Biomedical subjects
B L Klein
Publications and source records attributed to B L Klein.
A cystic gingival lesion associated with pneumococcal bacteremia.
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Delayed diagnosis of pediatric cervical spine injury.
We report on nine patients in whom there were delays in establishing a diagnosis of cervical spine injury and discuss the causes that contributed to the delays, their clinical significance, and whether or not asymptomatic injury occurs.
Prospective randomized double-blind study comparing L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup).
Aerosolized racemic epinephrine, but not L-epinephrine, is commonly used in treating croup. The efficacy and adverse effects of nebulized racemic and L-epinephrine in the treatment of laryngotracheitis were compared. Children 6 months to 6 years of age with a croup score of 6 or above were assigned in a randomized double-blind fashion to receive either racemic (n = 16) or L-epinephrine (n = 15) aerosols. Croup score, heart rate, blood pressure, respiratory rate, fraction of inspired oxygen, and oxygen saturation were recorded before treatment and at 5, 15, 30, 60, 90, and 120 minutes after the aerosol. Patients in both groups showed significant transient reduction of the croup score and respiratory rate following the aerosol (P less than .001), but there were no differences between treatment groups when croup score, heart rate, blood pressure, and respiratory rate were assessed over time. It is concluded that L-epinephrine is at least as effective as racemic epinephrine in the treatment of laryngotracheitis and does not carry the risk of additional adverse effects. L-Epinephrine is also more readily available worldwide, is less expensive, and can be recommended for this purpose.
Pretreatment of formula with sodium polystyrene sulfonate to reduce dietary potassium intake.
Sodium polystyrene sulfonate (SPSS) is commonly administered for the acute and chronic treatment of hyperkalemia. Its oral intake is complicated by poor compliance due to multifaceted reasons. We therefore analyzed a method of reducing potassium (K) in formula by pretreatment with SPSS. If effective, this would bypass complications of enterally administered SPSS and provide low-K formula. Thirteen formulas and nutritional supplements were pretreated with SPSS to determine if one could bind K and provide formulas with decreased K contents. Using an SPSS concentration of 1 g/l mEq K in the formula, 62 +/- 2.6% (P less than 0.01, mean +/- SEM) of the K was removed in 30 min, while the sodium (Na) concentration was increased by 234 +/- 37% (P less than 0.01). Analysis suggests that the disproportionate increase in Na is due to exchange for calcium (Ca) and magnesium (Mg), interaction with proteins, and Na suspended with SPSS in the formula. Thus, SPSS pretreatment of formula is an effective method of making low-K formula, but the increase in Na exceeds the K reduction. Attention to possible complications of increased Na intake as well as decreased Ca and Mg intake is warranted.
In-flight esophageal variceal bleeding en route for liver transplantation: a case report and review of the literature.
Esophageal variceal bleeding owing to portal hypertension is a potential threat in pediatric patients awaiting liver transplantation. We report a case of a three-year-old boy with severe congenital hepatic fibrosis, Caroli's disease, and portal hypertension who developed a life-threatening variceal hemorrhage for the first time in his life during commercial air transport to a liver transplantation center. Factors precipitating variceal bleeding are discussed, particularly those resulting from changes in altitude. It is recommended that prophylactic treatment for variceal bleeding be at least considered in children awaiting liver transplantation prior to prolonged air transportation. Because of differences in capabilities of treatment providers in various locales, and because there are as yet no conclusive data, the treatment of choice must be decided on an individual basis. Equipment for treating in-flight hemorrhage should be available.
Comparison of a tympanic thermometer to rectal and oral thermometers in a pediatric emergency department.
We performed a clinical trial of a new tympanic thermometer to test its accuracy in a pediatric emergency department. Tympanic temperature was compared to oral or rectal glass and electronic temperature, depending on the developmental age of the child. Results were controlled for age of the child, cooperation, quantity of cerumen, and the presence or absence of otitis media. Our results suggest good correlation of tympanic with oral and rectal glass thermometry except in infants less than three months of age. Sensitivity and specificity, respectively, were 80% and 93% for detecting fever of 38 degrees C and 80% and 95% for detecting fever of 38.5 degrees C.
Observation unit management of pediatric emergencies.
Observation units for children in an Emergency Department setting can serve to improve the quality of medical care provided as well as reduce overall costs; however, they must be properly organized with careful consideration for the needs of children. Policies must be written specifying who is in charge as well as who can be accepted into these units and for how long. Procedures regarding documentation and sign-out must be formulated. These units must be well staffed and fully equipped, and they should be pleasant places for the children to stay; otherwise, what might begin as assets can quickly become disorganized and potentially dangerous liabilities.
Conscious sedation of the pediatric patient for suturing: a survey.
No single drug or combination of drugs was used routinely in pediatric emergency departments to sedate children for suturing. A meperidine-promethazine-chlorpromazine "cocktail" was chosen most frequently. Many physicians were dissatisfied with the method they selected, however, leading some to experiment with newer medications such as fentanyl. The American Academy of Pediatrics (AAP) guidelines for the elective use of conscious sedation, specifically, those regarding monitoring during sedation and discharge post sedation, were not adhered to uniformly. Further study of conscious sedation in children is needed.
