Cases of acquired methemoglobinemia have been identified with increasing frequency in Los Angeles during the last several years. Among 18 patients, both infants and adults, the most commonly incriminated agent was silver nitrate used for topical antibacterial prophylaxis of burn wounds. One burned child died from overwhelming septicemia complicated by hypoxia with a methemoglobin level of 5.4 grams per dl. Other causative factors included nitrate-rich vegetables used in early infancy, additives in ethnic foods, and prescribed and overdosed drugs. Discontinuation of the precipitating agent and methylene blue therapy were usually followed by prompt improvement. In burned patients treated with silver nitrate, careful regular monitoring of serum methemoglobin levels and early initiation of specific therapy are mandatory.
Introduction: Football is a contact sport that is played on a field similar to football, with eleven players on each side like football is a sport that grew out of a rugby variation and that requires its practitioners: speed, agility , tactical ability and brute force as players jostle, block and chase each other, trying to advance a ball into a territory. The physiological demands of football game are complex, always demanding the maximum of the physical abilities of your players in a row. Considering the differences in skills and abilities, soil conditions, refereeing standards and attitudes of aggression and violence, injury rates may be higher in amateur football players. Objective: the objective of this study is to report injuries that affect football players. Development: Ankle ligament injuries are the most common injuries that occur, regardless of the sport or type of exposure, Concussions and ACL injuries were other high-profile injuries that occurred less frequently, but often carry most significant health consequences. Conclusions: Injuries are common in contact sports such as football, however the vast majority of them do not generate any risk to physical suade athlete unless long-term when excesses of blows to the head can lead to greater central nervous system problems. Knee injuries and ankle are more common in athletes, however the number of surgeries is considered low for the type of sport.
Physical wellness is an often tricky concept, and the wellness dimension to most likely be confused as a one size fits all approach when considering what physical health, activity levels, and even body type and size mean to each individual. Generally speaking, physical wellness involves maintaining a healthy quality of life that allows us to get through our daily activities without undue fatigue or physical stress. Physical wellness is not only the absence of illness, but also living a thriving, active life whatever that activity level is for each person. Adopting healthful habits (i.e., routine medical exams, immunizations, a balanced diet, daily exercise of some type, sufficient rest and managing stress, etc.) while avoiding or minimizing higher risk choices and behaviors (i.e. tobacco, drugs, alcohol, etc.) are also included in this dimension.
While domestic pets are capable of transmitting disease and inflicting injury, they may also be of benefit to human health. Studies suggest that companion animals, in addition to their well-known role as helpers to the handicapped, may alleviate depression, solace the lonely, facilitate psycho-therapy, socialize criminals, lower blood pressure, increase survivorship from myocardial infarction and ease the social pain of aging in our society.
Heparin is an effective anti-coagulant for the prevention of venous thromboembolism and for the treatment of venous thrombosis and pulmonary embolism (Girolami et al., 2003; Hirsh et al., 2004; Shantsila et al., 2009). It is often used for patients with unstable angina and acute myocardial infarction, and for patients who have undergone vascular surgery (Battistelli et al., 2010). The administration of heparin frequently induces a reduction in platelet counts. This phenomenon is called heparin-induced thrombocytopenia (HIT) and be classified as either type I or II. To avoid confusion between the syndromes, “HIT type I” has been changed to “non-immune heparin associated thrombocytopenia”, and ‘‘HIT type II’’ is simply called ‘‘HIT’’.
Heparin is an effective anti-coagulant for the prevention of venous thromboembolism and for the treatment of venous thrombosis and pulmonary embolism (Girolami et al., 2003; Hirsh et al., 2004; Shantsila et al., 2009). It is often used for patients with unstable angina and acute myocardial infarction, and for patients who have undergone vascular surgery (Battistelli et al., 2010). The administration of heparin frequently induces a reduction in platelet counts. This phenomenon is called heparin-induced thrombocytopenia (HIT) and be classified as either type I or II. To avoid confusion between the syndromes, “HIT type I” has been changed to “non-immune heparin associated thrombocytopenia”, and ‘‘HIT type II’’ is simply called ‘‘HIT’’.
