The parachute reactions in normal and late walkers

To study the relationship of the parachute responses to the age of independent walking, three groups of infants were prospectively examined: a normal sitting, normal walking group; a late sitting, normal walking group; and a late sitting, late walking group. All other spheres of the neurodevelopmental examination were normal. It was found that when the parachute responses appeared by age 10 months in the late sitting infants, most of them would achieve independent walking by 15 months. A delay in the parachute reaction in these infants predicted a delay in walking.

CPAP treatment of obstructive sleep apnoea and neurodevelopmental deficits

Four boys aged 6-16 years with neurodevelopmental deficits were treated with CPAP for obstructive sleep apnoea. Their diagnoses were: Obesity with mild mental retardation, (2) attention deficit hyperactivity disorder, (3) epilepsy associated with left hemiparesis and (4) mild mental retardation due to fragile X syndrome. Previous therapeutic attempts, including adenotonsillectomy, amitriptyline and methylphenidate in our patients prior to CPAP treatment were unsuccessful. A follow-up period of 12-48 months demonstrated a number of clinical benefits such as improvement in sleep quality and daily arousal, and a decrease in the frequency of seizures and episodes of pneumonia. Polysomnographic studies indicated a significant improvement in sleep parameters such as apnoea frequency, awakenings, sleep efficiency and arterial oxygen saturation. Side effects were mild and readily alleviated. CPAP is a feasible therapeutic intervention in intractable obstructive sleep apnoea of childhood, even when associated with neurodevelopmental deficits.

Infection after radial keratotomy

PURPOSE/METHODS

Eight years after eight-incision radial keratotomy, a corneal ulcer developed around the inferotemporal incision in an otherwise healthy 39-year-old man. There was no history of corneal trauma or contact lens wear.

RESULTS/CONCLUSIONS

Both Fusarium and Acanthamoeba organisms were eventually isolated from the ulcer. A therapeutic keratoplasty was performed. Inferotemporal incisions may be predisposed to epithelial breakdown and infection many years after radial keratotomy.

Apparent life-threatening event: a neurologic perspective

Of 46 infants who were investigated for apparent life-threatening events, central nervous system disorders were diagnosed in seven (15%). Convulsive disorders, intraventricular hemorrhage and hydrocephalus, absent corpus callosum, and development deficits were found. In four of the seven, no neurologic deficit was suspected before the event. Electroencephalographic studies (overnight in two) would have identified the disorder in all four. Electroencephalography is therefore a recommended routine procedure in investigation of apparent life-threatening events. Central nervous system disorders should be routinely ruled out in cases of apparent life-threatening event, even in the absence of clinical clues.

Congenital toxoplasmosis: a significant cause of neurological morbidity in Israel?

The incidence of congenital toxoplasmosis in Israel is largely unknown, as is the impact of this condition on the neurological diseases of childhood. We examined the association between toxoplasmosis and three neurological disorders: epilepsy, cerebral palsy, and nerve deafness. Ninety-five children 1-15 years of age who had one of these three diagnoses but who had not had perinatal meningitis or anoxia and had no genetic predisposition for the documented neurological disorder were eligible for the study; 109 children hospitalized for elective surgery served as age-matched controls. Demographic and serological data were analyzed by logistic regression. The prevalences of serum antibodies to Toxoplasma gondii in the study and control groups were 22% and 9%, respectively. Children with one of the three neurological disorders were significantly more likely to have IgG antibodies to T. gondii (relative risk, 2.5; P = .03). The relative risk of seropositivity was remarkably high (7.1) among children with nerve deafness (P = .01). Large-scale prospective cohort studies of pregnant women are needed to substantiate the impact of congenital toxoplasmosis on the neurological diseases of childhood in Israel.

