[Birdshot retinochoroidopathy. Five clinical cases analysis]

PURPOSE

The Birdshot retinochoroidopathy is a rare chronical intraocular inflammatory disease. The authors made a comparative study of the disease's clinical manifestations and its response to therapy.

METHODS

We selected five patients who had ocular inflammation which presented on the ocular fundus examination typical multifocal yellow-white patches of depigmentation of choroid and pigment epithelium and vitreous inflammation.

RESULTS

All the patients showed early spots of hypofluorescence that became hyperfluorescent in the venous phase of angiography, a depression of b-wave amplitude of electroretinogram, a blue-yellow defect of colour vision and carried HLA-A 29 antigen. We recorded an improvement of the visual acuity and of the clinical picture after treatment with corticosteroid and cyclosporine A.

CONCLUSION

Even though Birdshot retinochoroidopathy is a rare pathology in Southern Europe, the cases presented allowed us to conclude that early diagnosis and appropriate therapy greatly improve the well being of these patients (Arch Soc Esp Oftalmol 2002; 77: 247-256).

Human secretory immune response to fatty acid-binding protein fraction from Giardia lamblia

The secretory immune response in humans infected with Giardia lamblia was studied by using saliva samples and an 8-kDa antigen capable of binding fatty acids. This antigen was not recognized by saliva samples from healthy individuals. The antigen may be useful in diagnostic studies of G. lamblia infection.

Transmission of Mycobacterium tuberculosis to contacts of HIV-infected tuberculosis patients

We assessed the infectiousness of human immunodeficiency virus (HIV)-seropositive and HIV-seronegative individuals with pulmonary tuberculosis (TB) in a prospective cohort study. We enrolled, evaluated, and followed 104 close contacts of HIV-seropositive pulmonary TB patients and 256 close contacts of HIV-seronegative pulmonary TB patients using a standardized questionnaire, symptom review, chest radiograph, HIV serology, and tuberculin skin testing (TST). Contacts were followed for > or = 12 mo. TB infection at enrollment was 27% (28/104) among contacts of HIV-seropositive TB patients and 35% (90/256) among contacts of HIV-seronegative TB patients (odds ratio [OR] = 0.68, 95% confidence interval [CI] 0.41 to 1.12; p = 0.130). TST conversion occurred in 21% (42/ 204) of subjects; 8% (5/63) of contacts of HIV-seropositive index cases and 26% (37/141) of contacts of HIV-seronegative index cases (OR = 0.24, 95% CI 0.09 to 0.65; p = 0.003). TB was diagnosed in nine contacts; eight were contacts of HIV-seronegative index cases. HIV seropositivity in the index case was independently associated with a lower risk of TB infection among contacts, even among household contacts younger than 15 yr of age. Contacts of HIV-seropositive persons with pulmonary TB were less likely to have a positive TST response at 1 yr of follow-up than contacts of HIV-seronegative persons.

Enhanced serum glucocorticoid levels mediate the reduction of serosal mast cell numbers in diabetic rats

Rats turned diabetic by treatment with alloxan exhibit a significant reduction in serosal mast cell numbersin parallel with decreased insulin levels in the plasma. Our aim was to investigate the putative involvement of endogenous glucocorticoid hormone in this phenomenon. The findings indicated that rats treated with alloxan responded with an increase in levels of serum corticosterone concomitantly with decreased mast cell numbers in the pleural space. We found that either surgical bilateral adrenalectomy or pretreatment with the steroid antagonist RU 486 (20 mg/kg, i.p.) impaired the drop in pleural mast cell counts in alloxinated rats. Administration of insulin (15 U/kg) prevented the increase in corticosterone levels and restored pleural mast cell levels in diabetic animals. In addition, treatment of naive rats with corticosterone (0.5 mg/kg, s.c.) or dexamethasone (0.1 mg/kg, s.c.), for 3 consecutive days, led to a reduction in the number of mast cells recovered from the pleural cavity as noted in diabetic animals. In contrast, insulin reduced serum corticosterone levels and induced a significant elevation in pleural mast cell numbers in naive rats. We conclude that there is a causative relationship between increased levels of glucocorticoids and down-regulation of mast cell numbers associated with the diabetic state, both phenomena clearly sensitive to insulin.

