kindergarten suspension.

Thomas is a 5-year 6-month-old boy whose parents requested an urgent care appointment because he has recently been suspended from kindergarten stating "and his doctor must see him before he can come back." His suspension from kindergarten was due to kicking and biting his classmates, but he has also become increasingly aggressive at home. His teacher reported that he has always had a high activity level and difficulty shifting attention between tasks, as well as noncompliance with rules and directions. He is noted to have learning challenges and is showing difficulties in the concept of numbers and letter sounds. The practice has followed Thomas since his healthy birth. He has a history of delayed language development, and he received early intervention services from 2 years of age. He spoke his first word at 2 years 6 months. He started a half-day preschool program at 3 years of age. He had difficulty acclimating to preschool, interacting with peers, and was described as "hyperactive" by his teachers. His program was modified to decrease his time having to sit in a circle time, and he often required the support of the paraprofessional in the classroom. His parents have always described him as a "difficult child." He gets frustrated easily and can tantrum for up to 2 hours multiple times in a week when his immediate needs or requests are not met. He has difficulty falling asleep, has frequent night awakenings, and often has trouble getting back to sleep. His self-help skills are poor, and he has difficulty with activities such as brushing his teeth and dressing. His parents report that he does not seem to remember rules from day to day. He was evaluated at 5 years of age and diagnosed with Attention Deficit Hyperactivity Disorder, but his response to stimulants has been limited. Thomas is an only child. His parents are college educated and professionally employed. They deny drug use, domestic violence, and guns in the home. They reported that prior to the pregnancy, they enjoyed "partying" with friends on the weekends, but Thomas's mother reported that she stopped drinking as soon as she realized she was pregnant. All are wondering whether this child might have a fetal alcohol spectrum disorder, although he seems to have no clear facial dysmorphology. It is unsure what the next step might be and if there is value added in pursuing this diagnosis. What do you do next?

[Imminent peritonsillar abscess: when should a general practitioner refer?].

Antimicrobial management of an imminent peritonsillar abscess is still under debate. Clinical experience shows that early administration of amoxicillin-clavulanic acid could prevent unilateral peritonsillitis from developing into an abscess. Here we describe two patients who initially received penicillin V treatment. They both recovered but only after the ENT specialist switched their antibiotic treatment to amoxicillin-clavulanic acid. Although sound evidence is lacking, we suggest that the Practice Guidelines should be revised. In the primary health care setting, amoxicillin-clavulanic acid should become the first drug of choice for patients presenting with unilateral peritonsillar swelling and trismus in situations where the patient is still able to eat and drink and can be seen again within 24 hours.

[A 56-year-old man with fever, backache and tetraparesis].

We report a 56-year-old man who developed progressive paraparesis. He was apparently well, except for left Bell's palsy which developed on May 9 of 1994, for which he received stellate ganglion block on the left side more than ten times until July 2nd of 1994, when he noted pain in his left shoulder and in his lumbar region. On July 5th, he noted some difficulty in urination. On July 6th, he noted tingling sensation in his four extremities and difficulty in gait. He was admitted to another hospital where he was treated with intravenous infusion of glycerol. After this treatment, his gait and sensory disturbance showed some improvement, however, on July 7th, his shoulder and lumbar pain worsened, and he became unable to stand. His temperature went up to 39 degrees C on the next day. Lumbar CSF on that day contained 119 cells/microliters, 112 mg/dl of protein, and 53 mg/dl of sugar. He was transferred to our hospital on July 14th. His past medical history revealed that he had suffered from frequent bouts of osteomyelitis since the age of 13 years. He was operated on several times on osteomyelitis. He had been treated on his tooth ache until shortly before the onset of the present illness. He also received steroid hormone for his Bell's palsy. On admission, his consciousness varied from alert to stupor. His BP was 150/100 mmHg, HR 98/min and regular, BT 39.4 degrees C. The bulbar conjunctiva appeared somewhat icteric. Otherwise, general physical examination was unremarkable. On neurologic examination, there was no apparent dementia. Higher cerebral functions appeared intact. The optic discs were flat. Pupils were round and isocoric reacting to light and accommodation promptly. Ocular movements were full without nystagmus. Some exophthalmos was noted bilaterally. The sensation of the face and facial muscles were intact. The remaining cranial nerves also appeared intact. Nuchal rigidity was present. He was unable to stand or walk. Muscle strength was markedly diminished in all four limbs; manual muscle testing revealed 1 to 2/5 weakness in both upper and lower extremities bilaterally. Muscle stretch reflexes were decreased or lost in both upper and lower limbs, but the plantar response was extensor on the right. Sensation appeared to be diminished in legs, but detail was not clear because of disturbance of consciousness. Pertinent laboratory findings were as follows: WBC 12,800/microliter, GPT 58 IU/l, total bilirubin 2.65 mg/dl, and CRP 16.8 mg/dl. Cerebrospinal fluid contained 34 cells/microliter (approximately two thirds were neutrophils), RBC 1,110/microliter, 2,949 mg/dl of protein, and 119 mg/dl of glucose; stapylococcus aureus was cultured from the CSF. Myelogram showed a filling defect in the anterior epidural space between the low thoracic and the upper lumbar region. The patient was treated with cephotaxim, aminobenzyl penicillin, and chloramphenicol. On the second hospital day, his BT was still 39 degrees C and he was agitated His weakness was worse than the previous day. Spinal MRI was attempted; as he was agitated 5 mg of diazepam was given intravenously at 4 PM. His respiration was rapid and somewhat shallow. At 6 PM, gadolinium DTPA was injected intravenously; at that time, he was breathing and pupils were 3 mm on both sides. At 6:35 PM, an examiner noted that he stopped breathing; the left pupil was dilated to 5 mm. Cardiopulmonary resuscitation was initiated immediately, and intubation was performed. He was placed on a respirator. His blood pressure did not reach 100 mmHg; he was in deep coma. Cardiac arrest occurred at 8:53 AM on the next morning. The patient was discussed in a neurological CPC. Most of the participants thought that the patient had either spinal epidural empyema or spinal subdural abscess. The question was what might be the original focus of infection. Three possibilities were considered, i.e., stellate ganglion block, teeth infection, and osteomyelitis...

[A case of favorable outcome of conservative treatment of acute otogenic cerebellar abscess].

The authors report a case of conservatively cured abscess in the left cerebellar hemisphere demonstrated by CT. The patient was admitted in serious condition to a neurotraumatology centre. After pharmacological treatment a quick improvement of patient's health was achieved and control CT examination during his stay in hospital and after discharge from hospital confirmed the relation between clinical improvement and regression of changes in CT. The presented case points to the possibility of conservative treatment of brain abscesses if the patient meets certain clinical criteria, and CT provides the possibility of repeated checking of the dynamics of intracranial lesion.