Mental development and growth in children with chronic liver disease of early and late onset

Comparison was made of the mental function and physical growth of 21 children in whom liver disease occurred in the first year of life with 15 patients with late (17 months of age to 12 years of age) manifestation of liver disease. Ages (mean +/- SD) at testing for the two groups was 8 +/- 3 years for the early group and 11 +/- 5 years for the late group. Wechsler verbal, performance, and full-scale IQ scores were lower for the early group (range of mean scores: early, 85 to 86 v late, 96 to 103). Growth measures were significantly different in the two groups. Means +/- SD (percentage of standard) were: length for early group, 92 +/- 9; for late, 99 +/- 7; and head circumference for early, 98 +/- 4; for late, 101 +/- 2. The groups were similar in severity of liver disease and acute nutritional status, however. Patients with intellectual impairment had a longer duration of illness, poor nutritional status, and vitamin E deficiency; 82% of impaired patients were in the early group. The data suggest that liver disease during early life has pernicious effects on intellectual function and linear growth. Careful monitoring of nutritional status of children with early-onset liver disease and aggressive nutritional support beginning at the time of diagnosis may help reduce delays in growth and mental development.

Epithelial restitution in the large intestine of the rat following insult with bile salts

In situ loops of large bowel of anaesthetised rats were used to observe epithelial restitution following surface desquamation using solutions of bile salts. The treatment induced complete surface desquamation but no disruption of the basal lamina. There was evidence of, cell migration at 30 min, and a complete surface epithelium two h post treatment. Neither a continuous contact between migrating cells and the basal lamina, nor a complete covering of secreted mucus, appeared necessary for epithelial restitution to occur.

Mental and motor development correlates in patients with end-stage biliary atresia awaiting liver transplantation

We measured mental and motor development in 27 infants and 14 children with end-stage biliary atresia who were awaiting liver transplantation, and we measured disease-related variables (physical growth, liver function, and severity and duration of disease) that may relate to development. We then determined the relationship between development and the disease-related variables. Infants were assessed with the Bayley scales, and children were assessed with the Stanford-Binet scales of intelligence and the Minnesota Child Development Inventory. The mean +/- SD mental and motor scores for infants were 79.5 +/- 19.6 and 69.7 +/- 17.6, respectively. The mean +/- SD IQ and motor development scores for children were 76.1 +/- 16.6 and 56.9 +/- 18.1, respectively. For infants, mental and motor development were related significantly to height and weight (r values ranged from .42 to .72). Mental development in infants was also related significantly to serum vitamin E levels (P = .03). Multiple regression analyses combining growth and disease-related indices predicted 70% of the variance in mental and motor development in infants (P = .001). For children, development was related to measures of liver function (ie, to serum bilirubin, r = -.51, P = -.08, and to serum albumin, r = .54, P = .06) but not to growth. Careful nutritional support during infancy and aggressive management of liver disease prior to transplantation may be important in optimizing the development of children with biliary atresia who subsequently undergo liver transplantation.

Eating behavior and plasma beta-endorphin in bulimia

To study the possible role of plasma beta-endorphin in bulimia, we measured plasma beta-endorphin immunoreactivity in 34 female patients with normal-weight bulimia and 34 normal female controls matched for weight as percent of ideal. Plasma beta-endorphin immunoreactivity in bulimics (mean 59.6 pg/ml; SEM 5.6) was significantly lower (p less than 0.05) than in controls (mean 79.5 pg/ml; SEM 8.5). Within the bulimic group, plasma beta-endorphin immunoreactivity correlated inversely with severity of bulimic symptomatology as measured by the Eating Attitudes Test Bulimia Subscale (p less than 0.05). Endorphin level did not correlate with severity of depression or with percent ideal body weight. Abnormalities in opioid metabolism may be implicated in eating disorders and account for the addictive properties of these disorders.

Perspectives on patient noncompliance

Patient noncompliance can sabotage the best clinical efforts to provide effective treatment. Psychiatrists consulting in a medical setting can promote patient compliance by using insights from four conceptual models of psychiatry: medical, psychodynamic, behavioral, and social. The authors describe the models and illustrate their clinical application with examples from their work with diabetic patients.

Recognizing and managing the adolescent with Kleine-Levin syndrome

This report calls attention to the Kleine-Levin Syndrome, a sleep disorder which predominantly occurs in adolescent males. It can easily be mistaken for other psychiatric or neurologic illness. Differential diagnosis and treatment are discussed.

Acute psychosis complicating induction therapy for acute lymphoblastic leukemia

Two adolescents with acute lymphoblastic leukemia developed acute psychotic episodes shortly after induction therapy, which included prednisone, was begun. Symptoms included regressive behavior, incontinence, fluctuating levels of activity, and delusions. Both patients regained normal mental status after a number of weeks. Treatment included tapering of steroid dosage, introduction of a highly structured environment, and early use of chlorpromazine. Psychosis persisted beyond discontinuation of steroid therapy, but both patients subsequently received steroids after return of normal mentation, and in neither did psychosis recur.

Coping with poor prognosis in the pediatric intensive care unit. The Cassandra prophecy

The intensive-care pediatrician who prophesies to parents that their child's illness is irreversible may encounter denial and hostility. The physician may compare his plight to that of Cassandra--the mythical Greek prophetess of doom, who was cursed to see into the future and not be believed. Four cases are reported in which parents rejected their child's hopeless prognosis, counterprophesied miraculous cures, resolved to obtain exorcism, criticized the care, or accused nurses of neglect. This produced a painful breakdown in the usually harmonious relationships between doctors, nurses, and parents. Parental denial as a coping mechanism is discussed. Guidelines are presented for the prevention and/or early recognition and management of the Cassandra Prophecy phenomenon. A miraculous recovery in one case is a potent reminder to physicians and nurses that they do not have the gift of divine prophecy and cannot see with certainty into the future.