Droperidol in the Management of Phantom Limb Pain: Case Report.

INTRODUCTION: Phantom limb pain (PLP) is a poorly understood phenomenon experienced by amputees. The pain is typically classified as neuropathic, and there is no established first-line therapy. Droperidol is an antipsychotic with a wide array of pharmacologic activity including gamma-aminobutyric acid-A channel modulation, µ opioid receptor potentiation, dopamine-2-receptor blockade, and alpha-2-receptor agonism. Due to this broad therapeutic activity, droperidol is used for many off-label indications. CASE REPORT: Our patient was a 25-year-old male with a history of lower limb amputation who presented for evaluation and management of an acute exacerbation of PLP. On arrival, the patient was in 10/10 pain (numeric pain rating scale) described as cramping and burning. He had been previously successfully managed with subdissociative ketamine. However, during a recent exacerbation he experienced an emergence reaction to ketamine. Literature guiding pharmacotherapy in the management of PLP is sparse and of low quality. Based on the prior emergence reaction to subdissociative ketamine we explored other pharmacotherapy options. Droperidol has a wide array of pharmacologic activity and is used off label for the management of some pain syndromes. Therefore, we administered an intravenous dose of droperidol 5 milligrams. Approximately 15 minutes after receiving droperidol the patient's pain was visibly improved, and 30 minutes later he rated his pain at 3/10. CONCLUSION: The success in treating this patient provides encouragement for future research and bolsters confidence that droperidol could be another tool in the management of complex pain syndromes.

Can Neck Contusions in Unexplained Pediatric Deaths be Explained by Cardiopulmonary Resuscitation?

The distribution of cutaneous contusions in infants may raise the possibility of maltreatment. Neck contusions are particularly problematic since they seldom occur outside the setting of abuse, while cardiopulmonary resuscitation (CPR)-related maneuvers may involve the neck. To address the role of CPR in neck findings, we examined 260 consecutive pediatric autopsies in which CPR was attempted. No neck contusions were identified in manners of death classified as natural, undetermined, or suicide. Contusions were present in two of 80 deaths classified as accident and had obvious accidental causes. About 26% of deaths classified as homicide had neck contusions with no explanation provided by the caregiver (p < 0.0001). In conclusion, neck contusions in deceased children with no apparent explanation should be regarded as suspicious for abuse and investigated accordingly. CPR is not a plausible explanation for neck contusions in children.

Glycogen metabolism and glycogen storage disorders.

Glucose is the main energy fuel for the human brain. Maintenance of glucose homeostasis is therefore, crucial to meet cellular energy demands in both - normal physiological states and during stress or increased demands. Glucose is stored as glycogen primarily in the liver and skeletal muscle with a small amount stored in the brain. Liver glycogen primarily maintains blood glucose levels, while skeletal muscle glycogen is utilized during high-intensity exertion, and brain glycogen is an emergency cerebral energy source. Glycogen and glucose transform into one another through glycogen synthesis and degradation pathways. Thus, enzymatic defects along these pathways are associated with altered glucose metabolism and breakdown leading to hypoglycemia ± hepatomegaly and or liver disease in hepatic forms of glycogen storage disorder (GSD) and skeletal ± cardiac myopathy, depending on the site of the enzyme defects. Overall, defects in glycogen metabolism mainly present as GSDs and are a heterogenous group of inborn errors of carbohydrate metabolism. In this article we review the genetics, epidemiology, clinical and metabolic findings of various types of GSD, and glycolysis defects emphasizing current treatment and implications for future directions.

Neurodevelopmental readiness of children for participation in sports.

Many children participate in organized sports each year as a means of socialization, and physical skill building. Sports participation is dependent on physical growth, and neurodevelopmental readiness of the child. It is important to be aware of a child's level across the various streams of development and engage in specific strategies to optimize their ability at each age group. This article first outlines developmental skills across various age groups in childhood, and makes suggestions for such strategies.

Challenges Associated with Informed Consent in Low- and Low-Middle-Income Countries.

Obtaining informed consent from research participants is a generally recognized step of undertaking research. While the concept of informed consent is well understood in western research environments, it requires further consideration when reviewing studies involving humans and owned animals in low- and low-middle-income countries (LMICs), in order to take account of different social, educational, and research norms. Here, we identify some of the challenges that need to be considered, and how they might affect the process of obtaining informed consent. We explain the approach taken by an animal welfare non-governmental organization working in LMICs to addressing these challenges. There are also questions that reviewers might consider when commenting on work originating in this context.

The Implications of Brain MRI in Autism Spectrum Disorder.