Value of antibodies to GAD65 combined with islet cell cytoplasmic antibodies for predicting IDDM in a childhood population

The value of a test for islet cell cytoplasmic antibodies together with a test for GAD65 antibodies to predict the subsequent development of diabetes over a period of 11.5 years was assessed in an open childhood population comprising 2,805 individuals. A single serum sample was obtained from each individual between 1975 and 1977 and screened for islet cell cytoplasmic antibodies for which eight individuals were positive (0.29%). During the average follow-up period of 11.5 years, four of eight islet cell antibody positive and three islet cell antibody negative individuals developed clinical diabetes. Sera from all individuals, who were islet cell antibody positive and/or developed diabetes (total of 11) and from 100 randomly selected control subjects were analysed for GAD65 antibodies. Six of eight islet cell antibody positive individuals were GAD65 antibody positive including all four who subsequently developed IDDM. Furthermore, one of the three islet cell antibody negative individuals who developed IDDM was GAD65 antibody positive both in 1976 and in 1989. Thus, a positive test for GAD65 antibodies alone correctly predicted diabetes in five of seven children, who developed the disease. Only one of the children, who developed diabetes was positive for insulin autoantibodies and this individual was also positive for islet cell cytoplasmic antibodies and GAD65 antibodies. One of the 100 control subjects was positive for GAD65 antibodies (1%). The results suggest that a single GAD65 antibody test may have a higher sensitivity for predicting IDDM than a test for islet cell cytoplasmic antibodies, but that a combined positive test for both antibodies increases the specificity for predicting IDDM over a period of 11.5 years.

Higher autoantibody levels and recognition of a linear NH2-terminal epitope in the autoantigen GAD65, distinguish stiff-man syndrome from insulin-dependent diabetes mellitus

The smaller form of the GABA-synthesizing enzyme glutamic acid decarboxylase (GAD65) is a major autoantigen in two human diseases that affect its principal sites of expression. Thus, destruction of pancreatic beta cells, which results in insulin-dependent diabetes mellitus (IDDM), and impairment of GABA-ergic synaptic transmission in Stiff-Man syndrome (SMS) are both characterized by circulating autoantibodies to GAD65. Anti-GAD65 autoantibodies in IDDM are predominantly directed to conformational epitopes. Here we report the characterization of humoral autoimmune responses to GAD65 in 35 SMS patients, of whom 13 (37%) also had IDDM. All SMS patients immunoprecipitated native GAD65 and the main titers were orders of magnitude higher than in IDDM patients. Furthermore, in contrast to the situation in IDDM, autoantibodies in 35 of 35 (100%) of SMS patients recognized denatured GAD65 on Western blots. Two major patterns of epitope specificity were identified on Western blots. The first pattern, detected in 25 of 35 SMS patients (71%), of whom 11 had IDDM (44%), was predominantly reactive with a linear NH2-terminal epitope residing in the first eight amino acids of GAD65. Nine of nine individuals who were HLA-haplotyped in this group carried an IDDM susceptibility haplotype and HLA-DR3, DQw2 was particularly abundant. The second pattern, detected in 10 of 35 patients (29%) of whom two had IDDM (20%), included reactivity with the NH2-terminal epitope plus strong reactivity with one or more additional epitope(s) residing COOH-terminal to amino acid 101. The second epitope pattern may represent epitope spreading in the GAD65 molecule, but may also include some cases of epitope recognition associated with IDDM resistant HLA-haplotypes. The principal NH2-terminal linear epitope in GAD65 distinguishes the reactivity of SMS and IDDM autoantibodies and may be a determinant of pathogenicity for GABA-ergic neurons. The greater magnitude and distinct specificity of the humoral response to GAD65 in SMS may reflect a biased involvement of the T helper cell type 2 (Th2) subset of CD4+ T cells and antibody responses, whereas IDDM is likely mediated by the Th1 subset of CD4+ T cells and cytotoxic T cell responses.

