Congenital abnormalities of the lymphatic system: a new clinical classification.

The numerous clinical presentations of congenital abnormalities of the lymphatic system in children and the confusing terminology used to describe their pathologic diagnoses impede the physician's understanding of the condition. The clinical classification based on the actual symptoms of the congenital problems we have presented here should help the physician identify the specific abnormality and a potential treatment. Future research should concentrate on the specific causes and the treatment of these congenital abnormalities.

Prognosis of cutaneous polyarteritis nodosa.

A 17-year-old girl had cutaneous polyarteritis nodosa (CPN) of four years' duration. She had no clinical or laboratory evidence of associated systemic disease but was concerned about whether the CPN would remain cutaneous. Her case is reviewed in the context of previously reported cases. The authors include photographs and a microphotograph of the lesions that could help to alert clinicians to the possibility of this disease in their patients.

Direct costs of diabetes care: a survey in Ottawa, Ontario 1986.

205 unselected Ottawa area patients with diabetes completed questionnaires indicating their annual utilization of equipment, supplies, professional and institutional services. Respondents' average age was 47.3 and average duration of diabetes 18.3 years. About 70% used self-testing of blood glucose. Calculations of costs were based on prevailing local prices. Annual treatment-related costs for the 9.3% on anti-diabetic tablets averaged $236.40, for the 79% on injected insulin $362.34, and for the 7.3% on insulin-by-pump $1603.20. Averaged over all respondents, routine care costs were $962.01 annually, of which 23.4% was for at-home testing, 45.3% for treatment supplies, 20.9% for physicians' services and 10.4% for miscellaneous items. Non-routine care costs averaged $1982.24 with all except $45.84 for emergency room charges being in-hospital care costs. Cost of routine plus non-routine care averaged $2944.25 annually of which 64.4% was for hospital services, 13.9% for treatment needs, 9.6% for physicians' services and 7.7% for testing supplies. This type of survey, particularly if carried out with help from diabetes association volunteers, offers an affordable means to monitor utilization trends and costs of supplies and services for patient care.

Oxybutynin efficacy in the treatment of primary enuresis.

The effectiveness of oxybutynin in the treatment of primary enuresis was evaluated in a double-blind study. A total of 30 children (25 boys, five girls), at least 6 years of age, with primary enuresis and no daytime incontinence or history of other urinary tract problems were selected at random from an enuresis clinic population. The study was explained to the families and they were told how to keep records of nocturnal bed-wetting episodes and side effects. The patients were treated with a 10 mg of oxybutynin at suppertime for 28 days. Before or after the treatment period, all children received an identical placebo for 4 weeks. Two-sided paired t tests were used to compare frequency of nocturnal enuresis. Frequency during the drug regimen did not differ significantly from that during the placebo study. There were no differences in findings between boys and girls or between children who had previously taken imipramine and those who had not. The study showed no evidence that oxybutynin is effective in treating primary enuresis.

Effects of different methods of treatment of primary enuresis on psychologic functioning in children.

Sixty-two children with primary nocturnal enuresis were assigned randomly to one of two groups. Group 1 was treated with imipramine hydrochloride, and group 2 received a course of treatment with the Mozes Detector. Seventeen children from group 1 and 18 from group 2 were tested with the age-appropriate form of the Cattell personality questionnaire on three occasions: at the time of entry into the study, 2 months later and at follow-up, an average of 16 months later. The patients in group 2, who were older, had a higher rate of cure than did the patients in group 1. They also had significantly higher levels of extroversion and significantly lower levels of neuroticism at follow-up than did those in group 1. These findings indicate that better results are seen with the Mozes Detector than with imipramine in older children with primary nocturnal enuresis.

Diabetic ketoacidosis during long-term treatment with continuous subcutaneous insulin infusion.

