Silent eulogy. Elective mutism in a six-year-old Hispanic girl.

A case of elective mutism in a six-year-old Hispanic girl treated in a public mental health setting is presented. The central feature of the case was the facilitation of a delayed grieving process in a little girl who had witnessed her father's death. The presentation stresses the critical need to integrate the unfolding clinical material with the realities of the stresses of parental distress and resistance. An attempt is made to understand this "resistance" in the context of cultural and social realities, while attending to the possible underlying psychodynamic meaning.

Fenoldopam infusion for the treatment of postoperative hypertension.

STUDY OBJECTIVE: To examine the safety and efficacy of intravenous fenoldopam as compared to placebo for the treatment of postoperative hypertension. DESIGN: Randomized, placebo-controlled, double-blind study. SETTING: Community hospital. PATIENTS: 16 ASA I-III hypertensive patients scheduled for noncardiac surgical procedures. INTERVENTIONS: Treatment with fenoldopam or placebo was initiated immediately after other causes of hypertension had been ruled out. Hypertension was defined as a supine systolic blood pressure (SBP) or diastolic blood pressure (DBP) greater than 20% over the patient's preoperative baseline, which was obtained 6 hours prior to the procedure with the patient lying quietly. The baseline consisted of 3 consecutive blood pressure (BP) measurements obtained at 5-minute intervals and not varying by more than 10%. Fenoldopam or placebo infusion was initiated at 0.1 microgram/kg/min and increased and decreased as necessary until the therapeutic goal BP was reached or treatment failure had occurred. The therapeutic goal BP was a decrease to at least 10% above the preoperative baseline, and failure of treatment was defined as inability to reach this BP level after 15 minutes at 1.5 micrograms/kg/min. MEASUREMENTS AND MAIN RESULTS: BP and heart rate (HR) data were collected consistently throughout the study and 1 hour after termination of infusion. Laboratory studies and 12-lead electrocardiographic results were obtained at the start of the study and repeated 24 hours after termination of infusion. Blood samples were obtained for the measurement of epinephrine, norepinephrine, and dopamine levels and were analyzed using high-performance liquid chromatography with electrochemical detection. Pretreatment BP measurements were significantly elevated from baseline in both groups. Fenoldopam treatment significantly reduced BP to the therapeutic goal in 8 of 8 patients; placebo reduced BP to this goal in only 4 of 8 patients (p < 0.05). At the end of the titration period, the therapeutic goal BP was not significantly different from baseline in the fenoldopam group. HR was significantly elevated (p < 0.05) at goal in the fenoldopam group as compared with the placebo group. Fenoldopam administration lowered SBP and DBP to goal in a mean time of 28 minutes versus 42.5 minutes in the placebo group. There were no significant differences in catecholamine levels at any of the measurement periods. CONCLUSION: Fenoldopam is an effective drug for reducing BP following hypertensive episodes in the postoperative setting. Fenoldopam use is associated with an increase in HR versus placebo.

Perioperative arrhythmias with a propofol-based anesthetic.

Propofol was used for the induction and maintenance of anesthesia in a patient undergoing a laparoscopic tubal ligation. This new anesthetic has not been associated with postoperative ventricular arrhythmias. This report demonstrates the occurrence of supraventricular tachycardia deteriorating to ventricular tachycardia in a patient who received propofol. Included is a discussion of the possible causes of this event.

Immersion hypothermia: comparative protection of anti-exposure garments in calm versus rough seas.

To evaluate the thermal performance of anti-exposure garments in rough seas, eight garment-ensembles were studied: 7 foam-insulated garments (2 tight-fitting "wet" suits, 3 loose-fitting "wet" garments, 2 "dry" suits) and 1 uninsulated, loose-fitting control. Mean calm and rough water temperatures were 10.7 and 11.1 degrees C, respectively. Rectal temperature, back skin temperature, heart rate, and subjective evaluations of garment protection were measured. Loose-fitting, "wet" garments allowed significantly greater (approximately 50-100%) mean rectal temperature cooling rates and significantly larger declines in skin temperature in rough water than in calm water. Such differences were not found for either the tight-fitting "wet" suits or the "dry" suits. Heart rates were significantly higher in rough seas than in calm seas for all garments. Rectal and skin temperature changes were positively correlated with each other and with subjective evaluation of cold water flushing; they were negatively correlated with warmth and tightness-of-fit. "Dry" garments provided better protection than did "wet" garments in both sea conditions, and tight-fitting "wet" garments provided better protection than did loose-fitting "wet" garments in rough but not in calm seas. Accidental immersion in rough seas may be associated with significantly lower survival times than previously estimated from calm-water studies.

Mass carbon monoxide poisoning: clinical effects and results of treatment in 184 victims.

