The longer term outcome of children born to mothers with epilepsy

OBJECTIVES

To determine the prevalence of cognitive delay and possible associated dysmorphic features in children exposed to antiepileptic drugs (AEDs) in utero.

DESIGN

Retrospective study of children born to mothers with epilepsy.

SETTING

Regional epilepsy clinics in Liverpool and Manchester, UK.

PARTICIPANTS

Children aged between 6 months and 16 years born to mothers with epilepsy.

MAIN OUTCOME MEASURES

Structured interviews, hospital records, clinical examination, and psychometric tests (Wechsler) were used to assess exposure and intelligence quotient (IQ). Blinded assessment of photographs was used to score children with characteristic dysmorphic features.

RESULTS

A total of 249 children aged 6 and over were studied: 41 were exposed to sodium valproate, 52 to carbamazepine, 21 to phenytoin, 49 to polytherapy, and 80 were unexposed. Mean verbal IQ was significantly lower in the valproate group compared to unexposed and other monotherapy groups. Multiple regression analysis showed that both valproate exposure and frequent tonic-clonic seizures in pregnancy were significantly associated with a lower verbal IQ despite adjusting for other confounding factors. There was a significant negative correlation between dysmorphic features and verbal IQ in children exposed to valproate.

CONCLUSIONS

This study identifies valproate as a drug carrying potential risks for developmental delay and cognitive impairment and is the first to suggest that frequent tonic-clonic seizures have a similar effect. Our results need to be interpreted with caution given their retrospective nature. Women with epilepsy need careful counselling about individual risk benefit of AED treatment before pregnancy.

Hydraulic redistribution of soil water during summer drought in two contrasting Pacific Northwest coniferous forests

The magnitude of hydraulic redistribution of soil water by roots and its impact on soil water balance were estimated by monitoring time courses of soil water status at multiple depths and root sap flow under drought conditions in a dry ponderosa pine (Pinus ponderosa Dougl. ex Laws) ecosystem and in a moist Douglas-fir (Pseudotsuga menziesii (Mirb.) Franco) ecosystem. The fate of deuterated water applied to small plots to create a strong horizontal soil water potential gradient was also monitored to assess the potential for horizontal redistribution of water and utilization of redistributed water by co-occurring shallow-rooted plants. In a 20-year-old Douglas-fir stand, approximately 28% of the water removed daily from the upper 2 m of soil was replaced by nocturnal hydraulic redistribution during late August. In an old-growth ponderosa pine stand, approximately 35% of the total daily water utilization from the upper 2 m of soil appeared to be replaced by hydraulic redistribution during July and August. By late September, hydraulic redistribution in the ponderosa pine stand was no longer apparent, even though total water use from the upper 2 m of soil was nearly identical to that observed earlier. Based on these results, hydraulic redistribution would allow 21 and 16 additional days of stored water to remain in the upper soil horizons in the ponderosa pine and Douglas-fir stands, respectively, after a 60-day drought. At both sites, localized applications of deuterated water induced strong reversal of root sap flow and caused soil water content to cease declining or even temporarily increase at locations too distant from the site of water application to have been influenced by movement of water through the soil without facilitation by roots. Xylem water deuterium values of ponderosa pine seedlings suggested utilization of redistributed water. Therefore, hydraulic redistribution may enhance seedling survival and maintain overstory transpiration during summer drought. These first approximations of the extent of hydraulic redistribution in these ecosystems suggest that it is likely to be an important process in both wet and dry forests of the Pacific Northwest.

Mixed blessings: cervical cancer screening in Recife, Brazil

This study examines the effects of a large-scale cervical cancer prevention campaign in Recife, Brazil between 1994 and 1995. It suggests that while this program effectively motivated women to get pap smears, it reinforced local understandings of the pap smear that ultimately had unintended negative consequences for women's health. It argues that because the campaign connected female sexual activity directly with cervical cancer, the program's message was interpreted by many women to mean that cervical cancer was a sexually transmitted disease and that it would behave like one. Women who were no longer sexually active believed that they did not need to be screened. In addition, women who were sexually active believed that they could use pap smears to diagnose and cure sexually transmitted diseases.

