Tonsillar hypertrophy and prolapse in a child - is epiglottitis a predisposing factor for sudden unexpected death?

BACKGROUND: Tonsillitis, with associated tonsillar hypertrophy, is a common disease of childhood, yet it is rarely associated with sudden death due to airway obstruction. Lethal complications involving the inflamed tonsils include haemorrhage, retropharyngeal abscess and disseminated sepsis. CASE PRESENTATION: We report on a case of sudden and unexpected death in an 8-year-old female who was diagnosed with and treated for tonsillitis. The child was diagnosed with acute tonsillitis 2 days prior to her collapse and was placed on a course of oral antibiotics. There were no signs of upper or lower airway obstruction. She was found to be unresponsive by her caregiver and gasping for air in her bed in the early hours of the second morning after the start of treatment. Autopsy showed massive and symmetrically enlarged palatine tonsils. The tonsils filled the pharynx almost completely. The epiglottis and laryngeal mucosa at the base of the epiglottis in the vicinity of the aryepiglottic membrane and the superior aspect of the larynx displayed red-purple discoloration, with mucosal swelling and edema. Histological examination of the palatine tonsils revealed prominent lymphoid hyperplasia, but no evidence of acute inflammation. CONCLUSION: Palatine tonsillar hypertrophy in infants is a common feature of both viral and bacterial tonsillitis and has been postulated as a possible risk factor for Sudden and Unexplained Death in Infancy (SUDI), based on the theory of mechanical impediment of breathing by narrowing of the upper airway. The rounded shape of the tonsils may facilitate some airflow past the enlarged structures and hence protect against asphyxial death when the enlarged tonsils fill the laryngo-pharynx. Epiglottal and proximal laryngeal edema may play a more significant role in asphyxial unexpected deaths in cases of tonsillitis with tonsillar hypertrophy than previously suspected. This focusses the importance of careful examination of the epiglottis and proximal laryngeal mucosa, as part of a thorough examination of the laryngo-pharynx in cases of sudden death associated with tonsillar hypertrophy.

Driving performance of long-term users of sedating antidepressants and benzodiazepines.

OBJECTIVE: Using benzodiazepines and certain antidepressants is associated with an increased risk of motor vehicle crashes due to impaired driving skills. Hence, several countries prohibit people who use these drugs from driving. Traffic regulations for driving under the influence of these drugs are, however, largely based on single-dose studies with healthy participants. The effects of drugs on chronic users may be different because of potential development of tolerance or by adapting behavior. In this study, we test the effects of anti-depressants, hypnotics, or anxiolytics use on driving performance in patients who use these drugs for different durations and compare the effects to healthy controls' performance. METHODS: Sixty-six healthy controls and 82 medication users were recruited to perform four drives in a driving simulator. Patients were divided into groups that used anti-depressants, hypnotics, or anxiolytics, for shorter or longer than 3 years (i.e. LT3- or LT3+, respectively). The minimum term of use was 6 months. Driving behavior was measured in terms of longitudinal and lateral control (speed variability and Standard Deviation of Lateral Position: SDLP), brake reaction time, and time headway. Impaired driving performance was defined as performing similar to driving with a Blood Alcohol Concentration of 0.5‰ or higher, determined by means of non-inferiority analyses. RESULTS: Reaction time analyses revealed inconclusive findings in all groups. No significant performance differences between matched healthy controls, LT3- (n = 2), and LT3+ (n = 8) anxiolytics users were found. LT3+ antidepressants users (n = 12) did not perform inferior to their matched controls in terms of SDLP. LT3- hypnotics users (n = 6) showed more speed variability than their matched healthy controls, while this effect was not found for the LT3+ group (n = 14): the latter did not perform inferior to the healthy controls. Regarding Time Headway, no conclusions about the LT3- hypnotics group could be drawn, while the LT3+ group did not perform inferior compared to the control group. CONCLUSIONS: The small number of anxiolytics users prohibits drawing conclusions about clinical relevance. Although many outcomes were inconclusive, there is evidence that some elements of complex driving performance may not be impaired (anymore) after using antidepressants or hypnotics longer than 3 years.

Validating lane drifts as a predictive measure of drug or sleepiness induced driving impairment.