Relationship between the parachute reactions and standing and walking in normal infants

Assumption of the vertical position and independent walking are potentially hazardous motor milestones in the developing infant. It has been presumed that the parachute reactions evolved to protect infants from injury during this developmental stage. To determine the relationship between the appearance of the upper and lower parachute reactions and the developmental milestones of unsupported standing and independent walking, 190 normal infants were prospectively studied. The upper parachute reaction was found to precede the lower by less than a month (mean age of appearance: 8.9 and 9.2 months, respectively). More than one-half of the cohort achieved standing without either the upper (49%) or lower parachute reaction (57%); however, no independent walking occurred without the upper parachute reaction, and only 2 of 190 infants (1%) walked independently without the lower parachute reaction. Onset of walking occurred about 4 months after the appearance of the upper parachute reaction. The significance of these findings is discussed.

Direct gene transfer for the understanding and treatment of human disease

Direct gene transfer has been used to develop molecular genetic interventions for acquired diseases in several animal models. Through the use of intravascular catheters or anatomically localized injection of DNA liposome complexes, specific tissues can be transduced with recombinant genes. Several promising applications of this method for the study of vascular biology have been demonstrated by direct gene transfer into arteries in vivo. Delivery, via catheter, of genes that modulate the thrombogenic or proliferative properties of vascular cells may someday provide therapy for stenotic lesions of atherosclerosis or following angioplasty. Cancer is another acquired disorder in which direct gene transfer may improve the efficacy of treatment. Introduction of class I MHC or cytokine genes with antitumor or immunostimulatory effects have demonstrated promise in animal models. Direct transfer of an allogeneic class I MHC gene into tumors in vivo induces a CD8+ CTL response against weak antigens on poorly immunogenic tumors. The efficacy of this antitumor response can be augmented to induce regression of actively growing established tumors. Additional strategies, such as intratumoral delivery of combinations of multiple cytokine and MHC genes, may serve to improve the antitumor response. A clinical gene therapy protocol is underway to analyze the safety and efficacy of DNA liposome-mediated gene transfer in humans. Development of improved gene delivery systems and introduction of recombinant genes into visceral tumors by intravascular catheter will extend the application of direct gene transfer to immunotherapy of malignancies. These clinical trials of direct gene transfer will help to develop new treatment strategies for human diseases.

Unexpected death in infancy. An epidemiologic study in the Haifa district, Israel

The incidence of unexpected death in infancy (UDI) (2 weeks-12 months) in the Haifa area is 1.17 per 1000 live births. We found a significant interethnic difference between Israeli Jews and Arabs. The incidence among Arabs was 4 per 1000, but was only 0.77 per 1000 among Jews (p < 0.01). When the UDI Jewish group was compared to both the group of infants dying of known causes and the surviving group, the only significant factors related to UDI were found to be: young maternal age and low maternal education. No such association was evident among Arabs. Following logistic regression analysis, low maternal age and low socioeconomic status, but not ethnicity, were significantly associated with UDI as compared to the non-UDI infants. In comparison to non-UDI, UDI was significantly more prevalent during the cold season. UDI incidence has apparently been stable over the past 15 years. Demographic risk factors are similar to those reported from other communities, and ethnicity is possibly mediated through those factors.

Infrainguinal revascularization in end-stage renal disease

Patients with end-stage renal disease are being maintained for longer periods with dialysis or renal transplantation. Although renal failure itself is associated with occlusive peripheral vascular disease, such patients often have additional comorbid risk factors. In this series, 88% of patients were diabetic, 93% were hypertensive, and 44% were smokers, all factors that exacerbate the severity of their vasculopathy. As a consequence, the vascular surgeon is increasingly being confronted with limb-threatening peripheral vascular disease in this population. We performed 34 infrainguinal bypasses in 27 patients during a 8-year period from 1986 to 1993. Fifty percent of these were bypasses to the infrapopliteal level. The 12- and 48-month graft patency was 64% and 38%, respectively, by life-table analysis. The limb salvage rate was 65% and 58% at 12 and 48 months. The perioperative mortality rate was 5.9% and the morbidity rate was 37%. Most of the limb loss (66%) occurred during the first 3 months after surgery as a result of acute graft occlusion or nonhealing of an ulcer or minor amputation site. We believe that this reflects an increasingly aggressive approach to limb salvage in patients with end-stage renal disease. Four limbs were lost despite a patent graft. Infrainguinal bypass is a viable management option for limb salvage in patients with end-stage renal disease. These procedures can be undertaken with acceptable perioperative mortality and with a 12-month limb salvage rate of 65%.