Klinefelter's syndrome as a model of anomalous cerebral laterality: testing gene dosage in the X chromosome pseudoautosomal region using a DNA microarray

Consistent handedness and language laterality are two of the most striking behavioral and cognitive asymmetries observed in humans. Alterations in the typical pattern of cerebral laterality, termed "anomalous dominance," is observed in left-handers and some patients with verbal learning disabilities. We undertook the study of a genetically distinct group of subjects, XXY males (Klinefelter's syndrome; KS), who demonstrate anomalous dominance in a variety of testing paradigms in order to begin to elucidate the molecular basis of anomalous dominance in this population. KS subjects manifest specific verbal learning disability, evidence of altered functional laterality for phonologic processing, and an increase in left-handedness when measured by skill. It is proposed that an alteration in gene dosage in the pseudoautosomal region (PAR) of the sex chromosomes is the most likely explanation for anomalous dominance in these patients. This is especially intriguing in light of previously described genetic models of cerebral laterality that suggest a contributing locus in the PAR, or adjacent high homology regions of the X chromosome. We have developed an ordered DNA microarray covering the X chromosome PAR at high resolution for hybridization with two-color fluorescently labeled probes. We demonstrate the ability to detect changes in hybridization signal that will facilitate efficient large-scale screening of this region for alterations in gene dosage associated with features of anomalous dominance and other cognitive or behavioral phenotypes.

The impact of loading on deformation about posteromedial meniscal tears

To simulate the effects of partial weight bearing on meniscal repair, full-thickness tears were produced in the posteromedial aspect of seven ACL-intact cadaveric knees. Following suture repair, metal markers were imbedded to index the position of the tear. A radiolucent chamber was used to position and load each knee for computed tomography scanning at flexion angles of 0 degrees, 30 degrees, and 60 degrees with and without a load force of 100 lb. Sutures were removed and the tests repeated. Changes in marker distances were obtained for each test condition. Loading produced average dimensional changes of < or =0.5 +/-0.6 mm in either sutured or unsutured menisci. Based on the Friedman test, neither flexion angle, loading, nor suture exerted a significant impact (P> or =.52). These data support clinical accelerated rehabilitation programs previously published. Therefore, partial weight bearing during convalescence is tenable.

Detection of differentially expressed genes in primary tumor tissues using representational differences analysis coupled to microarray hybridization

The identification of differential gene expressionbetween cells is a frequent goal in modern biological research. Here we demonstrate the coupling of representational difference analysis (RDA) of cDNA with microarray analysis of the output for high throughput screening. Two primary Ewing's sarcoma tissue samples with different biological behavior in vivo were compared by RDA: one which was metastatic and progressed rapidly; the other localized and successfully treated. A modified RDA protocol that minimizes the necessary starting material was employed. After a reduced number of subtractive rounds, the output of RDA was shotgun cloned into a plasmid vector. Inserts from individual colonies from the subtracted library were amplified with vector-specific primers and arrayed at high density on glass slides. The arrays were then hybridized with differentially fluorescently labeled starting amplicons from the two tissues and fluorescent signals were measured at each DNA spot. We show that the relative amounts of fluorescent signal correlate well with the abundance of fragments in the RDA amplicon and in the starting mRNA. In our system, we analyzed 192 products and 173 (90%) were appropriately detected as being >2-fold differentially expressed. Fifty unique, differentially expressed clones were identified. Therefore, the use of RDA essentially provides an enriched library of differentially expressed genes, while analysis of this library with microarrays allows rapid and reproducible screening of thousands of DNA molecules simultaneously. The coupling of these two techniques in this system resulted in a large pool of differentially expressed genes.

A randomized controlled trial of early physiotherapy for high-risk infants

The aim of this study was to investigate the hypothesis that infants at high risk of cerebral palsy would benefit from early physiotherapy. In total, 105 infants with abnormal cranial ultrasound scans were randomized at around term to early physiotherapy or standard treatment (delaying physiotherapy until abnormal physical signs became apparent). At 12 and 30 months there were clinical and objective assessments. Nine infants died and nine were lost to follow-up by 12 months when 87 infants were assessed. One other child had died and three others were lost to follow-up by 30 months when 83 children were assessed. Cerebral palsy was only accurately predicted in 45 (54%) infants. There was no difference in outcome. The difficulty of predicting cerebral palsy reliably and the heterogeneity of the condition should be borne in mind when planning treatment and assessing its efficacy.

Explanatory models for cancer among African-American women at two Atlanta neighborhood health centers: the implications for a cancer screening program

This paper examines cultural models for breast and cervical cancer among low-income African-American women over 40, in order to better understand how those models might affect cancer screening behavior. The study is part of The Community-Based Cancer Screening Project, which is sponsored by Emory University, Grady Memorial Hospital, and the American Cancer Society. The Screening Project attempts to increase the use of mammography, clinical and self-examination of the breast, and cervical Pap smear among women aged 40 or older in a predominantly African-American, low-income, low educational level population that is currently underserved by any screening activities. The study of cultural models of cancer within the project was prompted by the recognition that if screening programs targeted at specific, underserved, populations are to succeed, cultural as well as logistical barriers to screening must be overcome. Patients and clinicians must each understand how the other perceives cancer, its prevention, and its treatment. Only with this mutual understanding as a foundation, can physicians and their clients cooperate to improve cancer screening rates. Our research results indicate that the cancer models held by the patient population differ significantly from those held by clinicians. Women attending the clinics endure cancer screening tests that to them seem to serve only as heralds of a disease that will ultimately kill them. Most women doubt there is a cure for cancer, though some believe a person may live if the disease is caught in time.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of esophageal ligation on the development of fetal rabbit intestinal lactase

