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Tick paralysis syndrome (TPS) is an uncommon cause of ascending paralysis in children. Familiarity with its clinical features is important, since prompt diagnosis and removal of the tick is curative. We report the case of a 5-year-old girl with TPS manifested as lower extremity ataxia and paralysis and briefly discuss the salient features of TPS.

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To determine if routine, noninvasive parameters could be measured which predict early (4-6 hour) discharge from the emergency department (ED) in mildly symptomatic and asymptomatic victims of childhood near-drowning, a retrospective cohort study was undertaken. Patients with fresh water near-drowning were studied over a 3-year period who presented with Glascow Come Scale (GCS) > or =13 and required no advanced life support prior to or < or =4 hours after ED presentation. Three groups of patients were found: 39 patients (81%) had normal pulmonary examination (PEx) and normal room air oxygen saturation (RASaO2) by 4 to 6 hours and did not deteriorate during the hospital admission (<24 hours); 5 patients (10%) had normal PEx by 4 to 6 hours and RASaO2 by 8 to 12 hours and did not deteriorate during hospitalization (<24 hours). Four patients (8%) were hospitalized for more than 24 hours. No patient with normal RASaO2 at 6 hours deteriorated while in the hospital (CI 92.3-100%). Children who present to the ED with GCS > or =13 and have normal PEx/respiratory effort and RA-SaO2 more than 95% at 4 to 6 hours after ED presentation can be safely discharged home.

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Nebulized beta 2-receptor agonists may cause neutrophil demargination and result in misleading total circulating leukocyte counts (WBCs) in patients with acute bronchospasm. Varying underlying adrenergic stimulation in these patients also makes interpretation of these data difficult. This study examined the direct effect of these agents on the measured WBCs of healthy adults without evidence of bronchospasm or illness. A prospective, blinded, randomized study of 30 healthy volunteers (aged 18-50 years) was performed in a controlled environment. Subjects were excluded if they were pregnant, had a known underlying medical disorder or have had a prior reaction to albuterol or similar medications. Participants in the study were given either a nebulized albuterol treatment or nebulized normal saline (control group). Leukocyte counts were then obtained before and after treatments. Paired data were analysed using a one-tailed t-test while considering an increase of 40% in WBCs to be significant, P = 0.05, and beta = 0.10. Mean leukocyte counts were 5.9 (+/- 1.2) before treatment as compared to 6.0 (+/- 1.3) after albuterol nebulization. Using the coefficient of variance of WBCs in normal humans as c. 50% (6000 +/- 3000 cells mm-1) we were unable to demonstrate a significant difference in variation in post-nebulized leukocyte counts between the control group and the nebulized albuterol group. While there is concern that the treatment of patients experiencing acute bronchospasm with beta 2 agonists may result in factitious elevations in peripheral leukocyte counts, were found no direct effect of these agents on measured counts in normal subjects.

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Studies were conducted to examine the effects of low, yet physiologically relevant, temperatures on murine T lymphocyte responses. Akin to ectothermic vertebrate responses, lectin-induced murine T cell proliferation was previously shown to be ablated at temperatures 10 degrees C below optimal (i.e. 27 degrees C); responsiveness at 27 degrees C was restored by the addition of oleic acid (18:1). The aim of the present study was to address the mechanism involved in such low temperature suppression. Murine splenic CD4+ T lymphocytes stimulated with either alpha CD3 or SEB exhibited cell death, as opposed to anergy, at 27 degrees C. However proliferation was observed in the presence of 18:1. Thus low temperature-suppression of murine CD4+ T cells is also mediated through TCR and/or CD3 pathways. Additional studies examining the temporal effects of adding 18:1, as well as temperature shifts, indicated that the cell death induced by stimulation at low temperature was preventable by 18:1.

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A study was conducted to compare the presenting complaints and historical information of adolescents diagnosed as pregnant (DP) in the emergency department (ED) with adolescents seen in the ED who were pregnant and not diagnosed (MP). Medical records for the period 1980-94 were retrospectively analyzed to identify patients 16 years of age or younger who were diagnosed as pregnant in the ED or who had a live birth and had an ED visit during pregnancy. This analysis was done in a university-affiliated tertiary referral hospital with approximately 65,000 ED visits and 3,500 deliveries each year. The DP patients had complaints referable to the abdomen or genitourinary system more commonly than the MP patients (91% v 22%). Less than 10% of the DP patients mentioned the possibility of pregnancy at initial triage, 10.5% denied being sexually active, and 5% had a pelvic examination and sexually transmitted disease screening; 68% of MP patients did not have sexual or menstrual history documented, and 5% had a pelvic examination. The diagnosis of pregnancy can be a challenge in patients who present to a busy ED with complaints that are not necessarily suggestive of pregnancy. Historical information regarding menses and sexual activity is either not obtained or is incomplete or inaccurate. We recommend a low threshold for the consideration of pregnancy in adolescents irrespective of the presenting complaint.

