Lack of agreement on colour description between clinicians examining childhood bruising.

INTRODUCTION: In child protection cases clinicians are often asked to describe and age bruises. This paper looks at both intra- and inter-observer variability in the description of childhood bruising. METHODS: Fifty-eight bruises on 44 children were described by three observers, the bruises were then photographed and the same observers described the bruises at a later date. The descriptions were compared and classified in terms of complete, partial, or no agreement, both between observers and between the in vivo and photographic descriptions. RESULTS: Complete agreement on colour description between two observers in vivo occurred in 27% of descriptions in vivo and 24% of photographs. Only 31% of descriptions completely agreed with the later description of a photograph of the same bruise. CONCLUSIONS: This marked variability in colour description, severely questions the practice of estimating the age of bruises especially from clinical photographs as evidence in child protection proceedings.

Presenting features of paediatric meningococcal disease--a five year experience from a paediatric accident and emergency department.

OBJECTIVES: To determine the clinical features, initial management and outcome of meningococcal disease presenting to a paediatric accident and emergency (A&E) department. DESIGN: A retrospective study of all cases of meningococcal disease seen in the department over a five year period. SETTING: A paediatric A&E department which treats approximately 30,000 patients a year. SUBJECTS: All children under the age of 13 years with a discharge diagnosis of meningococcal disease RESULTS: Fifty patients, forty-six with microbiological confirmation of their diagnosis were identified. Sixty six percent of patients were seen first by their general practitioner. However only 28% had received prehospital parenteral antibiotics. Twenty six percent of children had neither meningism nor a classical purpuric rash, 60% showed signs of shock and 66% had an altered conscious level. The case fatality rate was 4%, with 78% making a full recovery. CONCLUSION: Classical features of meningococcal disease are often absent. Assessing simple clinical parameters such as capillary refill, respiratory rate and conscious level adds to the detection of the disease. If meningococcal disease is suspected parental benzylpenicillin should be given and the child transferred to hospital.

Under representation of morbidity from paediatric bicycle accidents by official statistics--a need for data collection in the accident and emergency department.

OBJECTIVES: To determine the accuracy of currently available data on bicycle related injuries in children. SETTING: A paediatric accident and emergency (A&E) department which annually treats approximately 30000 new patients under the age of 13 years. METHODS: Data on all attendances with bicycle related injuries over a four week period were compared with that currently available from police road traffic accident data (Stats 19) and the International Classification of Diseases, 10th revision, hospital discharge coding. RESULTS: Eighty six children attended the A&E department. Only two bicycle related injuries were identified from Stats 19, and 10 from hospital discharge data. CONCLUSION: Currently available official data do not give an accurate representation of the incidence of bicycle related injuries in children. If health promotion measures are to be assessed properly data collection needs to be improved.

Triclosan: applications and safety.

Triclosan (2,4,4'-trichloro-2'-hydroxydiphenyl ether) is a nonionic, broad spectrum, antimicrobial agent that, because of its favorable safety profile, has been incorporated into a variety of many personal care products, including deodorant soaps, underarm deodorants, shower gels, and health care personnel handwashes. Triclosan exhibits a moderate degree of substantivity to the skin, and, in many products, it imparts a remnant antimicrobial effect. Although direct contact with the material under exaggerated exposure conditions causes dermal irritation in laboratory animals, it has only rarely been associated with skin irritation or sensitization in human being in formulated products. Acute, subacute/subchronic, and chronic toxicity profiles have been established to determine that triclosan is neither an acute oral toxicant nor that it acts as a carcinogen, mutagen, or teratogen. A new application for triclosan is in oral dentifrices for plaque control. Currently under investigation in the United States, it is approved for oral care application in Canada and many European countries.

Induction of autoimmune arthritis in rats by immunization with homologous rat type II collagen is restricted to the RT1av1 haplotype.

OBJECTIVE: To test for genetic differences in susceptibility to homologous (rat) type II collagen-induced arthritis (RII-CIA). METHODS: Nine inbred and RT1-congenic rat strains were immunized with native rat type II collagen and evaluated for arthritis and IgG anti-RII serum antibody titers. RESULTS: Only RT1av1 strains developed a high incidence of severe RII-CIA and high titers of IgG anti-RII serum antibody. Rats having RII-CIA-resistant haplotypes, RT1u,n,l (which are known to develop CIA after immunization with heterologous type II collagen), were shown to also be susceptible to passive transfer of CIA with immune serum concentrates. Clinical expression of RII-CIA was down-regulated by non-RT1 genes of BN origin. No strong gender differences in anti-RII autoimmune responses were observed. CONCLUSION: Arthritogenic, autoimmune reactivity to homologous RII is under strict genetic control but occurs readily in RT1av1 rats.

Complications of secondary surgical capsulotomy in pseudophakic and aphakic eyes.

