Biomedical subjects
W G Mitchell
Publications and source records attributed to W G Mitchell.
Very-high-dose phenobarbital for refractory status epilepticus in children.
Status epilepticus refractory to initial anticonvulsant therapy is a serious condition with a high morbidity and mortality. We present 50 cases with refractory status epilepticus (RSE) treated with very-high-dose phenobarbital (VHDPB) without reference to a predetermined maximum level or dose. Maximum serum levels ranged from 70 to 344 micrograms/ml (median, 114 micrograms/ml). VHDPB controlled seizures in all cases where no limits were imposed upon maximum dose (47/50). We found no maximum dose beyond which further doses are likely to be ineffective. Forty patients were intubated prior to VHDPB, but recovered respiratory drive and could be removed from the ventilator despite very high serum levels. This is explained by acute drug tolerance. Hypotension was unusual, related to the highest levels, and easily controlled. VHDPB has many relative advantages over other therapies presently used for RSE.
Encephalitis lethargica-like illness in a girl with mycoplasma infection.
We describe a patient with mycoplasma infection and clinical manifestations of encephalitis lethargica. The patient was brought to our attention after acute neurologic deterioration followed by a prolonged sleep-like state and the emergence of extrapyramidal features. MRI of the brain disclosed a striking pattern of subcortical involvement by the inflammatory process, corroborating the clinical picture.
Intraparenchymal cerebral cysticercosis in children: diagnosis and treatment.
Cerebral cysticercosis is being diagnosed with increasing frequency in children in the United States. A total of 52 patients with intraparenchymal cerebral cysticercosis, 21 months to 20 years of age, were observed for 2 to 72 months. Actively inflamed acute lesions, with or without coexisting chronic calcified lesions, were seen in 42 patients. Solitary lesions were seen in 39 patients, multiple lesions in 13. Chronic inactive calcified lesions were seen in ten children. A total of 51 patients had seizures that were either partial or partial with secondary generalization. Patients were treated with anticonvulsants. Praziquantel was not used. All active lesions resolved completely or with punctate calcification in 2 to 9 months, according to radiographic findings. Seizures were easily controlled. Patients were gradually weaned from anticonvulsants and in 60% no seizures recurred. Prognosis was generally good. Characteristics of the CT scans are detailed.
Human immunodeficiency virus-associated Kaposi's sarcoma in a pediatric renal transplant recipient.
An 11-year-old boy developed Kaposi's sarcoma and progressive T lymphocyte deficiency 5 years after cadaveric kidney transplantation for end-stage renal disease. He had received 17 individual red blood cell transfusions prior to and during transplantation in 1980. Human immunodeficiency virus (HIV) was cultured from blood in cerebrospinal fluid and HIV antibodies were detected with enzyme immunoassay and immunoblot techniques. The recipient of the donor's other kidney was well and HIV antibody-negative. The patient was treated with etoposide with excellent although transient regression of tumor. Allograft function has remained stable despite minimal immunosuppressive therapy and the need for high-dose anticonvulsant therapy. This case represents the first pediatric patient with acquired immune deficiency syndrome (AIDS) and Kaposi's sarcoma following kidney transplantation.
Intraventricular alpha 2b interferon for SSPE.
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Lorazepam in childhood status epilepticus and serial seizures: effectiveness and tachyphylaxis.
We report our experience with 300 consecutive parenteral doses of lorazepam (LOR) for status epilepticus (SE) or serial seizures in 77 children and young adults. The median dose for SE in children less than 12 years old was 0.10 mg/kg. LOR stopped the SE in 79% and diminished the intensity of SE in an additional 4%. Prior acute or chronic anticonvulsant use (excepting chronic benzodiazepines) did not alter effectiveness or increase side effects. Duration of freedom from seizures following acute therapy was independent of LOR dosage. In patients requiring sequential doses, LOR becomes progressively less effective. Side effects were few and, when present, always associated with a single or first dose in a series. LOR is a safe and effective acute anticonvulsant agent for in-hospital control of SE in the pediatric age group. Tachyphylaxis of anticonvulsant action occurs when serial doses are used.
Interventional radiology in the management of hepatic trauma.
Interventional radiology (catheter placement under radiologic guidance) is a safe and effective technique in the management of hemorrhage and infection after hepatic trauma. Twenty procedures in 17 patients were reviewed. All patients with hemorrhage, vascular lesions, and intra-abdominal fluid collections were successfully treated without mortality or substantial morbidity. These techniques are recommended in complicated liver trauma.
Routine versus selective exploration of penetrating neck injuries: a randomized prospective study.
In an effort to settle the controversy regarding the optimal management of penetrating trauma to the neck, a randomized prospective study was conducted in which 160 patients with penetrating neck injuries admitted to Kings County Hospital between 1977 and 1982 were placed, by protocol, into two groups. Group A patients were explored routinely for all injuries to the neck violating the platysma muscle. Group B patients were managed selectively with operation based on clinical or radiographic evidence of major vascular, visceral, or airway injury. Data were collected retrospectively. Length of hospital stay, morbidity, and mortality were compared between groups A and B, as well as between patients explored or not, and no statistical difference was noted. Since there is no clear advantage to either routine or selective exploration in the management of penetrating neck wounds, we conclude that surgeons should base their treatment on their own experience, house staff and nursing support, and radiologic and operating room availability.
Abdominal epilepsy. Cyclic vomiting as the major symptom of simple partial seizures.
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The relative roles of neurological examination, functional abilities, and computed tomography in the definition of treatment failure in patients with anaplastic gliomas.
