Sudden infant death syndrome risk questionnaire: a mirror of parental awareness rather than a prospective diagnostic tool

AIM

In 1989, a scoring system that aimed to identify infants at risk of sudden infant death syndrome (SIDS) by a structured questionnaire [SIDS risk questionnaire (SRQ)] consisting of 25 items was introduced in Styria (Austria). It was the aim of the study to compare SIDS rates in the population that had access to the SRQ with the population that had no access. Furthermore, for the population receiving the SRQ, the responding (compliant) and non-responding (non-compliant) groups were compared concerning the incidence of SIDS.

METHODS

Within the study period, 53 865 births and 57 SIDS cases were recorded (incidence 1.06/1000) and analysed retrospectively.

RESULTS

The incidence of SIDS was significantly higher in the non-responding population (2.36/ 1000) than in the responding group (0.81/1000, p < 0.001). However, the incidence of SIDS was not significantly different in the population that had access to the risk questionnaire (1.29/1000) and the group without access (0.86/1000, p = 0.145).

CONCLUSION

The value of any questionnaire used for SIDS prevention may be limited by the existence of a non-compliant population which represents a risk group and should be targeted by other preventive measures.

[Ileocoecal intussusception of the terminal ileum caused by a carcinoid tumor]

Intussusception of the intestine is a frequent reason for intestinal obstruction in infants; the course is acute but the causes are often not recognizable. In adults intussusception is the cause for bowel obstruction in only 1% of cases. The course is subacute and in over 90% a benign or malignant process in this part of the intestine is found. We report the case of a 45-year-old male with abdominal discomfort, increasing over weeks. The preoperative ultrasonography and computed tomography of the abdomen revealed the typical finding of ileocoecal intussusception. An ileocoecal resection was performed. The histopathological workup showed a small carcinoid tumour of the terminal ileum.

Persistent hypercapnia in children after treatment of obstructive sleep apnea syndrome by adenotonsillectomy

Obstructive sleep apnea syndrome (OSAS) in childhood is frequently in part a consequence of enlarged adenoids and/or tonsils and may lead to hypoxemia and hypercapnia during sleep. Whereas long-term blood gas alterations are well documented in adults, only few polygraphic data are available for children. It was the aim of this study to document blood gas alterations before and after treatment in this population. 9 children with OSAS (6 male, 3 female, median age 5.9 years, range 1.1-13.5 years) were investigated by polysomnography before and after adenotonsillectomy. Prior to intervention most children presented with moderate hypercapnia (ETCO2 mean 44.3 +/- 3.8 mm Hg, ETCO2 maximum 53.2 +/- 5.2) and hypoxemic episodes (oxygen saturation mean 93.2 +/- 3.2%, minimum 74.4 +/- 16.5%). Following adenotonsillectomy subsequent polygraphic investigations displayed normalisation of oxygen saturation (saturation mean 96.1 +/- 0.8%, minimum 90.1 +/- 3.1%). In contrast, moderate hypercapnia in several patients persisted up to five months after treatment (ETCO2 mean 44.9 +/- 2.8 mm Hg, ETCO2 maximum 51.2 +/- 3.6). Persistent hypercapnia most likely reflects an adaptation process of chemosensitivity and respiratory control due to preceding long-term hypercapnia.

[Actinomycosis of the pelvis with an indwelling IUD]

Infection with actinomycosis israeli (an anaerobic, gram-positive bacterium) presents as chronic inflammation with tendency to fibrosis and suppuration with formation of external sinuses. Cervicofacial, thoracic and abdominal forms of the disease made up 95% of cases of actinomycosis. A 53-year-old woman was admitted to the hospital because of a pelvic mass which was thought to be malignant. A laparotomy was performed and the histologic examination showed actinomycosis. The patient first received penicillin followed by tetracyclin and the pelvic mass shrunk. One year later no more mass was detectable. We think that the IUP in place over years is the source for this infection.

[4th Austrian SIDS Consensus-Consultation and the Viennese SIDS prevention campaign "Secure Sleep"]

Despite numerous investigations the pathophysiologic mechanisms of SIDS have not been fully elucidated. In large epidemiologic studies highly variable SIDS mortality rates were noted between different countries and cultures. This presumably is due not only to differences in diagnostics and classification of SIDS but also in lifestyle and newborn care. The common denominator is the identification and prevention of the main risk factors: smoking, sleeping in the prone position, over-heating, wrong "bedding". SIDS prevention campaigns that have focussed upon these risk factors have led to a dramatic reduction in the incidence of SIDS. In preparation for the SIDS prevention campaign of Vienna ("Safe Sleep") the content, strategy and procedure of the Austrian prevention campaigns were analysed. The current focus is to convey a clear and uniform message in personal conversations before and after birth of the child. These conversations with parents are the most important tool to detect SIDS related anxiety and a possibly increased risk of SIDS. In the last 30 years various polysomnographic parameters were published that were associated with an increased risk of SIDS. Today there is international consent that polysomnography is not an efficient screening method to demonstrate increased risk of SIDS. Therefore the use of polysomnography, besides research purposes, has been limited to investigating clinical symptoms of infants and children. Concerning monitoring it is important to note that--in contrast to the undisputed importance of monitoring breathing disorders--the effectiveness in SIDS prevention is unproven. State of the art are instruments that monitor heart and breathing rate and have adequate storage functions. The duration of monitoring should encompass the symptomatic period as well as a safety period of three months. The monitor should not be routinely prescribed for a year. The guiding principle is "As short as possible with stringent indication". Prerequisite for the monitoring is good instruction of the parents and a continuous consultation by competent outpatient clinics.

