He gave me a bill for a $50.00 minimum service call. As he was walking away, I called after him, "So what was wrong?" He replied, "It was an ID ten T error." What's that… in case I need to fix it again?

Harold grinned… "Haven't your ever heard of an ID ten error before?"

"No", I replied.

"Write it down", he said, "and I think you'll figure it out". So I wrote down. I D 1 0 T

I used to like Harold.

A recent article in the New England Journal by James Cherry reviews several important items. Croup (laryngotracheitis) or spasmodic croup usually occurs in infants and children younger than six years of age. Boys are infected 1.5 times more often than girls and during the second year of life about 5% of children will have croup. Parainfluenza virus type 3 is thought to be one of the most common causative agents. The differential diagnosis includes epiglotitis which is suggested by the absence of the typical barking seal cough, the sitting posture of the child with the chin pushed forward, a refusal to lie down and much apprehension on the part of the child. A lateral neck x-ray will often confirm the diagnosis. Foreign body obstruction and angioneurotic edema can also mimic croup.

Laryngotracheobronchitis and laryngotracheobronchopneumona can be usually differentiated from croup by signs of lower airway involvement. These diseases frequently have a bacterial cause and appropriate antibiotic therapy is needed.

The treatment for croup has evolved over time but most experts now routinely advise corticosteroid therapy. This author advises a single dose of dexamethazone 0.6 mg per kilo given orally or intramuscularly or nebulized budesonide 2 mg in 4 ml of water. A review on the data of humidified air concluded that there was no evidence that inhalation of humidified air is helpful. Nebulized epinephrine has also been extensively studied and this author suggests that in severe croup it is useful and often decreases the need for intubation. Croup may also be caused by influenza A and B virus and during an epidemic treatment with neuramidase inhibitors should be considered. Perhaps now that more children are being given influenza vaccine a decrease in croup will be seen. (N Engl J Med 2008 January; 358;4)

A recent meta-analysis of 22 randomized trials involving nearly 2000 patients looked at tamsulosin (Flomax) and the calcium channel blocker nifedipine. Most of these patients had distal ureteral stones less than 5mm in diameter. The time to passage of the stone was shortened by an average of 2-6 days in the alpha blocker group/tamsulosin. Roughly the same results were found when using a calcium channel blocker drug. These drugs are generally well tolerated. They are probably worth considering in this common cause of pain. (Ann Emerg Med 2007 Nov; 50:552)

As our population ages, more and more patients are being seen with dementia/Alzheimer's disease. Survival time after onset and factors that influence survival have been the subject of some speculation. This large population based study of 13, 000 people over the age of 65 involve follow-up for 14 years. Four hundred thirty eight of these patients developed dementia based on a geriatric mental state examination. Eighty-one percent of them died. Median survival was 4.5 years after the onset of the dementia, 4.6 years for women and 4.1 years for men. The younger the patient was with the onset of dementia the longer they generally lived. Functional impairment such as inability to perform household tasks was also associated with shorter survival time. Studies such as these are helpful when advising care givers regarding dementia patients about prognosis, appropriate screening, interventions, and advanced care planning. (BMJ 2008 Jan 10 [e-pub ahead of print].-)

John J. Mohr, M.D.