Long-Term outcome of mitral balloon valvotomy in pregnant women.

BACKGROUND AND AIM OF THE STUDY: The study aim was to examine the long-term outcome (nine years) of mitral balloon valvotomy in pregnant patients with severe mitral stenosis. METHODS: Twenty-three patients with severe, symptomatic (NYHA class III/IV) mitral stenosis underwent mitral balloon valvotomy using an Inoue balloon technique during the second trimester of their pregnancy; mean follow up in 19 patients was 5.1 +/- 2.8 years (range: 1 to 9 years). RESULTS: The procedure was successful in all patients. Immediately after valvotomy, the Doppler-derived mitral valve area increased from 0.90 +/- 0.18 to 1.97 +/- 0.36 cm2 (p <0.0001), and the transmitral mean gradient decreased from 15.7 +/- 4.7 to 5.5 +/- 1.6 mmHg (p <0.0001). Four patients had mild worsening of mitral regurgitation, and six developed insignificant interatrial communication immediately after valvotomy. There was no other morbidity or mortality. Patients showed a significant improvement in mean NYHA class, from 3.0 +/- 0.1 to 1.0 +/- 0.02 (p <0.001). Twenty-two patients had normal deliveries; one cesarean section in week 36 resulted in stillbirth. No developmental abnormalities were seen in the babies. At long-term follow up of mothers, the mitral valve area was 1.8 +/- 0.52 cm2; restenosis developed in three patients (16%). One baby died at one week from sudden infant death syndrome, and one at eight months, from pneumonia. All other children showed normal growth, development and speech for their age. CONCLUSION: Mitral balloon valvotomy using the Inoue balloon technique can provide satisfactory immediate relief and long-term outcome in pregnant patients with severe mitral stenosis.

A pilot study of the relationship between Down's syndrome and hearing loss.

OBJECTIVE: Hearing loss is one of the most common disabilities in children with Down's syndrome. The objective of this study is to investigate the incidence and types of hearing loss in Down's syndrome patients. METHODS: Twenty-six subjects with Down's syndrome aged between 2 and 17 year old were evaluated during the year 1998, referred randomly by the Pediatric Department and the Down's Syndrome Centre. Screening audiological procedures were used to evaluate these patients, which include behavioral audiometry, play and pure tone audiometry, tympanometry and ABR, which is the measurement of the activity of the auditory pathway structures from the distal auditory nerve to the midbrain using clicks or tonepips. RESULTS: The study showed that 35% were found to have normal hearing compared to 4% found to have sensorineural hearing loss, while the majority of patients were found to have a conductive hearing loss (50%). CONCLUSION: Hearing evaluation of children with Down's syndrome revealed a high prevalence of conductive hearing loss. This study proposed that this might be attributed to eustachian tube dysfunction and middle ear ciliary malfunction. Further diagnostic studies need to be carried out.

A pilot study of the relationship between Down`s syndrome and hearing loss.

OBJECTIVE: Hearing loss is one of the most common disabilities in children with Down`s syndrome. The objective of this study is to investigate the incidence and types of hearing loss in Down`s syndrome patients. METHODS: Twenty-six subjects with Down`s syndrome aged between 2 and 17 year old were evaluated during the year 1998, referred randomly by the Pediatric Department and the Down`s Syndrome Centre. Screening audiological procedures were used to evaluate these patients, which include behavioral audiometry, play and pure tone audiometry, tympanometry and ABR, which is the measurement of the activity of the auditory pathway structures from the distal auditory nerve to the midbrain using clicks or tonepips. RESULTS: The study showed that 35% were found to have normal hearing compared to 4% found to have sensorineural hearing loss, while the majority of patients were found to have a conductive hearing loss (50%). CONCLUSION: Hearing evaluation of children with Down`s syndrome revealed a high prevalence of conductive hearing loss. This study proposed that this might be attributed to eustachian tube dysfunction and middle ear ciliary malfunction. Further diagnostic studies need to be carried out.

Latex allergy in Saudi children with spina bifida.