Developmental disabilities among children between birth and 3 years old in the Haifa district: a population study

The incidence of major neurodevelopmental deficits among children between birth and 3 years of age in the Haifa district was evaluated. Routine standardized developmental screening at the well-baby clinics was employed. The records of all children referred to the only two child developmental centers in the district during a period of 4 years were analyzed. The overall incidence was 31 per 1000 and was lower than expected. The age at diagnosis and associated disorders are discussed. In 30% of the cohort the diagnosis was inaccurate, and a 22% false positive referral rate was noted. A more thorough training in the early diagnosis of psychomotor developmental problems in childhood in the well-baby clinics is indicated.

Sleep characteristics of asthmatics in the first four years of life: a comparative study

The association between asthma and sleep disturbances was assessed as part of a community survey of sleep patterns in children aged 4-48 months. A questionnaire covering the area of past and present sleep and settling behaviour, as well as health history and demographic data, was administered to 752 mothers of children visiting 14 well baby clinics. Fifty one (6.8%) of the children who were diagnosed as having asthma by their paediatricians were compared with the remaining healthy controls (children with perinatal problems, other chronic illnesses, developmental problems, or repeat admissions to hospital were excluded). Thirty nine per cent of the children with asthma and 38% of the normal controls were identified as regular wakers. The number of interrupted nights each week, settling time, and sleep duration were comparable. In the children with asthma an uninterrupted night's sleep was acquired later than in the control group. Parental perception of the severity of the sleep problem was similar in the two groups, as were the calming techniques. It is concluded that this study does not support a significantly increased prevalence of sleep disturbances among young children with asthma compared with their healthy peers.

An effective community-based approach to the identification of neurodevelopmental delay in childhood

The contribution of specially trained developmental nurses (DNs) to the accuracy of developmental screening in well-baby units was assessed. Of 13,580 children between two and 48 months of age, the well-baby clinic identified definitive developmental delay in 310, and 357 children were classified as 'questionable'. After DN assessment at 12 months follow-up, only 31 per cent of the questionable group required referral to the Child Development Centre (CDC). Comparison of the original queried recommendations to the CDC with the DN's recommendation indicated a false-positive and -negative rate of 60 and 20 per cent, respectively. This procedure resulted in false-positive and -negative screening accuracies of 1.2 and 6 per cent, respectively, for the total cohort of children screened. The economic and clinical advantages of this model are discussed.

The effects of illness on sleep behaviour in infants

For the purpose of evaluating the association between health problems and sleep disturbances as part of a community survey of sleep patterns in childhood, a questionnaire was administered to 752 mothers of children between the ages of 4 months and 4 years, and to the nurses at their regular baby clinics. The questionnaire covered the areas of past and present sleep and settling behaviour, as well as health history and demographic data. The study group consisted of 66 (8.9%) children who had either chronic medical problems, or history of an illness requiring hospitalisation. Regular night waking was reported in 35% and 34% of the group with and without history of illness, respectively. The mean number of interrupted nights per week was similar in both groups and so were the sleep problems perceived by the mothers. We conclude that in this age group the results do not support an association between health problems and prolonged sleep disturbances.

Severe visual deficits in infancy in northern Israel: an epidemiological perspective

The characteristics of 193 legally blind children ranging in ages from birth to 4 years were analyzed. The overall incidence was 1/1000 live births; however, the ethnic specific incidence varies. All children were diagnosed before the age of 20 months and the most frequent alerting sign was lack of visual tracking. In 33.3%, the deficit was first suspected by a family member. A genetic etiology accounted for 38% of the cohort. The relative risk for an associated handicap was significant as well as the rate of hospitalizations for apparently unassociated diseases. It appears that both prevention and early detection could be achieved by a risk index.

