going chronic hemodialysis and were refractory to very large doses of orally administered antihypertensive agents. The third child is a 7-year-old girl who had hypertensive encepha¬ lopathy and azotemia at age 6. She was found to have bilateral hypoplastic kidneys and high renal-vein renin levels, and she was refractory to all antihypertensives and diuretics used except diazoxide, which she required frequently. Minoxidil was given, and she has remained an outpatient for 20 months with satisfactory control of blood pressure, slight improvement of renal function, continuing growth, and full participation in school and play activities. Minoxidil is usually used with one or more antihypertensive, beta-adrenergic blocking or diuretic agents. Its major side-effect is rather striking hypertrichosis. Though unfortunate,
this side-effect is tolerable consid¬ ering the rehabilitation that is achieved. It should also be noted that reduction of blood pressure occurs in patients with or without elevated re¬ nin levels. It is possible that with control of hypertension Dr. Siegler's patient would have had healing of the renal hypertensive arteriolitis and im¬ provement of renal function. With the use of minoxidil and other potent
antihypertensives, nephrectomy may be necessary in very few patients and hopefully never in those with ade¬ quate residual renal function. ANDREW J. ARONSON, MD Department of Pediatrics The University of Chicago La Rabida Children's Hospital East 65th Street at Lake Michigan
Chicago, IL 60649
1. Aronson AJ, Kallen JR: The efficacy of minoxidil in the outpatient management of accelerated nephropathic hypertension, abstracted. Presented in program of the Midwest Society for Pediatric Research Meeting, Pittsburgh, 1973. 2. Makker S: Treatment of high renin refractory hypertension in children with minoxidil: A new hypertensive drug not previously used in children, abstracted. Pediatr Res 8:458, 1974. 3. Chandra M, Exeni M, McVicar N: Minoxidil control of high renin refractory hypertension in a child. Read before the Third International Symposium of Pediatric Nephrology, Washington, DC, 1974.
In Reply.\p=m-\Thepoints raised in the letter of Dr. Aronson are certainly important and deserve emphasis. Bilateral nephrectomy is undeniably a drastic measure and should only be considered for those whose hyperreninemic hypertension is re-
fractory to medical management. I certainly wish that we had had minoxidil to use for our patient. Since then, pediatric experience with minoxidil has increased, though the total number of published cases is still relatively small. I, too, have recently used this experimental agent to successfully treat two pediatric patients with refractory hypertension. One patient had chronic interstitial nephritis from vesicoureteral reflux and the other had experienced a recurrence of the
In addition, those patients who have ingested large amounts and those for whom follow-up care or home surveil¬ lance is inadequate, even if asympto¬
matic, should also be admitted for ob¬ servation and early detection of pulmonary or cardiac complications.2 Therefore, to send this child home on a regimen of antibiotics, in the face of verified pulmonary involvement, was, I
think, inappropriate
ment, and should
standard
care.
CHRIS HOLMES, MD
hemolytic-uremic syndrome.
Even so, I doubt that minoxidil will turn out to be a hypertensive panacea. I suspect, therefore, that bilateral nephrectomy will still have to be considered for the occasional patient. But hopefully, the need for such an extreme measure will be rare indeed now that minoxidil is available. RICHARD L. SIEGLER, MD Department of Pediatrics University of Utah
Medical Center 50 N Medical Dr Salt Lake City, UT 84132
Pneumatoceles
Following Hydrocarbon Ingestion
Sir.\p=m-\Thearticle by Bergeson et al, which appeared in the January issue of the Journal (129:49, 1975), was a fine discussion of the stated problem.
The management of their first case however, suboptimal in my opinion. This 20-month-old boy ingested lighter fluid. He choked, coughed, vomited after ingestion, and was seen in the emergency room that night. He was sent home after a normal chest roentgenogram had been obtained. He was seen in the outpatient clinic the next day with fever, "harsh breath sounds," and "right middle lobe and left lower lobe infiltrates." At this point he should have been admitted to the hospital. Instead, he was given ampicillin sodium and sent home. The authors themselves point out that "pleural effusion, pneumothorax, pneumomediastinum, subcutaneous emphysema, and pneumopericardium have been encountered as complications of hydrocarbon ingestion" (p 51). Others have reported serious cardiac complications following hydrocarbon ingestion.1 Most poison control experts suggest that all children who are symptomatic from hydrocarbon ingestion be admitted to the hospital. was,
manage¬ not be construed as
Taylor Ave Ogden, UT 84403
3021
1. James FW, Kaplan S, Benzing G III: Cardiac complications following hydrocarbon ingestion. Am J Dis Child 121:431-433, 1971. 2. Temple A, Veltri J: Interesting intoxications. Bull Intermountain Regional Poison Control Center 2:8, 1974.