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A 7-year-old boy is referred to you with h concerns about developmental delay. On assessment, he is found to have moderate mental retardation (1Q of 50) but no remarkable physical findings. His parents are considering having another child, and they wonder what caused the retardation in their first child and whether it is likely to recur in future offspring.
Competing interests: H Chung is Medical Director, Depression andAnxiety Management Team, Pfizer, Inc.
Uncomplicated urinary tract infections are among the most frequently occurring infections in the United States, resulting in an estimated 8 million office visits and 1 million hospital admissions each year.1,2,3 Between 40% and 50% of women have reported having at least one urinary tract infection in their lives.4 Urinary tract infections can be classified by anatomic site of involvement into lower and upper urinary tract infections. Infections of the lower urinary tract include cystitis, urethritis, prostatitis, and epididymitis, and those of the upper urinary tract include pyelonephritis. Urinary tract infections may be further classified as complicated or uncomplicated. In women with a structurally and functionally normal urinary tract, cystitis and pyelonephritis are considered uncomplicated urinary tract infections. Urinary tract infections in men, elderly people, pregnant women, or patients who have an indwelling catheter or an anatomic or functional abnormality are considered complicated urinary tract infections. In this article, we outline the pharmacologic approach to the prevention and treatment of uncomplicated cystitis.
Headache is the most common complication after lumbar puncture (LP), with reported frequency rates ranging from 6% to 36% of patients.1 August Bier (1861-1949) was the first to describe the phenomenon of post-dural puncture headache in his patients and experienced the same effect when he had the procedure performed on himself.2 Most (90%) post-LP headaches occur within 3 days of the procedure and are characteristically described as being present when the patient is in the upright position and diminished in intensity when supine. The cause of post-LP headache is uncertain. One idea is that it is possibly due to low cerebrospinal fluid (CSF) pressure as a result of CSF leakage through a dural and arachnoid tear produced by the puncture that exceeds CSF production. The continuous decrease in CSF pressure may lead to subsequent stretching of pain-sensitive structures. Another notion is that cerebral vasodilatation, in addition to traction, is responsible for headache following LP. Various treatments for this condition are thought to be effective, even though its cause is unclear. Many of these are implemented routinely in daily practice—including increased fluids, bed rest, and caffeine—despite the lack of evidence of their effectiveness. There is no evidence supporting the use of increased fluids to prevent post-LP headache.1 The only prospective study of this intervention involved oral hydration. Dieterich and Brandt performed a prospective study of 100 age-matched, randomly allocated neurologic patients and found no correlation between the incidence of post-LP headache and the amount of fluid intake.3 Half of the patients were asked to drink 1.5 L of fluids per day during the 5 days after an LP, and the other half was asked to drink 3.0 L of fluids per day for the same period. The intensity of the headache was classified into four grades according to the severity and onset of symptoms after getting up from the LP. The proportion of symptom-free individuals was 64% in both groups of patients; therefore, the incidence of post-LP headache is independent of fluid intake. Another commonly held belief is that bed rest or various body positions after LP reduce the incidence of post-LP headache compared with immediate ambulation. But Carbaat and van Crevel performed a controlled prospective study that showed that no benefit was found with 24 hours of bed rest in preventing the headache.4 A diagnostic LP was performed in 100 neurologic patients by one investigator. Half of the patients were immediately mobilized, and the other half had bed rest. To account for the possibility of improved technique by the same investigator with successive LPs, the first 25 were immediately mobilized, the next 50 were given bed rest, and the last 25 were immediately mobilized. Follow-up was for 7 days, and no significant differences were found between the two groups. Other similar studies have confirmed these findings. Oral and intravenous administration of caffeine has been recommended as a therapeutic option for post-LP headache, often as an effort to avoid using the more invasive treatment of epidural blood patching. The presumed mechanism is thought to be