Paralyzed left vocal cord associated with ligation of patent ductus arteriosus.

We reviewed the records of 167 neonates and older children undergoing ligation of a patent ductus arteriosus to determine the prevalence of recurrent laryngeal nerve injury and identify risk factors that might increase the likelihood of injury. Paralysis or paresis of the left vocal cord was identified by fiberoptic laryngoscopy in seven patients. All seven weighted less than 1500 gm at the time of operation and the ductus had been ligated with a metal clip. All had persistent symptoms when observed for 5 to 19 months. Injury to the left recurrent laryngeal nerve occurs infrequently but may have long-term consequences.

Aortic translocation and biventricular outflow tract reconstruction in an infant.

Successful surgical repair of an 8 1/2-month-old infant weighing 8 kg with d-transposition of the great arteries associated with ventricular septal defect and left ventricular outflow tract obstruction was accomplished utilizing a recently described technique. To our knowledge, this is the first attempt to use this technique in an infant.

Thoracoscopic closure of patent ductus arteriosus: a less traumatic and more cost-effective technique.

The authors have developed a technique of thoracoscopic closure of patent ductus arteriosus (PDA) that significantly reduces the surgical morbidity, recovery time, and hospital costs traditionally associated with the standard open procedure. Ten patients have undergone the procedure, with nine completed successfully. One patient required conversion to an open thoracotomy. There were no operative complications, and closure of the ductus was confirmed in all cases with a postoperative echocardiogram. Eight of ten patients were discharged in under 24 hours, and hospital charges were on the average 30% to 40% less.

Mitral Valve Prolapse in Active Youth.

In brief Mitral valve prolapse (MVP) often brief manifests among active children and adolescents. Techniques for detecting clicks and systolic nonejection murmurs can help physicians identify MVP, and diagnostic tests can help confirm the findings. Tracking the patient's chest pain, palpitations, shortness of breath, and other symptoms can help clinicians decide if treatment should include medication-and if medication helps symptoms. Sometimes, simple reassurance will be enough to ease symptoms. With annual follow-up, patients can lead normal lives, which includes reaping the benefits of physical activity.

Interventions to reduce cardiovascular risk factors in children and adolescents.

Certain modifiable risk factors for cardiovascular disease have their beginnings in childhood. Cigarette smoking, hypertension, physical inactivity, obesity, hypercholesterolemia, hyperinsulinemia, homocysteinemia and poor nutrition in childhood and adolescence may all contribute to the development of cardiovascular disease in adulthood. Identifying at-risk children and adolescents is the first step in modifying or preventing these risk factors. Intervention is most effectively accomplished with an integrated family-oriented approach. Involving the entire family in counseling about interventions to reduce the risk factors for coronary artery disease is important. The family should complete a questionnaire about the family's history and risk of cardiovascular disease. The child, along with other family members, should be given advice on dietary changes to reduce fat intake. Incorporating a cardiovascular health schedule into routine office visits is useful for monitoring the risk of cardiovascular disease and for reinforcing the need to maintain healthy habits.

Pediatric wheelchair athletics: sports injuries and prevention.

Two hundred and forty-seven competitors at the 1990 Junior National Wheelchair Games (USA) were surveyed for general information, training techniques, and injury patterns. Eighty-three athletes (34%) responded to the retrospective survey. Injuries were reported by 97% of those participating in track, 22% of the field participants, and 91% of the swimming competitors. A wide variety of injuries was reported ranging from minor bruises, blisters and abrasions to more serious problems (bladder infections, hyperthermia, and soft tissue injuries). While information-reporting biases may be inherent in this type of study, these data are significant in that they are the first obtained for this specific pediatric population via a systemic scientific approach and not from merely anecdotal information.

Congenital polyvalvular disease in trisomy 18: echocardiographic diagnosis.

