Headache in Chiari malformation: a distinct clinical entity?

A relatively common group of developmental anomalies of the posterior fossa and its contents make up the Chiari malformations. The most common of these anomalies are the Chiari malformations type I and type II. Many patients with these defects are asymptomatic, but many of them suffer from headaches. Although the prevalence of common primary headache disorders in patients with Chiari malformations is similar to that of the general population, a particular type of occipital headaches occurs more frequently in patients with a Chiari malformation. In the two patients described in the illustrative case presentations, the major complaint was headache. Both had Chiari malformation type I diagnosed. Chiari malformation should be considered in the differential diagnosis of patients who complain of exertional headache. Exertional headaches or worsening of pain during Valsalva's maneuver should prompt clinical suspicion of an underlying intracranial lesion and warrants further evaluation by appropriate neuroimaging studies.

Pontine cryptococcoma in a nonimmunocompromised individual: MRI characteristics.

The case of a pontine cryptococcoma in a nonimmunocompromised, previously healthy 16-year-old boy is presented. The patient had slowly progressive brainstem signs with right cranial nerves V, VII, and VIII palsies, and contralateral corticospinal and spinothalamic deficits. Magnetic resonance images (MRI) revealed, within the right pons, a 1-cm diameter round mass lesion, hypointense on T1-weighted images, hyperintense on T2-weighted images, and with rim enhancement after infusion of gadopentetate dimeglumine. This is the only report of the MRI findings in an isolated pontine cryptococcoma in an immunocompetent patient. Early recognition of this specific MRI pattern is essential, because complete recovery can be achieved with prompt antifungal treatment.

Digital sympathectomy for refractory Raynaud's phenomenon in an adolescent.

We describe the case of an adolescent with severe Raynaud's phenomenon refractory to conventional medical management. Her course was complicated by fingertip ulceration and necrosis. The localized surgical technique of digital sympathectomy was successfully used in the management of her disease, and should be considered for intractable Raynaud's phenomenon.

Effects of sow-crate design on health and performance of sows and piglets.

The effects of sow-crate design on certain health and performance traits of 211 sows and their piglets were evaluated with a 2 X 2 X 4 factorial arrangement of crate width (narrow [N = 55 cm] or wide [W = 64] between lowest horizontal pipes), length (short [S = 183 cm] or long [L = 198] from rump stop to front gate) and side type (lower side of sow crate "fingered" [F], "bowed" bottom bar--marking the sow zone 19.3 cm wider at the bottom--20 cm above the floor [B], or straight bottom bar 20 cm [S20] or 25 cm above the floor [S25]). Between d 107 to 110 postcoitum and d 21 postpartum, no crate design variable affected the sow's body-weight change, but side type tended to affect the most prominent head-neck and leg integumentary lesions. Number of stillborn piglets/litter was greater with W crates than with N, except with crates having S20 sides, and was greater with L crates than with S. More piglets were crushed to death in W crates than N crates, and stillbirth frequency was greater in L crates than in S, but overall preweaning piglet mortality was affected by no crate-design feature. At both 7 and 21 d of age, piglets' knee lesions were most severe with S20 crates and least with S25, whereas face-lesion score was unaffected by crate design. Piglet body weight at age 21 d was least with S20 crates and greatest with F and S25. No crate-design variable affected within-litter variation in piglet growth rate. Sow-crate design affected important health and performance traits of piglets through postnatal d 21.

Reflex sympathetic dystrophy in children: treatment with transcutaneous electric nerve stimulation.

During the past 6 years, ten children with reflex sympathetic dystrophy were treated. Pain in an extremity was the initial complaint in all patients. The pain was unilateral in 90% of the patients; upper and lower extremities were affected with equal frequency. Tenderness to palpation, extreme hyperesthesia, and dysesthesia were other dominant features. All patients had some evidence of autonomic nervous system dysfunction in the affected extremity (swelling, color change, decreased temperature, and/or hyperhidrosis). The median duration of symptoms prior to referral and diagnosis was 5 months. All children were treated as outpatients with a transcutaneous electric nerve stimulator and home-based physical therapy. With this regimen, seven patients had complete remission within 2 months. Two other patients improved with transcutaneous electric nerve stimulation therapy, and one patient had no response to transcutaneous electric nerve stimulation. Reflex sympathetic dystrophy is frequently underdiagnosed in children. Increased awareness of this syndrome is important because accurate diagnosis is crucial and transcutaneous electric nerve stimulation offers a safe, simple, and effective outpatient therapy for reflex sympathetic dystrophy in children.

Intern ranking versus subsequent house officer performance.

