Deep vein thrombosis in a tetraparesic patient with mental retardation: case report and review of the literature.

OBJECTIVE: To report a case of deep vein thrombosis (DVT) in a tetraparesic patient, a member of a population in which DVT is reportedly rare. CASE REPORT: A 36-year old tetraparesic resident of a developmental centre suddenly developed swelling of one leg. Her plasma D-dimer level was 751 (normal<500) ng ml-1. A Doppler ultrasound revealed femoral vein thrombosis. She usually spent 10-12 hours daily in a chair. For menstrual problems, she had received oral contraceptives (OC) for 23 months. She had no other genetic or acquired predisposition to DVT. She was anti-coagulated for 6 months and the OC was discontinued. She recovered without complications. Her DVT was probably caused by her immobility, prolonged sitting and OC. CONCLUSION: DVT may develop in tetraparesic patients if they are exposed to additional prothrombotic factors. OC should be prescribed cautiously to such people. Relevant literature, prevention and treatment are discussed.

Bloodborne pathogen exposures in a developmental center: 1993-2000.

In a developmental center, 257 potential bloodborne pathogen exposures (119 bites, 91 scratches, 30 sharps injuries, 17 mucosal breaks) occurred during 8 years (13,187 employee-years and 6,980 resident-years). Of the residents, 9% were hepatitis B virus (HBV) surface antigen carriers. Serological follow-up of exposed, susceptible employees and residents identified no transmission of HBV, hepatitis C virus (HCV), or human immunodeficiency (HIV) virus. This outcome has been due primarily to hepatitis B immunization and low prevalences of HCV or HIV infections among the subjects. Proper follow-up of all potential exposures is crucial to identify transmission promptly, allay anxiety, and prevent unwarranted workmen's compensation claims. Measures are suggested to reduce exposure further.

Epidemiology and control of enterobiasis in a developmental center.

OBJECTIVE: To determine if enterobiasis could be controlled in a developmental center. DESIGN: Population-based study. Annual screening of all residents by perianal swabs for enterobiasis and on admission or discharge. Treatment of infected residents and their contacts with mebendazole, 100 mg orally, with two doses given 14 days apart. MAIN OUTCOME MEASURES: The number of residents with enterobiasis and the cost of the program. RESULTS: The prevalence of enterobiasis fell rapidly and progressively, from 21% before mass medication to 1% after 3 years. CONCLUSION: Mass medication of residents with enterobiasis and their contacts was beneficial, harmless, and cost effective.

Fracture epidemiology and control in a developmental center.

During 3.5 years, 182 fractures occurred among 994 residents of a developmental center. The fracture rate was 5.2 per 100 person-years (1.7 times greater than the rate in the US population). Fracture rate was significantly greater in residents with: epilepsy, older age, male gender, white race, independent ambulation, osteoporosis, and residence in intermediate care (versus skilled nursing) units; it was not affected by severity of mental retardation. Hand and foot bones were fractured in 58% of cases. Femur fracture occurred in 13 cases (7%). Fracture was caused by a fall in 41 cases (23%); its cause was indeterminable in 105 cases (58%). Fractures, occurring without significant injury, may be an important cause of preventable disability in this population. Control measures are suggested.

Eighteen fractures in a man with profound mental retardation.

A 39-year-old man with generalized tonic clonic epilepsy and profound mental retardation sustained 18 fractures (15 in appendicular and 3 in axial bones) during 19 years. Both femoral necks were fractured, requiring surgical repair. Although he had been on antiepileptic drugs for 35 years, he had no radiographic or biochemical sign of osteomalacia. He had a very low bone mineral density, suggesting osteoporosis. This case illustrates an important medical problem affecting people with developmental disability and a management challenge for their caretakers.

Parvovirus B19-antibody serosurvey in 500 developmentally disabled subjects.

Sera of 500 residents were screened for parvovirus B19 immunoglobulin M (IgM) and immunoglobulin G (IgG) by enzyme-linked immunosorbent assay. Positive IgM and equivocal IgG or IgM results were confirmed by immunofluorescent antibody and Western blot. IgM was detected in 13 sera (2.6%), and IgG was detected in 285 (57%). Records of IgM-positive residents contained no evidence of erythema infectiosum or polyarthropathy.