Congenital heart disease is known to occur in greater than 90% of patients with trisomy 18, with ventricular septal defect and patent ductus arteriosus being the most frequently encountered lesions. The presence of congenital polyvalvular disease in trisomy 18 as assessed by pathological specimens has also been noted. Echocardiograms were obtained in 15 patients with trisomy 18 and in 12 infants with dysmorphic features, who did not have chromosomal abnormalities, in order to obtain an echocardiographic assessment of the frequency of polyvalvular disease in living patients with trisomy 18. In this series all patients with trisomy 18 had structural defects (seven ventricular septal defects, three patent ductus arteriosus, five both). All trisomy 18 patients also had congenital polyvalvular disease with six patients having four affected valves, five patients having three affected valves, and four patients with two affected valves. In patients with normal chromosomes, two had a single abnormal valve, and structural lesions included patent ductus arteriosus (3), ventricular septal defect (2), pulmonary atresia with ventricular septal defect (1), transposition of the great arteries (1), and atrioventricular canal with patent ductus arteriosus and coarctation (1). In infants with features suggestive of trisomy 18, structural cardiac lesions are a nonspecific finding. However, the presence of polyvalvular disease may be a more specific and useful adjunct to other clinical investigations pending chromosomal analysis for definitive diagnosis.

In vivo indomethacin treatment causes microglial activation in adult mice.

The current study was undertaken to study the role of prostaglandins in regulating microglial activation. Mice were treated with indomethacin (2 microg/ml) in their drinking water to selectively inhibit cyclooxygenase activity. After 4-8 days, the effect of inhibiting prostaglandin synthesis on microglial activity was evaluated. This was accomplished by analyzing microglial expression of Mac-1 (C3 complement receptor) as an indicator of activation. Mac-1 expression was assessed by immunohistochemistry of fixed brain cryosections, and by flow cytometric analysis of immunostained single cell suspensions. Both methods demonstrated that compared to age-matched, untreated controls, brains of indomethacin-treated mice had increased levels of Mac-1 expression, suggesting an increase in the state of microglial activation. These results demonstrate the importance of prostaglandins in down regulating microglial activity, and that inhibition of prostaglandin synthesis with indomethacin may act to increase the reactivity of the brain's immune system.

Hereditary atrioventricular conduction defect in a child.

Hereditary atrioventricular conduction defect is an uncommon cause of acquired complete heart block in children. We report a father and son, both of whom presented with seizures as the initial manifestation of acquired complete heart block and required permanent pacemaker implantation. A review of the variations of this entity and the histopathological findings of previously reported cases is presented. Family members of patients with acquired heart block of uncertain etiology should be examined for the presence of conduction abnormalities that may progress to complete heart block.

Congenital vertebral-jugular fistula in an infant.

Pediatric cardiologists are often consulted to evaluate continuous murmurs in children. This case report describes a child with a congenital vertebral-jugular fistula who presented with torticollis and a continuous murmur. The differential diagnosis of continuous murmurs in this setting is discussed.

Normal aerobic and anaerobic exercise data for North American school-age children.

The purpose of this study was to establish normative data for untrained, healthy North American children by means of the James protocol for bicycle ergometry. Data were obtained on 151 of 185 children (70 girls and 81 boys). Their ages ranged from 7 years 6 months to 12 years 9 months. All subjects were divided into groups by gender and body surface area (BSA). Maximum heart rates were greater in girls. The mean difference between maximum and recovery heart rates differed significantly by gender, girls taking longer to recover than boys. Maximum oxygen consumption (measured in cubic centimeters per minute per kilogram body weight) did not differ in boys and girls. Ventilatory anaerobic threshold (VAT) occurred when there was an isolated increase in the slope for ventilatory equivalent for oxygen consumption (VE/VO2) with no change in the slope for ventilatory equivalent for carbon dioxide production (VE/VCO2) when both were plotted against time. Absolute oxygen consumption (VO2) at VAT increased with BSA in both sexes, and, when normalized to body size and expressed as a percent of VO2 maximum, no significant difference was observed between the sexes. These data may be used in the fitness evaluations of preadolescent children from North America.

Cardiac dysrhythmia with the use of clonidine in explosive disorder.

Clonidine has been used in the management of hypertension in adults with few cases of cardiac dysrhythmia reported. These appear to occur most frequently in association with preexisting cardiac disease or toxic concentrations of the drug. We observed a case of clonidine-induced bradycardia and irregular firing of the sinoatrial node in a child who does not have cardiac disease given low doses of the drug in the treatment of intermittent explosive disorder.

Reading grade levels and health behaviors of parents at child clinics.

