Ventilatory chemosensitivity in subjects with a history of childhood cyanotic breath-holding spells.

The ability of children with cyanotic breath-holding spells to respond to anger or frustration by voluntary breath-holding for prolonged periods (often to the point of precipitating hypoxic seizure activity) suggested the hypothesis that such children may have a less powerful urge to breathe in the presence of hypoxia and/or hypercapnia than children who do not have breath-holding spells. Because ventilatory chemosensitivity is difficult to measure in infants and young children, this hypothesis was tested indirectly by measuring the ventilatory responses to hyperoxic progressive hypercapnia and to isocapnic progressive hypoxia of seven individuals who had a history of cyanotic breath-holding spells in infancy and 17 control subjects. The mean values for sensitivity to hypoxia and to hypercapnia were not significantly different between the two groups, and the responses of the majority of the subjects with cyanotic breath-holding spells were clearly within the normal range. There were fewer individuals with high-normal ventilatory responses among the subjects with cyanotic breath-holding spells. Although children with cyanotic breath-holding spells may have decreased ventilatory chemosensitivity transiently during infancy or may differ from other children in some other aspect of the control of breathing, the pathogenesis of infantile cyanotic breath-holding spells does not involve a permanently blunted sensitivity to hypercapnia or hypoxia.

Postnatal growth preceding sudden infant death syndrome.

OBJECTIVE: To compare postnatal growth preceding the sudden infant death syndrome (SIDS) with that of age matched controls. DESIGN: Retrospective case-control study. Each SIDS victim was matched with two controls on date of parental interview, postnatal age, and neighborhood. Clinical and demographic data were collected by parental interview and by review of medical records, and interval body weights were obtained from health visitors' records. STUDY POPULATION: All infants dying of SIDS between 1 May, 1987 and 30 April, 1989 in a geographically defined region consisting of four health districts in Avon and North Somerset in southwest England. Seventy-eight of the 99 SIDS victims and 139 of 156 control infants were included in the final analysis. RESULTS: There was no significant difference between SIDS victims and the controls in either of the two indices of postnatal growth which were analyzed. The mean growth rates (+/- 1 SEM) between birth and the last live weight (age equivalent weight for control infants) were 27.1 +/- 1.0 g/day for the SIDS cases and 28.3 +/- 1.5 g/day for the control infants. The mean growth rate (+/- 1 SEM) between the last two live weights were 31.5 +/- 2.9 and 24.9 +/- 2.1 g/day for the SIDS and control infants, respectively. Stratification of the infants by sex, gestational age, maternal smoking during pregnancy, breast versus bottle feeding, or age at death, did not result in any significant differences between SIDS and controls in either of the indices of postnatal growth rate. The 20 SIDS cases which were excluded from the final analysis did not differ from 78 whose data was analyzed, with regard to established SIDS risk factors, age at death, or postmortem weight. CONCLUSIONS: No difference was found between the postnatal growth of SIDS victims and that of age matched control infants.

The "88% saturation test": a simple lung function test for young children.

OBJECTIVE: The 88% saturation test (88%-SAT) was developed as an alternative to standard spirometry for those young children unable to perform standard forced expiratory maneuvers. In adults, this test revealed rapid desaturation in those persons with a history of asthma when compared with healthy control subjects. Similar findings in children were tested. SETTING: Tertiary care hospital. PATIENTS: Thirty-three former premature infants (28.3 +/- 2.3 weeks gestation), aged 5 to 7 years, who were participating in a follow-up study, were enrolled in this study. DESIGN: The study compared the 88%-SAT with standard spirometry and respiratory health characteristics ascertained through a parental questionnaire. The 88%-SAT consists of continuous measurement of hemoglobin saturation by pulse oximetry (SaO2) while the subject breathes a nonhumidified 12% oxygen and nitrogen mixture for 10 minutes or until SaO2 decreases to 88%, whichever occurs first. Abnormal 88%-SAT was defined as a decrease of SaO2 to 88% within the 10-minute period, and abnormal spirometry was defined using standardized values. RESULTS: Of the 20 children who successfully completed both spirometry and the 88%-SAT, 10 had normal spirometry results and did not desaturate to 88%, and 5 had abnormal spirometry and 88%-SAT results. Four children did not desaturate during the 88%-SAT, but had abnormal spirometry results, and one child had abnormal 88%-SAT results, but normal spirometry. Ten additional children completed the 88%-SAT, but not standard spirometry. Three children were unable to complete either test. Of those 30 children tested, 7 (23%) had a history of reactive airways disease, and all 7 had abnormal 88%-SAT results. The 88%-SAT had greater sensitivity (100% vs 75%) and specificity (87% vs 63%) than spirometry in identifying children with known reactive airways disease. The mean McCarthy general cognitive index (GCI) of the group performing both spirometry and the 88%-SAT (n = 20) achieved a mean (+/- SD) GCI of 96.2 +/- 16.7, and the group (n = 30) that completed the 88%-SAT had a mean (+/- SD) GCI of 75.2 +/- 26.3 (chi 2 P < .012). The 10 children able to perform only the 88%-SAT had a mean GCI (+/- SD) of 72.8 +/- 26.9, and the 3 children unable to perform either test had a mean GCI (+/- SD) of 63 +/- 11. CONCLUSIONS: Our data suggest that the 88%-SAT may be more effective than spirometry for identifying reactive airways disease in young, uncooperative, or developmentally delayed children. The dry air of the hypoxic inspired gas may function as an airway challenge, leading to decreased oxygenation in patients with reactive airways.