increased cerebral arterial vasoconstriction, resulting in decreases in cerebral blood inflow and blood volume in the brain. No well-designed, adequately powered, randomized controlled studies have been performed to prove the effectiveness of caffeine. Published information on this therapy comes from case reports or reviews that cite one study in 1975.5 The investigators in that study used a double-blind demand method to evaluate the intravenous administration of caffeine sodium benzoate in 41 patients for whom treatment with more conservative measures had failed. This study was limited in that the study size was small, it did not control for known risk factors such as sex and age, it did not include patients undergoing diagnostic LPs, and it did not investigate or correlate the quantity of daily caffeine intake before the LP was performed. In addition, the placebo arm of the study crossed over into the treatment arm. Given these limitations of the one study that is consistently cited, the evidence supporting the use of caffeine in treating post-LP headache remains weak.weak. Table 1 Effective measures for preventing and treating post-LP headache Prevention Needle size: Halpern and Preston7 Bevel direction: Flaatten et al8 Stylet replacement: Strupp et al9 Treatment Epidural blood patch: Safa-Tisseront et al10 View it in a separate window Factors that have been shown to be associated with post-LP headache include needle size, bevel orientation, and replacement of the stylet before withdrawing the needle (box).1,7,8,9,10 Articles in the anesthesia literature have suggested that needle design is also associated, but the data in articles on diagnostic LP are conflicting and have been inadequate to assess this factor. When headache does occur, epidural blood patching had been effective in 85% to 98% of patients and is indicated for those with moderate to severe headache for more than 24 hours.2 It is performed by slowly injecting 10 to 20 mL of the patient's blood into the lumbar epidural space at the same interspace or the interspace below the previous puncture. Although it might be intuited that epidural blood patching relieves post-LP headache by tamponading the dural hole through a mass effect, the actual mechanism of action is unclear.6
Childhood anxiety disorders are the most common type of psychiatric problemin children.1 Thesedisorders cause severe impairment and excessive distress. Although effectivepsychosocial and drug therapy exists, these anxious youngsters are virtuallyignored compared with children with other psychiatric problems. Few clinicallyanxious children come to the attention of physicians or other mental healthproviders.2 In 11 of 15 studies worldwide of impairing childhood anxiety disorders, theprevalence was greater than10%.3 In four offive large US surveys, prevalence was between 12% and20%.3 Otherpsychiatric problems are common in anxious children, particularly depression,behavior disorders, and substance misuse. Childhood anxiety disorderstypically onset in early childhood and follow a chronic and fluctuating courseinto adulthood.4 Although historically thought to be benign, these disorders can interferewith academic, social, and familyfunctioning.5 Theyare associated with an increased risk of failure in school and, in adulthood,low-paying jobs and financial dependence on welfare or other governmentsubsidies. Childhood anxiety is predictive of adult anxiety disorder, majordepression, suicide attempts, and psychiatrichospitalization.4,6 Children born to anxious parents are themselves more likely to be anxious.The mechanism for this association is unclear—both environmental(parenting style, parentchild interactions) and genetic factors have beenimplicated. Anxious parents may exacerbate their children's anxiety through aparticular style of interaction, including overprotection and excessivecontrol.7,8 Unfortunately, most children with anxiety disorders do not receive adequateassessment andtreatment.2 Thisfact is particularly disturbing because these disorders can be treatedeffectively with cognitive behaviortherapy9 and the useof selective serotonin reuptakeinhibitors.10 Why do practitioners neglect childhood anxiety? The reason may be a common,yet inaccurate, belief that anxiety in children and adolescents isdevelopmentally normal, typically transient, and innocuous. Terms such asfear, phobia, and anxiety are often used interchangeably among mental healthprofessionals and physicians, leading to diagnostic confusion andmisperceptions of the actual significance of anxiety disorders inchildhood.11 Fears are developmentally appropriate reactions to threats, which may beobjective (blood tests, tooth extractions) or subjective (strangers,lightning). During the first year of life, children typically fear intensestimuli, such as loud noises; potentially