An epidemiologic and clinical investigation of 184 persons exposed to toxic levels of carbon monoxide (CO) in a public high school has been carried out. Exposure to 500 ppm of CO for periods up to 150 minutes resulted in carboxyhemoglobin (COHb)levels as high as 30% and symptomatic illness in 87% of persons exposed before the possibility of mass CO poisoning was recognized. Severity of symptoms was a reliable basis for triage of victims for immediate hospital treatment, and correlated both with duration of exposure and the length of time it took for victims to feel normal. Therapy consisting of oxygen delivered by mask achieved a half-life for COHb of 137 minutes in hospital-treated patients (compared to 320 minutes with no treatment), but did not fully reverse the symptoms of CO toxicity.

Massive arterial air embolism due to rupture of pulsatile assist device: successful treatment in the hyperbaric chamber.

We present the case of a patient who had rupture of a pulsatile assist device (PAD) accompanied by massive air embolism, and the treatment that brought it to a successful outcome. After rupture of the skin of the PAD balloon, a massive amount of air was injected into the ascending aorta. The patient was placed in Trendelenburg position and cooled in deep hypothermia with cardiopulmonary bypass. He was given 1 gm of methylprednisolone intravenously, and the aortic valve replacement and double vein bypass graft were performed. After completion of the operation, the patient was partially rewarmed to 30 degrees C central temperature and transported by ambulance to a hyperbaric chamber where he was compressed to 6 atmospheres absolute 9 hours after the accident with clinical signs of severe brain dysfunction. The patient recovered completely and was discharged from the hospital on the tenth postoperative day.

Multiple hyperbaric exposures during pregnancy in sheep.

Eleven sheep were subjected to hyperbaric comparable to 165 feet of sea water 31 times between the one hundred twelfth and one hundred thirty-seventh days of pregnancy. During 13 dives the maternal and fetal circulations were monitored for bubble formation during decompression. Bubbles were detected by external doppler probes in eight of 12 ewes, but in none of the fetuses. Nine ewes were delivered of normal lambs at term. In one, twin fetuses died during an abnormal labor. The pregnancy of another was terminated by cesarean section after decompression to look for bubbles in the fetal circulation.

Effect of hyperbaric oxygen on the cytotoxicity of adriamycin and nitrogen mustard in cultured Burkitt's lymphoma cells.

The effects of hyperbaric oxygen (HPO) exposure on the cytotoxicity of Adriamycin (ADM) and nitrogen mustard have been examined in Burkitt's lymphoma cells (P3J) in vitro. Exposure of cells to 3 atmospheres of pressure HPO for 2 hr produces inhibition of DNA synthesis and mitosis. Simultaneous exposure to HPO and ADM results in decreased cytotoxicity compared to drug treatment alone. However, exposure to ADM (0.15 microgram/ml) 2 to 8 hr before or after HPO produces an increase in drug effect. There is no potentiation of lower ADM concentrations. Cytotoxicity is increased when cells are exposed to HPO during, before, or after exposure to nitrogen mustard (NSC 762) (0.15 and 0.25 microgram/ml). Lower nitrogen mustard (NSC 762) concentrations are not potentiated. HPO potentiation of antineoplastic agents appears to depend upon the agent studied, the concentration of the agent, and the scheduling of the drug and HPO exposure.

Hard metal pneumoconiosis: another cause of diffuse interstitial fibrosis.

Three patients developed diffuse pulmonary fibrosis caused by exposure to aerosolized cobalt while working in the tungsten carbide tool industry. Two cases were severe and one of these has died of cor pulmonale. The third is mildly disabled. The pathophysiology is reviewed. Clinicians and radiologists should be aware of hard metal exposure as a cause of diffuse interstitial fibrosis.

The incidence of urine cultures positive for Mycobacterium tuberculosis in a general tuberculosis patient population.

When urine specimens from a general tuberculosis patient population of 328 were submitted routinely for mycobacterial cultures, 33 patients (10 per cent) a positive turine cultures for Mycobacterium tuberculosis. In 22 patients (7 per cent) a positive urine culture for M. tuberculosis was unanticipated. Review of these 22 patients revealed that all had denied current genitourinary symptoms, 58 per cent had urinalyses within normal limits, and 58 per cent had normal intravenous pyelograms. Thus, lack of symptoms and normal tests do not necessarily exclude the possibility of genitourinary tuberculosis. Only 4.7 per cent of patients with pulmonary tuberculosis but 21 per cent of those with extrapulmonary tuberculosis had unanticipated positive urine cultures for M. tuberculosis. This suggests that routine submission of urine specimens for mycobacterial cultures can be a valuable adjunct to the bacteriologic confirmation of the diagnosis of extrapulmonary tuberculosis.