Clonidine therapy for comorbid attention deficit hyperactivity disorder and conduct disorder: preliminary findings in a children's inpatient unit

This retrospective study examined the clinical course of 18 prepubertal boys (aged 6 to 12) who had dual diagnoses of attention deficit hyperactivity disorder and conduct disorder and who received clonidine on an inpatient basis after failed trials of conventional drug therapy, consisting predominantly of psychostimulants. The effects of clonidine were assessed during inpatient treatment and after discharge at intervals of 1 to 2 months. Eleven (61%) of the children had marked improvement as measured by clinical impression. Transient sedation lasting 2 to 3 days occurred after initial administration or dosage increase; otherwise, clonidine was well tolerated. Our findings suggest that clonidine may prove to be an alternative treatment of comorbid attention deficit hyperactivity disorder and conduct disorder.     

The primary aortoenteric fistula in The Netherlands--the unpublished cases

OBJECTIVE: Primary aortoenteric fistula is a rare disorder of which only four patients have been reported in the Dutch literature so far. The objective of our study was to obtain more realistic figures on the incidence of this condition, with data on the clinical presentation, diagnostic procedures, treatment and results in a group of patients not previously reported as "case histories". METHODS: A questionnaire was sent to all surgical clinics in The Netherlands. Out of 180 questionnaires, 102 have been returned reporting 27 patients to which data of eight others treated in our own institution were added. RESULTS: In all but one of these 29 patients the fistula was caused by an atherosclerotic aneurysm, the one exception being caused by an ingested cocktail pin. Gastrointestinal haemorrhage was the predominant symptom, being present in 28 of the patients, while the complete triad of haemorrhage, pain and a pulsating mass was found in only eight patients. Twenty-seven patients were treated with an in situ graft of which 14 are doing well at long term follow-up. CONCLUSIONS: Primary aortoenteric fistula is far more common than one would expect from the number of patients reported in literature. A high index of suspicion based on a complete physical examination remains the key to a correct diagnosis. Direct closure of the intestine and in situ grafting of the aorta is the treatment of first choice.     

Recognition of depressed affect in hospitalized psychiatric patients: staff and patient perceptions

A comparison of self-report vs. observer rating of depressed mood in a heterogenous inpatient population revealed wide variations in concordance among diagnostic groups. Patients diagnosed as having Affective Psychosis and "Other' illnesses showed the highest correlation between four self-report scales and an observer rating scale. Patients with a diagnosis of depressive Neurosis showed only modest correlation, while Schizophrenics revealed no significant correlation, on these instruments, suggesting inconsistent communication of affect from Schizophrenic patients to observers. In contrast, when self-report scales were intercorrelated, patients in all four diagnostic categories showed highly significant correlations, indicating that they were consistently reporting their affective state on these instruments. The implications of these findings for future research as well as for practical clinical management are discussed.     

Reconstruction and quantification of the carotid artery bifurcation from 3-D ultrasound images

Three-dimensional (3-D) ultrasound is a relatively new technique, which is well suited to imaging superficial blood vessels, and potentially provides a useful, noninvasive method for generating anatomically realistic 3-D models of the peripheral vasculature. Such models are essential for accurate simulation of blood flow using computational fluid dynamics (CFD), but may also be used to quantify atherosclerotic plaque more comprehensively than routine clinical methods. In this paper, we present a spline-based method for reconstructing the normal and diseased carotid artery bifurcation from images acquired using a freehand 3-D ultrasound system. The vessel wall (intima-media interface) and lumen surfaces are represented by a geometric model defined using smoothing splines. Using this coupled wall-lumen model, we demonstrate how plaque may be analyzed automatically to provide a comprehensive set of quantitative measures of size and shape, including established clinical measures, such as degree of (diameter) stenosis. The geometric accuracy of 3-D ultrasound reconstruction is assessed using pulsatile phantoms of the carotid bifurcation, and we conclude by demonstrating the in vivo application of the algorithms outlined to 3-D ultrasound scans from a series of patient carotid arteries.     

Macroinvertebrate assemblages of littoral habitats in the Macquarie and Mersey rivers,Tasmania: Implications for the management of regulated rivers

Littoral habitats in large rivers are influenced to varying degrees by changes in discharge. Irrigation abstractions can increase the amount of habitat that would naturally be dewatered during low flow periods and therefore it is important to have some knowledge of the potential impact this may have on riverine macroinvertebrates. The macroinvertebrate assemblages of common littoral habitats in riffles, pools and runs in two reaches each of the Macquarie and Mersey Rivers, northern Tasmania, Australia were compared from samples collected during the low flow and irrigation season, between December 1991 and April 1992. The area under water of these habitats, riffle substrata, macrophyte beds and coarse woody debris, responded differently to changes in discharge. Within a reach, the same taxonomic groups often dominated the total number of macroinvertebrates for all habitats, but there were differences in the proportions contributed by these taxa to the different habitats. In general, taxa characteristic of slow-flowing or lentic habitats, such as ostracods and amphipods, were dominant in macrophyte beds in pools and runs, whereas taxa such as larval elmid beetles and hydropsychid caddisflies were dominant in riffles. A substantial component of the fauna from each habitat within a reach was unique to that habitat, but there was always a similar number of taxa common to all habitats. Classification and ordination grouped samples from both rivers firstly by habitat and secondly by month and reach. Total density and family richness of invertebrates differed by reach, habitat and month in both rivers, except for richness in the Mersey River where habitat was not significant. Differences in densities and numbers of invertebrate families among habitats were not consistent between reaches for each river. This study has highlighted the differences in macroinvertebrate assemblages of several littoral habitats in two lowland rivers in Tasmania. Differences in taxonomic composition, density and richness among habitats within reaches strongly imply the uniqueness of these habitats in terms of the invertebrate faunas that occupy them. We suggest that if maintenance of biotic diversity is an aim of instream flow management, water allocations that address low flows should place a high priority on the maintenance of a diversity of habitats.     

Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines

CONTEXT: Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs, but the length of time until a patient hospitalized with pneumonia becomes clinically stable has not been established. OBJECTIVE: To describe the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability. DESIGN: Prospective, multicenter, observational cohort study. SETTING: Three university and 1 community teaching hospital in Boston, Mass, Pittsburgh, Pa, and Halifax, Nova Scotia. PATIENTS: Six hundred eighty-six adults hospitalized with community-acquired pneumonia. MAIN OUTCOME MEASURES: Time to resolution of vital signs, ability to eat, mental status, hospital length of stay, and admission to an intensive care, coronary care, or telemetry unit. RESULTS: The median time to stability was 2 days for heart rate (< or =100 beats/min) and systolic blood pressure (> or =90 mm Hg), and 3 days for respiratory rate (< or =24 breaths/min), oxygen saturation (> or =90%), and temperature (< or =37.2 degrees C [99 degrees F]). The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition. Patients with more severe cases of pneumonia at presentation took longer to reach stability. Once stability was achieved, clinical deterioration requiring intensive care, coronary care, or telemetry monitoring occurred in 1% of cases or fewer. Between 65% to 86% of patients stayed in the hospital more than 1 day after reaching stability, and fewer than 29% to 46% were converted to oral antibiotics within 1 day of stability, depending on the definition of stability. CONCLUSIONS: Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence-based estimate of optimal length of stay, and outline a clinically sensible approach to improving the efficiency of inpatient management.