Lead exposure of people with developmental disabilities: success of control measures.

In a developmental center, blood lead level was determined by atomic absorption for individuals who were admitted, discharged, or had pica. In 1977, blood lead level was 0 to 29 ug/dL in 298 (92%), 30 to 49 ug/dL in 20 (6%), and 50 to 79 ug/dL in 5 (2%) of the 323 individuals screened. In contrast, in 1994, blood lead level was 0 to 4 ug/dL in 58 (88%) and 5 to 9 ug/dL in 8 (12%) of 66 individuals screened. The observed marked decline in blood lead levels in this population has been the result of effective pica management, several local lead abatement measures, and reduced environmental lead contamination. Medical Practice Guidelines are suggested for prevention of lead poisoning in developmental centers.

Parvovirus B19 outbreak in a developmental center.

Of 49 employees serving developmentally disabled persons, 13 (27%) were found to have parvovirus B19 infection on the basis of serum positivity for parvovirus B19 IgM by enzyme-linked immunosorbent assay. Two employees had severe peripheral symmetric polyarthropathy lasting longer than 6 months. Infection control measures are described.

Os odontoideum: chronic neck pain after car accident; failure of two posterior atlantoaxial arthrodeses--medicolegal issues in the occupational setting.

OBJECTIVE: To present the case of a woman with previously asymptomatic os odontoideum (OO) who developed chronic neck pain after a car accident. CLINICAL FEATURES: A 32-yr-old woman developed slight constant neck pain following a car accident. Radiographs revealed OO with 12-mm atlantoaxial subluxation on neck flexion. There was no spinal cord compression clinically or on magnetic resonance imaging. INTERVENTION AND OUTCOME: Posterior atlantoaxial arthrodesis was performed twice but the bone graft resorbed for no apparent reason. The patient was treated with analgesics, physiotherapy and a Philadelphia collar to prevent accidental spinal cord compression. CONCLUSION: OO patients may remain asymptomatic if "space available for cord" is sufficient. Even low velocity rotational injury can precipitate chronic neck pain in adults with OO. Posterior atlantoaxial arthrodesis can fail inexplicably even under the best circumstances. Medicolegal issues in the occupational setting are discussed.

Human immunodeficiency virus type-1 antibody in 6703 institutionalized mentally retarded clients: an unlinked serosurvey at seven California developmental centers.

All clients residing in seven California developmental centers were tested for human immunodeficiency virus type 1 (HIV) antibody in an unlinked serosurvey. Of 6703 clients, 11 (0.16%) were found positive for HIV-1 antibody by confirmatory Western blot and immunofluorescent antibody tests. Universal blood and body fluid precautions should be rigorously enforced to prevent institutional spread of HIV even in this low-risk population.

Serum alpha fetoprotein in 714 mentally retarded carriers of hepatitis B surface antigen.

Sera from 714 mentally retarded carriers of hepatitis B surface antigen were screened for alpha fetoprotein (AFP) by monoclonal radioimmunoassay. Serum AFP levels were less than 20 mcg/L in 708 (99.2%) carriers. One 29-year-old carrier with normal liver function had serum AFP level of 1500 mcg/L, which increased to 12,500 mcg/L after 72 days. She died of multifocal hepatocellular carcinoma (HCC) with cirrhosis. Five other carriers with serum AFP levels between 20 and 165 mcg/L are alive without clinical HCC. No correlation was found between serum AFP level and race, age, sex, Down's syndrome, serum alanine aminotransferase level, and hepatitis B e antigen positivity. Single cross-sectional serum AFP screening by itself is not sufficient for early diagnosis of HCC.

Hepatocellular carcinoma in hepatitis B surface antigen carriers in eight institutions.

We reviewed records of all persons dying between 1979 and 1986 in eight California institutions for the mentally retarded. Autopsies had been done in 71% of the 1,181 deaths. Nine deaths were due to hepatocellular carcinoma, which invariably developed in carriers of hepatitis B surface antigen (HBsAg) and was fatal within four months of diagnosis. The mean age at death was 32.7 years. The incidence of hepatocellular carcinoma in HBsAg carriers was 140 times greater than in the US population. Persistent hepatitis B infection was probably etiologically related to hepatocellular carcinoma in this population, which is relatively free of exposure to other hepatocarcinogens.