Statistical properties of inter-series mixing in helium: from integrability to chaos

The photoionization spectrum of helium shows considerable complexity close to the double-ionization threshold. By analyzing the results from both our recent experiments and ab initio three- and one-dimensional calculations, we show that the statistical properties of the spacings between neighboring energy levels clearly display a transition towards quantum chaos.

Sistema de Informações Hospitalares como ajuste de risco em índices de desempenho

OBJETIVO: Analisar o uso do Sistema de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS) no ajuste de risco das taxas de mortalidade hospitalar e avaliar a utilidade do índice de comorbidade de Charlson (ICC) no ajuste de risco de indicadores de desempenho. MÉTODOS: Foram selecionadas 40.299 internações ocorridas no Município do Rio de Janeiro entre dezembro de 1994 e dezembro de 1996. A medida de gravidade foi testada pelo ICC, que atribui pesos a 17 condições clínicas presentes nos diagnósticos secundários, a fim de obter a carga de morbidade do paciente (gravidade) independentemente do diagnóstico principal. Utilizou-se a regressão logística para avaliar o impacto do ICC na estimativa da chance de morrer no hospital. RESULTADOS: Nas internações selecionadas, observou-se que o ICC foi igual ou superior a um em apenas 5,7 % dos casos. Quando se aplicou o ICC combinado à idade, o percentual de casos com pontuação diferente de zero aumentou substancialmente. Os modelos testados apresentaram reduzida sensibilidade. CONCLUSÕES: Apesar de a presença de comorbidade ser importante na predição do risco de morrer, essa variável pouco discriminou a gravidade dos casos na base de dados do SIH/SUS, o que é explicado pela qualidade da informação diagnóstica nessa base de dados, na qual a idade é o preditor mais importante do risco de morrer, afora o diagnóstico principal. Apesar das limitações ainda existentes na qualidade da informação diagnóstica disponível no SIH/SUS, sugere-se o uso do ICC combinado como medida para ajuste do risco de morrer nas taxas calculadas a partir desses dados.

Palatal myoclonus: report of two cases

We describe two cases of palatal myoclonus (PM), one essential and another secondary to a stroke. Case 1: a 64 years old female who developed clicking sounds in both ears after a stroke and three years later on noticed a progressive involuntary movement of the throat associated with rhythmic contractions of the soft palate, muscles of tongue and throat. MRI showed an ischemic area in brainstem. The patient had a partial response to the use of sumatriptan 6 mg subcutaneously. Case 2: a 66 years old female who began with ear clicking at left ear that worsed slowly associated with tinnitus and arrhythmic movements of soft palate and an audible click at left ear. Brain MRI was normal; audiometry showed bilateral neurosensory loss. She was prescribed clonazepan 1 mg daily with complete recovery. Primary and secondary palatal myoclonus share the same clinical features but probably have different pathophysiological underlying mechanisms.

Molecular tools for the identification of Tuber melanosporum in agroindustry

Tuber melanosporum Vitt., Tuber magnatum Pico, and Tuber uncinatum Chat. can be differentiated by their morphological characters. Fraud problems have arisen recently with the importation to Europe of truffles from China. T. melanosporum is morphologically very close, but distinct from the Chinese species [Tuber indicum (Cooke and Massee) and T. himalayense BC (Zhang and Winter)]. We have optimized molecular tools to unequivocally identify T. melanosporum. DNA extraction from ascocarps of black truffles is not straightforward. Problems to obtain pure DNA are due to high contents of phenolic compounds, melanine, and various polymers (proteins, polysaccharides, etc). These compounds coprecipitate with the DNA during extraction and strongly inhibit the PCR reaction. We have developed an efficient and reliable protocol for DNA extraction from truffle ascocarps. It was used successfully for DNA extraction from mycorrhizal root tips as well as from canned preparations of T. melanosporum. Several approaches to identify T. melanosporum by PCR were developed. Two specific primers for T. melanosporum were designed after comparison of the ITS region of this species with those of three Chinese fungi. They proved to be efficient to specifically detect the presence of T. melanosporum by PCR. The mycorrhizal status of trees inoculated with T. melanosporum but unable to produce truffles was confirmed in a single-step PCR reaction. A multiplex PCR approach was also developed with three sets of primers (including a specific one for Chinese truffles) to detect, in one PCR reaction, the presence of any other Tuber species mixed with T. melanosporum ascocarps. This optimized protocol, in association with the specific primers we designed, is applicable to quality control in the truffle industry from the production stages to final commercial products.