To investigate the effect of normal fetal swallowing and amniotic fluid ingestion on small intestinal disaccharidase development, 13 pregnant New Zealand White rabbits underwent operation on day 24 of a normal 31-day gestation. The right ovarian fetus in the bicornuate uterus underwent esophageal ligation (EL), while the contralateral left fetus underwent cervical exploration only, and served as the control (C). Rabbits were sacrificed on gestational day 31, fetal somatic measurements obtained, and the midjejunum removed for determination of disaccharidase activity and protein content. There was one maternal death, and 9 of 12 fetal pairs survived the entire study period (75%). Results are reported as mean +/- SEM, analyzed by two-tailed Student's t testing with P < .05 being considered significant. Fetal weight was decreased in EL (48.6 +/- 2.7 g) versus C (51.4 +/- 3.2 g) (P = .06). Small intestinal length decreased in EL (49.2 +/- 2.0 cm) versus C (54.9 +/- 1.1 cm) (P = .01). Midjejunal protein content (mg/mL homogenate) was also significantly decreased in EL (38.4 +/- 3.4) versus C (46.2 +/- 3.7) (P = .05). Sucrase activity was not detectable in either group. Lactase activity in jejunal mucosa was not effected when expressed as units of enzyme per milliliter of homogenate (EL = 0.357 +/- 0.03 v C = 0.373 +/- 0.04; P = .70) and units enzyme per gram of protein (EL = 38.8 +/- 4.2 v C = 34.2 +/- 4.6; P = .44). We have confirmed previous studies demonstrating decreases in somatic growth, small intestinal length, and mucosal nutrient transport in rabbit fetuses following esophageal ligation.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary immunisations in Liverpool. II: Is there a gap between consent and completion?

The association between completion of primary dipht eria, tetanus and pertussis, measles, mumps, and rubella and polio immunisation courses in Liverpool and five sociodemographic factors, namely the child's sex, position in the family, family type, migration into Liverpool since birth, and local deprivation was examined. Only 68% of children were fully immunised by their second birthday. The immunisation rate for pertussis was 74%, compared with 85-89% for the other antigens. Children who had older siblings, were recorded as living with one parent, had moved into Liverpool or who lived in areas of high deprivation were less likely to complete the full set of antigens and individual courses. Boys were significantly less likely than girls to be fully immunised against pertussis. Differences in the completion of pertussis immunisation associated with the child's sex and with local deprivation were a direct reflection of differences in rates of parental consent. Parental consent did not wholly account for significantly lower rates among children with older siblings, those living with a lone parent, and those who had moved into Liverpool, however. This may reflect the practical difficulties of attending immunisation clinics. To achieve immunisation targets, a more flexible and targeted approach is required of health professionals. This may include the careful targeting of efforts to increase consent and the improvement of access to immunisations by providing domiciliary services or by opportunistic immunisation of infants when they are in contact with primary and community health care services.

A comparison of three procedures to assess the motor ability of 12-month-old infants with cerebral palsy

This study compared three methods of assessing motor impairment during infancy. The 77 infants studied were considered to be at high risk of motor impairment because of abnormal neonatal cranial ultrasound scans or abnormal somatosensory responses. The children were assessed at eight and 12 months post-term by the Movement Assessment of Infants, the Griffiths locomotor development quotient and the limb-by-limb approach, and the results were compared with clinical assessment at 12 months post-term. The sensitivity of the limb-by-limb approach was highest, although its specificity was slightly lower than the other tests. It was also the easiest to perform. While giving information about the quality of movement, none of these methods is a quantitative test of movement.

Primary immunisations in Liverpool. I: Who withholds consent?

The association between parents in Liverpool consenting to their children being invited for primary immunisations and five sociodemographic factors, namely sex, position of child in the family, family type, migration into Liverpool since birth, and local deprivation was examined. Rates of consent to invitation were over 97% for each antigen except pertussis, which had a consent rate of 83%. Consent to invitation for pertussis vaccine was least likely to have been given for boys, children with older siblings, those recorded as living with a single parent, and those in the most deprived areas. Local deprivation also had an effect on consent to the measles, mumps, and rubella vaccine. Migration into Liverpool had a significant effect on consent to invitation for all antigens except pertussis. The child's sex, family type, and local deprivation had no effect on consent to diphtheria, tetanus, and polio immunisations. Maximising pertussis vaccine uptake will require more attention to be paid to those parents who have been identified as being less likely to give consent. It is particularly important that consistent and clear advice about immunisations is made available to parents with two or more children, lone parents, and those living in materially deprived areas. Our findings challenge some of the assumptions underlying the principles of 'first parent visiting', at least so far as pertussis is concerned.

