To the Editor: Sleep disordered breathing (SDB) is underdiagnosed in children and difficult to differentiate from attention deficit hyperactivity disorder (ADHD). Both may present with similar symptoms of inattention, hyperactivity, irritability, and daytime sleepiness. Sleep disordered breathing includes primary snoring or obstructive sleep apnea, which are surprisingly common among children with hyperactivity. Adenotonsillar hypertrophy is the primary cause of obstructive sleep apnea between the ages of 2 and 8 years, coinciding with the age onset of ADHD, thus creating a difficult differential diagnosis. Sleep in these cases may be adequate in duration, but fragmented with frequent arousals that result in daytime dysfunction. Intermittent hypoxia during apnea causes inflammatory vascular changes in the brain, resulting in neurocognitive dysfunction, while sleep fragmentation causes inattentiveness. Approximately 25% of children with signs of ADHD also have evidence for SDB; about 28% of those scheduled for adenotonsillectomy exhibit criteria for ADHD (vs 7% for surgical controls). At 1 year post-adenotonsillectomy, 50% of them no longer meet the criteria for ADHD. Among adenotonsillectomy subjects with ADHD symptoms, 78% no longer evidenced ADHD after 6 months. Significant snoring is reported to be 2 times more common in children with ADHD than in other pediatric populations. It is important to screen for SDB in children who present with hyperactivity and/or inattention. Children with ADHD-like symptoms should be screened for signs of sleep disorders, such as snoring, apneas, and/or awakenings accompanied by gasping. When SDB is suspected, assessment includes a history, physical examination, X-ray of the neck, and fiberoptic endoscopy to rule out adenotonsillar hypertrophy. Polysomnography is the definitive means to diagnose SDB. Since SDB is rarely suspected in hyperactive children, detailed screening and diagnostic evaluation are critical. Psychostimulant treatment of a child with SDB may result in more sleep disturbance and dysfunctional behavior.
Pentazocine is a mixed agonist/antagonist opioid analgesic agent that can induce an atypical myopathy following intramuscular injections. This iatrogenic myopathy is rare, typified by fibrosis, and should be differentiated from other myopathies. We describe a case of pentazocine-induced myopathy that caused wasting of musculature in the gluteal region bilaterally and stiffness and woody induration in the legs of 42-year-old man. Though rare, clinicians should be alerted to this potential side effect and avoid repeated administration of intramuscular pentazocine.
In this chapter the treatment of psychiatric disorders are reviewed including antidepressants, mood stabilizers, antianxiety agents, antipsychotics, psychostimulants, hypnotics, sedatives, electroconvulsive therapy, vagal nerve stimulation, psychotherapy, repetitive transcranial nerve stimulation (rTMS), vagal nerve stimulation and self-help groups
Article AbstractAdulteration of cocaine with levamisole is common and can induce serious medical complications. Levamisole is an antihelminthic agent originally approved as an immunomodulator in the treatment of autoimmune disorders and as a chemotherapy adjunct. It was withdrawn from the US market in 2000 but is available in veterinary medicine. Cocaine-using patients may present with nonspecific constitutional symptoms, cutaneous eruptions, leukopenia, vasculitis, and organ damage. Skin manifestations may include severe necrosis, especially of the ear lobes. Here, a case of levamisole toxicity is presented and treatment options are discussed.
Article Abstract†‹†‹Because this piece does not have an abstract, we have provided for your benefit the first 3 sentences of the full text.To the Editor: Sudden unexpected death in epilepsy (SUDEP) occurs sometimes in people with ictal disorders. The diagnosis does not require evidence of a seizure and excludes status epilepticus as a cause of death. The postmortem examination must not reveal any toxic or anatomic pathology, and death must not be due to trauma or drowning.
