Parental perception of the adequacy of pain control in their child after discharge from the emergency department.

OBJECTIVE: To determine how well the pain of pediatric patients who are discharged from our emergency department (ED) is managed. DESIGN: Prospective, observational case series conducted from 9/21/96 to 3/16/97. SETTING: University tertiary care ED with an annual pediatric census of 11,000, consisting of a diverse racial and socioeconomic population. PATIENTS: Children ages < or = 15 years and discharged from the ED with one of the preselected acute, painful, conditions including fracture, corneal abrasion, ankle sprain with swelling, burn, otitis media with pain at discharge, or exudative pharyngitis. STUDY PROTOCOL: At time of discharge from the ED, data collectors not involved in the patients' care obtained consent from the patient's parent or guardian and completed data collection that included the final diagnosis and any recommended analgesic. Physicians were blinded to patient enrollment. Parents were phoned 48 hours after ED discharge and asked if they believed their child's pain was adequately controlled at home and if they had sought medical care elsewhere. Data were reported as percentages, and confidence intervals (CI) were calculated. RESULTS: From a convenience sample of 75 patients, five could not be contacted, leaving 70 for analysis. The mean age was 5.4+/-4.7 years. Sixty-seven parents (96%; 95% CI, 91-100%) believed their child's pain was well controlled, and 67 patients (96%; 95% CI, 91-100%) received an analgesic prescription. Five parents did not administer the prescribed analgesic because they believed their child's pain was controlled without it. No parent sought further medical care for pain medication for their child. CONCLUSIONS: Our pediatric pain management study showed high analgesic use and high parental satisfaction. Lectures and bedside education may be a way to improve pain management in pediatric patients.

Spontaneous rupture of an amyloid spleen in a patient on continuous ambulatory peritoneal dialysis.

An unusual case is reported of spontaneous rupture of the spleen in a 67-year-old woman suffering from end-stage renal disease secondary to amyloidosis. The splenic rupture is attributed to amyloid involvement of the spleen.

Computed tomography detection of active mesenteric hemorrhage following blunt abdominal trauma.

Following blunt abdominal trauma, patients still may be actively bleed ing, despite seeming hemodynamically stable. By detecting extravasation of contrast-enhanced blood in the absence of any other evidence to support solid visceral injury as the source, computed tomography (CT) scanning was able to indicate ongoing hemorrhage in two patients, thought most likely of mesenteric origin. This information influenced the decision for intervention, which in these two cases was laparotomy, where bleeding torn mesenteric vessels were confirmed.

Mast cells and calcium in severe uremic itching.

Mast cells may be more abundant in the tissues of uremic patients and may contribute to itching via mediator release. Because mast cell (MC) granule release may be inhibited by ultraviolet B (UVB) radiation, we investigated skin MC in the superficial dermis by quantitative histomorphometry before and after whole body UVB for uremic itching. Toluidine blue-stained 3.5 mm punch biopsy specimens were examined with a micrometer grid after separate coding. Upon entry to the study, itching dialysis patients indicated their itching intensity on a visual analog scale (0 to 10). Concurrent study of living, related kidney donors (controls, n = 11) and their recipients (n = 11) showed no differences in MC number per unit area. Compared to controls, skin MC number was not greater in itching dialysis patients (n = 20). MC number decreased after 2 months of UVB from 1.6 +/- 0.6 (standard deviation) to 1.0 +/- 0.7 (n = 11, p = 0.025). Pre-UVB total plasma calcium correlated directly with itching intensity, but not with MC number. Plasma phosphate and intact parathyrin level were not statistically related to itching or MC number. Of the 14 subjects that completed UVB, 8 had objective benefit, and mean itching intensity declined from 7.1/10 to 5.2/10 in the 14 subjects. The conclusion is that although skin MC number may decline with chronic UVB, MC number is not related to uremic itching, and hypercalcemia, but not elevation of parathyrin or plasma phosphate, relates statistically to severe uremic itching.

Primary care-based dermatology practice: internists need more training.