Trauma to elbows, knees, and ankles

In summary, the emergency department or office-based physician should distinguish first between inflammation and injury. A clinical diagnosis of fracture should be made before obtaining and reading films. Comparison views help to resolve doubt. A neurologic examination should be documented before undertaking reduction. Finally, if in doubt, a splint for 24 to 48 hours until an orthopedic opinion is available causes no harm.

Radionuclide imaging in internal derangements of the knee

The clinical specificity and sensitivity of imaging with 99mTc was evaluated prospectively in 104 consecutive patients admitted to the hospital for diagnostic/surgical arthroscopy. Four distinct patterns of radionuclide activity were seen that correlated with observed arthroscopic findings. These patterns of activity were seen with degenerative joint disease (DJD) or severe rotational instability, meniscal pathology, fracture of the subchondral plate or full thickness cartilaginous ulceration, and synovitis. Radionuclide imaging was seen to be extremely sensitive and highly specific for all four patterns of activity. The observed association of subchondral plate injury with meniscal pathology may present an explanation for the observed poor outcome in a limited number of patients following meniscectomy.

Osteoid osteoma. Distant, periarticular, and subarticular lesions as a cause of knee pain

Osteoid osteoma, a benign osteoblastic tumour comprised of osteoid and atypical bone, is a well-known entity. However, clinical diagnosis may be delayed, especially when the pain is referred to a nearby joint. This paper reports a series of 11 cases occurring in physically active patients in whom the diagnosis was delayed because of pain referral to the knee. The mean duration from the onset of symptoms to diagnosis of osteoid osteoma was 20 months (range 3 to 48 months). Review of these 11 lesions indicates that they can be classified on the basis of their anatomical location: (a) distant to the knee; (b) periarticular; or (c) subarticular (intraarticular). It should be noted that initially only 5 of the 11 cases displayed characteristic x-ray findings; in the remaining 6 cases, diagnosis was dependent on positive 99mTc radionuclide bone scans, tomograms, and computerised tomography scans. Of the 9 patients who underwent surgical resection of their lesions, all had complete relief of symptoms and all continued to be asymptomatic at follow-up evaluations.

Pancreas divisum and its association with choledochal sphincter stenosis. Diagnosis by endoscopic retrograde cholangiopancreatography and endoscopic biliary manometry

Choledochal sphincter stenosis was demonstrated in 37 of 90 patients with pancreas divisum. In 21 of the patients, stenosis was diagnosed during ERCP by endoscopic calibration of the choledochal sphincter, delayed drainage of contrast material from the bile duct, or a dilated common duct with or without elevation of the serum alkaline phosphatase level. In 12 patients, stenosis was diagnosed during endoscopic manometry with the demonstration of elevated basal choledochal sphincter pressures. Stenosis was initially diagnosed during surgery in four patients. Common duct diameters were normal in all patients who had not had cholecystectomy. Choledochal sphincter stenosis was confirmed in all patients who subsequently underwent sphincteroplasty. The surgical approach to patients with pancreas divisum and intractable obstructive pain should include sphincteroplasty of both the major and minor sphincters rather than the minor sphincter alone.

The isolation of identical thyroxine containing amino acid sequences from bovine, ovine and porcine thyroglobulins

Identical, thyroxine containing tryptic peptides have been isolated from digests of bovine, ovine and procine thyroglobulins. This 19 residue hormone containing sequence, NH2-Asn-Ile-Phe-Glu-T4-Gln-Val-Asp-Ala-Gln-Pro-Leu-Arg-Pro-Cys-Glu-Leu-G in-Arg- COOH, is completely conserved across these three species, and it represents a principal site of thyroxine synthesis. HPLC maps of tryptic digests of the thyroglobulins have been monitored at several wavelengths and suggest that, in each case, only a small number of tryptic peptides are iodinated in vivo and that an even smaller number of tryptic peptides contain thyroid hormone. These data are consistent with a high degree of selectivity in iodination of tyrosines within thyroglobulin and the subsequent coupling of these selected tyrosines to form thyroid hormone.

Normal organ weights of infants and children: graphs of values by age, with confidence intervals

This study subjects the Coppoletta-Wolbach data of normal organ weights of children from birth to 12 years of age to statistical analysis, producing a set of curves that show the linear regression of organ weight versus age for each set of weights plus, for each organ, the 75%, 80%, 90%, 95%, and 99% confidence bands for single new values.