Psychodynamics of four women with delayed cancer diagnosis.

Four young women from 28 to 35 years old were referred for psychiatric evaluation because of anxiety, depression, and rage following diagnosis and treatment (radical hysterectomy in all plus radiation therapy in two) of carcinoma of the cervix. Negligence and dishonesty on the part of the laboratory that reported their Pap smears as normal when actually they had been either carelessly examined or not read at all intensified their emotional reactions of shock, panic, and fury. Feelings of injustice and victimization and fantasies about the laboratory technicians, who were women in their age group, complicated the clinical picture. The depressions that ensued in all of the women were prolonged and the working-through processes were impaired despite the fact that three have apparently been cured of their malignant disease.

Evaluation of the Oxford and Sheffield SIDS risk prediction scores.

STUDY OBJECTIVE: To evaluate the clinical usefulness (sensitivity and specificity) of the Oxford and Sheffield birth scores for prospective identification of infants at high risk of SIDS. DESIGN: Retrospective medical record reviews of prospectively identified, autopsy-validated SIDS and living control infants. STUDY SUBJECTS: Consecutive sample of 140 infants, born between 1/1/83 and 12/31/87, who died suddenly and unexpectedly in the Avon Area Health Authority in southwest England between 1/1/84 and 12/31/88. Seventeen of the cases were excluded: 6 because they lacked adequate clinical records, 11 because they were not SIDS. The 637 control infants were comprised of every 80th delivery between 1/1/83 and 12/31/87 in the three major hospitals in the area. RESULTS: SIDS incidence was 2.85/1,000 live births. Using standard cut scores to define high SIDS risk (2.0 for Oxford and 500 for Sheffield), sensitivities were 0.55 and 0.35 and specificities were 0.78 and 0.89 for the Oxford and Sheffield scores, respectively. SIDS risk for infants in the high risk group was 7.3/1,000 (Oxford) and 9.3/1,000 (Sheffield). CONCLUSIONS: Since there is no intervention with proven efficacy for SIDS prevention, and since approximately one half of SIDS cases occur in low risk groups, clinical use of these scoring systems for allocation of health care resources or personnel for the sole purpose of SIDS prevention is not justified.

Airway hyperreactivity and a history of clinical manifestations of asthma in childhood.

The relationship between airway hyperreactivity and a history of the clinical manifestations of asthma was investigated in 54 children between the ages of 8 and 12. Airway reactivity was assessed by measuring the change in pulmonary function following the hyperventilation of subfreezing air. Clinical manifestations of asthma were assessed by a standardized questionnaire regarding lower respiratory symptoms and by medical records review. The subjects were participating in a study of the sequelae of bronchiolitis; 25 had seen a physician for mild bronchiolitis during the first 2 years of life, and the remainder had not. Airway hyperreactivity was demonstrated in 8 of the 54 children and correlated with use of medication for asthma in the 2 years before pulmonary testing and positive parental response to the question, "Does your child wheeze apart from colds?" Airway hyperreactivity did not correlate with a history of other respiratory symptoms or with a history of physician-diagnosed wheezing or asthma. No questionnaire or chart review item identified over 50% of the children with reactive airways, and most subjects identified by each of the items did not demonstrate hyperreactive airways. These data suggest that airway reactivity is only weakly associated with a history of the clinical manifestations of asthma in childhood, in part because children with clinically inactive asthma do not consistently demonstrate airway hyperreactivity and in part because many children with hyperreactive airways have never had respiratory symptoms.

Theophylline in acute childhood asthma: a meta-analysis of its efficacy.