During 1880 patient-months of treatment with continuous subcutaneous insulin infusion in 101 patients with IDDM, 36 episodes of acute, severe loss of glycemic control, including 29 with significant ketoacidosis, occurred in 20 patients. Fifteen episodes were attributable to failure of insulin delivery to the patient while 13 were precipitated by infection. Insufficiently frequent blood glucose monitoring, failure by patients to detect mechanical and technical problems with infusion systems, failure to adhere to "sick day" regimens, and delay in seeking medical help all contributed to the progression of a number of episodes. Thirst, nausea, and vomiting were the common clinical manifestations of decompensation; and the degree of acidemia was often mild in relation to the degree of hyperglycemia. Response to conventional management was usually prompt.

Multidisciplinary survey of erectile impotence.

A study was done of 220 men referred principally by family physicians to a multidisciplinary erectile dysfunction study group to determine the factors causing or contributing to impotence that had persisted for more than 2 months and for which no cause was apparent. The men were aged 21 to 79 (mean 50.3) years, and the duration of impotence was a few months to 15 years (mean 2.65 years). The men were to be assessed from general medical, endocrinologic/metabolic, psychiatric and urogenital viewpoints. The significance of the causal or contributory factors detected was scored by application of defined criteria and a four-point scale. The degree of loss of potency and of libido as well as level of concern were also scored by each specialist. Impotence was complete in 60%, and an associated decline in libido was reported by 38%. The level of concern was high--that is, normal--in 81% and slightly reduced in 9%. Full investigation by all the specialists was precluded by the severity of other conditions in 16 patients, by the return of potency following relief of anxiety/depression or genitourinary tract infection in 16 and for logistic or other reasons in 34. Although the cause of the impotence could be attributed in 186 of the patients, only 154 were fully assessed. Among these patients general medical factors were contributory in 46%, endocrinologic/metabolic factors in 44%, psychogenic factors (primary or secondary) in 60% and urogenital factors in 49%. Multiple contributing factors were identified in 65%, which underscores the importance of a multidisciplinary approach to assessing many cases of impotence.

Erectile impotence: a clinical challenge.

The wide range of factors that may contribute to impotence is reviewed in an attempt to establish a systematized approach for assessing etiologic factors. The effects on potency of ageing, general fitness, weight, debilitating disease, use of therapeutic and other drugsincluding alcohol and neurogenic, vasculogenic, endocrine/metabolic, urogenital and psychogenic factors are considered and discussed. The review also affords a rationale for the methodology employed.

Calcific bridging of dental pulp caused by iatrogenic hypercalcemia. Report of a case.

A case of renal osteodystrophy treated with high doses of vitamin D is presented. The treatment, carried out when the patient was between 3 1/4 and 6 years of age, induced hypercalcemia (up to 13.9 mg./dl.) which resulted in dentinal bridging corresponding chronologically to the part of the root developing at this age. Dentinal bridging associated with iatrogenic hypercalcemia has not been reported previously.

Salmonella epididymitis with recurrent septicemia in diabetic patient.

A diabetic male patient presented with recurrent septicemia due to Salmonella panama. The nidus from which reinfections of the blood stream occurred was apparently localized in the epididymis. Cultures of semen grew Sal. panama while cultures of urine and stool showed no pathogens. This is the fifth reported case of salmonellosis involving epididymis and/or testicle, the first in a diabetic, and the first in which salmonella was found in cultures of semen. In this patient bacteriologic cure was obtained by use of trimethoprim-sulfamethoxazole obviating need for surgical extirpation of the infective focus as had been required in previously reported cases of salmonella epididymitis/orchitis.

Gastroenteritis in children: new concepts and old affirmations.

Gastroenteritis is a common pediatric problem in primary care practice. Some etiological agents are viruses. Maintaining an adequate fluid intake is important: in mild cases a five percent oral dextrose solution can usually prevent the development of significant dehydration. In patients with significant fluid loss, an intravenous infusion of hypotonic, dextrose-containing solution should be instituted before recognizable clinical signs of dehydration develop.