harmful stimuli, such as fallingover or strangers, and novel stimuli. Fears of tangible items (dogs, bodilyinjury) and vague objects (monsters, dark, separation) are most prevalentduring the preschool years (ages 1 to 4). During the school years, appropriatefears of evaluation, school-related events (tests, oral presentations), andaspects of peer relationships are most common. Phobias are different fromfears in that they are more persistent, disproportionate to the demands of thesituation, and impervious to reasoning. Phobias often occur outside the normaldevelopmental period during which fears occur (for example, a fear of the darkat age 15 instead of age 4). Anxiety is more diffuse, lacks specificity, andcan be thought of as a “state of apprehension withoutcause.”11 Although transient fears and anxieties are considered part of normaldevelopment, an anxiety disorder should be diagnosed if the anxiety becomes apersistent negative force in a child's life and cuases excessive distress orsignificant interference with school, peer involvement, autonomous activities,and/or family functioning. Separation anxiety disorder (excessive anxiety concerning separation fromhome or major attachment figures) and selective mutism (the persistent failureto speak in specific social situations despite speaking in other settings) arethe only anxiety-related diagnoses confined to childhood and adolescence bythe latest Diagnostic and Statistical Manual of Mental Disorders,4th edition (DSM-IV). For the remaining disorders (includinggeneralized anxiety disorder, social anxiety disorder, panic disorder with orwithout agoraphobia, obsessive-compulsive disorder, posttraumatic stressdisorder, and specific phobia), the manual's adult criteria are applied tochildren and adolescents. Because childhood fears and worries are variable, the assessment of ananxiety disorder in childhood requires paying attention to developmental,cognitive, socioemotional, and biological factors. Physicians and other mentalhealth providers require multisource (parent, child, and teacher) andmultimethod (rating scale, interview, and observational) data in order toascertain the presence of a disorder, to establish levels of current severityand impairment, and to identify appropriate targets for intervention. Whereas individual behavioral techniques, such as exposure and systematicdesensitization, can be effective for patients with simple phobias and otherless complicated clinical presentations, multicomponent cognitive-behavioraltreatment packages are the treatment of choice for most children with otheranxietydisorders.12 Thesetypically address the child's illness across many dimensions, includingsomatic (physical complaints), cognitive (biased thinking), and behavioral(clinging, crying, avoidance) problems. Results of controlled trials show thatcognitive behavior therapy can be effective in as many as 70% of clinicallyanxiouschildren.9,13Such therapy can be adapted for use in family, group, and school-basedintervention and prevention programs. Few high-quality studies have focused on effective drug treatments forchildhood anxiety disorders. The strongest research effort has been directedtoward the selective serotonin reuptakeinhibitors.11 Inthe RUPP Anxiety Study, a five-center trial initiated by the NationalInstitute of Mental Health, fluvoxamine was better than placebo when treatingpatients with separation anxiety disorder, social anxiety disorder, orgeneralized anxietydisorder.10 No goodevidence supports the use of tricyclic antidepressant or benzodiazapinemedication as a first-line treatment for suchdisorders,14 andmedication is often associated with sideeffects.15 Should cognitive behavior therapy or specific serotonin reuptake inhibitorsbe the first-line treatment? The National Institute of Mental Health recentlyfunded a large multicenter study (Child and Adolescent Multimodal TreatmentStudy) to address this issue. Meanwhile, cognitive behavior therapy should bethe treatment of choice. Despite dramatic gains in understanding the etiology and treatment ofchildhood anxiety disorders, far too few anxious children have benefited fromthese advances. Primary care physicians should take childhood anxietyseriously and promptly refer affected youngsters to specialists for furtherevaluation and effective treatment.
The wind wheeled with deliberate menace, chopping the water white withfroth. The sheet of black rain riding in on it promised to arrive in less than5 minutes. Pauker muttered to himself, stomped off the dock, and headed up thetrail back to the cabin. After the briefest thought of braving the weather, Ifollowed him through the swaying pines toward the amber light above. I reachedthe porch door just as the shatter of rain began to pound the cabin roof. Thewind behind it gusted to gale force. I was glad to be inside.
