Encopresis treatment outcome: long-term follow-up of 45 cases.

Among children diagnosed and treated for encopresis (N = 88) at either of two incontinence clinics between 1986 and 1994, 45 could be assessed for long-term (>12 months) outcome. Measures consisted of retrospective analysis of clinical charts and parent report of child soiling status. At follow-up (mean duration 53 months, range 15 to 99 months), 26 children (58%) were in remission, 13 (29%) were improved, and six (13%) showed no improvement. Logistic regression showed that children who presented with no previous encopresis treatment(s) (odds ratio 5.88, 95% confidence interval 1.61 to 21.55, p < .01) and/or children who presented with fecal retention (odds ratio 17.8, 95% confidence interval 2.70 to 153.37, p < .01) were more likely to be in remission. The interval between treatment and follow-up was significantly longer (mean 62 months, range 26 to 94) for children in remission than for children still soiling (mean 45 months, range 15 to 75) (p < .01). At follow-up 1 year or more after treatment for encopresis, a significant number of children may continue to soil. Previous encopresis treatment(s) and/or nonretentive encopresis may be risk factors for persistent soiling. The chances of complete remission of encopresis tend to increase with the passage of time.

The plain abdominal roentgenogram in the management of encopresis.

OBJECTIVE: To determine whether fecal retention in encopretic children can be assessed objectively using the plain abdominal roentgenogram and whether roentgenographic evidence of fecal retention is associated with clinical findings on presentation in encopretic children. DESIGN: Retrospective case studies. SETTING: Two pediatric incontinence clinics. PARTICIPANTS: Sixty children (72% male), aged 4 to 18 years (mean, 8 years), who met Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria for the diagnosis of encopresis. All had a plain abdominal roentgenogram obtained on presentation. INTERVENTIONS: None. RESULTS: Using a systematic assessment tool with good interrater reliability (kappa = 0.65), 78% (47) of the children had fecal retention by roentgenographic criteria on presentation, while 22% (13) did not. Retentive encopretic children were less likely to have a history of difficult toilet training (P = .018) than nonretentive encopretic children. There was no association between fecal retention and several clinical factors, including historical features commonly attributed to fecal retention. Retentive encopretic children were no more likely to have a palpable abdominal mass than nonretentive encopretic children, but they were more likely to have excessive stool on rectal examination (P = .015). Using the plain abdominal roentgenogram as the gold standard, the rectal examination showed a positive predictive value of 84.8% and a negative predictive value of 50% in assessing fecal retention. CONCLUSIONS: Fecal retention in encopretic children can be assessed objectively from a plain abdominal roentgenogram. Most, but not all, encopretic children present with fecal retention. A positive rectal examination is strongly predictive of fecal retention, in which case a roentgenogram is not necessary to make that diagnosis. A negative rectal examination may not rule out fecal retention, in which case an abdominal roentgenogram may be useful to make that diagnosis.

Plasma levels and efficacy of imipramine treatment for enuresis.

OBJECTIVE: To determine the relationship between serum drug level and treatment efficacy in enuretic children treated with imipramine (IMI). METHOD: Eighteen children with primary nocturnal enuresis recruited from an ambulatory enuresis clinic population were the subjects of the study. After a baseline period of 2 weeks, children received placebo for 1 week followed by treatment with IMI in increasing dosages (1.0 mg/kg, 1.5 mg/kg, 2.0 mg/kg, and 2.5 mg/kg), each dosage being given for 2 weeks. Steady state IMI and desipramine levels were determined in each child for each dosage. Medication response ([drug % dryness-placebo % dryness] divided by [100%-placebo % dryness]) was determined for each dosing interval. RESULTS: Average dryness increased from 27.8% on placebo to 73% with 2.5 mg/kg of IMI. The overall correlation between medication response and combined serum level was .26 (p < .05). Side effects were monitored throughout the study and were found to be rare. CONCLUSIONS: The efficacy of IMI over placebo in reducing the frequency of nocturnal enuresis in children was confirmed. Efficacy was moderately but significantly related to increasing mg/kg dose. A higher serum level tended to be associated with a better response, but there was at least 700% variation in serum level between subjects at every dosage. Monitoring serum levels of imipramine in children with idiopathic functional nocturnal enuresis treated with that medication has a limited but real usefulness in clinical management.