Altered amount and activity of superoxide dismutase in sickle cell anemia.
The amount and activity of superoxide dismutase (SOD) (EC 1.15.1.1) were measured in red cells collected from 50 white controls, 101 black controls, 50 patients with sickle hemoglobin (SS Hb), 12 with sickle trait, and 11 with other sickling hemoglobinopathies. Red cells from normal black subjects had more SOD amount and activity than normal whites (1.77 U/mg Hb and 2.96 micrograms/mg Hb vs. 1.47 U/mg Hb and 2.64 micrograms/mg Hb, respectively) or blacks with SS Hb or other sickling hemoglobinopathies. Patients with more severe manifestations of SS Hb had lower levels of SOD activity than those with milder symptoms but had the same amount of enzyme protein. Individuals with sickle trait had amounts and activities of SOD comparable to black controls. An alteration in defense to free radical oxygen may play a role in the severity of symptoms experienced by patients with homozygous sickle cell disease.
Impact of AccuLevel on treatment of acute asthma.
Study of the impact of rapid availability of theophylline concentrations on emergency treatment of acute asthma disclosed use of AccuLevel in 50 children significantly shortened the time required to reach concentrations of at least 10 micrograms/mL and shortened time spent in the emergency room as compared with 50 children in whom serum concentrations were measured only by EMIT.
Hydrocarbon poisonings.
Many different compounds are classified as petroleum distillates. Most ingestions can be managed by careful observation and respiratory support.
Red cell superoxide dismutase and sickle cell anemia symptom severity.
Patients with sickle cell anemia vary in the severity of their symptoms but the basis of this variability is unknown. We have tested the hypothesis that this variability is related to differences in the activity of the antioxidant superoxide dismutase (SOD). The amount of superoxide dismutase I (SOD) enzyme activity in red cells of patients with different degrees of symptom severity and healthy black and white controls was measured and correlated with symptom severity in SCA patients. Blacks with normal (AA) hemoglobin had significantly (p less than .001) more SOD activity (1.82 U/mg Hb) than white controls (1.44 U/mg Hb). Patients with moderate or severe symptoms had less SOD activity (1.16 and 0.95 U/mg Hb, respectively) than control blacks or SCA patients with mild symptoms (1.62 U/mg Hb). The correlation of SOD activity and symptom severity was not a function of age or sex and was unrelated to reticulocyte count or fetal hemoglobin level.
Reduction of contact factors in sickle cell disease.
Surface-mediated reactions of clotting were compared in 21 black children with homozygous sickle cell disease, 12 age-matched controls, and 15 adults. Both the coagulant and antigen titers of Hageman factor (factor XII) were decreased in asymptomatic patients compared with those in the control groups. These findings were associated with slight but significant reductions in the plasma titers of prekallikrein and high molecular weight kininogen. A further decrease from the initially low titers of these contact factors was observed during vaso-occlusive crises. Additionally, we observed a disparate relationship between Hageman factor coagulant activity and its antigen titers. These data provide evidence for reduction of the contact factors in patients with homozygous sickle cell disease.
Hemophilus influenzae type f meningitis in an adolescent.
A 17-year-old male with Hemophilus influenzae type f meningitis is reported. Recent studies which suggest that the incidence of H. influenzae meningitis in older individuals is increasing are reviewed. Therefore, we recommend that antimicrobial therapy directed against H. influenzae be included in the initial management of older children, adolescents, and adults with acute bacterial meningitis.
Transdermal scopolamine intoxication in a child.
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Coronary artery disease confined to secondary branches of the left coronary system.
Among 3,000 patients studied by coronary arteriography during a 4-year period, 31 patients (1%) had coronary artery disease limited to a diagonal branch of the left anterior descending (15 patients), marginal branch of the left circumflex (10 patients), or to both branches (6 patients). Ten patients had 50-69% and twenty-one had greater than or equal to 70% diameter narrowing. The suitability for grafting was noted in 20 patients as judged by the caliber and distribution of the diseased branches. Collaterals were noted in seven patients. Disease was present in 28 men and 3 women (age range 38-70 years). At least one major coronary risk factor was present in 27 patients. Angina was noted in 27 patients; prior myocardial infarction was noted in 5 patients by history and in 4 by ECG. The left ventriculogram was normal in 22 patients and showed mild segmental asynergy in 9; ejection fraction was normal in all. Exercise ECGs were positive in 12 of 25 patients; exercise 201thallium scans were positive in 13. All patients responded to medical therapy. In conclusion, among the population of patients who undergo catheterization, coronary branch disease is rare. The clinical findings are indistinguishable from patients with major coronary disease. Prognosis remains benign and patients respond to medical therapy.
Hypothetical case: coarctation of the aorta.
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