[Mesenteric infarct in primary antiphospholipid antibody syndrome]

The mesenteric infarction is a rare but life threatening cause of acute abdomen. A 55-year-old woman was referred to the hospital because of acute mesenteric infarction and in the history claudication. In the absence of risk factors (atrial fibrillation, atherosclerosis, nicotin abusus) a postoperative work up was started to identify the cause of the arterial occlusions. A primary antiphospholipid-antibody syndrome was found. The patient is now receiving low-dose aspirin and anticoagulation therapy. The follow-up over now 14 months shows no further events.

Congenital central hypoventilation syndrome (Ondine's curse syndrome) in two siblings: delayed diagnosis and successful noninvasive treatment

Congenital central hypoventilation syndrome (CCHS, Ondine's curse syndrome) is a rare respiratory disorder; less than 100 cases have been reported. Familiality of the disease has been discussed, but only few familial cases have been reported so far. In this report we describe the occurrence of CCHS in two male siblings. Diagnosis was established only at the age of 4 years in the first case, although the patient had disease related symptoms since early infancy. The second patient was one of dizygotic twins, he was diagnosed with CCHS at the age of 8 months. Up to that age only moderate desaturations had been observed. The other twin was unaffected by the disease. Both patients were successfully treated by nocturnal positive-pressure ventilation via a specially adapted face mask. They show satisfactory physical and neurologic development.

CONCLUSION

Our cases support the assumption of familiality in CCHS although the mode of inheritance remains to be clarified. Polygraphic recordings including capnography should be performed in siblings of CCHS patients early in life in order to avoid secondary complications. Noninvasive treatment by ventilation via special face masks is feasible.

[Ileus of the small intestine caused by an enterolith]

Adhesions, tumours and hernias are frequent reasons for an ileus of the small intestine in adults. We describe the rare case of an ileus of small intestine caused by a big enterolith which was formed in a duodenal diverticulum. As a predisposing condition we identified a bone of a chicken.

[Experience of parents in home monitoring of apnea for prevention of sudden infant death (SIDS)]

89 of 119 parents of infants with apnea home monitoring answered to a standard questionnaire concerning different aspects of home monitoring. In almost all cases the home monitoring was finished at the begin of the study, lasting from six months to 12 months. The indications for an apnea monitor were: apparent life threatening event (n = 8), SIDS-sibling (n = 24), sleep apnea syndrome (n = 40) and parents pressing request (n = 17). 90% of parents felt to have got enough information about the function of the apnea monitor (mostly Graseby MR-10 monitor) and what they have to do when there is an apnea alarm. 6% of parents changed the monitor because of technical problems. Most of the alarms were registrated by almost all parents between 24 h and 6 h. 35% of parents stimulated their infants in case of an apnea alarm gently to vigorously, one infant had a mouth to mouth resuscitation. Questions concerning the psychological and social impact of home monitoring on parents demonstrated that there was some stress like anxiety, sleep disturbances mainly in the mothers. We conclude from parents experience with apnea home monitoring the need for an adequate medical, technical and psychological support.

Electrophysiological effects of myocardial stretch and mechanical determinants of stretch-activated arrhythmias

BACKGROUND

Although the existence of myocardial mechanoelectrical feedback is well established, the mechanism of arrhythmia induction by ventricular dilatation or stretch remains insufficiently defined. In particular, controversy exists when comparing the arrhythmogenic potential of chronic versus acute myocardial stretch. Also, assessment of cellular electrophysiological effects of myocardial stretch has been incomplete.

METHODS AND RESULTS

To evaluate the electrophysiological and arrhythmogenic effects of slow versus rapid ventricular wall stretch, we developed an isolated Langendorff-perfused rabbit heart model in which left ventricular (LV) volume can be changed by a computer-controlled servopump. Cellular electrophysiological effects and premature ventricular excitations (PVEs) and their origin produced by the volume increases were assessed by a multiple-site monophasic action potential (MAP) recording system and by volume-conducted ECGs obtained by immersing the entire preparation in a saline-filled tank. Volume was increased either gradually with slow volume ramps (0.1 ml/sec) or suddenly by volume pulses of varying pulse waveforms (three different amplitudes and five different rise velocities) applied randomly 250-350 times to each of eight hearts. Gradual LV volume loading caused gradual decreases in MAP resting and action potential amplitude, whereas rapid, transient volume pulses caused transient depolarizations. Despite similar membrane potential effects of stretch, gradual volume increases rarely (11%) produced PVEs, even with large volume loads, whereas rapid volume pulses of moderate amplitudes regularly triggered PVEs (45-100% of interventions). Logistic regression analysis showed that the probability of PVE occurrence increased independently with both the amplitude and the velocity of the volume increase, with the greatest sensitivity to stretch velocity exhibited at low and intermediate pulse amplitudes. Faster volume pulse rise velocities triggered PVEs at a lower instantaneous pulse amplitude than lower rise velocities, further corroborating the dependence of stretch-activated arrhythmias on the velocity of stretch. In contrast, an increase in the basic ventricular volume had no effect on the probability of PVE occurrence during the volume pulses. The MAP recordings demonstrated spatial variability in the extent of local depolarizations and site of PVE origin; transient depolarizations occurred, and PVEs originated most often in the posterolateral region of the left ventricle.

