Development of clinical practice guidelines for allied health and nursing assessment and management of Duchenne muscular dystrophy

PURPOSE

To provide evidence-based guidance specific to allied health and nursing practice for the assessment and management of individuals with Duchenne muscular dystrophy (DMD).

MATERIALS AND METHODS

Thirteen key focus areas were identified in consultation with health professionals and consumer advocacy groups. A series of systematic literature reviews were conducted to identify assessment and management strategies for each key focus area. A consensus process using modified Delphi methodology, including an Australia-New Zealand expert consensus meeting, was conducted. Recommendations underwent consultative review with key groups before being finalised and prepared for dissemination.

RESULTS

This clinical practice guideline (CPG) generated 19 evidence-based recommendations, 117 consensus-based recommendations and five research recommendations across the 13 focus areas to inform allied health assessment and management of individuals with DMD.

CONCLUSIONS

The resulting recommendations can be used in conjunction with existing medical CPGs to improve, standardise and advocate for allied health and rehabilitation care in DMD. The process used here may be useful for the development of CPGs in other rare diseases.Implications for rehabilitationImplementation-ready evidence-based statements to guide clinical care of individuals with DMD are provided with the potential to improve participation, function in the community and quality of life.A model for developing best practice statements for other rare neurological diseases is described.Allied health and nursing health professionals should focus research efforts to generate quality evidence to support rehabilitation practice.

Reliability and validity of the FSHD-composite outcome measure in childhood facioscapulohumeral dystrophy

This study aims to investigate intra-rater reliability and construct validity of the Facioscapulohumeral Dystrophy Composite Outcome Measure (FSHD-COM), in childhood FSHD. Participants included eighteen children with FSHD, and matched healthy controls. Reliability data were collected from 15 participants with FSHD over two testing sessions. Validity data were collected from all participants. Participants with FSHD completed; the FSHD-COM (and modified pediatric version), Motor Function Measure-32 (MFM-32), FSHD Severity Scales, Performance of the Upper Limb 2.0, Pediatric Quality of Life™ Neuromuscular Module and pediatric FSHD Health-Index Questionnaire. Both versions of the FSHD-COM showed excellent intra-rater reliability (ICC_1,2 > 0.99, lower 95%CI > 0.98) with a Minimal Detectable Change (MDC95%) of ≤14.5%. The FSHD-COM had robust and widespread correlations with other related outcome measures. The FSHD-COM versions and 6 min walk test effectively discriminated between children with and without FSHD; the MFM-32 and 10 m walk/run test did not. Ceiling effects were not observed on either version of the FSHD-COM. Reliability and validity findings in this childhood FSHD study concord with estimates in adults. Both versions of the FSHD-COM were effective in discriminating disease in children with mild FSHD symptoms. The FSHD-COM has the potential to be a useful measure of function across the life span.

Is Reluctance to Share Alzheimer's Disease Biomarker Status with a Study Partner a Barrier to Preclinical Trial Recruitment?

BACKGROUND

Preclinical Alzheimer's disease clinical trials test candidate treatments in individuals with biomarker evidence but no cognitive impairment. Participants are required to co-enroll with a knowledgeable study partner, to whom biomarker information is disclosed.

OBJECTIVE

We investigated whether reluctance to share biomarker results is associated with viewing the study partner requirement as a barrier to preclinical trial enrollment.

DESIGN

We developed a nine-item assessment on views toward the study partner requirement and performed in-person interviews based on a hypothetical clinical trial requiring biomarker testing and disclosure.

SETTING

We conducted interviews on campus at the University of California, Irvine.

PARTICIPANTS

Two hundred cognitively unimpaired older adults recruited from the University of California, Irvine Consent-to-Contact Registry participated in the study.

MEASUREMENTS

We used logistic regression models, adjusting for potential confounders, to examine potential associations with viewing the study partner requirement as a barrier to preclinical trial enrollment.

RESULTS

Eighteen percent of participants reported strong agreement that the study partner requirement was a barrier to enrollment. Ten participants (5%) agreed at any level that they would be reluctant to share their biomarker result with a study partner. The estimated odds of viewing the study partner requirement as a barrier to enrollment were 26 times higher for these participants (OR=26.3, 95% CI 4.0, 172.3), compared to those who strongly disagreed that they would be reluctant to share their biomarker result. Overall, participants more frequently agreed with positive statements than negative statements about the study partner requirement, including 76% indicating they would want their study partner with them when they learned biomarker results.

CONCLUSIONS

This is one of the first studies to explore how potential preclinical Alzheimer's disease trial participants feel about sharing their personal biomarker information with a study partner. Most participants viewed the study partner as an asset to trial enrollment, including having a partner present during biomarker disclosure.

Observations of body mass index in Duchenne muscular dystrophy: a longitudinal study

BACKGROUND/OBJECTIVES

Nutritional issues that are associated with Duchenne muscular dystrophy (DMD) remain poorly understood. The aim of this analysis was to describe and explore longitudinal observations of body mass index (BMI) in a cohort of children with DMD.

