Joseph S. Barr

Comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: prospective randomised study

Abstract Objective: To compare the safety and efficacy of midazolam given intranasally with diazepam given intravenously in the treatment of children with prolonged febrile seizures. Design: Prospective randomised study. Setting: Paediatric emergency department in a general hospital. Subjects: 47 children aged six months to five years with prolonged febrile seizure (at least 10 minutes) during a 12 month period. Interventions: Intranasal midazolam (0.2 mg/kg) and intravenous diazepam (0.3 mg/kg). Main outcome measures: Time from arrival at hospital to starting treatment and cessation of seizures. Results: Intranasal midazolam and intravenous diazepam were equally effective. Overall, 23 of 26 seizures were controlled with midazolam and 24 out of 26 with diazepam. The mean time from arrival at hospital to starting treatment was significantly shorter in the midazolam group (3.5 (SD 1.8) minutes, 95% confidence interval 3.3 to 3.7) than the diazepam group (5.5 (2.0), 5.3 to 5.7). The mean time to control of seizures was significantly sooner (6.1 (3.6), 6.3 to 6.7) in the midazolam group than the diazepam group (8.0 (0.5), 7.9 to 8.3). No significant side effects were observed in either group. Conclusion: Seizures were controlled more quickly with intravenous diazepam than with intranasal midazolam, although midazolam was as safe and effective as diazepam. The overall time to cessation of seizures after arrival at hospital was faster with intranasal midazolam than with intravenous diazepam. The intranasal route can possibly be used not only in medical centres but in general practice and, with appropriate instructions, by families of children with recurrent febrile seizures at home.

Arthrodesis of the ankle joint indications, operative technic and clinical experience.

THE ankle joint — to function properly — must have smooth articular cartilage, proper weight- bearing alignment, intact supporting ligaments and good musculature under adequate voluntary control. A...

Visual evoked potentials: a diagnostic test for migraine headache in children

Visual evoked potentials (VEPs) were performed in a blind fashion in 114 children aged 3 to 17 years with different types of headaches, in order to investigate whether this could be helpful in the diagnosis of migraine versus other types of headaches in children. The study showed that the amplitude between P100 and N2 was significantly larger in children with migraine headaches (mean 19.8 nvol, SD 7.75) compared with other types of headaches (mean 13.1 nvol, SD 7.45). These results suggest that the sensitivity of VEP P100 amplitude to distinguish migraine headaches in children is 67%, the specificity of VEP is 83%, and the predictive positive value is 83%. VEP study might be helpful in workup of a child with headache, particularly a young child, when signs and symptoms may not be characteristic.

PREDICTION OF UNEQUAL GROWTH OF THE LOWER EXTREMITIES IN ANTERIOR POLIOMYELITIS

Of 166 adults in whom poliomyelitis developed before the age of eleven, varying degrees of muscle power and shortening were present in the lower extremities. There was no specific relationship between the age of onset and the amount of discrepancy in limb length. There was, however, a definite relationship between the relative muscle strength in the two extremities and the discrepancy in limb length. These data may be utilized clinically in predicting the amount of shortening that will occur in a patient having poliomyelitis before the age of eleven.

Neurodevelopmental and behavioral abnormalities associated with deletion of chromosome 9p.

We report a child with craniosynostosis, partial absence of the corpus callosum, developmental delay, precocious puberty, and deletion of chromosome 9(p 12p 13,3). A review of the literature did not reveal any previous combination of the same kind. Craniosynostosis and partial absence of the corpus callosum, separately or in conjunction, may be part of the spectrum of malformations in the chromosome 9p deletion syndrome, and its presence, in combination with other known features, should prompt a search for this particular deletion as part of the differential diagnosis. (J Child Neurol 2002;17:50-51).

Fracture Of The Carpal Navicular (scaphoid) Bone: An End-result Study in Military Personnel

As the result of an end-result study of forty-four veterans who had fractures of the carpal navicular, recognized while in Military Service during World War II, the following conclusions seemed warranted: 1. If healing by primary union occurs, there is minimal residual disability which does not interfere with the performance of duty. 2. About 50 per cent. of the ununited fractures were surveyed from the Service for wrist symptoms. If non-union is established before induction, this injury should be disqualifying for full-duty status. 3. The incidence of non-union in Military Service was 22 per cent. The factors tending to produce non-union appeared to be insufficiently prolonged immobilization and delay in instituting treatment. Immobilization must be maintained until there is union as shown by x-ray. This may require more than eight weeks, even in acute fractures promptly diagnosed and treated. 4. The treatment of non-union in this series was unsatisfactory. Of the fourteen men with non-union, nine were treated conservatively without improvement; five were operated upon, union and a satisfactory result being obtained in two. 5. Persistent non-union results in partial absorption, displacement and fragmentation of the fragments, cyst formation in the navicular, and degenerative arthritic changes. Functional impairment was present in every case, but earning power was impaired in only 42 per cent. of the cases. 6. A psychiatric study of these patients revealed the personalities to be heterogeneous with no particular trait outstanding. In only six instances were there clearly discernible psychological factors related to the fracture or the veterans adjustment following the fracture. 7. The work capacity of these injured wrists, as determined by a specially designed recording ergograph, in cases with primary union showed little or no impairment. Only one of the fourteen wrists with non-union showed a normal work capacity. The ergographic tracing in the uncooperative patient was characteristic and proved to be an aid in detecting lack of cooperation.