A retrospective study was conducted to analyze the complications of surgical capsulotomy in 587 eyes--51 aphakic and 536 pseudophakic. Transient or permanent complications occurred in 20 (3.4%). One eye was seriously damaged by perforation during retrobulbar anesthesia, and another eye was lost due to endophthalmitis. Endophthalmitis developed in two other eyes, but it readily resolved with medication. Two eyes had markedly elevated intraocular pressure (IOP) (greater than 35 mm Hg), which was associated with the presence viscoelastic material in one eye; in the other eye, elevated IOP was the result of vitreous blocking of the pupillary aperture. Retinal detachments developed in nine patients (eight of whom, a significant number [P = .006], were males). Apart from the eyes in which endophthalmitis developed, all were markedly quiet after the procedure, and pressure elevation was not significant.

A comparison of the vasodilating effects of halothane and isoflurane on the isolated rabbit basilar artery with and without intact endothelium.

Although volatile anesthetics result in cerebral arterial dilation, the precise mechanisms underlying this effect are not known. In vitro tension recordings were used to study the vasodilating potencies of halothane and isoflurane in isolated cerebral vessels and to examine the possible role of the endothelium in modulating any effects observed. Cylindrical segments of the rabbit basilar artery and midline ear artery from the same animal were placed in a flow-through bath of 37 degrees C oxygenated (95% O2/5% CO2) physiologic salt solution and stretched to a resting tension of approximately 2,000 dynes. They were then constricted with 3.0 x 10(-2) M K+, 1.0 x 10(-3) M norepinephrine, or 5.0 x 10(-6) M serotonin and exposed to either halothane or isoflurane at concentrations of approximately 0.5, 1.0, 1.5, and 2.0 MAC in varied order for 15 min at each concentration. A 30-min period of perfusion with anesthetic-free, vasoconstrictor-containing perfusate separated successive exposures to an anesthetic. Vessels prepared in this fashion retained their responsiveness to both vasoconstrictors and volatile anesthetics for as long as 4 h. They also relaxed appropriately to acetylcholine, indicating that the endothelium was intact. Concentrations of volatile anesthetic in the tissue perfusate were directly measured using gas chromatography, and the relationship between bath concentrations (expressed as MAC fractions) and the degree of relaxation were determined. The data were analyzed by parallel line regression. Halothane was found to be a significantly more potent vasodilator of the isolated basilar artery than was isoflurane. For example, in K(+)-constricted vessels, the concentration of halothane needed to produce a 50% reduction in tension was 1.32 MAC, compared with 1.66 MAC for isoflurane. Comparable differences were found in the basilar artery in the presence of other constrictors. However, there was no significant difference between the two agents in their effects upon the ear artery. In a separate series of experiments, the endothelium of basilar artery segments was removed by drying. Removal was confirmed by observing a diminished dilator response to acetylcholine. These vessels were subsequently constricted with K+, and relaxation dose-response curves were obtained for both halothane and isoflurane. There were no differences in the dose-response curves for deendothelialized versus intact vessels, with halothane still the more potent relaxant after endothelial removal. These data demonstrate that halothane and isoflurane cause a dose-dependent relaxation of rabbit cerebral vessels, regardless of the vasoconstrictor used. Halothane was a more potent relaxant of the basilar artery when expressed on a MAC-fraction basis.(ABSTRACT TRUNCATED AT 400 WORDS)

Dopaminergic structure-activity relationships of 2-aminoindans and cardiovascular action and dopaminergic activity of 4-hydroxy, 5-methyl, 2-di-n-propylaminoindan (RD-211).

Dopaminergic structure-activity relationships of 2-aminoindans were evaluated for their ability to inhibit responses to stimulation of cardioaccelerator nerves in cats. The major observations were as follows: 1) Unsubstituted di-n-propyl- and diethyl 2-aminoindan derivatives do not inhibit responses to stimulation of cardioaccelerator nerve, although previous studies identified stimulation of DA2-receptors. 2) 4-Hydroxy, 4,7-dimethoxy and 4-hydroxy, 5-CH3, -CH2OH or -H substitutions on selected indan derivatives produce dopaminergic activity in the cardioaccelerator nerve preparation. 3) 4-Hydroxy-2-di-n-propylaminoindan is stereoselective with the R-isomer being more potent than the S-isomer. One derivative, 4-hydroxy-5-methyl-di-n-propyl-2-aminoindan (RD-211) produced dose-dependent decreases in heart rate and mean arterial pressure. Larger doses also inhibited cardiac responses to stimulation of cardioaccelerator nerve in vivo and in isolated right atria of cats. All of the above responses were significantly inhibited by the dopamine-receptor antagonist sulpiride and not by the alpha 2-adrenoceptor antagonist yohimbine. RD-211 also possesses high affinity for 5-hydroxytryptamine1A receptors as revealed by radioligand binding studies. Results suggest that RD-211 stimulates dopamine DA2-receptors and may also activate 5-hydroxytryptamine1A receptors, but is inactive at alpha 2-adrenoceptors. RD-211 appears not to require metabolic activation even though it has the same chemical moiety as the aminotetralin homolog, which is a dopaminergic prodrug (5-hydroxy-6-methyl-2-di-n-propylaminotetralin).

