School-age follow-up of prophylactic versus rescue surfactant trial: pulmonary, neurodevelopmental, and educational outcomes.

BACKGROUND: Exogenous surfactant replacement has improved survival and reduced pulmonary complications of prematurity. Improved early outcomes for infants of <30 weeks' gestation treated with a strategy of prophylactic versus rescue surfactant, if needed, were demonstrated in a multicenter, randomized trial conducted between 1985 and 1988. We reevaluated a subset of survivors from this trial to determine the pulmonary and neurodevelopmental outcomes at school age. METHODS: At 4.5 to 8 years of age, all survivors from one of the three centers were located, and 96% were evaluated. The original randomization included stratification by center and followed an intention-to-treat methodology in assessing the efficacy of prophylactic versus rescue treatment with surfactant. The follow-up test battery included a health-assessment questionnaire, spirometry, 88% saturation test, neurologic examination, and the McCarthy Scales of Children's Abilities (MSCA) and the Conners' Parent Rating Scale-48. Educational achievement was determined by school class placement and teachers' reports of achievement. RESULTS: Of the 192 children originally enrolled, 154 survived. Evaluations were performed on 148 of these infants. An abnormal pulmonary history was found in 45 (30%) of the children: 16 (22%) in the prophylactic group and 29 (39%) in the rescue group. Formal pulmonary function was evaluated in 81 children; 29 (78%) in the prophylactic group and 33 (75%) in the rescue group were considered abnormal. No significant differences were found between the two groups on either cognitive or motor subscales of the MSCA, the Conners' Parent Rating Scale-48, the neurologic examination, the education services received in school, or the teacher ratings of below-average academic performance. Intelligence scores measured on the MSCA were low-normal for both groups. Some level of educational assistance was being provided to 72 (49%) of the cohort studied, and both groups had below average educational performance and increased needs for educational assistance. CONCLUSIONS: Prophylactic surfactant administration to infants of <30 weeks' gestation was associated with fewer long-term clinical pulmonary complications than assignment to rescue administration. Formal pulmonary testing at school age did not reveal significant differences between treatment groups in those infants who could be tested. There also were no group differences found on neurologic, cognitive, behavioral, or educational assessments at school age.

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.

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.

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.

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.

Arthrogryposis multiplex congenita: a report of two cases.

Arthrogryposis multiplex congenita refers to a group of birth defects characterised by multiple joint contractures. The syndrome is caused by neuropathic disease, myopathic disease, or any other cause of decreased fetal joint mobility. Multiple and usually symmetric joint abnormalities with associated muscular and soft tissue hypoplasia are noted at birth. A variety of associated congenital anomalies affecting many organ systems are frequently found. Ocular and orbital findings have been described in patients with arthrogryposis but corneal disease has only rarely been reported. We present corneal findings in two patients with arthrogryposis and discuss the implications for disease pathogenesis. Previous ophthalmologic reports are also reviewed.

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.

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.

Hindlimb loading, morphology and biochemistry of articular cartilage in the ACL-deficient cat knee.

The cat hindlimb is the best studied animal model of neuromuscular control, muscle mechanics/muscle morphology, and locomotor kinematics. Therefore, this model offers itself for intervention studies, where a musculoskeletal parameter is perturbed and the effects of this perturbation are compared with normal function. The objective of this study was to describe the effects of anterior cruciate ligament (ACL) transection in the cat knee and to correlate hindlimb loading with morphological and biochemical changes of articular cartilage. A distinct unloading of the deficient hindlimb was found when compared with the nonoperated hindlimb immediately after ACL transection, and persisted for about 16-18 weeks. Beyond about 18 weeks post-ACL transection, hindlimb loading returned to the symmetric pattern observed before surgery. In accordance with the expectations from the force-platform results, a decrease in muscle mass was found from muscles of the experimental hindlimb when compared to the mass of muscles from the contralateral hindlimb. This decrease of muscle mass was largest at 4 weeks and smallest at 35 weeks post-ACL transection. At 12 and 35 weeks post-ACL transection, cell density was increased and absolute amounts of hexuronic acid were elevated in the articular cartilage of the experimental knee compared with the corresponding values of the contralateral knee. Progressive changes of the articular cartilage towards osteoarthritis (OA) were not observed in the time frame of this experiment. The results suggest that anterior cruciate ligament transection in the cat produces initial changes in the knee that are similar to those observed previously in the dog and rabbit.

Unraveling the mysteries of sudden infant death syndrome.

The major contributions to the understanding of sudden infant death syndrome (SIDS) from the 1992 literature are in the area of epidemiology. The SIDS incidence, both in the overall population and in the Native American population, is decreasing. There was an additional report identifying overwrapping as a risk factor for SIDS, and several models of infant hyperthermia have been developed and studied. New data from New Zealand and England lend further support to the association between prone sleeping and SIDS, a relationship that has prompted a sleeping position recommendation from the American Academy of Pediatrics. Several studies suggest an association between SIDS and toxigenic bacteria in the upper respiratory tract, but no significant association was found between SIDS and positive viral cultures. Two studies report that medium-chain acyl-coenzyme A dehydrogenase deficiency is not significantly associated with SIDS. Of particular interest in the near future will be additional data about the effect of changing sleeping position on the incidence of SIDS in the United States.