Long QTc predicts future cardiac death in stroke survivors.

OBJECTIVES: To test the hypothesis that the QTc of any lead of the ECG predicts death after stroke, and to determine which lead of the ECG carries the greatest risk of cardiac death when its QTc is measured. DESIGN: Standard 12 lead ECGs were analysed by one observer who was blind to patient outcome. SETTING: A major teaching hospital in Scotland. PATIENTS: 404 stroke survivors were studied at approximately one year after the cerebrovascular event and followed for up to 6.3 years. OUTCOME MEASURES: Death from any cause and cardiac mortality. RESULTS: The QTc measured from any lead of the ECG (except aVR) was associated with death from any cause. A prolonged QTc in limb lead III and chest lead V6 carried the highest relative risk of cardiac death (a 3.1-fold incease). After adjusting for overt ischaemic heart disease, pulse pressure, glucose, and cholesterol, a prolonged QTc in lead V6 was associated with a relative risk of cardiac death of 2.8 (95% confidence interval (CI) 1.1 to 7.3) (p = 0.028) and of death from all causes of 2.9 (95% CI 1.6 to 5.3) (p < 0.001). If the QTc in V6 exceeded 480 ms, then the specificity of predicting cardiac death within five years after the stroke was 94%. CONCLUSIONS: Although treatment of the conventional modifiable risk factors is important, stroke survivors with a prolonged QTc in lead V6 are still at a high risk of cardiac death and may need more intensive investigations and treatments than are currently routine practice.

Use of glycopyrrolate and other anticholinergic medications for sialorrhea in children with cerebral palsy.

Fifty-four parents/caretakers of children with cerebral palsy were surveyed regarding their use of antisialorrheic medication for excessive drooling. Glycopyrrolate was used by 37 of 41 respondents, with significant improvement in drooling noted in the vast majority (95%) of cases as indicated by a five-point rating scale. Side effects (dry mouth, thick secretions, urinary retention, or flushing) surfaced in almost half (44%) of the patients but necessitated discontinuation of pharmacologic treatment in less than a third. While larger clinical studies are needed, our preliminary data indicate a trial of glycopyrrolate should be considered in children with cerebral palsy where drooling is a significant problem.

Cat scratch disease presenting with peripheral facial nerve paralysis.

Acquired peripheral facial nerve paralysis is a relatively common disorder that affects both children and adults. The most frequent nontrauma-related etiologies in otherwise neurologically intact patients are idiopathic (Bell's palsy) and infectious, which includes otitis media, herpes zoster, Lyme disease, herpes simplex virus, Epstein-Barr virus, and Mycoplasma pneumoniae. Cat scratch disease (CSD) is typically a subacute, regional lymphadenitis caused by Bartonella henselae that is seen in children and young adults. CSD most often has a benign, self-limited course. However, 11% of CSD patients may present atypically, most commonly with Perinaud's oculoglandular syndrome or acute encephalopathy. We present a child with the first reported case of acute facial nerve paralysis in serologically proven CSD with typical lymphadenitis.

Radiology practices in emergency departments associated with pediatric residency training programs.

To examine the current radiology practices in academic emergency departments (EDs) serving children, a postal survey was done of 116 directors of EDs that serve as routine teaching sites for pediatric residents. One hundred three ED directors (89%) completed the survey, representing 75 pediatric-only EDs and 28 combined pediatric/adult EDs. Thirty-four of these EDs offer a pediatric emergency medicine fellowship. Hospitals were self-categorized as children's hospitals in 41 and non-children's hospitals in 62. Radiologists immediately read every study in 8% of the 103 EDs. Overall, 66% of the EDs have a radiology resident in-house overnight, which is significantly more likely in non-children's hospitals than in children's (79 vs 46%, P < 0.001). Overnight, ED radiographs of children may at times be solely interpreted by emergency attending physicians in 57% or emergency house staff in 44%. In EDs that allow their house staff to interpret solo overnight, emergency attending physicians are readily available to help with these interpretations less than half the time. A radiologist's second opinion overnight is readily or usually available in 63% of EDs. When any emergency physician interprets a radiograph solo overnight, the interpretation is almost always or often available later to the radiologist during the official interpretation only 40% of the time. Overnight, pediatric cervical spine studies are cleared, at times, solely by emergency attending physicians in 46% and by emergency house staff in 4%. Only 18% of programs have a daily or weekly ED radiograph review with radiologists. An ED atlas of common radiographic variants or a pediatric radiology textbook is available in 69% of EDs.(ABSTRACT TRUNCATED AT 250 WORDS)

Taxicabs and child restraint.

For young urban families who may not own a car, taxicabs are a common mode of transportation. We surveyed the frequency of taxicab use involving children younger than age 4 years in a Baltimore, Md, clinic population and studied pediatric occupant safety issues, including taxicab child restraint law exemptions, taxicab occupant morbidity/mortality data, and taxicab child restraint device availability. In our inner-city clinic, 84 (78%) of 108 families reported that they did not own a car and 64 (76%) of those without cars rode with their small children in taxicabs at least monthly (n = 28), weekly (n = 27), or daily (n = 9), all without child restraints. Thirty-five of 50 states (70%) plus Washington, DC, exempt taxicabs from child restraint laws. Only 11 (27%) of 41 states with safety belt laws exempt taxicabs. There were 106 reported taxicab occupant fatalities from 1986 to 1990 in the United States, including 11 children and adolescents. National and state data on motor vehicle occupant morbidity do not separately examine taxicabs. Individual taxicab fleets we contacted would not release injury data. Of 50 urban taxicab fleets in four states (Delaware, Maryland, New Jersey, and Pennsylvania), only three (6%) offered child restraint devices by advance telephone request. There was no difference in availability based on state taxicab exemptions from child restraint laws. We conclude that taxicab use involving young children is common in this inner-city population. Data on taxicab occupant injuries are needed. Child restraint law exemptions for taxicabs should be eliminated. Education about, and enforcement of, child restraint laws for taxicabs is needed. Recent local legislation linking child restraint device availability to taxicab licensure should be encouraged.

Ultrasound screening of high-risk infants. A method to increase early detection of congenital dysplasia of the hip.

Congenital dysplasia of the hip (CDH) continues to be missed by routine physical screening examinations in the early months when treatment is most effective. Real-time ultrasonography (US) is valuable in the detection of CDH in the young infant. We performed a prospective study to evaluate one US screening strategy that targets a select "high-risk newborn" population at risk for CDH aiming to increase the early diagnosis of this condition. From 1772 consecutive births at one hospital, we identified 97 (5.5%) newborns with risk factors for CDH: breech delivery, 73 babies; family history, 26 babies; postural abnormalities, five babies; and oligohydramnios, four babies. Eleven newborns had two risk factors. We studied 69 of these newborns with US. There were four cases of CDH in this group. Three of these babies had completely normal pediatric physical examination results at the time of the US study (at 14, 75, and 100 days, respectively) despite dysplasia diagnosed by US. All were successfully treated with a harness as outpatients. We conclude that a screening program entailing identification and subsequent US of the hip of newborns with specific physical and historical risk factors for CDH increases early diagnosis. Further analysis suggests this approach is cost-effective.