BACKGROUND: Standard deviation of lateral position (SDLP) has been accepted as a reliable parameter for measuring driving impairment due to lowered vigilance caused by sleepiness or the use of sedating drugs. Recently, lane drifts were proposed as an additional outcome measure quantifying momentary lapses of attention. The purpose of this study was to validate lane drifts as outcome measure of driver impairment in a large data pool from two independent research centers. METHODS: Data from 11 placebo-controlled studies that assessed the impact of alcohol, hypnotics, and sleep deprivation on actual driving performance were pooled. In total, 717 on-the-road tests performed by 315 drivers were subjected to an automated algorithm to detect occurrences of lane drifts. Lane drifts were defined as deviations > 100 cm from the mean (LDmlp) and from the absolute lateral position (LDalp) for 8 s. RESULTS: The number of LDmlp was low and did not differ between treatments and baseline, i.e., 14 vs. 3 events, respectively. LDalp were frequent and significantly higher during treatment relative to baseline, i.e., 1646 vs. 470 events. The correlation between LDalp and SDLP in the treatment conditions was very high (rs = 0.77). The frequency of the occurrence of treatment-induced lane drifts however depended on baseline SDLP of drivers, whereas treatment-induced changes in SDLP occurred independent of baseline SDLP. CONCLUSION: LDmlp is not useful as an outcome measure of driver impairment due to its rare occurrence, even when treatment-induced increments in SDLP are evident. Treatment effects on LDalp and SDLP are closely related.

Event-related potentials and secondary task performance during simulated driving.

Inattention and distraction account for a substantial number of traffic accidents. Therefore, we examined the impact of secondary task performance (an auditory oddball task) on a primary driving task (lane keeping). Twenty healthy participants performed two 20-min tests in the Divided Attention Steering Simulator (DASS). The visual secondary task of the DASS was replaced by an auditory oddball task to allow recording of brain activity. The driving task and the secondary (distracting) oddball task were presented in isolation and simultaneously, to assess their mutual interference. In addition to performance measures (lane keeping in the primary driving task and reaction speed in the secondary oddball task), brain activity, i.e. event-related potentials (ERPs), was recorded. Performance parameters on the driving test and the secondary oddball task did not differ between performance in isolation and simultaneous performance. However, when both tasks were performed simultaneously, reaction time variability increased in the secondary oddball task. Analysis of brain activity indicated that ERP amplitude (P3a amplitude) related to the secondary task, was significantly reduced when the task was performed simultaneously with the driving test. This study shows that when performing a simple secondary task during driving, performance of the driving task and this secondary task are both unaffected. However, analysis of brain activity shows reduced cortical processing of irrelevant, potentially distracting stimuli from the secondary task during driving.

How representative are insomnia clinical trials?

OBJECTIVES: To address the question of how representative subjects studied in hypnotic clinical trials are of the broader insomnia population, this study assessed initial contact rates and reasons for inclusion and exclusion during recruitment to an efficacy trial and to a safety trial of Food & Drug Administration (FDA) approved hypnotics. METHODS: Otherwise heathy persons meeting Diagnostic Statistical Manual, Fourth Edition, Revised (DSM-IVR) criteria for insomnia were recruited. In one study, persons 32-65 yrs, were invited to a 12 month trial of nightly use of zolpidem or placebo. In the other, persons 21-64 yrs with driver's licenses were recruited to test the effects of a hypnotic on live on-the-road driving ability. In both studies screening was conducted through an initial telephone interview followed by a clinic visit. RESULTS: In the United States (US) study 13% (n = 410) of 3180 initial contacts and in the Netherlands (NL) study 67% (n = 53) of the 79 initial contacts proceeded to the clinic visit. Of those at clinic 25% of US and 37% of NL participants failed to meet additional insomnia criteria. Mental health exclusions accounted for 24% of US and 23% of NL participants and medical problems accounted for 23% of US and 9% NL exclusions. Finally 20% of US and 26% of NL participants were excluded for drug use/abuse histories. After all screening 4% of the initial US contacts and 0% of the NL contacts entered the study. CONCLUSIONS: These data suggest persons entering insomnia hypnotic clinical trials are a highly selected sample that is unlikely to be representative of the broad insomnia population or the population of potential medication users.

Alcohol metabolism in hangover sensitive versus hangover resistant social drinkers.