In
Reply.\p=m-\Inresponse to Dr. Holmes' pertinent observations, let us say that
agree that the management of the first case was suboptimal. This points up the fact that in a large hospital with hundreds of attending physicians and dozens of house officers, a uniform approach to any selected disease rarely exists. The article, however, was not published on the pretense of describing the subtleties of therapy of hydrocarbon ingestion and never implied that the therapeutics described were to be "construed as standard care." The article makes no claim outside of reviewing the pertinent data on one selected aspect of the disease. Nevertheless, we disagree that "all children who are symptomatic from hydrocarbon ingestion [should] be admitted to the hospital" (italics ours). This would imply that any child with slight fever or cough should be admitted regardless of time since ingestion, reliability of parents, access to medical care, or other important factors taken into consideration. This is cookbook medicine and denies the physician any freedom of choice to fit the individual situation. We should all refuse to practice medicine in this fashion. PAUL S. BERGESON, MD STEPHEN W. HALES, MD Good Samaritan Hospital 1033 E McDowell Rd Phoenix, AZ 85006 HERMAN W. LIPOW, MD University of California School of Medicine San Francisco we
Downloaded From: http://archpedi.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 05/24/2015
this side-effect is tolerable consid¬ ering the rehabilitation that is achieved. It should also be noted that reduction of blood pressure occurs in patients with or without elevated re¬ nin levels. It is possible that with control of hypertension Dr. Siegler's patient would have had healing of the renal hypertensive arteriolitis and im¬ provement of renal function. With the use of minoxidil and other potent
antihypertensives, nephrectomy may be necessary in very few patients and hopefully never in those with ade¬ quate residual renal function. ANDREW J. ARONSON, MD Department of Pediatrics The University of Chicago La Rabida Children's Hospital East 65th Street at Lake Michigan
Chicago, IL 60649
1. Aronson AJ, Kallen JR: The efficacy of minoxidil in the outpatient management of accelerated nephropathic hypertension, abstracted. Presented in program of the Midwest Society for Pediatric Research Meeting, Pittsburgh, 1973. 2. Makker S: Treatment of high renin refractory hypertension in children with minoxidil: A new hypertensive drug not previously used in children, abstracted. Pediatr Res 8:458, 1974. 3. Chandra M, Exeni M, McVicar N: Minoxidil control of high renin refractory hypertension in a child. Read before the Third International Symposium of Pediatric Nephrology, Washington, DC, 1974.
In Reply.\p=m-\Thepoints raised in the letter of Dr. Aronson are certainly important and deserve emphasis. Bilateral nephrectomy is undeniably a drastic measure and should only be considered for those whose hyperreninemic hypertension is re-
fractory to medical management. I certainly wish that we had had minoxidil to use for our patient. Since then, pediatric experience with minoxidil has increased, though the total number of published cases is still relatively small. I, too, have recently used this experimental agent to successfully treat two pediatric patients with refractory hypertension. One patient had chronic interstitial nephritis from vesicoureteral reflux and the other had experienced a recurrence of the
In addition, those patients who have ingested large amounts and those for whom follow-up care or home surveil¬ lance is inadequate, even if asympto¬
matic, should also be admitted for ob¬ servation and early detection of pulmonary or cardiac complications.2 Therefore, to send this child home on a regimen of antibiotics, in the face of verified pulmonary involvement, was, I
think, inappropriate
ment, and should
standard
care.
CHRIS HOLMES, MD
hemolytic-uremic syndrome.
Even so, I doubt that minoxidil will turn out to be a hypertensive panacea. I suspect, therefore, that bilateral nephrectomy will still have to be considered for the occasional patient. But hopefully, the need for such an extreme measure will be rare indeed now that minoxidil is available. RICHARD L. SIEGLER, MD Department of Pediatrics University of Utah
Medical Center 50 N Medical Dr Salt Lake City, UT 84132
Pneumatoceles
Following Hydrocarbon Ingestion
Sir.\p=m-\Thearticle by Bergeson et al, which appeared in the January issue of the Journal (129:49, 1975), was a fine discussion of the stated problem.
The management of their first case however, suboptimal in my opinion. This 20-month-old boy ingested lighter fluid. He choked, coughed, vomited after ingestion, and was seen in the emergency room that night. He was sent home after a normal chest roentgenogram had been obtained. He was seen in the outpatient clinic the next day with fever, "harsh breath sounds," and "right middle lobe and left lower lobe infiltrates." At this point he should have been admitted to the hospital. Instead, he was given ampicillin sodium and sent home. The authors themselves point out that "pleural effusion, pneumothorax, pneumomediastinum, subcutaneous emphysema, and pneumopericardium have been encountered as complications of hydrocarbon ingestion" (p 51). Others have reported serious cardiac complications following hydrocarbon ingestion.1 Most poison control experts suggest that all children who are symptomatic from hydrocarbon ingestion be admitted to the hospital. was,
manage¬ not be construed as
Taylor Ave Ogden, UT 84403
3021
1. James FW, Kaplan S, Benzing G III: Cardiac complications following hydrocarbon ingestion. Am J Dis Child 121:431-433, 1971. 2. Temple A, Veltri J: Interesting intoxications. Bull Intermountain Regional Poison Control Center 2:8, 1974.
In
Reply.\p=m-\Inresponse to Dr. Holmes' pertinent observations, let us say that
agree that the management of the first case was suboptimal. This points up the fact that in a large hospital with hundreds of attending physicians and dozens of house officers, a uniform approach to any selected disease rarely exists. The article, however, was not published on the pretense of describing the subtleties of therapy of hydrocarbon ingestion and never implied that the therapeutics described were to be "construed as standard care." The article makes no claim outside of reviewing the pertinent data on one selected aspect of the disease. Nevertheless, we disagree that "all children who are symptomatic from hydrocarbon ingestion [should] be admitted to the hospital" (italics ours). This would imply that any child with slight fever or cough should be admitted regardless of time since ingestion, reliability of parents, access to medical care, or other important factors taken into consideration. This is cookbook medicine and denies the physician any freedom of choice to fit the individual situation. We should all refuse to practice medicine in this fashion. PAUL S. BERGESON, MD STEPHEN W. HALES, MD Good Samaritan Hospital 1033 E McDowell Rd Phoenix, AZ 85006 HERMAN W. LIPOW, MD University of California School of Medicine San Francisco we
Downloaded From: http://archpedi.jamanetwork.com/ by a CAMBRIDGE UNIVERSITY LIBRARY User on 05/24/2015