BACKGROUND: Children with spina bifida (SB) are exposed to latex soon after birth during bladder catheterization, rectal disimpaction, and multiple surgical procedures. IgE-mediated latex-allergic reactions have been reported recently in these children. Our study was designed to assess the prevalence of allergic reactions to latex products in a group of Saudi Arabian children with SB in a tertiary care hospital. METHODS: Fifty-nine patients, aged 1-20 years, with SB were evaluated by a questionnaire on type of latex reactions; family and personal history of other allergic disorders, such as asthma, rhinitis, and urticaria; type and number of surgical procedures; and frequency of bladder catheterization and manipulation with latex materials. Confirmation of latex sensitivity was measured by skin prick test (SPT), CAP test, and latex skin challenge. RESULTS: Allergy to latex was detected in 25% of the study group. There was a significant variation in allergic reaction by sex (males 42%, females 12%) (P<0.01), use of catheters (yes 38%, no 13%) (P<0.05), and urologic surgery (yes 60%, no 18%) (P<0.01). The number of surgical procedures, age of patient, and V-P shunt were not significantly related to allergic reactions. CONCLUSIONS: Our findings support previous studies indicating a high prevalence of latex allergy among SB patients. The CAP test was a more sensitive measure of latex allergy in SB patients than SPT or latex challenge. There was significant correlation with urologic procedures and the use of urethral catheters.

Different faces of non-autoimmune diabetes of infancy.

The aim of this report is to describe four cases of non-autoimmune diabetes that presented in infancy. Three had transient neonatal diabetes mellitus (TNDM) with diabetic ketoacidosis at onset, followed by complete remission after several months of insulin treatment. While the fourth case was initially diagnosed as TNDM, she had renal, hepatic and pancreatic dysplasia. These cases illustrate that diabetes in infants can be difficult to diagnose and that patients with TNDM can have a recurrence of diabetes several years later.

Atlanto-occipital and atlanto-axial instability in children with Down syndrome.

Thirty-six children with Down syndrome, between two-and-ne-half and 13 years of age, were evaluated for instability of the cervical spine, in order to determine the prevalence of upper cervical spine instability in Saudi children with this condition. Nine patients exhibited abnormal cervical spine movement. Eight patients had atlanto-occipital instability and three had atlanto-axial instability. None of the nine patients with abnormal cervical spine movements developed any neurological deficit. Our survey confirms the data from the literature that there is a high incidence of cervical spine instability in children with Down syndrome.

Structured guidelines for the use of influenza vaccine among children with chronic pulmonary disorders.

National committees recommend annual influenza vaccination for children > or = 6 months of age with chronic pulmonary diseases, but several studies have suggested that many high risk children do not receive the vaccine. The purpose of this pilot study was to determine whether the use of structured guidelines for which pulmonary disorders warrant influenza vaccination would increase agreement among physicians on whether specific children should be vaccinated. Hospital records of 73 children with an outpatient appointment during the previous month in the pulmonary, allergy or high risk neonatology clinics were reviewed independently by 4 pediatricians. Two reviewers used a set of specific guidelines in deciding whether influenza vaccination was indicated, whereas the other 2 used unspecified clinical judgment. Interrater agreement concerning the advisability of vaccination was higher between the reviewers using the guidelines (overall agreement, 0.89; kappa = 0.73) than between the reviewers using clinical judgment (overall agreement, 0.68; kappa = 0.31). Even among the 34 children for whom all 4 reviewers thought the vaccine advisable, only 13 (38%) had been vaccinated. Studies to define the risk of severe influenza among children with specific lung disorders are needed, but these guidelines can serve as a starting point for the identification of children who deserve individual consideration for annual influenza vaccination.

Child abuse in Saudi Arabia: Report of ten cases.

Ten abused children under five years of age (four males, six females) were seen in King Faisal Specialist Hospital and Research Centre (KFSH&RC) between 1989G and 1992G. Two children died, five had serious injuries and three had moderately severe injuries. In one of the fatalities, the diagnosis was not suspected until four years after death, when her sister was diagnosed as a case of child abuse. Six children suffered varying degrees of physical neglect and abuse and sexual abuse. The remaining four children had Munchausen syndrome by proxy. Parentally induced illness should therefore be considered in the differential diagnosis of unusual illness with bizarre features, even if the parents' behavior appears normal.

Clinical and serologic responses of Saudi children to Hemophilus influenzae type B capsular polysaccharide diphtheria toxoid conjugate vaccine.

