Special situations: pediatric, pregnant, and geriatric patients.

Venous thromboembolic disease is not an uncommon problem associated with the geriatric patient. These patients are at significantly increased risk of DVT and PE compared with their younger counterparts. Their associated morbidity and mortality is also higher. Treatment of thrombotic disease in these patients necessitates close monitoring owing to their enhanced sensitivity to the effects of anticoagulants.

Overdose of Rogaine Extra Strength for Men topical minoxidil preparation.

CASE REPORT: Minoxidil is a potent arterial vasodilator used in the treatment of hypertension. A side effect, hypertrichosis, has prompted the marketing of a topical preparation, Rogaine, for the treatment of male-pattern baldness. Recently, a 5% solution of minoxidil became available over-the-counter as Rogaine Extra Strength For Men Hair Regrowth Treatment. We describe an oral overdose of minoxidil 3 g as the Rogaine Extra Strength preparation. Toxicity manifested as profound hypotension, requiring vasopressor support, intubation, prolonged tachycardia, and fluid overload with pleural effusions, requiring several days of therapy with furosemide. This is the largest reported ingestion of minoxidil and the first reported overdose of the extra strength 5% solution.

Blood lead levels in emergency department patients with retained lead bullets and shrapnel.

OBJECTIVE: To determine whether patients with retained lead shrapnel who present to the ED have elevated whole blood lead levels (BLLs) compared with matched control patients. METHODS: Test subjects were patients with x-ray evidence of retained lead shrapnel who presented to any of three urban EDs, and consented to inclusion in the study. BLLs were obtained from 15 ED patients, and data regarding time since injury and symptoms of plumbism were collected. Control subjects consisted of 15 ED patients, without similar lead exposure, matched for age, sex, race, and place of dwelling as determined by zip code, who also presented to any of the same three EDs. RESULTS: The mean (+/-SD) BLL in the test subjects was 17+/-9.78 microg/dL (range 7-50 microg/dL). Time since impalement ranged from 1 to 45 years. The mean BLL in the control subjects was 7+/-3.77 microg/dL (0-16 microg/dL). This difference was statistically significant (two-tailed t-test p = 0.002). CONCLUSIONS: In this preliminary study, the patients with retained lead shrapnel who presented to the ED had significantly elevated BLLs, compared with the matched control subjects. Chronic plumbism may be considered in patients with retained lead shrapnel, and a history should be taken to assess the presence of symptoms referable to plumbism. These patients may require long-term follow-up to assess the development of elevated blood lead level and lead toxicity.

Poisoning from "Spanish fly" (cantharidin).

Cantharidin, known popularly as Spanish fly, has been used for millennia as a sexual stimulant. The chemical is derived from blister beetles and is notable for its vesicant properties. While most commonly available preparations of Spanish fly contain cantharidin in negligible amounts, if at all, the chemical is available illicitly in concentrations capable of causing severe toxicity. Symptoms of cantharidin poisoning include burning of the mouth, dysphagia, nausea, hematemesis, gross hematuria, and dysuria. Mucosal erosion and hemorrhage is seen in the upper gastrointestinal (GI) tract. Renal dysfunction is common and related to acute tubular necrosis and glomerular destruction. Priapism, seizures, and cardiac abnormalities are less commonly seen. We report four cases of cantharidin poisoning presenting to our emergency department with complaints of dysuria and dark urine. Three patients had abdominal pain, one had flank pain, and the one woman had vaginal bleeding. Three had hematuria and two had occult rectal bleeding. Low-grade disseminated intravascular coagulation, not previously associated with cantharidin poisoning, was noted in two patients. Management of cantharidin poisoning is supportive. Given the widespread availability of Spanish fly, its reputation as an aphrodisiac, and the fact that ingestion is frequently unwitting, cantharidin poisoning may be a more common cause of morbidity than is generally recognized. Cantharidin poisoning should be suspected in any patient presenting with unexplained hematuria or with GI hemorrhage associated with diffuse injury of the upper GI tract.

Growth and development of infants with end-stage renal disease receiving long-term peritoneal dialysis.

The growth and development of four infants with end-stage renal disease receiving long-term peritoneal dialysis was studied during the first year of life. In each patient, dialysis was begun before 4 weeks of age. A nutritional regimen was designed to attain a daily weight gain appropriate for height age while minimizing the blood urea nitrogen level. A neurodevelopmental evaluation of gross and fine motor, cognitive, language, and psychosocial skills was performed at least every 3 months. At age 1 year, the mean height standard deviation score (SDS) was -1.33 +/- 0.2. Weight for height was greater than 95th percentile in one patient and normal in three. Mean caloric and protein intake were 105 +/- 20 kcal/kg/d (11.4 +/- 2.7 kcal/cm/d) and 2.7 g/kg/d (0.30 +/- 0.11 g/cm/d), respectively. Mean blood urea nitrogen was 53.6 +/- 17.8 mg/dL. Developmentally, three of the patients were functioning in the normal range and one was mildly retarded. However, gross motor skills were delayed in all patients. Although infants with end-stage renal disease are usually severely growth retarded and developmentally delayed, our observations suggest that early nutritional intervention and dialysis can yield improved results.

Cerebral palsy. A pediatric developmentalist's overview.

Exploration of the history, terminology, and classification of cerebral palsy reveals it as a complex entity. Criteria exist that may make early diagnosis and appropriate intervention possible. Dealing with patients who have cerebral palsy requires recognition of the associated problems and deficits. Comprehensive management usually requires a multidisciplinary setting, which is used to outline the contributions of many therapeutic modalities--developmental pediatrics, occupational and physical therapy, hearing and speech, psychology, social services, special education, ophthalamology, neurology, orthopedics and neurosurgery. The poor prognosis for full function within the community is recognized, as are areas of research that require investigation.