BACKGROUND: Previous research demonstrated that urinary ethanol concentrations were significantly lower in hangover resistant individuals compared to drinkers who reported having a hangover. This finding suggests that the rate of ethanol metabolism is faster in drinkers who do not experience an alcohol hangover. This study aimed to directly compare alcohol metabolism after administering a low dose of ethanol to hangover sensitive drinkers and hangover resistant drinkers. METHODS: Social drinkers who previously participated in hangover trials at Utrecht University were invited to participate. It was aimed to include 12 hangover resistant drinkers and 12 hangover sensitive drinkers. Participants consumed alcohol to reach a breath alcohol concentration (BrAC) of 0.05%. Every 5 min BrAC was determined, until BrAC reached zero. Every 15 min, the Karolinska Sleeping Scale (KSS) was administered to assess subjective sleepiness, and subjective intoxication was measured. RESULTS: Data of N = 23 participants with a mean age of 22.4 (±1.9) years was included in the analyses. No significant difference in BrAC over time was found between the hangover resistant group and the hangover sensitive group. In line, subjective sleepiness scores and subjective intoxication ratings did not significantly differ between the groups at any point in time after alcohol consumption. CONCLUSION: Hangover resistant individuals and hangover sensitive drinkers did not significantly differ on BrAC, subjective sleepiness, and subjective intoxication after consuming a moderate amount of alcohol. These findings suggest that drinkers who usually experience hangovers after a heavy drinking occasion do not experience alcohol intoxication differently than hangover resistant drinkers.

The 2D : 4D Digit Ratio as a Biomarker for Autism Spectrum Disorder.

It has been suggested that the second (2D, index finger) to fourth (4D, ring finger) digit ratio, 2D : 4D, may be a biomarker for the risk of developing autism. The aim of the current study was to determine the usefulness of the 2D : 4D digit ratio as biomarker for autistic traits. N = 401 healthy young volunteers participated in the study. For both hands, digit lengths were measured using digital Vernier calipers. In addition to demographics, the Autism Spectrum Quotient (AQ) questionnaire was completed, comprised of five subscales, assessing "social insights and behavior," "attention switching," "communication," "imagination," and "attention to detail." Overall, no significant correlations were observed between the AQ total score, its subscales, and the 2D : 4D digit ratio. For women, the left hand 2D : 4D digit ratio correlated significantly with the subscale score "communication" (r = -0.142; p = 0.036). For men, a significant positive correlation was found between the left 2D : 4D digit ratio and the total AQ score (r = 0.157; p = 0.042) and AQ subscale "attention switching" (r = 0.182; p = 0.017). In conclusion, gender specific associations between the 2D : 4D digit ratio and specific autism traits were observed, which were stronger in men than in women. Future studies should be conducted in patients that are formally diagnosed with autism.

Urine methanol concentration and alcohol hangover severity.

BACKGROUND: Congeners are substances, other than ethanol, that are produced during fermentation. Previous research found that the consumption of congener-rich drinks contributes to the severity of alcohol hangover. Methanol is such a congener that has been related to alcohol hangover. Therefore, the aim of this study was to examine the relationship between urine methanol concentration and alcohol hangover severity. METHODS: N = 36 healthy social drinkers (22 females, 14 males), aged 18-30 years old, participated in a naturalistic study, comprising a hangover day and a control day (no alcohol consumed the previous day). N = 18 of them had regular hangovers (the hangover group), while the other N = 18 claimed to be hangover-immune (hangover-immune group). Overall hangover severity was assessed, and that of 23 individual hangover symptoms. Urine methanol concentrations on the hangover and control days were compared, and correlated to hangover (symptom) severity. RESULTS: Urine methanol concentration was significantly higher on hangover days compared to control days (p = 0.0001). No significant differences in urine methanol concentration were found between the hangover group and hangover-immune group. However, urine methanol concentration did not significantly correlate with overall hangover severity (r = -0.011, p = 0.948), nor with any of the individual hangover symptoms. These findings were observed also when analyzing the data separately for the hangover-immune group. In the hangover group, a significant correlation with urine methanol concentration was found only with vomiting (r = 0.489, p = 0.037). CONCLUSION: No significant correlation was observed between urine methanol concentration and hangover severity, nor with individual core hangover symptoms.

Sleep disorders, sleepiness and traffic safety: a public health menace.

Sleep disorders are not uncommon and have been widely reported throughout the world. They have a profound impact on industrialized 24-h societies. Consequences of these problems include impaired social and recreational activities, increased human errors, loss of productivity, and elevated risk of accidents. Conditions such as acute and chronic insomnia, sleep loss, excessive sleepiness, shift-work, jet lag, narcolepsy, and sleep apnea warrant public health attention, since residual sleepiness during the day may affect performance of daily activities such as driving a car. Benzodiazepine hypnotics and zopiclone promote sleep, both having residual effects the following day including sleepiness and reduced alertness. In contrast, the non-benzodiazepine hypnotics zolpidem and zaleplon have no significant next-day residual effects when taken as recommended. Research on the effects of wakefulness-promoting drugs on driving ability is limited. Countermeasures for excessive daytime sleepiness have a limited effect. There is a need for a social awareness program to educate the public about the potential consequences of various sleep disorders such as narcolepsy, sleep apnea, shift-work-related sleep loss, and excessive daytime sleepiness in order to reduce the number of sleep-related traffic accidents.