Tendon Transplantations In The Lower Extremity: A Review of End Results in Poliomyelitis Ii. Tendon Transplantations at the Knee

Early tendon transplantations were confined to the foot following Nicoladonis original operation in 1881. The knee offered the next logical site for experimentation and Goldthwait in 1897 reported on successful sartorius transplants to strengthen weak quadriceps muscles. Subsequently all the thigh muscles, individually or in combination, have been so employed. In this end-result study we have evaluated thirty-eight patients in whom thirty-nine transplantations at the knee were done between 1922 and 1946 with an average followup of nine and two-tenths years. The subjective results were similar to those in other reports and were in general good, but on objective grounds the results were disappointing. Knee-extension power following tendon transplantation was rated fair or better in only 30 per cent. of the cases. Seven of twelve patients using braces preoperatively were enabled to discard their braces. Even in these apparently successful cases the effect of the tendon transplantation and of other operative procedures could not be evaluated separately. Comparison of the transplantation cases with control groups with similar patterns of muscle weakness leads us to draw certain important conclusions. The function of the extremity, as well as the ability to walk without apparatus, is dependent on a number of factors. There has been a tendency to assume that the most important factor is quadriceps or extensor power. Our study suggests that other factors are of equal importance. Good hip, posterior thigh, and calf musculature will permit excellent function, even when the quadriceps is paralyzed. On the contrary, the extremity with good quadriceps power and poor posterior musculature usually requires bracing. Good power in extension of the knee is less important in brace-free walking than is a stable foot and good posterior musculature. Tendon transplantation at the knee in some instances impairs function by the production of hyperextension deformities, dislocation of the patella, or lateral instability. Although a number of cases in this series have apparently been greatly benefited by muscle transplants, others must be rated as failure. The indications for tendon transplantation to improve extensor power of the knee are not easy to formulate. It is our belief that in the past such operations have been done too frequently. Poliomyelitis has been described as a subtractive disease, and ill-advised tendon transplantation at the knee in some instances is a subtractive operation.

Tendon Transplantations In The Lower Extremity: A Review of End Results in Poliomyelitis I. Tendon Transplantations about the Foot and Ankle

Early tendon transplantations were confined to the foot following Nicoladonis original operation in 1881. The knee offered the next logical site for experimentation and Goldthwait in 1897 reported on successful sartorius transplants to strengthen weak quadriceps muscles. Subsequently all the thigh muscles, individually or in combination, have been so employed. In this end-result study we have evaluated thirty-eight patients in whom thirty-nine transplantations at the knee were done between 1922 and 1946 with an average followup of nine and two-tenths years. The subjective results were similar to those in other reports and were in general good, but on objective grounds the results were disappointing. Knee-extension power following tendon transplantation was rated fair or better in only 30 per cent. of the cases. Seven of twelve patients using braces preoperatively were enabled to discard their braces. Even in these apparently successful cases the effect of the tendon transplantation and of other operative procedures could not be evaluated separately. Comparison of the transplantation cases with control groups with similar patterns of muscle weakness leads us to draw certain important conclusions. The function of the extremity, as well as the ability to walk without apparatus, is dependent on a number of factors. There has been a tendency to assume that the most important factor is quadriceps or extensor power. Our study suggests that other factors are of equal importance. Good hip, posterior thigh, and calf musculature will permit excellent function, even when the quadriceps is paralyzed. On the contrary, the extremity with good quadriceps power and poor posterior musculature usually requires bracing. Good power in extension of the knee is less important in brace-free walking than is a stable foot and good posterior musculature. Tendon transplantation at the knee in some instances impairs function by the production of hyperextension deformities, dislocation of the patella, or lateral instability. Although a number of cases in this series have apparently been greatly benefited by muscle transplants, others must be rated as failure . The indications for tendon transplantation to improve extensor power of the knee are not easy to formulate. It is our belief that in the past such operations have been done too frequently. Poliomyelitis has been described as a subtractive disease, and ill-advised tendon transplantation at the knee in some instances is a subtractive operation.

Heliox Use in the Treatment of Acute Hyperammonemia

The objective of this study was to evaluate a new method for the treatment of acute hyperammonemia with a helium-oxygen mixture (heliox). We conducted a prospective, randomized, controlled study of male Sprague-Dawley rats. Experimental hyperammonemia was induced by 7 days of a high-ammonia diet. Subsequently, the animals were randomly divided into two groups: the study group treated with heliox breathing for 24 hours and a control group breathing room air for 24 hours. A prospective, randomized, controlled laboratory animal study was conducted at an animal research facility. The baseline plasma ammonia level was 9.49 ± 10.96 μmol/L. After 7 days of a high-ammonia diet, the plasma ammonia level rose to 31.53 ± 8.86 μmol/L. There was a significant statistical difference between the plasma ammonia level following 24 hours of heliox therapy ( 23.14 ± 13.97 μmol/L) and the ammonia level in the control group (42.31 ± 24.25 μmol/L) (P < .05). Heliox breathing was found to be an efficient treatment modality for decreasing plasma ammonia levels in an animal model. Further studies are required to evaluate its potential application in the treatment of patients with hyperammonemia. (J Child Neurol 2001;16:456-458).

Effect of Elementary Phosphorus Upon the Epiphysis of the Albino Rat.

Summary and Conclusions Twenty-two albino rats were given small amounts of elementary phosphorus supplementary to an adequate diet. Roentgenograms taken before and during the experimental period demonstrated the development of an area of increased density in the subepiphyseal region. Histologic studies revealed a failure of resorption of the usual number of primary epiphyseal trabeculae. Since bone was deposited upon these persistent spicules in an otherwise normal fashion an apparent sclerosis was produced. Although the degree of ossification was distinctly greater than normal there was no evidence of direct stimulation of osteoblastic activity. The lesion was dependent entirely upon the unusual preservation of mineralized cartilage. It was thought that the persistence of these primary trabeculae was related to the influence of elementary phosphorus deposited in this region.