PIP: A retrospective study was performed at a tertiary care hospital in Mississippi to compare the emergency room (ER) presenting complaints during 1980-1994 of the 171 pregnant adolescents 16 years old and younger whose pregnancies were diagnosed with the 100 whose pregnancies were not diagnosed. Data were collected from the medical records of those diagnosed as pregnant and from the 2945 records available of the 4125 patients under 16 who delivered babies at the hospital during the same period. It was found that 100/2945 were seen in the ER while pregnant but the pregnancy was not diagnosed. It was found that 91% of the pregnancy diagnosed patients versus 22% of the missed diagnosis patients had complaints relating to the abdomen or genitourinary system. Less than 10% of the diagnosed patients indicated the possibility of pregnancy at the initial examination, and 10.5% denied being sexually active. No sexual or menstrual history was documented for 68% of the missed diagnosis patients, and 5% of each group had pelvic examinations. No significant differences were found for patient age or demographics, gestation at ER visit, or gestation at delivery. In 30 cases of missed diagnoses (all with gestation at 8 weeks or more), 23 presented with abdominal, genitourinary, or mammary complaints, and 7 presented with drug overdoses. In 22 patients, diagnosis was missed even though the pregnancy was at 22 weeks gestation or more. One extraordinary case involved a 14-year-old who was admitted for treatment of a gunshot to the head. Her pregnancy was not diagnosed until her second follow-up visit after a lengthy hospital stay (gestation was 30 weeks at ER presentation). Because many treatments are modified by pregnancy, it is recommended that pregnancy be assumed in all females of child-bearing age presenting to the ER with consideration given to degree of sexual maturity.

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Foreign body aspirations in children are relatively uncommon occurrences, but they can be a serious events, causing respiratory distress, atelectasis, chronic pulmonary infections, or death. Safety pins are not commonly aspirated objects and account for less than 3% of all foreign bodies found in the tracheobronchial tree. Fewer than 2% of patients require thoracotomy, and most aspirated materials can be removed by bronchoscopy, with low morbidity and mortality. A discussion of airway foreign bodies follows the presentation of a case of an older child who aspirated a safety pin, which required open thoracostomy for removal.

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Intervertebral disk calcification in children can result in a syndrome of neck pain, muscle spasm, and torticollis. Usually the clinical course is benign with spontaneous recovery; however, occasionally nerve root or spinal cord compression can be seen. We report a seven-year-old patient with symptomatic cervical disk calcification and briefly discuss the salient clinical and radiographic features.

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Slipped capital femoral epiphysis (SCFE) is a fairly common condition affecting older children and adolescents, and has the potential for long-term, crippling sequelae. Early recognition is the single most important controllable factor, but the diagnosis is often missed or delayed, resulting in progression of the slip. A SCFE should be suspected and promptly evaluated in any older child or adolescent presenting with a limp or complaints of hip, groin, thigh, or knee pain, especially if the patient is overweight. The diagnosis is usually made by anteroposterior and frog-leg lateral radiographs of the hips. Common errors at initial presentation include: not obtaining hip radiographs (due to either no hip pain or the lack of an impressive history and physical findings); misreading hip radiographs (the findings can be subtle); and lack of timely referral. Early involvement of and treatment by an orthopedic surgeon can greatly reduce the potential complications. We present three cases of SCFE that highlight common errors made at initial presentation, and a discussion that includes the differential diagnosis of an older child or adolescent with a painful limp.

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This paper describes a defined serum-free medium (SFM), designated A-X, which supports in vitro proliferation of human primary T cells stimulated with mitogens, two-way mixed leukocyte reactions, anti-CD3, and a superantigen. A-X is a 1:1 mixture of two commercially available SFM, AIM V and EX-CELL 300. In each assay tested it supported uptake of [3H]thymidine as well as or better than the standard culture medium, namely RPMI 1640 supplemented with 10% fetal calf serum. A-X also allowed the detection of interleukin-2 by ELISA at levels comparable to those produced in serum-supplemented medium. A-X will likely be useful in further studies as it eliminates many of the problems usually associated with the use of serum-supplemented media.

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Henoch-Schönlein Purpura (HSP) is a common, usually self-limited, vasculitis affecting children and young adults. Manifested by a characteristic rash, the course of HSP is typically a benign one, but may be accompanied by varying degrees of abdominal pain, arthritis or arthralgia, gastrointestinal bleeding, and nephritis. The various manifestations of HSP may present at any stage during the illness and mimic other disease processes, some of which may be life threatening. Thus, the emergency physician must consider the diagnosis of HSP in order to detect complications and avoid needless intervention in what usually is an otherwise benign process. We present four cases and a brief review of the literature to highlight HSP in the differential diagnosis of patients who present with any of the typical clinical signs and symptoms.

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