The impact of chronic pain patients' psychotropic drug knowledge and warning labels on the decision whether to drive a car or not.

OBJECTIVE: The attitudes of patients towards driving a car while taking medication with psychotropic side effects is unclear. A growing number of patients use these psychotropic medicines on a daily basis, and this may interfere with their ability to drive a car. METHODS: By means of a survey, we examined attitudes towards driving while using psychotropic medicinal drugs and the effect of warning labels on the decision whether to drive a car or not in patients with chronic pain. RESULTS: Fifty-eight of 100 patients possessing a driver's license used psychotropic medication. Despite warning labels affixed on the packages that these drugs might impair driving ability, the majority (71%) of these patients continued driving a car. A point of concern is that 40% of these patients reported not to be more cautious in traffic after taking psychotropic drugs. CONCLUSION: The results of this survey indicate that drug warning labels applied by Dutch pharmacies do not significantly change attitudes towards driving a car in patients taking medicinal drugs with psychotropic side effects. Future road-safety campaigns should pay more attention to the impairing effects of psychotropic drugs on driving.

Characteristics of social drinkers with and without a hangover after heavy alcohol consumption.

BACKGROUND: A number of social drinkers claim that they do not experience next-day hangovers despite consuming large quantities of alcohol. The aim of this study was to investigate the characteristics of drinkers who claim to be hangover immune and compare them with drinkers who do report having hangovers. METHODS: A total of 36 social drinkers participated in a naturalistic study consisting of a hangover day (alcohol consumed) and a control day (no alcohol consumed). Data were collected on alcohol consumption, demographics, sleep, next-day adverse effects, and mood. Data from drinkers with a hangover (N=18) were compared with data from drinkers who claim to be hangover immune (N=18). RESULTS: Drinkers with a hangover reported drowsiness-related symptoms, symptoms related to reduced cognitive functioning, and classic hangover symptoms such as headache, nausea, dizziness, weakness, and stomach pain. Corresponding mood changes comprised increased feelings of depression, anger-hostility, fatigue, and reduced vigor-activity. In contrast, hangover-immune drinkers reported relatively few hangover symptoms, with only mild corresponding severity scores. The reported symptoms were limited to drowsiness-related symptoms such as sleepiness and being tired. The classic hangover symptoms were usually not reported by these drinkers. CONCLUSION: In contrast to drinkers with a hangover, for those who claim to be hangover immune, next-day adverse effects of alcohol consumption are limited to a mild increase in drowsiness-related symptoms.

Effects of mixing alcohol with energy drink on objective and subjective intoxication: results from a Dutch on-premise study.

BACKGROUND: The purpose of this on-premise study was to determine if alcohol mixed with energy drink (AMED) consumption masks the subjective feelings of intoxication when compared to consuming alcohol only. METHODS: The study was conducted on five nights in the city center of Utrecht. N = 997 people leaving bars were interviewed about their alcohol consumption with and without energy drinks, for that particular evening and for other occasions. People reporting drug and medication use were excluded (N = 84). Subjective intoxication was rated on a 10-point scale. Objective intoxication (breath alcohol concentration, BrAC) was determined with a breath alcohol test. Three groups were identified: (1) the AMED-tonight group (N = 185, 20.2 %), (2) the AMED-other-nights group (N = 246, 27.1 %), and (3) the no-AMED group (N = 482, 52.7 %). RESULTS: Objective intoxication (BrAC) did not significantly differ (p = 0.94) between the AMED-tonight group (0.074 % ± 0.05), AMED-other-nights group (0.073 % ± 0.05), and the no-AMED group (0.074 % ± 0.05). In line, subjective intoxication was not significantly different (p = 0.96) between the AMED-tonight group (4.5 ± 2.2), AMED-other-nights group (4.6 ± 2.3), and no-AMED group (4.6 ± 2.2). Within-subjects comparisons revealed no significant differences in total alcohol consumption between AMED occasions and alcohol only occasions. Regression analyses showed that "gender" (beta = 0.078, p = 0.016), "time of testing" (beta = 0.085, p = 0.009,) and "BrAC" (beta = 0.574, p = 0.0001) together explained 37.7 % of variance of subjective intoxication scores (Cohen's f (2) = 0.605). Whether or not subjects consumed energy drinks did not predict subjective intoxication scores. CONCLUSION: The data suggests that mixing alcohol with energy drink does not mask subjective intoxication.