Fang tip spread, puncture distance, and suction for snake bite

We measured the distance between fang tip punctures in defensive bites by western diamondback rattlesnakes (Crotalus atrox) and the distance between their retracted fangs. Because the fang tips at penetration average 112% further apart than their bases at rest, The Extractor, a device widely marketed in the United States for snake bite first aid, will not simultaneously cover both punctures of most adult New World pitvipers.

[Kikuchi and Fujimoto disease]

We present a case of Kikuchi and Fujimoto's disease (KFD), revealed by malar rash, fever, arthritis and lymphadenopathy, suggesting Systemic Lupus Erythematosus (SLE). The relation between KFD and SLE is not yet completely understood and remains complex. There are few cases with a lupus-like presentation and the histopathologic features may be insufficient to confirm the KFD diagnosis definitively. The clinical presentation, the IgM deposits at the dermal-epidermal transition in the Lupus Band Test, and the presence of anticardiolipin antibody emphasises the relationship between these two entities and does not exclude the possibility of evolution to SLE, which makes the prognosis doubtful.

Phylogenetic relationships between European and Chinese truffles based on parsimony and distance analysis of ITS sequences

Phylogenetic relationships among truffle species from Europe and China were investigated through parsimony analysis of the ITS sequences. Three major clades were obtained among the species analysed. The so-called white truffles appeared polyphyletic since Tuber magnatum was grouped with brown truffles and not with the other white species (T. maculatum, T. borchii, T. dryophilum, T. puberulum). The black truffles investigated in this study, T. brumale, T. melanosporum, T. indicum and T. himalayense, were grouped in an independent clade. The Périgord black truffle T. melanosporum and the Chinese black truffles T. indicum and T. himalayense, were very closely related. The delimitation of these species was estimated by a distance analysis on several isolates collected from different geographic areas. In spite of intraspecific variations of the internal transcribed spacers (ITS) sequences, T. melanosporum and the Chinese black truffles can be unambiguously attributed to distinct taxa.

Teleconsultation for cooperative acquisition, analysis and reporting of ultrasound studies

We have developed a teleconsultation system to support cooperation between doctors at different institutions in the acquisition, analysis and reporting of ultrasound studies. All the relevant activities were supported by the application. The system enabled remote supervision of the ultrasound study as it was being performed, cooperative static image acquisition and analysis, as well as report writing. Cooperative analysis of previously acquired studies was also possible. The system is undergoing evaluation in five hospitals in Portugal.

A fully human antibody neutralising biologically active human TGFbeta2 for use in therapy

Phage display provides a methodology for obtaining fully human antibodies directed against human transforming growth factor-beta (TGFbeta) suitable for the treatment of fibrotic disorders. The strategy employed was to isolate a human single chain Fv (scFv) fragment that neutralises human TGFbeta2 from a phage display repertoire, convert it into a human IgG4 and then determine its TGFbeta binding and neutralisation properties and its physical characteristics. Several scFv fragments binding to TGFbeta2 were isolated by panning of an antibody phage display repertoire, and subsequent chain shuffling of the selected V(H) domains with a library of V(L) domains. The three most potent neutralising antibodies were chosen for conversion to IgG4 format. The IgG4 antibodies were ranked for their ability to neutralise TGFbeta2 and the most potent, 6B1 IgG4, was chosen for further characterisation. 6B1 IgG4 has a high affinity for TGFbeta2 with a dissociation constant of 0.89 nM as determined using the BIAcore biosensor and only 9% cross-reactivity with TGFbeta3 (dissociation constant, 10 nM). There was no detectable binding to TGFbeta1. 6B1 IgG4 strongly neutralises (IC50 = 2 nM) the anti-proliferative effect of TGFbeta2 in bioassays using TF1 human erythroleukaemia cells. Similarly, there was strong inhibition of binding of TGFbeta2 to cell surface receptors in a radioreceptor assay using A549 cells. 6B1 IgG4 shows no detectable cross-reactivity with related or unrelated antigens by immunocytochemistry or ELISA. The 6B1 V(L) domain has entirely germline framework regions and the V(H) domain has only three non-germline framework amino acids. This, together with its fully human nature, should minimise any potential immunogenicity of 6B1 IgG4 when used in therapy of fibrotic diseases mediated by TGFbeta2.