OBJECTIVE: To evaluate the ability of teachers in an internal medicine clinic to appropriately diagnose, treat, and refer for specific dermatologic disorders. DESIGN: Prospective study. SETTING: Medical school-affiliated primary care clinic. PATIENTS/PARTICIPANTS: Case presentations of 20 patients who had dermatologic problems were prepared in the form of photographs with accompanying histories. All cases were presented to 17 of 21 available faculty internists who answered questions concerning diagnosis and management of the cases on a questionnaire. The responses of three board-certified faculty dermatologists were used as a reference standard. MEASUREMENTS AND MAIN RESULTS: The internists had had an average of three weeks' total formal dermatology training. Overall, 60% of cases were correctly diagnosed by the internists and 89% of these were either treated appropriately or referred to dermatologists. In 40% of incorrectly diagnosed cases, internists failed to refer and the majority of these were treated inappropriately. Of referrals deemed appropriate by dermatologists, only 62% were made. Conversely, 33% of referrals were deemed unnecessary. CONCLUSIONS: Faculty internists were able to diagnose many common skin diseases despite having received little dermatology training. However, errors in diagnosis occurred frequently and when diagnoses were incorrect there was a tendency to mismanage. These data suggest that the current amount of dermatology training is inadequate to prepare future primary care physicians for their increased role in the management of skin disorders.

Evaluation of ammonium lactate in the treatment of seborrheic keratoses.

A double-blind, paired comparison study was used to evaluate treatment effects of 12% ammonium lactate lotion (Lac-Hydrin) against its vehicle on seborrheic keratoses. Fifty-eight volunteer patients, 37 to 82 years of age, were studied for 16 weeks. The patients had a minimum of two seborrheic keratoses at least 10 cm apart. They applied the medication twice daily. The lesions were evaluated for height, surface characteristics, color, and length with the use of 7X calibrated loupe, a template, skin replicas, and scanning electron microscopy. Lac-Hydrin 12% lotion significantly reduced the height (elevation) of seborrheic keratoses, and two seborrheic keratoses cleared completely; however, there was no statistically significant difference in the length, color, and surface characteristics between the study group and the control group. Skin replicas and scanning electron microscopy can be used to evaluate lesion surface characteristics, dimensions, and therapeutic effects.

Recurrent herpes simplex labialis: viral replication and clinical course.

The purpose of this study was to provide additional information on the clinical course and viral replication kinetics of herpes simplex virus (HSV) in recurrent herpes labialis. Data were obtained on 20 subjects who were followed for five days from the first day of the lesion. HSV was isolated in 17 subjects (85%); 75% were positive on day 1 of the lesion. Median HSV titer on day 1 was 1.7 x 10(3)/0.2ml. Isolation rates and titers dropped sharply and virus could no longer be detected by day 4. The clinical course both in terms of the frequency and the severity of the symptoms paralleled the kinetics of viral replication. Thermography delineated location of subsequent lesions in three early symptomatic patients who were studied at the time when no visible lesions were observed. These data are felt to provide useful background information for future studies on the efficacy of topical antiviral agents.

Influence of an oral contraceptive progestin-estrogen combination on simian uterine phosphatases.

PIP: 16 adult female rhesus monkeys received combined oral quingestanol acetate and ethinyl estradiol in a 10:1 ration, 4 received steroids in a 20:1 ration. After 6 cycles of 21 days on and 7 days off the uterine alkaline and acid phosphatases were analyzed histologically. Dose groups included: 4 monkeys given 4 mcg per kg ethinyl estradiol and 40 mg quingestanol acetate, 4 given 20 and 200, 8 given 10 and 100, 4 given 50 and 1000. Most monkeys were killed 8 days after the last dose. In the 6 controls glandular phosphatases were low in early follicular phase, highest in late follicular phase, and declining in the stratum functionale in luteal phase; also acid phosphatase appeared in the stromal cells with eccentric nuclei in luteal phase. 90% of the low and middle dose monkeys were in follicular phase and had normal menstrual cycles. Their alkaline phosphatase was greater in stratum functionale than in stratum basale, and the acid phsophatase resembled controls in follicular phase. Most monkeys given high doses were in luteal phase and their enzymes were correlated with cycle phase.^ieng