Forty-one patients with anaplastic gliomas undergoing postoperative treatment and evaluation underwent bimonthly evaluation of the following indices of treatment failure: neurological examination; Karnofsky functional rating; and computed tomography (CT) brain scanning. Treatment failure was declared when neurological examination or Karnofsky rating showed increased impairment or when CT scan revealed an increase in tumor sizes. Most often, all three indices simultaneously indicated treatment failure. In only 6 of 41 cases the CT scan alone was the first indication of treatment failure. During the first 6 months of follow-up, tumor enlargement on CT scan as a sole index of treatment failure occurred in only 3 of 26 cases that showed evidence of treatment failure during that time. For patients with glioblastoma, about 6% of treatment failures within 6 months are predicted to be missed by Karnofsky rating plus neurological examination, whereas CT scan alone is predicted to miss about 30%. It would seem reasonable to rely on the neurological examination and Karnofsky rating for follow-up during the first 6 months after surgery, without routine serial CT scanning during that time.
Interventional radiology in trauma victims: analysis of 51 consecutive patients.
Injured patients whose treatment included the use of radiologic catheter techniques were reviewed to determine the clinical utility of radiologic intervention. In the past 4 years, 51 patients have undergone 53 radiologic procedures, predominantly angiographic hemostasis. Thirty-eight of 45 sites of hemorrhage from the neck, abdomen, pelvis, and extremities were successfully controlled. Nine of 11 abscesses were adequately drained and definitively treated by percutaneous methods. Twenty-eight of the 31 patients with shock or with life-threatening hemorrhage or sepsis, treated by the radiologist, were salvaged. Based on our results, we believe that a radiologist, knowledgeable about trauma and expert in catheter techniques, plays a vital role in improving patient survival and should be integrated into the trauma team approach.
Radiologic management of traumatic hepatic artery-portal vein arteriovenous fistulae.
Traumatic hepatic artery portal vein arteriovenous fistulae (HPF) are uncommon but potentially life-threatening distortions of hepatic circulation. They are curable causes of gastrointestinal bleeding and portal hypertension. HPF may result from lacerations of adjacent arterial and venous walls, pseudoaneurysms, or liver erosion causing a shunt into the portal vein. Symptoms are GI bleeding, or crampy abdominal pain and diarrhea, or in delayed HPF, signs of portal hypertension. Angiography can make the diagnosis and may be therapeutic, as in one reported case, in which successful transcatheter embolization obviated the need for surgical treatment.
Retrograde venous bullet embolism.
Bullets may embolize against normal blood flow into distal veins because of gravity or the Valsalva maneuver. A case is described in which a bullet was fluoroscopically repositioned from the popliteal vein into the area of a lacerated iliac vein and trapped with a balloon catheter obviating popliteal exploration.
Good performance rewarded in cash.
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Failure-to-thrive: a study in a primary care setting. Epidemiology and follow-up.
A cohort of 312 children followed in three rural primary care centers was studied. All cases of failure-to-thrive were identified (30) and compared to the remainder of the group. With the use of data from medical records, children with history of failure-to-thrive were found to be significantly lighter and shorter than the remainder of the population in each of the first five years of life. More cases had family problems. No differences were found in demographic characteristics or chronic illnesses. In the second phase of the study, cases and an equal-sized control group, from the same social setting, matched for age, sex, mother's marital status, and family problems, were examined at 3 to 6 years of age to assess outcome. This included physical examination, the McCarthy Scale of Children's Abilities, a behavior questionnaire, and an interview to assess life events. Cases were lighter but not shorter than controls. No instances of occult organic disease causing failure-to-thrive were identified. No behavioral or developmental deficits could be attributed to the failure-to-thrive.
Mandatory open reduction: its role in displaced ankle fractures.
"Satisfactory reduction" is insufficient in discussing ankle fractures; only perfect anatomic reduction will suffice. Fractures extending into joint surfaces carry a higher incidence of disability than those involving the metaphysis and/or diaphysis. The end result is further adversely affected when such fractures occur in weight-bearing joints with resulting disability from persistent pain and stiffness. It is our belief that anatomic reduction of displaced ankle fractures, especially the restoration of fibular length, is almost impossible by closed reduction. Closed reduction may require frequent manipulation and plaster changes as the swelling subsides, and the fragments become displaced. This encourages ankle and subtalar stiffness. For these reasons mandatory open reduction and rigid internal fixation of these fractures are recommended. A review of 300 nonconsecutive cases of open and closed displaced ankle fractures treated by open reduction had an overall infection rate of 1% and an incidence of degenerative arthritis of 3%.
Pesticide residue levels in soils and crops from 37 states, 1972--National Soils Monitoring Program (IV).
Residue data from the 1972 (FY--73) National Soils Monitoring Program are summarized. Composite samples of agricultural soil and mature crops were collected from 1,483 of the 1,533 selected 4-hectare sites in 37 states. Analyses were performed for organochlorine and organophosphorus compounds, trifluralin and polychlorinated biphenyls (PCBs); analysis for atrazine was performed only when pesticide application data indicated current-year use. Organochlorine pesticides were detected in 45 percent of the soil samples. The most frequently detected compound was dieldrin, found in 27 percent of all soil samples. Other compounds detected, in order of frequency, included DDT, aldrin, chlordane, and heptachlor epoxide, found, respectively, in 21, 9, 8, and 7 percent of all soil samples. Crop samples were collected from 727 sites. All were analyzed for organochlorines; analyses were performed for organophosphates and atrazine only when pesticide application data indicated current-year use. For all crops, 40 percent of the samples contained detectable levels of organochlorines and 10 percent contained detectable levels of organophosphates. Atrazine was not detected.