Inhibition by the anti-mitotic drug doxorubicin of platelet-activating-factor-induced late eosinophil accumulation in rats

Platelet-activating factor (PAF) has been shown, in the rat model of pleural inflammation, to induce the generation of an intermediate proteic factor able to cause eosinophil proliferation in vitro. This study was undertaken to investigate the effect of the anti-mitotic compound doxorubicin on PAF-induced eosinophilia in rats, in order to evaluate the contribution of local cell proliferation to this phenomenon. The late eosinophil infiltration caused by another chemoattractant leukotriene B4 was used for comparison. We observed that local treatment with doxorubicin (20 and 40 microg/cavity), given 6 h after PAF (1 microg/cavity), suppressed the eosinophil accumulation within 24 h, whilst only the higher dose was effective when the drug was given 12 h post-PAF. An effect on chemotaxis was ruled out, since local doxorubicin (40 microg/cavity) failed to modify the eosinophil migration noted 24 h after leukotriene B4 (0.5 microg/cavity) and the neutrophil/eosinophil infiltration noted at 6 h after PAF injection. Transfer of the pleural fluids collected 6 h after PAF from donors to recipient rats caused significant eosinophil accumulation in the recipient rats, an effect which was inhibited by the co-administration of doxorubicin (40 microg/cavity). No inhibitory effect was noted when the drug was given 6 h after the pleural fluids were transferred. We also found no change in the number of blood or bone marrow eosinophils after PAF stimulation. We conclude that doxorubicin selectively impaired the late eosinophil accumulation triggered by PAF in the pleural cavity of rats, clearly indicating that local cell proliferation seems to contribute to the development of this inflammatory response.

Assessing the availability of casemix information in hospital database systems in Rio de Janeiro, Brazil

OBJECTIVE

This article considers the possibility that using secondary diagnoses extracted from hospital medical records of patients would modify the diagnosis related groups (DRG) allocated to a case and the Charlson comorbidity index (CCI) calculated from data in the Brazilian hospital information system.

DESIGN

This study used two databases: the administrative database of the Brazilian health care system which consists of claim forms abstracted from medical records and is primarily linked to reimbursement, and the medical records that correspond to a sample of claims forms of which the first data source is composed. Changes in DRG were tested by analyzing percent of agreement and the kappa index. Logistic regression was employed to evaluate the impact of using CCI scores.

SETTINGS AND PATIENTS

This study is based on a sample of claim forms and medical records (n = 1331) from a number of private acute-care hospitals which had contracts with the municipality of Rio de Janeiro in 1986.

RESULTS

Use of information on comorbidity shown in medical records caused changes both in the classification of cases into DRG and in the scores of the CCI. The impact of restrictions on the number of secondary diagnoses in the Brazilian administrative database is comparatively more important for the CCI than for DRG allocation since the Charlson method is based on an additional model where every case of comorbidity is taken into account cumulatively for the final score.

CONCLUSION

These findings indicate the importance of taking a number of measures to improve the quality of information systems in order to increase their potential role in the evaluation of Brazil's health services.

Tennessee's failed managed care program for mental health and substance abuse services

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.

Addressing a state's physician workforce priorities through the funding of graduate medical education: the TennCare model

TennCare is Tennessee's innovative program that replaces the state's Medicaid program with a health care system based on managed care and designed to cover the vast majority of the state's poor and uninsured. The program provides health care benefits not only to those eligible for Medicaid, but also to the uninsured poor who do not qualify for Medicaid and those who are uninsurable because of existing medical conditions. This article describes the allocation of TennCare graduate medical education funding, which is designed to address the state's physician workforce priorities regarding specialty mix and practice location. Under the new TennCare graduate medical education funding design, funds flow to the state's 4 medical schools and then to the sites of the residents' training. Allocation to the medical schools is based primarily on the number of primary care residents in residency programs under sponsorship of each.