Variability in head circumference growth rate during the first 2 years of life

The head circumference (HC) curves were plotted for a group of 415 healthy full-term babies over the first 2 years of life. Two hundred ten (51%) of the cohort demonstrated HC variability, defined as an HC acceleration or deceleration of at least 1 centile curve for at least 2 months. Of these, the deceleration pattern was predominant (80.9%), and also frequently permanent (87%). The HCs of 3 (1.42%) of 210 infants with HC variability ended up with a deviation of 2 standard deviations or more from the mean. The onset of HC transition occurred from the mean age of 1.3 months, and the new curve had stabilized by age 13 months in 95% of the study group. Parallel changes occurred in body weight and body length in approximately 48% of the total cohort, but more frequently in the variable-HC group. The clinical interpretation of these findings is discussed.

Relationship between neonatal excitability and respiratory habituation

The Brazelton Neonatal Behavioral Assessment Scale was administered and analyzed in the cases of 25 full-term infants in order to assess the relationship between a behavioral measure of excitability and respiratory habituation. Sound and light stimuli were sequentially delivered, and prestimulus and poststimulus respiratory amplitude mean and standard deviation were analyzed. The stimulus with the least interperiod difference was considered as habituation. The correlation between arousal behavioral items and respiratory habituation ranged between 0.16 and 0.44. The two significant correlations were between peak of excitement and respiratory habituation to light (0.44) and between rapidity of buildup and respiratory habituation to sound (0.38). These results may indicate an interrelation in neonates between temperamental excitability attributes and respiratory regulation.

Preservation of regional myocardial ultrasonic backscatter and systolic function during brief periods of ischemia by synchronized coronary venous retroperfusion

This study examines the effects of brief periods of ischemia on average and cardiac cycle-dependent variation of regional ultrasonic backscatter paralleled with changes in regional myocardial contraction, and to what extent these changes could be reversed by synchronized coronary venous retroperfusion. In five closed-chest dogs, the left anterior descending coronary artery was occluded on four occasions for a 2-minute period and retroperfusion was applied randomly to two of the coronary occlusions. Complete functional recovery was allowed between the occlusions. Two-dimensional echocardiographic images were obtained before and at the peak of the 2-minute occlusion period. Regional myocardial contraction as measured by fractional area change and systolic wall thickening during untreated occlusions decreased from 33.9 +/- 14.0% to -0.15 +/- 6.2%, and from 22.0 +/- 1.8% to -17.9 +/- 2.2%, whereas during retroperfusion-treated occlusions it changed from 37.4 +/- 8.5% to only 23.4 +/- 11.2% (p less than 0.005 versus baseline), and from 24.1 +/- 2.8% to only 12.7 +/- 2.0% (p less than 0.005 versus baseline), corresponding to a preservation of 62% and 52% of baseline regional contraction, respectively. Average regional gray level (arbitrary units) during untreated coronary occlusions exhibited a significant increase in the ischemic regions, from 5.6 +/- 2.7 at baseline to 11.5 +/- 4.4 during occlusion (p less than 0.005); during retroperfusion-treated occlusions, average gray level increased from 4.7 +/- 3.6 to only 6.3 +/- 3.6 (NS). Untreated coronary artery occlusions resulted in a systolic increase in gray level in the ischemic region, followed by a diastolic decrease.(ABSTRACT TRUNCATED AT 250 WORDS)

Brucellosis: an unusual diagnosis for a seronegative patient with abscesses, osteomyelitis, and ulcerative colitis

A 16-year-old girl developed multiple subcutaneous abscesses, osteomyelitis, and severe colitis. On the patient's second admission, a single blood culture--and, subsequently, a specimen of pus--yielded Brucella melitensis biovar 1. A second set of serologic tests, including the rose bengal test, the standard tube agglutination test, the CF test, and Coombs' test, were all negative for Brucella on the patient's second admission and 1 month later. However, a lymphocyte proliferation assay with extracted antigen of Brucella was markedly positive. Thus, this case illustrates that patients with B. melitensis infection may have a unique clinical presentation and that the lymphocyte proliferation assay is an important diagnostic tool for patients whose serologic test results are negative but for whom brucellosis is suspected.