Our objective was to describe the types of providers who refer children with autism spectrum disorder (ASD) for brain magnetic resonance imaging (MRI), the referral reason, and MRI results. The most common referral reasons were autism spectrum disorder with seizures (33.7%), autism spectrum disorder alone (26.3%), and autism spectrum disorder with abnormal neurologic examination or preexisting finding (24%). Neurology (62.5%), general pediatric (22.3%), and developmental/behavioral practitioners (8.9%) referred the most patients. The prevalence of definite pathology was highest in children referred for autism spectrum disorder with abnormal neurologic examination/preexisting finding (26.2%, 95% CI: 16.8%-36%), headaches (25.7%, 95% CI: 11.2%-40.2%), or seizures (22%, 95% CI: 14.6%-29.5%), and was lowest in children referred for autism spectrum disorder alone (6.5%, 95% CI: 1.5%-11.6%). We concluded that there is a low prevalence of definite pathology in children with autism spectrum disorder undergoing brain MRI. In children with abnormal neurologic examination or preexisting finding, seizures, or headaches, one may consider performing brain MRI given the higher prevalence of pathology.

Modeling age and nest-specific survival using a hierarchical Bayesian approach.

Recent studies have shown that grassland birds are declining more rapidly than any other group of terrestrial birds. Current methods of estimating avian age-specific nest survival rates require knowing the ages of nests, assuming homogeneous nests in terms of nest survival rates, or treating the hazard function as a piecewise step function. In this article, we propose a Bayesian hierarchical model with nest-specific covariates to estimate age-specific daily survival probabilities without the above requirements. The model provides a smooth estimate of the nest survival curve and identifies the factors that are related to the nest survival. The model can handle irregular visiting schedules and it has the least restrictive assumptions compared to existing methods. Without assuming proportional hazards, we use a multinomial semiparametric logit model to specify a direct relation between age-specific nest failure probability and nest-specific covariates. An intrinsic autoregressive prior is employed for the nest age effect. This nonparametric prior provides a more flexible alternative to the parametric assumptions. The Bayesian computation is efficient because the full conditional posterior distributions either have closed forms or are log concave. We use the method to analyze a Missouri dickcissel dataset and find that (1) nest survival is not homogeneous during the nesting period, and it reaches its lowest at the transition from incubation to nestling; and (2) nest survival is related to grass cover and vegetation height in the study area.

Cardiac risk factors in polio survivors.

OBJECTIVE: To assess the prevalence of dyslipidemia and other risk factors for coronary heart disease in a sample of polio survivors with and without postpoliomyelitis syndrome. DESIGN: Retrospective chart review. SETTING: A multidisciplinary outpatient postpolio clinic. PARTICIPANTS: Eighty-eight consecutive symptomatic postpolio patients, 50 women (mean age, 59.0y; range, 36-81y) and 38 men (mean age, 61.2y; range, 44-83y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Presence of risk factors for coronary heart disease: clinical atherosclerotic disease, male age >or=45 years or female age >or=55 years, history of hypertension (blood pressure >or=140/90mmHg or on antihypertensive medication), diabetes mellitus, cigarette smoking, and high-density lipoprotein (HDL) less than 35mg/dL. Obesity (body mass index [BMI], >25kg/m(2)) was assessed as an intervention target. Laboratory values included fasting total cholesterol, HDL, low-density lipoprotein, triglycerides, and glucose. RESULTS: Of the total sample, 61.3% had dyslipidemia. Average HDL cholesterol ratio was 4.01 (women, 3.68; men, 4.55). Forty-four patients (50%) had a history of hypertension or had elevated blood pressure. Seven patients (8%) had a history of diabetes or had elevated fasting blood glucose (>110). Eighteen patients (20.4%) were smokers or had a history of smoking; 9 continued to smoke and 9 had quit smoking. Twenty-five patients (28.4%) were overweight (BMI, >25kg/m(2)). Forty-one patients (46.5%) had more than 1 risk factor for coronary heart disease. Nine of the total sample (10.2%) had a history of heart disease ranging from atrial fibrillation to angina. Only 19 patients had a previous diagnosis of dyslipidemia and only 12 were on a lipid-lowering medication. CONCLUSION: Polio patients have a high prevalence of dyslipidemia. The study sample supports the National Cholesterol Education Program's Adult Treatment Panel III statements that hypercholesterolemia is underdiagnosed and undertreated. The postpolio population carries a high prevalence of 2 or more coronary heart disease risk factors. Evaluation and rehabilitation of polio patients should include screening for dyslipidemia and education about elimination of controllable risk factors.