Volume 96, Issue 5

The effect of gentle, soft tissue manipulation in the suboccipital region on digital blood flow, as a measure of sympathetic nervous system activity, was studied. Digital strain gauge plethysmography was used to measure the changes in pulse contour during (1) a normative test period with the subject in the supine position, (2) after a control interval (placebo) during which the investigator placed his hands under the suboccipital region, and (3) after an interval during which the investigator's fingers applied slow, steady, circular kneading in the suboccipital triangle region. Twenty-five studies were performed in a crossover design with the patient as his or her own control. Total pulse amplitude (Y) and the height from the dicrotic notch to the peak (X) were measured. Examination of the total data of all subjects revealed the occurrence of a significant change in X and Y with simply touching the suboccipital region with the hands. An even more favorable response ensued when suboccipital manipulation was applied. Those subjects reporting comfort or neutral responses had larger significant changes with manipulation when compared with the group reporting the experience as uncomfortable. The response within each group suggests that favorable autonomic changes (sympathetic dampening) occur with specific suboccipital manipulation as well as, indeed, the simple touching of the suboccipital triangle.

The author provides practitioners with a summary of recent trends in the management of acute pain in children. This review encompasses pharmacologic techniques as they pertain to two common acutely painful conditions in children: postoperative and procedural pain. In the area of postoperative analgesia, reviewed are the use of regional anesthesia, spinal opioids, antagonists, preemptive analgesia, and patient-controlled analgesia. In the area of procedural pain, current standards for safety guidelines and several recently introduced sedative and analgesic medications are discussed. The author emphasizes that the proper and safe alleviation of acute pain in the pediatric population is not only feasible but is currently the standard of care in the United States.

Musculoskeletal problems account for the majority of initial complaints attended to by primary care physicians. It is likely that a child who eventually has juvenile rheumatoid arthritis diagnosed will initially be evaluated by a family physician or a pediatrician. Primary care physicians will play an increasingly important role in management of juvenile rheumatoid arthritis, as the availability of specialists in many communities is limited, and access to them may be further limited by managed care initiatives. This article offers a brief review of the definition and classification of juvenile rheumatoid arthritis and introduces a diagnostic algorithm to provide a simplified approach toward evaluating children with arthritis. Treatment and outcomes are summarized in text and graphic formats.

To determine if primary care physicians have been adhering to guidelines set forth by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report Guidelines for the Diagnosis and Management of Asthma, the author gauged the use of peak flow meters in a hospital family training program. Specifically investigated were the physicians' response to results from the peak flow meters and their prescribing practices regarding the beclomethasone dipropionate metered-dose inhaler. Overall, the use of peak flow meters among the 20 patients included in this study averaged 70%, up from 10% in earlier studies. Similarly, 45% of these patients received prescriptions for beclomethasone metered-dose inhalers with spacer devices. Although these results appear to indicate that physicians are following the aforementioned guidelines, the author cautions that the peak expiratory flow rate measurement is not a perfect indication of asthma severity. Likewise, the spacer devices are not indicated for all patients with asthma who are taking inhaled corticosteroids. Finally, the author emphasizes that anti-inflammatory agents should be effectively used when indicated.

A 49-year-old man was seen with an unusual complication of diverticulitis-a giant sigmoid diverticulum. This patient had undergone an extensive workup during a 5year period, ranging from multiple extensive gastroenterology evaluations and procedures to an eventual psychiatric evaluation to rule out the possibility of a functional cause for his chronic, intermittent abdominal pain. Later, an accurate diagnosis of a giant sigmoid diverticulum resulted in an en bloc resection of the sigmoid colon and cyst. The patient had an uncomplicated recovery with no return of his previous symptoms. The authors review the many proposed causes of the giant sigmoid diverticulum and possible differential diagnoses. Initially, the diagnosis is usually missed as plain roentgenograms, upper and lower gastrointestinal x-ray studies, and computed tomography scans generally show no abnormality. Management methods are also discussed.

Renal cell carcinoma is known to metastasize to many different organ systems. Lung and bone are clearly the most common sites of metastasis, but the symptoms at presentation may simulate those of other diseases of the organ system involved. The patient with metastatic renal cell carcinoma described here had symptoms of acute cholecystitis.