Munchausen Syndrome by Proxy: A Review Munchausen syndrome by proxy is believed to be more c o m m o n than previously suspected because it can be easily overlooked. A literature review was conducted to identify c o m m o n features of the syndrome; profiles of victims, perpetrators, and other family members; and to provide guidelines for clinical care. Victims tend to be young, with complaints beginning within the first year of life. More than one child in a family may be abused, which makes it necessary to carefully examine the medical history of siblings. The perpetrator is virtually always a mother or female caregiver, the dominant parent, w h o has medical knowledge and a familiarity with the workings of health care facilities. She insists on being a care provider while the child is hospitalized, flatters the medical and nursing staff, and convinces them that she is a help to their work load. The involved parent is likely to have a personality disorder, Munchausen syndrome, or somatization behavior; may have an eating or weight problem; and may be a victim of an emotionally difficult childhood. The father or nondominant parent has been described as passive or emotionally uninvolved. Some studies suggest the family lacks protective mechanisms for the nondominant family members. Recognition of Munchausen syndrome by proxy is difficult for many reasons. The authors identified six warning signals, which include the nature of the illness, symptoms, response to treatment, reported history of allergies, mother's behavior, and family history of sudden infant deaths or multiple medical disorders. Once suspected, diagnosis can be facilitated with a proposed course of action for intervention. The authors note. that successful treatment is difficult and that there is a tendency for mistreatment to continue if the child is not removed from the perpetrator.
(Skau K, Mouridsen SE. Munchausen syndrome by proxy: a review. Acta Paediatr 1995;84:977-82.)
scars. The majority of victims are children. In most cases a single dog is responsible for the attack. The authors present seven case reports in which a pack of dogs attacked a child or elderly victim, causing severe injury and death. The dogs involved were greyhounds (five cases), boxers (one case), and cross-breeds (one case). In four cases the victim was acquainted with the dogs, either as o w n e r or frequent playmate. O n c e the attack began, the dogs continued until the victim was killed or the dogs were driven off. Dogs have an inherent pack instinct. Even benign dogs can be excited to a frenzy w h e n united as a group and stimulated by the smell and taste of blood. The characteristics of a dog that enable it to view humans as prey include (1) genetic predisposition toward aggressiveness, (2) training, (3) maltreatment, (4) hunger, (5) previous predation, (6) group behavior, and (7) defense of territory. H u m a n factors that contribute to a person b e c o m i n g a victim are behavior, age, and size of victim and the absence of other p e o p l e in the vicinity of the attack. Most dog bites occur in or near the h o m e and involve a dog or dogs k n o w n to the victim. The site of injury involves the head, neck, and face or lower limbs and extremities. It appears the size of the victim influences where the dog attacks. The dog inflicts muhiple punctures, lacerations, and soft tissue avulsions with biting, clawing, tearing, and crushing forces. Bleeding is the most c o m m o n cause of death, and fatal injuries occur most often in young children and elderly females. The authors submit that pack attacks can be prevented if dogs and children are kept apart, especially if a child is alone. Multiple dogs should not be allowed to unite as a group. It is important to recognize that dogs acting as a group are m u c h more dangerous than the same animals alone. The first act of aggression displayed by a dog may produce devastating wounds.
(Kneafsey B, Condon KC. Severe dog-bite injuries, introducing the concept of pack attack: a literature review and seven case reports. Injury 1995;2~'37-41.)
Severe Dog-Bite Injuries, Introducing the Concept of Pack Attack: A Literature Review and Seven Case Reports Dog bites are c o m m o n injuries that resuh in soft tissue injury, blood loss, infection, and, if not fatal, permanent INT J TRAUMA NURS 1996;2:59-62. Copyright 9 1996 by the Emergency NursesAssociation.
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Declaring Pediatric Brain Death: Current Practice in a Canadian Pediatric Critical Care Unit A retrospective review was m a d e of 60 medical records of patients 16 years old or less admitted to a regional pediatric intensive care unit in a southwestern Ontario hospital and w h o had a diagnosis of "brain death." The objective was to d o c u m e n t what criteria w e r e used to
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Abstracts of the Literature