OBJECTIVES: Recent reports suggest alarmingly low levels of literacy among adults in the U.S., but these are not expressed in grade levels. Assessment of the epidemiology of reading grade levels is necessary for development of patient education materials written at appropriate levels. METHODS: We measured demographics, reading ability and self-described health behaviors of 646 parents at two private, two university, two indigent and six public child-related clinics in a midwestern city using a bilingual oral interview and the Wide Range Achievement Test. RESULTS: Parents were 59% white, 92% female, with mean age 28 years, mean years of school 12.1 and mean reading grade 8.7. Parents tended to read four to five grades below their highest completed school grade. Analysis of self-reported health behaviors showed that 69% had no private insurance, 31% smoked cigarettes, 35% had body mass index greater than 27, and 46% of parous mothers had never breast-fed. Prevalence odds ratios showed that all adverse health risks except obesity were associated with low reading ability. CONCLUSIONS: These findings have important implications for public health professionals working in clinical care, health education and agency policy. Persons with low literacy levels appear to be at particularly high risk for adverse health behaviors. Education materials and teaching vocabulary should be appropriate for client reading grade levels.

Temporal artery tap: usefulness and limitations in carotid sonography.

PURPOSE: To examine the effectiveness of percussion of the superficial temporal artery for identification of the external carotid artery (ECA). MATERIALS AND METHODS: The temporal artery tap maneuver was performed on 324 carotid arteries (163 patients). Evidence for transmission of the effect of the temporal tap was sought in the pulsed Doppler ultrasound waveforms of the ECA, common carotid artery (CCA), and internal carotid artery (ICA). The location and severity of stenotic lesions were recorded. The relative amplitudes of the oscillations created by the tap were compared. RESULTS: The temporal tap effect could be seen in 262 ECAs (81%), 174 CCAs (54%), and 106 ICAs (33%). The tap effect can be seen in the ICA at all grades of ICA disease. When the oscillations were seen in only one of the two major branches, that branch was always the ECA. When the temporal tap effect was found in the ICA, the amplitudes of the oscillations were the same as or greater than those of the ECA in 26% of cases. CONCLUSION: Waveform oscillations from the temporal tap maneuver often can be found beyond the ECA in the CCA and ICA. Thus, the temporal tap alone may not reliably distinguish the ECA from the ICA or CCA.

Association of toxic shock syndrome toxin-secreting and exfoliative toxin-secreting Staphylococcus aureus with Kawasaki syndrome complicated by coronary artery disease.

Kawasaki syndrome (KS) has been reported to be associated with selective expansion of Vbeta2+ T cells and either staphylococcal toxic shock syndrome toxin-1 or streptococcal pyrogenic exotoxin C in uncomplicated cases. However, there have been no previous studies on the role of superantigens in KS associated with coronary artery disease, the major complication of this illness. The present study characterized bacteria isolated from three acute KS patients who developed coronary artery disease. Staphylococcus aureus secreting either TSST-1 (n = 3) or exfoliative toxin A (n = 1), both known to stimulate expansion of Vbeta2+ T cells, were isolated from all three patients. The percent Vbeta2+ T cells was determined in three patients with coronary artery disease. On presentation, one patient demonstrated reduction, whereas the other two showed expansion, of Vbeta2+ T cells. Repeat analyses of the latter two children showed their percent Vbeta2+ T cells to decrease toward normal. These observations suggest that coronary artery disease in KS may result from superantigenic stimulation of Vbeta2+ T cells. This is also the first demonstration of an association of staphylococcal exfoliative toxin with acute KS. The observation that three different bacterial toxins associated with KS are potent activators of Vbeta2+ T cells suggests an important role for this T cell subset in the pathogenesis of this autoimmune disease.

Guidelines for exercise testing in the pediatric age group. From the Committee on Atherosclerosis and Hypertension in Children, Council on Cardiovascular Disease in the Young, the American Heart Association.

Exercise testing of children differs from adult exercise testing in many ways beyond the technical issues related to test performance that are addressed in this report. Disease processes that produce myocardial ischemia are relatively rare in children compared with adults. Exercise testing may be useful in these cases, but the use of testing to assess functional capacity or cardiac rhythms will be encountered more often. Although the precise role of exercise testing in patient evaluation or long-term management of the cardiac patient will vary somewhat from center to center, exercise testing is often essential to diagnose and to direct treatment in a wide variety of clinical problems. An understanding of the role of exercise testing for children with known or suspected heart abnormalities is an essential part of the training of pediatric cardiologists. The staff of the pediatric exercise laboratory should be available to discuss with the clinician when a test might be of value in a specific case in addition to providing advice about the specifics of the performance of the test and offering age- and size-appropriate normal data from the laboratory with test interpretation.