Although theophylline is a widely used drug for the treatment of acute childhood asthma, its efficacy has not been clearly established. This study constitutes a meta-analysis of published randomized clinical trials of theophylline in children hospitalized with acute asthma. We conducted a search of English language MEDLINE citations from 1966 to 1995 and analyzed the methods of each report meeting study criteria. We pooled similar clinical measures across studies if a test for homogeneity of effect size was non-significant. The six methodologically acceptable randomized clinical trials included a total of 164 children less than 18 years of age. Incomplete reporting of measures and variances was common. No study included children in intensive care settings. Using pooled results, pulmonary function parameters [forced expired volume in 1 second (FEV1), forced expired flow (FEF)] appeared better at 24 hours in the theophylline group, but the results did not reach statistical significance (mean effect difference, + 3.9% predicted values; pooled effect size, + 1.6 SDS; P = 0.25). A mean of 2.1 more albuterol treatments were administered in the theophylline group (pooled effect size, - 0.18 SDS; P = 0.02), and the mean hospital stay was slightly longer (mean effect difference, - 0.31 days; pooled effect size, - 0.18 SDS; P = 0.03). We conclude that currently available data do not indicate a significant beneficial effect of theophylline in children hospitalized with acute asthma. There is evidence for weak detrimental effects. Theophylline efficacy in intensive care unit settings remains unstudied.

Acanthamoeba keratitis. Resolution after epithelial debridement.

Two patients presented with dendritiform epithelial irregularities of the cornea that were unresponsive to topical acyclovir. Both were soft contact lens wearers who had practiced inadequate lens hygiene. Acanthamoeba was cultured from a shallow corneal biopsy of one patient and from the contact lens of the other. Epithelial debridement resolved the condition in both patients without concomitant treatment with antiamoebic agents.

Sleep-associated airway problems in children.

Several of the most common and most important sleep-associated airway problems are discussed, including obstructive sleep apnea syndrome, gastroesophageal reflux and nocturnal aspiration, spasmodic croup, nocturnal asthma, and sleep hypoxemia in chronic lung disease, and guidelines are offered for the often difficult diagnosis and for treatment.

Apparent life-threatening events and apnea of infancy.

This article is a critical review of the literature relating to the incidence, causes, pathophysiology, and therapy of apparent life-threatening events in infants. The clinical characteristics at the time of presentation and follow-up of infants who experience apparent life-threatening events are also summarized.

School-age follow-up of a single-dose prophylactic surfactant cohort.

This study reports the school-age developmental and health status of a preventilatory surfactant cohort. The sample consisted of 39 surviving subjects (21 experimental and 18 controls) born at 25 to 29 weeks gestation who were studied at 6 and 12 months and 5 to 7 years of age. At 6- and 12-month follow-ups, the cohort was functioning close to the population normative mean. Although cognitive and motor assessments at school age also showed no group differences, 8 of 19 (42%) in the surfactant group and 9 of 17 (53%) in the normal saline group attained a McCarthy General Cognitive Index score of < or = 84 (abnormal range). On the Connors' Parental Questionnaire, both groups scored high on the Learning Disability Subscale. The surviving cohort at 5 to 7 years had no identified long-term sequelae due to surfactant therapy, yet both groups were at risk for neurodevelopmental and educational morbidity.

Endotracheal foreign bodies. Difficulties in diagnosis.

The diagnosis of foreign body aspiration into the lower airway depends primarily on the radiographic demonstration of partial bronchial obstruction causing localized air trapping or atelectasis, present in 95 per cent of the cases. Endotracheal foreign bodies may often be visualized directly on high kilovoltage radiographs of the airway of the airway or by fluoroscopy. In three of the four cases presented in this report, radiologic evaluation was normal, but endotracheal foreign bodies were subsequently demonstrated endoscopically. Foreign objects may remain in the trachea for prolonged periods of time, causing persistent coughing, wheezing, or stridor. When there is a clear history or strong suspicion of foreign body aspiration in a patient with persistent symptoms, bronchoscopy should be used for diagnosis and treatment.

Repositioning maneuver for benign paroxysmal positional vertigo (BPPV).

With vertigo, the symptom of unsteadiness is a common presenting complaint and the etiology protean. However, the specific subset of this patient population with benign paroxysmal positional vertigo (BPPV) is more defined. Cupololithiasis and canalithiasis are perhaps the best known and best described pathologic conditions resulting in vertigo. This condition occurs when otoconia from the utricle are displaced into the Posterior semicircular canal-cupula. The abnormal position of the otoconia often results in a pathological condition. The location of displacement is most often in the posterior semicircular canal. A better understanding of the etiology of BPPV has led to a simple and effective particle repositioning maneuver that allows the practitioner to alleviate vertigo symptoms for most patients using a simple manipulation.