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Hypertrophic osteoarthropathy (HOA) is a syndrome characterized by digital clubbing, arthralgias, and tissue swelling and is frequently described in association with bronchogenic carcinoma. The associated pain can be disabling, and symptoms are often resistant to conventional analgesic medications. We present a patient with HOA of the lower extremities and wrists that developed after bronchogenic carcinoma. The pain and swelling completely resolved after a single administration of 4 mg of zoledronic acid. The proposed pathogenesis of HOA and the mechanisms by which bisphosphonates might alleviate symptoms are reviewed.

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OBJECTIVE: To assess the relative contribution of potential risk factors for adverse neurobehavioral outcomes in children referred for evaluation of sleep-disordered breathing (SDB), including weight, mean sleep duration, and comorbid sleep disorders. DESIGN: Medical record review. SETTING: Academic pediatric medical center. PARTICIPANTS: Clinical sample of 235 children aged 3 to 18 years undergoing overnight polysomnography for symptoms of SDB. OUTCOME MEASURES: History of behavioral, emotional, and academic problems and Child Behavior Checklist (CBCL) scores. RESULTS: More than half (56%) of the sample was overweight or at risk for overweight, more than one-third (36%) was classified as being short sleepers, and almost half (49%) had at least 1 additional sleep diagnosis. Forty-seven percent had a history of behavioral problems and 23% had a reported diagnosis of attention-deficit/hyperactivity disorder. There were no significant differences in CBCL scores based on any measure of SDB disease severity. Increased weight was associated with increased internalizing CBCL scores in a dose-dependent fashion (P = .003), while short sleepers were more likely to have elevated externalizing scores (P < .001). Overall, the strongest predictor of adverse behavioral outcomes was the presence of at least 1 additional sleep diagnosis (P < .001). CONCLUSIONS: The relationship between SDB and parent-reported behavioral outcomes in children is complex. In addition to SDB-related impairments, clinicians should consider the relative contributions of being overweight, insufficient sleep, and comorbid sleep disorders when assessing behavior in these children.

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BACKGROUND: Peripherally inserted central catheters (PICC) are common venous access devices. Clinical conditions and therapies that increase the risk of PICC-associated thrombosis have not been studied. METHODS: We performed a retrospective case-control analysis of all adult patients who underwent placement of a PICC at our hospital over a three-year period (n = 1296). Clinical variables examined were indication for PICC placement, active cancer treatment, history of DVT, diabetes mellitus, and use of prophylactic anticoagulation. RESULTS: The overall incidence of PICC-associated DVT was 2% (n = 27). Active cancer therapy was significantly associated with PICC-associated DVT (OR 3.5, 95% CI 1.3-9.8). The use of prophylactic anticoagulation did not reduce this risk. CONCLUSIONS: Patients who suffered a PICC-associated DVT were more likely to be undergoing treatment for cancer. This risk was not lowered by the use of prophylactic anticoagulation. These results suggest a need for prospective studies on effective anticoagulation for patients at high risk for PICC-associated DVT.

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UNLABELLED: Many tests are used to assess nociception in laboratory animals. The objective of this study was to compare morphine potency across tests. Rats were injected with saline or morphine (1-20 mg/kg SC), and nociception was assessed 15-20 min later. A consistent definition of antinociception-a change in response greater than 4 times the standard deviation above the mean for the saline-treated controls-was used to compare morphine potency on different tests. These data revealed 4 things. 1) Morphine potency was greatest on the paw pressure, hot plate, and tail withdrawal tests and lowest on the formalin test. 2) Stimulus intensity had no effect on morphine potency on the hot plate (ED50 = 4.5, 2.8, and 2.6 mg/kg for 49 degrees C, 52 degrees C, and 55 degrees C tests, respectively) or tail withdrawal tests (ED50 = 2.9 and 2.6 for 48 degrees C and 52 degrees C water, respectively). 3) Assessment of morphine potency using a within-subjects cumulative dosing procedure resulted in lower ED50 values compared to data collected using a between-subjects design (hot plate: 2.6 vs 4.9; tail withdrawal: 2.6-2.9 vs 5.7 mg/kg). 4) Adjusting the cutoff value from 4 to 5, 6, 7, and 8 standard deviations greater than the mean resulted in a progressive increase in ED50 values. These data demonstrate that morphine potency is dependent, in part, on the nociceptive test even when all other factors (eg, species, strain, age, gender, and cutoff value) are held constant. PERSPECTIVE: The ability of morphine to block nociception is influenced by many factors. The present study shows that the test used to assess nociception, but not the stimulus intensity, can have a dramatic effect on morphine potency. This finding shows that morphine potency varies depending on how pain is assessed.

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