CONCLUSIONS

Membrane depolarization is caused by both gradual and rapid ventricular stretch, but PVEs are more easily elicited by rapid stretch. Regions of greater myocardial compliance that experience greater relative stretch may act as "foci" for stretch-activated arrhythmias during dynamic ventricular loading. These whole-heart data corroborate the existence of stretch-activated membrane channels in ventricular myocardium and may help explain ventricular ectopy under conditions of differential ventricular loading, as in ventricular dyskinesia, or regional muscle traction, as in mitral valve prolapse syndrome.

Paraparesis secondary to a spinal mass as the presenting feature of erythroleukaemia in a 10-month-old child

Severe neurological impairment as the first symptom of acute leukaemia is a rather uncommon finding. We report the case of a 10-month-old infant who presented with acute paralysis of the lower extremities due to cord compression by an epidural tumour composed of malignant erythrocyte precursor cells. Diagnosis of erythroleukaemia (EL) was made by needle biopsy of the spinal epidural mass and confirmed by bone marrow aspiration. Antileukaemic treatment in combination with radiotherapy to the epidural tumour led to haematological remission and neurological recovery with disappearance of the mass lesion as demonstrated by MRI. However, haematological relapse occurred with death of the patient 7 months after diagnosis. This is the first reported case of EL presenting with paraparesis due to an epidural tumour. The clinical symptoms, results of cytogenetic and immunological studies and the clinical course are described.

[The Graz SIDS Risk Questionnaire: I. Development and validation]

Based on the results from semistructured interviews with parents of fifty SIDS victims and of fifty matched controls we developed a SIDS risk questionnaire, the so-called SRFB Graz. In a retrospective study this questionnaire was applied to 65 SIDS victims and 195 comparable controls. By statistical analysis a cut point was computed, which discriminates SIDS cases from controls with a sensitivity of 86% and a specificity of 95%.

[The Graz SIDS Risk Questionnaire: prospective study of 6,000 infants]

In a prospective study (1988-1990) the SIDS risk questionnaire SRFB was applied to 6000 infants born in the Department of Obstetrics, University Hospital Graz. In all infants at an increased statistical risk for SIDS a standardized intervention including pediatric and polysomnographic investigations was performed. As a result the SIDS incidence decreased from an average of 1.92 per thousand lifeborns (1984-1988) to 0.83 per thousand lifeborns (1989-1990) in our test group, which means a striking reduction of the SIDS incidence by 57%. In addition to this effect, the intensified information of parents and physicians about possible signs of an increased risk for SIDS lead to a general reduction of SIDS in Styria.

Carbamazepine maintenance treatment in outpatient schizophrenics

A double-blind crossover trial was used to evaluate carbamazepine as the sole maintenance treatment of chronic, nonmanic schizophrenic outpatients whose conditions had been stabilized with the use of neuroleptics prior to study. Criteria of treatment effectiveness included the number of patients relapsing and time to relapse over a 95-day neuroleptic-free period during which either carbamazepine or placebo was administered. Relapse was determined by the concordance of psychiatric ratings and independent clinical judgements indicating significant worsening. Results for 27 patients (13 receiving carbamazepine and 14 receiving placebo) involved in the first phase of this treatment comparison were nondifferentiating. Corroborating descriptive findings in the second phase were available for 14 of these patients. There was no evidence supporting the existence of a treatment-relevant subgroup defined by episodic dyscontrol phenomena.

Neurological status, sleep apnea frequency and blood oxygenation in six weeks old infants

A study was carried out to investigate the correlation between sleep apnea frequency, blood oxygenation and neurological condition in 21 infants at six weeks of age with inconspicuous medical history. Polygraphic recordings of respiratory behaviour and transcutaneous blood gas monitoring lasted for at least five hours. To quantify the results of the neurological examination we established a neurological optimality score (NOS). We found statistically significant correlations between several indexes of apneas and indexes of blood oxygenation and NOS. Thus, a reduced NOS was strongly correlated with higher apnea frequencies and with pronounced drops of transcutaneous PO2-values. In addition all but one infant who were diagnosed as having a sleep apnea syndrome showed a greater than ten percent reduction of NOS. Some pathophysiological considerations to explain our findings are put forward and the possible role of the neuromodulator adenosine is emphasized.