Meta-analysis of on-the-road experimental studies of hypnotics: effects of time after intake, dose, and half-life.

BACKGROUND: The use of hypnotics is prevalent in the general population. Though these drugs have been shown to be effective, their residual effects may cause significant impairment to the user's driving ability. The objective of this meta-analysis is to determine whether there is a residual effect on driving and better evaluate the safety of hypnotics. METHOD: Randomized double-blind placebo-controlled studies were selected that employed a commonly used and valid driving measure to determine the user's driving ability the day after drug administration. The primary outcome measure for the driving task in all included studies was the Standard Deviation of Lateral Position (SDLP). Fixed effects model meta-analyses were performed. RESULTS: Fourteen studies, published from 1984 to 2013 (295 subjects), were included in this meta-analysis. Overall, significant impairment was found when morning testing (i.e., 10-11 h after initiating sleep) was compared to afternoon testing (i.e., 16-17 h after initiating sleep; P = .0001). Twice the standard dose also showed significant impairment (P = .0001) relative to the standard dose. The time of the test, morning versus afternoon, also had an impact on individual drugs. Middle of the night administration (MOTN) of zolpidem and zopiclone caused significant impairment the following morning, though no such impairment was seen with zaleplon. Finally, half-life was also assessed (short: <6 h, intermediate: 6-12 h, long: >12 h) and both intermediate- and long-acting drugs caused significant impairment the morning after bedtime administration, whereas short acting hypnotics did not. CONCLUSIONS: These analyses indicate that the half-life, dose of the hypnotic, as well as time between treatment and driving, as measured by SDLP, all significantly impact the ability to drive a car after taking hypnotic drugs.

Consumer satisfaction and efficacy of the hangover cure after-effect(©).

A consumer satisfaction study was conducted to examine the effectiveness on hangover of After-Effect(©), a new food supplement dedicated to improve well-being after an occasion of alcohol consumption. N = 113 persons were invited to participate in a home-based open label study to test the effectiveness of After-Effect(©). On a night when they intended to consume alcohol, three pills were taken before alcohol consumption and two pills afterwards, before going to bed. The following day, participants completed a survey on the amount of alcohol consumed, hangover symptom severity, and satisfaction of the product. N = 103 participants completed the study. 88% of participants reported After-Effect(©) to be effective in reducing alcohol hangover. After-Effect(©) significantly improved overall hangover severity, and all individual hangover symptoms, except for palpitations. In addition, a significant reduction (P = 0.0001) in the severity score on concentration problems was reported when using After-Effect(©). No gender differences were observed, and there was no relationship with the number of alcoholic drinks that were consumed. Consumers were satisfied with the product. In conclusion, consumer satisfaction and hangover severity scores suggest that After-Effect(©) may be effective in reducing alcohol hangover. However, controlled, double-blind clinical trials should confirm these findings.

Effects of coffee on driving performance during prolonged simulated highway driving.

RATIONALE: Coffee is often consumed to counteract driver sleepiness. There is limited information on the effects of a single low dose of coffee on prolonged highway driving in non-sleep deprived individuals. OBJECTIVES: The aim of this study was to examine the effects of a single cup of coffee (80 mg caffeine) on simulated highway driving performance. METHODS: Non-sleep deprived healthy volunteers (n024) participated in a double-blind, placebo-controlled, crossover study. After 2 h of monotonous highway driving, subjects received caffeinated or decaffeinated coffee during a 15-min break before continuing driving for another 2 h. The primary outcome measure was the standard deviation of lateral position (SDLP), reflecting the weaving of the car. Secondary outcome measures were speed variability, subjective sleepiness, and subjective driving performance. RESULTS: The results showed that caffeinated coffee significantly reduced SDLP as compared to decaffeinated coffee, both in the first (p00.024) and second hour (p00.019) after the break. Similarly, the standard deviation of speed (p0 0.024; p00.001), mental effort (p00.003; p00.023), and subjective sleepiness (p00.001; p00.002) were reduced in both the first and second hour after consuming caffeinated coffee. Subjective driving quality was significantly improved in the first hour after consuming caffeinated coffee (p00.004). CONCLUSIONS: These findings demonstrate a positive effect of one cup of caffeinated coffee on driving performance and subjective sleepiness during monotonous simulated highway driving.