[A clinical case of restrictive myocarditis due to senile-type amyloidosis]

We describe the case of a patient with restrictive cardiomyopathy due to primary amyloidosis associated with aging. The patient had a complex myocardial function. A brief review is made of the etiology, diagnostic procedures and therapy of this clinical entity, which is an important rare cause of cardiac death in elderly patients.

Long-term effects of potassium citrate therapy on the formation of new stones in groups of recurrent stone formers with hypocitraturia

OBJECTIVE

To compare stone formation rates before (as total rates and during remote periods) and after therapy with potassium citrate in patients with hypocitraturia.

PATIENTS AND METHODS

The study comprised 15 patients with hypocitraturia only (Group I) and 12 patients with hypocitraturia associated with other abnormalities (Group II), all of whom were recurrent stone formers. Their urine chemistry, including citrate, was measured before and after treatment.

RESULTS

In both groups, the urinary citrate concentration increased significantly to within normal limits during therapy with potassium citrate (P < 0.005). The rate of total stone formation in patients in Group I decreased significantly from 0.7/year before to 0.13/year after treatment (P < 0.005). The corresponding remote stone formation rate before (0.88/year) was significantly greater than the rate after treatment (0.13/year; P < 0.005; follow-up 4.6 +/- 1.9 years). Patients in Group II showed a similar striking decrease in total stone formation rate, from 1.2/year to 0.08/year after treatment (P < 0.005). The corresponding remote stone formation rate (1.66/year) before was significantly greater than that after treatment (0.08/year; P < 0.005; follow-up 4.1 +/- 1.6 years). There was a remission rate of 93% for stone formation over the complete follow-up.

CONCLUSION

Potassium citrate appears to be the drug of choice in the long-term treatment of patients with hypocitraturia as it not only decreases the rate of stone formation but also maintains normal citrate levels in the urine.

The efficacy of individual computer heart rate indices in detecting acidemia at birth in growth-restricted fetuses

OBJECTIVE

To determine the efficacy of individual fetal heart rate (FHR) indices, as determined by computer analysis of the FHR tracing, in detecting fetal acidemia at birth in growth-restricted fetuses.

METHODS

The study population consisted of 38 growth-restricted fetuses at 26-37 weeks' gestation from pregnancies with abnormal uterine and/or umbilical artery Doppler velocimetry. The 1-hour FHR tracing was analyzed by computer within 4 hours of cesarean birth before the onset of labor. Umbilical artery cord blood was collected at birth, and pH was determined within 5 minutes of collection.

RESULTS

On linear regression, the duration of episodes of low variation in minutes (r = -0.77, r2 = 0.59) and short-term (r = 0.72, r2 = 0.52) and long-term (r = 0.69, r2 = 0.47) variation in milliseconds were significantly related to umbilical artery pH at birth, and more so than the number of accelerations of ten (r = 0.57, r2 = 0.32) and 15 (r = 0.38, r2 = 0.14) beats per minute. There were significant differences in computer measurements of FHR accelerations and variation between the umbilical artery pH categories of acidemia (pH less than 7.20), preacidemia (7.20-7.25), and nonacidemia (greater than 7.25). Stepwise regression revealed that episodes of low variation best described the model for predicting umbilical artery pH at birth (P < .001), with no improvement provided by the addition of other computer-analyzed FHR characteristics.

CONCLUSION

In this population of growth-restricted fetuses delivered by elective cesarean, the computer indices of duration of episodes of low variation and short-term and long-term variation were significantly associated with umbilical artery pH and predicted umbilical artery acidemia at birth.