Casualties from a junior-senior high school during the Persian Gulf War: toxic poisoning or mass hysteria?

Mass hysteria is a bizarre and uncommon epidemic phenomenon. The usual victims are adolescent females and school settings are frequent. The epidemics are characterized by the rapid onset of a constellation of symptoms and signs which resolve quickly in the absence of abnormal laboratory results and physical findings that confirm a specific organic cause. It is common, however, for unexpected laboratory results to cause confusion and promote controversy about suspected etiologies. These outbreaks are often noted to be associated with periods of uncertainty and social stress. We describe an epidemic involving the explosive onset and rapid resolution of a constellation of symptoms that sent 17 seventh and eighth grade students and four teachers to the emergency department of a hospital after an apparent toxic gas exposure. Mildly elevated carboxyhemoglobin levels (for nonsmokers) in some patients raised concern that there had been exposure to excessive levels of carbon monoxide. Although no specific unusual stress could be identified at the school, the event took place 3 1/2 weeks after the beginning of the Persian Gulf War.

Diaper choice. Too costly to bury.

Diaper choice (cloth vs. disposable) has become a controversial issue with increased public concern for the environment. One hundred and twenty-four consecutive mothers were surveyed during the postpartum period about diaper choice. Six percent reported physician/nurse discussion of diaper choice during prenatal care. Seventy-seven percent planned to use disposable diapers only. Twenty-two percent planned to use cloth diapers or a combination of cloth and disposable diapers. Major reasons for choice of disposables included convenience, avoidance of safety pins and cleanliness. Mothers selecting cloth or a combination cited environmental concerns, low cost and cleanliness as reasons for their choice. Factors found to be significantly associated with choice of cloth or combination were older maternal age, use of cloth with other children, and perception that disposables are more expensive. No significant association could be demonstrated between diaper choice and several demographic variables, breastfeeding, or knowledge of the environmental impact of disposables. An educational intervention promoting the use of cloth diapers did not influence diaper choice at two months. Most mothers have made a diaper choice by the time an infant is born. Providers of prenatal care seldom discuss diaper choice with pregnant women. An educational intervention to promote choice of cloth diapers had no effect on the diaper choices made by our population.

Pediatric Advanced Life Support: Part II. Fluid therapy, medications and dysrhythmias.

The first part of this two-part article discussed the equipment needed for pediatric resuscitations and the techniques used for cardiopulmonary assessment, airway securance, circulatory maintenance and intravascular access. In this second part, additional life support measures are reviewed, including fluid therapy, resuscitation medications and the management of cardiac rhythm disturbances.

Pediatric advanced life support: Part I. Airway, circulation and intravascular access.

Effective management of life-threatening emergencies in infants and children demands a high level of technical skill. The Pediatric Advanced Life Support (PALS) provider course, developed jointly by the American Academy of Pediatrics and the American Heart Association, is highly recommended to help physicians prepare for pediatric emergencies. Equipment, cardiopulmonary assessment, airway maintenance, circulation maintenance and intravascular access are discussed in this article. The description of pediatric emergency management follows that of the PALS course.

Spinal epidural abscess. An infectious emergency. Case report and review.

Spinal epidural abscess is an unusual disease in the pediatric age group, requires early diagnosis and prompt surgical drainage to insure a good clinical outcome. Back pain and fever are usually the only presenting symptoms occurring before precipitous neurologic deterioration. The causative organism is most often Staphylococcus aureus, which presumably is spread to the epidural space hematogenously. Diagnosis is facilitated by computed tomography (CT) scan, but the entire spine must be imaged by either myelography or magnetic resonance imaging (MRI) to assess for skip lesions.

Enuresis following masturbation in a mentally retarded adolescent.

An unusual presentation of enuresis is described. A mentally retarded adolescent male with normal bladder function wet his bed while awake following masturbation. Initially, this sequence was not apparent to the parents or physicians. A multidisciplinary approach to the symptom helped to define and focus on the circumstances of the symptom itself, allowing for successful intervention.

Newborn circumcision.

Routine circumcision of male newborns continues to be practiced widely in the United States, although many physicians believe there is little medical indication for the procedure. The parents' decision regarding circumcision is often based on inadequate information; however, attempts to provide information to parents have not had much impact on the frequency of circumcision. Many third-party payers have begun to refuse payment for the procedure, and there are indications that this action will diminish the number of circumcisions.