Oculomotor behavior of hemianopic chronic stroke patients in a driving simulator is modulated by vision training.

BACKGROUND: Visual Restorative function training aims to decrease visual field defect size after acquired brain damage. Some chronic stroke patients regain permission to drive a car after training. This points to a concomitant change in oculomotor behavior, because visual field enlargement is hardly ever large enough for legal driving. This study investigated vRFT-induced changes in oculomotor behavior, using a driving simulator. METHODS: Driving performance and oculomotor behavior were measured before and after training in 6 hemianopia patients who had trained 65 hours with vRFT on a PC at home. RESULTS: Two patients showed negligible visual field enlargement (VFE) and four showed moderate to substantial VFE. Because less visual cortex is devoted to the processing of peripheral than central visual field the same VFE corresponds to less functional restoration of cortex when the defect is at high eccentricity. When this is taken into account, then precisely the two patients that showed the largest cortical gains made significantly more eye movements in the direction of their visual field defect after training. CONCLUSIONS: vRFT with mandatory eye fixation can result in increased eye movement behavior towards the defect. Our study suggests that a threshold amount of cortical functional restoration is required for this effect.

Effect of chronic nonmalignant pain on highway driving performance.

Most pain patients are treated in an outpatient setting and are engaged in daily activities including driving. Since several studies showed that cognitive functioning may be impaired in chronic nonmalignant pain, the question arises whether or not chronic nonmalignant pain affects driving performance. Therefore, the objective of the present study was to determine the effects of chronic nonmalignant pain on actual highway driving performance during normal traffic. Fourteen patients with chronic nonmalignant pain and 14 healthy controls, matched on age, educational level, and driving experience, participated in the study. Participants performed a standardized on-the-road driving test during normal traffic, on a primary highway. The primary parameter of the driving test is the Standard Deviation of Lateral Position (SDLP). In addition, driving-related skills (tracking, divided attention, and memory) were examined in the laboratory. Subjective assessments, such as pain intensity, and subjective driving quality, were rated on visual analogue scales. The results demonstrated that a subset of chronic nonmalignant pain patients had SDLPs that were higher than the matched healthy controls, indicating worse highway driving performance. Overall, there was a statistically significant difference in highway driving performance between the groups. Further, chronic nonmalignant pain patients rated their subjective driving quality to be normal, although their ratings were significantly lower than those of the healthy controls. No significant effects were found on the laboratory tests.

Follow-up of conservatively treated sleep apnoea patients.

Polysomnograms have been recorded at our laboratory since 1985 for the diagnosis of sleep apnoea. Until the recent availability of continuous positive airway pressure devices in Johannesburg, it appeared that some of our subjects were receiving only conservative or no treatment. Structured interviews were conducted with 63 patients with positive polysomnographic findings of sleep apnoea/hypopnoea (SAH), and, where possible, with sleeping partners. Information was obtained about the patients' understanding of the diagnosis by the referring doctor, the recommended treatment and psychosocial consequences. The primary reason for the initial consultation was excessive daytime sleepiness (43%). Diagnoses following polysomnography included SAH (65%) and narcolepsy (6%), while 10% were told they had nothing to be concerned about. Some form of treatment was recommended to 80% of patients, usually weight loss (60%) or medication (59%). Psychosocial consequences were prominent and included a perception of reduced work capacity (62%) and compromised safety (56%). At the time of the interview 90% of patients were experiencing one or more symptoms associated with SAH. These findings support the serious nature of SAH and confirm the need for adequate treatment centres in South Africa.

Diaphragm pacing in the treatment of ventilatory failure.

Thirty years of clinical and technical research have produced a reliable apparatus for diaphragm pacing. This entails electrical stimulation to the phrenic nerve by a remote radio-frequency transmitter. Prerequisites for diaphragm pacing are adequate alveolar gas exchange, an intact phrenic nerve and diaphragm muscle, and a co-operative patient for the prolonged period of rehabilitation. Diaphragm pacing has been used in cases of central alveolar hypoventilation and chronic obstructive airway disease, as well as for lesions of the cervical cord. To avoid fatigue and possible irreversible injury to the muscle, the right and left hemidiaphragms are paced alternately. We demonstrate the effectiveness of diaphragm pacing for long-term artificial respiration in a patient with transection of the cord at C3/4. The decisive benefit of diaphragm pacing for the quadriplegic patient is that it renders him free of dependence on a mechanical ventilator with its associated social and psychological impediments.