[Exertion syncopal crisis in the young, associated with idiopathic long QT syndrome]

The cases of two young patients with repetitive syncopal attacks due to idiopathic long QT syndrome (ILQTS) are reported. Both had been primarily misdiagnosed for seizures. In one of the cases the QT interval in the ECG at rest was normal. The same patient had a previous episode of cardiac arrest with ventricular fibrillation. The treadmill stress test was of great value, revealing polymorphic ventricular tachycardia induced by exercise, and evaluating the efficacy of beta-blocking therapy in the follow-up. The ILQTS should be considered a possible etiology in any patient presenting with new onset seizures, especially in the young. The treatments were different in both cases. In the first one, the treatment with nadolol (100 mg od) revealed to be very effective with total remission of symptoms. The treadmill stress test performed 15 days after the beginning of treatment did not show any ventricular arrhythmias, and it was assumed that the patient was effectively protected against ventricular arrhythmias. After 4.5 months of follow up, no syncopal episodes occurred. In the second case due to young age, the frequency, and the severity of the attacks (cardiac arrest with ventricular fibrillation), and the inefficacy of beta-adrenergic-blocking agents, the implantable cardioversor-defibrillator was the treatment chosen, although the beta blocking therapy was maintained to reduce the number of arrhythmic events. The ILQTS is a rare anomaly related to sudden cardiac death. The ILQTS is characterised by the association of several distinctive electrocardiographic features, among which prolongation of the QT interval is the best known. Life-threatening arrhythmia occurs usually under conditions of physical or psychological stress. Relatively effective therapies do exist and are represented by antiadrenergic interventions: beta-adrenergic-blocking agents are the treatment of choice. When they fail, left sympathetic denervation or the automatic implantable cardioversor-defibrillator have also proved to be effective.

Twinning in the Palestinian population of Jerusalem and the West Bank

Although it is currently believed that the Palestinian population has relatively high twinning rates, to our knowledge no specific studies on this have yet been conducted. Therefore, and as a first step in our institutional program to develop medical and social care, as well as research programs specifically directed to twins in this area of the world, a number of observations have been conducted in order to gather estimates of twinning rates in the Palestinian population of East Jerusalem and the West Bank of the Jordan. This corresponds to the regions of Judea and Samaria, largely composed of small villages where most of the population lives, as well as a number of more important centers, such as Jenin, Nablus, Ramallah, Bethlehem, and Hebron.

Although we have, unfortunately, been unable to obtain vital statistics on the entire Palestinian population of the West Bank from the administrative offices of Judea and Samaria, information on total maternities and twin maternities by sex, for the period 1984-1988, was kindly provided by all Arab hospitals and maternity clinics in Jerusalem, and also by the United Nations Refugees World Agencies (UNRWA) with respect to the refugee camps.

The population we have studied, therefore, is limited to the Palestinians of East Jerusalem and the West Bank refugee camps, and corresponds to about one-third of the entire Palestinian population of the area. However, it does include both an urban setting (East Jerusalem) as well as a rural one (the refugee camps), and both Moslems and Christians, so it can be safely considered as representative of the entire Palestinian population. As for the period considered, we elected to limit our survey to the five-year period 1984-1988 because the records for then are considered to be more reliable than they had been previously, when little, if anything, was known on statistics, particularly on twin statistics relating to the West Bank population.

[Atresia of the common pulmonary vein]

A case of common pulmonary vein atresia is presented, in which all pulmonary veins drain into a venous confluence without outlet. The criteria helpful in differentiating this condition from other forms of anomalous pulmonary disease in the neonatal period are discussed.

Caudal block for analgesia after paediatric inguinal surgery

Two hundred and eleven children aged 1-5 years were studied after undergoing herniorrhaphy or orchiopexy. In 111 cases a caudal block was used for postoperative analgesia. This was administered immediately after induction of anaesthesia, using bupivacaine 0.25% plain (0.7 ml/kg lean body mass), and was successful in 100 patients. A mean analgesic level (+/- SE) of T9.9 +/- 0.47 was achieved (range L2-T6). In 5 cases no block occurred and in 6 the level was below T12. The other 100 children acted as controls. Behaviour patterns were more restful in the caudal block group on awakening and less opiate was required during the first 5 postoperative hours. No complications resulted.

[Occlusive adenoids causing cor pulmonale and pectus excavatum in a child (author's transl)]

In a Child respiration was impaired already during infancy by occlusive adenoids causing pectus excavatum, cardiomegaly with signs of right ventricular and right atrial hypertrophy, hepatomegaly and dystrophy. The child showed psychological injury as well. After adenectomy these symptoms gradually disappeared. The cardiorespiratory syndrome by obstruction of the upper airways demands active surgical therapy since it may lead to right ventricular failure and pulmonary edema.