The rankings of candidates for pediatric internship by the Pediatric Intern Selection Committee (ISC) of the University of Virginia Medical Center were compared with subsequent performance rankings of house officers by faculty members and chief residents. Although a positive correlation was found between the rankings, the absolute magnitude of the correlation coefficients was relatively low and not statistically significant. We discuss factors responsible for the poor correlation and suggestions for ISCs.

Medical examination of children referred for special education.

The results of medical examinations of 184 children referred for special educational services were reviewed, with particular attention paid to the value of the examination in the detection of abnormalities that would have an adverse educational impact and of previously undiagnosed abnormalities. Seventeen students (9%) were found to have educationally important abnormalities previously unknown to the school. Fifteen students had abnormalities detected through screening tests. The two remaining students had abnormalities apparent on physical examination that conceivably could interfere with physical education but should not hinder academic achievement. Thus, a separate physical examination, apart from those recommended for all children by the American Academy of Pediatrics, may not be productive for children referred for special educational services, but screening tests currently available in many schools are more likely to be beneficial.

Thrombocytosis in Henoch-Schönlein purpura.

The clinical and laboratory features of acute Henoch-Schönlein purpura in 18 patients are presented. Thrombocytosis was noted in 67 per cent of the patients and was significantly associated with the presence of abdominal pain and gastrointestinal bleeding. We found no correlation between increased serum IgA concentrations or elevated sedimentation rates and any of the clinical features of Henoch-Schönlein purpura.

Overlap syndrome of juvenile rheumatoid arthritis and systemic lupus erythematosus.

Two children with an overlap syndrome of juvenile rheumatoid arthritis (JRA) and systemic lupus erythematosus (SLE) are described. Both developed SLE years after presenting with typical JRA.

The value of the preschool examination in screening for health problems.

The effectiveness of physicians in detecting abnormalities of height, weight, vision, hearing, blood pressure, and the presence of dental caries in 1,158 kindergarten pupils was compared with that of a separate screening program staffed by trained volunteers and public health nurses. The screening program was significantly more effective in identifying abnormalities in vision, hearing, blood pressure, and the presence of dental caries. Pediatricians were no more effective than other physicians in detecting abnormalities. We conclude that the preschool examination should be modified to emphasize screening tests. These screening tests can be effectively performed by paramedical personnel, resulting in increased detection of health problems and decreased demands on physicians' time.

Prophylactic antibiotics in pediatric surgery.

The frequency and appropriateness of prophylactic antibiotic use in children less than 6 years of age who received surgery were examined. Antibiotics were prescribed for 62% of children who had surgery, and prophylaxis was the sole reason for antibiotic use in 73% of the patients. Prophylactic antibiotics were administered inappropriately with respect to timing or duration to 42% of the children receiving preoperative prophylaxis, 67% receiving intraoperative prophylaxis, and 55% receiving postoperative prophylaxis. Thus, prophylaxis alone is the major indication for antibiotic use in pediatric surgical patients, and prophylactic antibiotics are frequently administered inappropriately.

Three-day therapy of lower urinary tract infections with nitrofurantoin macrocrystals: a randomized clinical trial.

Forty-nine girls between the ages of 2 and 18 years with a symptomatic urinary tract infection documented by two clean-catch urine cultures completed a double-blind study comparing the effectiveness of three days versus ten days of nitrofurantoin macrocrystal therapy. Localization of the infection to the lower urinary tract was presumed on the basis of clinical presentation. All patients had sterile urine on day two or three of therapy. In the ten-day group, two of 23 patients (8.7%) experienced a single relapse, and seven patients (30%) had 12 episodes of reinfection during a six-month follow-up. In the three-day group, two of 26 patients (7.7%) had a single relapse, and six patients (23%) had 12 episodes of reinfection. The rates of relapse and reinfection in the compared groups were not statistically significantly different (P greater than 0.05). Three days of treatment with nitrofurantoin macrocrystals is an effective regimen for symptomatic girls presumed to have uncomplicated lower urinary tract infections.

The high cost of recruiting residents.

We have developed estimates for the cost of recruiting first-year residents through the National Resident Matching Program. The cost to our medical center was estimated to be $1,469 for each resident obtained through the matching program. The cost to each applicant averaged $659, and the cost to the applicants' medical schools for processing letters of recommendation was approximately $99 per student. We describe our recruiting methods and costs in order to provide other medical centers with a source for comparison and to stimulate suggestions for increasing the effectiveness of recruiting. We suggest that limiting the number of programs at which an applicant may interview would reduce costs without damaging the recruiting process.