Sixty-eight Saudi children, 17 to 19 months of age, were enrolled in a study to evaluate the safety and immunogenicity of Hemophilus influenzae type B capsular polysaccharide diphtheria toxoid (PRP-D) conjugate vaccine. Adverse reactions to the vaccine were determined through a questionnaire administered to the parents. Local and systemic reactions to the vaccine were mild and resolved within 24 to 48 hours. PRP antibody levels were measured prior to and one to two months following immunization. PRP antibody levels in the pre-immunization sera of 77% of subjects were below the level associated with immediate protection (>/=0.15 microg/ml), and 88% were below the level associated with long-term protection (>/=1 microg/ml) from Hemophilus influenzae type B (HIB) disease. After one dose of PRP-D vaccine, 100% of recipients achieved antibody levels of >/=0.15 microg/ml, and 85% achieved levels of >/=1 microg/ml. The geometric mean level of antibody after immunization (5.66 microg/ml) was significantly higher than that before immunization (0.098 microg/ml). All subjects had a twofold or greater increase in antibody level in response to the vaccine. We conclude that PRP-D is a safe and highly immunogenic vaccine in this age group of Saudi children.

Corneal steepening with final suture removal after penetrating keratoplasty.

We reviewed 53 patients after they underwent penetrating keratoplasty, comparing the change in average corneal curvature before and after final suture removal 15-18 months postsurgery. In 29 eyes with keratoconus, there was a significant increase in average curvature of 3.48 diopters +/- 3.76 (p less than 0.0005). In 24 eyes with other diagnoses, there was also a significant increase in the average curvature of 3.26 diopters +/- 3.98, (p less than 0.0005). The difference between these groups was not significant. The amount of steepening correlated negatively (-.6494) with the average corneal curvature before suture removal (p less than 0.005). We found no change in the average astigmatism after suture removal; however, large changes in astigmatism occurred unpredictably with some patients. This study shows that corneal curvature after penetrating keratoplasty steepens after suture removal, particularly in flat corneas, and astigmatism may shift unpredictably.

Nosocomial endophthalmitis survey. Current incidence of infection after intraocular surgery.

The authors reviewed the incidence of hospital-linked postoperative endophthalmitis at the Bascom Palmer Eye Institute between January 1, 1984 and June 30, 1989. After 30,002 intraocular surgical procedures, the following incidence of culture-proven endophthalmitis was observed: (1) extracapsular cataract extraction (ECCE) with or without intraocular lens (IOL) implantation--0.072% (17 of 23,625 cases); (2) pars plana vitrectomy--0.051% (1 of 1974 cases); (3) penetrating keratoplasty (PKP)--0.11% (2 of 1783 cases); (4) secondary IOL--0.30% (3 of 988 cases); and (5) glaucoma filtering surgery--0.061% (1 of 1632 cases). A statistically significant (P = 0.038, Fisher's exact test, two-tailed) increased incidence of endophthalmitis occurred in diabetic (0.163%, 6 of 3686 cases) compared with nondiabetic (0.055%, 11 of 19,939 cases) patients undergoing ECCE with or without IOL implantation. The authors also reviewed the incidence of postoperative endophthalmitis after intracapsular cataract extraction (ICCE) with and without IOL and observed an incidence of 0.093% (7 of 7552) in cases operated on between September 1, 1976 and December 31, 1982.

Topical anesthetic abuse.

Topical ocular anesthetic abuse is a serious disorder causing keratitis and persistent epithelial defects. It may be the result of either prescription by the patient's eye care practitioner, theft from the practitioner's office, or occult additives in therapeutic medications. The authors report observations of six individuals suffering from this disorder which suggest that persistent epithelial defects, corneal stromal ring infiltrates, disproportionate pain, and prescription or nonprescription substance abuse may be factors involved. Penetrating keratoplasty was required to treat corneal perforation in two patients, and permanent corneal structural damage was noted in two eyes. Two eyes had a relentless downhill course culminating in enucleation. Because five of the six patients were diagnosed and treated as having presumed Acanthamoeba keratitis during the course of their disease, topical ocular anesthetic use should be included in the differential diagnosis of chronic keratitis and may masquerade as Acanthamoeba keratitis. The authors believe that practitioners should not prescribe or dispense topical anesthetics and should avoid clinical settings which provide an opportunity for the theft of topical ocular anesthetics.

Development of presenile cataracts in association with high serum levels of phenytoin.

We report the occurrence of bilateral cataracts in a young adult which developed shortly after documented high serum levels of phenytoin. There are two previous reports (five patients) in the literature implicating this drug as a cause of cataract formation in humans. This is the first case in which toxic levels were measured.