Liver histology in patients receiving low dose pulse methotrexate for the treatment of rheumatoid arthritis.

The liver histology of 52 patients treated with intermittent low dose pulse methotrexate for rheumatoid arthritis was evaluated using a modification of the Roenigk grading system. Patients studied had had an average of 3.2 years of treatment or had received 1.7 g methotrexate. No patient had cirrhosis; 15 (29%) patients had evidence of mild fibrosis. Histological abnormalities were not predicted by liver function test changes, with the exception that hypoalbuminaemia occurred in 60% of those with grade IV (modified criteria) findings. The need for liver biopsy in patients with rheumatoid arthritis treated with methotrexate before two years or 1500 mg of treatment has not been established. Whether serial liver biopsies will be needed beyond this time has yet to be determined.

(R)-(-)-10-methyl-11-hydroxyaporphine: a highly selective serotonergic agonist.

Prior work in these laboratories identified (+/-)-5-hydroxy-6-methyl-2- (di-n-propylamino)tetralin as a dopaminergic agonist prodrug. The ortho methyl hydroxy aromatic substitution pattern in this molecule has now been incorporated into the aporphine ring system to give a congener of the dopaminergic agonist apomorphine in which the position 10 OH group has been replaced by methyl. Preparation of the target compound involved acid-catalyzed rearrangement of the 3-(1-phenyltetrazolyl) ether of morphine and subsequent molecular modification of the product, the 10-(1-phenyltetrazolyl) ether of (R)-(-)-apomorphine. Surprisingly, the target compound elicited no responses in any assays for effects at dopamine receptors, but rather it displayed pharmacological properties consistent with its being a serotonergic agonist with a high degree of selectivity for 5-HT1A receptors similar to the serotonergic agonist 8-hydroxy-2-(di-n-propylamino)tetralin.

Low dose pulse methotrexate in rheumatoid arthritis: an 8-year experience with hepatotoxicity.

The clinical utility of standard liver function tests for monitoring low dose pulse methotrexate therapy is reviewed in 163 rheumatoid arthritis patients over an eight-year period. Abnormalities of hepatic enzymes were seen in 58% of patients but led to cessation of therapy in only 5%. Moderate alcohol intake did not affect the frequency of liver test abnormalities. Abnormalities were seen more frequently in patients with longer duration of methotrexate therapy and in those with higher total dose. There was no correlation between liver test abnormalities and day of serum sampling relative to day of methotrexate dosing, nor was a correlation seen between liver test abnormalities and total weekly dose of methotrexate. Methotrexate has been demonstrated to be an effective drug in the treatment of rheumatoid arthritis. The clinical utility of standard liver tests to predict the potential for hepatotoxicity is questionable.

Banking services aid tax-exempt investments.

Many not-for-profit hospitals are facing a severe capital shortage. Their traditional sources of funding--government grants, philanthropy, and appropriations--have dramatically declined. Increasingly, these hospitals are turning to the tax-exempt bond market for their capital. It is important for the financial manager to understand the elements and the process of tax-exempt financing. One crucial element is the investment banker who handles the project's financing. This article focuses on the financing services investment banking firms provide to hospitals and explains how much these services will cost.

Hematuria in patients with rheumatoid arthritis receiving gold and D-penicillamine.

We reviewed the urinalyses from 2 multicenter controlled randomized trials, one comparing moderate and low dose D-penicillamine to placebo and another comparing gold sodium thiomalate (GSTM), auranofin (AF) and placebo. In the D-penicillamine trial 30% of the 40 patients taking placebo, 34% of the 70 patients receiving 125 mg/day of D-penicillamine and 31% of the 61 patients receiving 500 mg of D-penicillamine had recurrent hematuria. In the GSTM/AF trial, 35% of the 43 placebo treated patients, 35% of the 54 GSTM treated patients and 30% of the 64 AF treated patients had hematuria. No significant difference in the frequency of hematuria between the groups in either trial was apparent. These findings suggest that the traditionally held belief that gold and D-penicillamine cause hematuria should be reconsidered.

Chrysiasis: the role of sun exposure in dermal hyperpigmentation secondary to gold therapy.

To investigate the role of sun exposure in the pathophysiology of chrysiasis, we studied 10 Caucasian female patients with rheumatoid arthritis: 4 with clinically apparent chrysiasis and 6 without apparent pigmentation. Three patients without chrysiasis had received over 4 g of gold and 3 less than one g. The mean melanin score, determined by histological examination of sun exposed and nonsun exposed skin, was significantly higher in the sun exposed skin of the chrysiasis and high dose controls than low dose controls (p less than .05). Concentration of gold measured semiquantitatively by transmission electron microscopy and quantitatively by atomic absorption showed increased gold concentration in sun exposed when compared to nonsun exposed skin of chrysiasis and high dose controls (p = .26). Low dose controls had no gold demonstrated by either method. Our results suggest that gold deposition in the dermis stimulates melain production and that melanin is important in hyperpigmentation of chrysiasis. Furthermore ultraviolet light may induce preferential uptake of gold by the skin.