SUBJECTS/METHODS

Anthropometric and clinical characteristics were collected retrospectively and longitudinally for boys with DMD seen in two large neuromuscular clinics. BMI Z-scores were determined using the Centers for Disease Control and Prevention reference values for children (2000).

RESULTS

Medical records (n=193) were examined from which 75% were included for analysis. The mean age of the cohort at the time of data collection was 11.9 years, with 72% of patients currently or previously using steroids. The highest prevalence of obesity based on the BMI Z-score was 50% at the age of 10 years. Longitudinally, BMI Z-scores from the age of 2 to 12 years plot approximately one s.d. above the mean, after which there is a marked and progressive decline. BMI gainers were identified for whom BMI Z-score increased by 1.65 units compared with the 0.09 units in non-gainers. BMI gainers were younger when they had their first BMI measurement (5.9 vs 7.2 years), and this measure was significantly lower compared with the non-gainers (BMI Z-score: 0.04 vs 1.17). In this cohort, BMI was associated with age, ambulatory status and lung function.

CONCLUSIONS

This study demonstrates that boys with DMD using steroid therapy experience shifts in BMI. A declining BMI appears to be associated with increasing age. Interpretation of growth patterns is limited here by a lack of normative growth references in DMD.

Two novel germline KRAS mutations: expanding the molecular and clinical phenotype

Noonan and Cardio-facio-cutaneous (CFC) syndromes are characterized by typical dysmorphic features, cardiac defects, short stature, variable ectodermal anomalies, and intellectual disability. Both belong to the Ras/mitogen-activated protein kinase pathway group of disorders and clinical features overlap other related conditions, notably LEOPARD and Costello syndromes. KRAS mutations account for about 2% of reported Noonan and <5% of reported CFC cases. The mutation spectrum includes recurrent missense changes clustering in particular domains of the KRAS protein and conferring gain-of-function. We report three patients from two unrelated families with novel missense KRAS mutations, p.K147E and p.Y71H. Both mutations affect a residue which is highly conserved in KRAS and other RAS isoforms. One of the families includes a mother and son pair who represent the first report of a vertically transmitted KRAS mutation. In addition, the mother and son pair had peripheral neuropathy, complicated by Charcot arthropathy in the mother. An unusual phenotypic effect of the specific KRAS mutation or a coincidence of two independent disorders may be considered. KRAS mutation-associated phenotypes appear to be subject to considerable clinical heterogeneity. All three cases highlight the challenges of clinical assessment in KRAS mutation-positive patients, and the utility of molecular testing as an adjunct to diagnosis.

Randomized, blinded trial of weekend vs daily prednisone in Duchenne muscular dystrophy

OBJECTIVE

To perform a double-blind, randomized study comparing efficacy and safety of daily and weekend prednisone in boys with Duchenne muscular dystrophy (DMD).

METHODS

A total of 64 boys with DMD who were between 4 and 10 years of age were randomized at 1 of 12 centers of the Cooperative International Neuromuscular Research Group. Efficacy and safety of 2 prednisone schedules (daily 0.75 mg/kg/day and weekend 10 mg/kg/wk) were evaluated over 12 months.

RESULTS

Equivalence was met for weekend and daily dosing of prednisone for the primary outcomes of quantitative muscle testing (QMT) arm score and QMT leg score. Secondary strength scores for QMT elbow flexors also showed equivalence between the 2 treatment groups. Overall side effect profiles of height and weight, bone density, cataract formation, blood pressure, and behavior, analyzed at 12 months, did not differ between weekend and daily dosing of prednisone.

CONCLUSIONS

Weekend dosing of prednisone is equally beneficial to the standard daily dosing of prednisone. Analysis of side effect profiles demonstrated overall tolerability of both dosing regimens.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that weekend prednisone dosing is as safe and effective as daily prednisone in preserving muscle strength and preventing body mass index increases in boys with DMD over a 12-month period.

Pediatric sciatic neuropathies: a 30-year prospective study

OBJECTIVE

The incidence, cause, and prognosis of sciatic neuropathy in children is not well understood. We report our 30-year experience of 53 patients with pediatric sciatic neuropathies (SN).

METHODS

Prospective review of the history, physical examination, electrophysiologic findings, and clinical course of children with SN.

RESULTS

The etiology of SN injury was varied and included trauma (13), iatrogenic causes (13) (8 orthopedic surgeries and 5 miscellaneous surgeries), prolonged extrinsic compression and immobilization (6), tumors (7), vascular (5), idiopathic and progressive (4), infantile and nonprogressive (2), and unknown, presumed postviral (3). Electrophysiologic studies demonstrated abnormalities in motor conduction studies of the peroneal nerve in 44/53 (83%) or tibial nerve in 35/51 (67%). Sensory conduction studies were abnormal in sural nerve in 34 of 43 cases (79%), and superficial peroneal nerves in 15/25 (60%). Needle EMG was abnormal in peroneal innervated muscles in all subjects, in tibial nerve innervated muscles in 43/51 (84%), and in the hamstrings in 18/29 (62%). Prognosis for recovery was variable and depended on the etiology and the severity of the nerve injury.

CONCLUSIONS

SN is an uncommon mononeuropathy in children. The causes of SN are varied in children compared to adults. Electrophysiologic studies in children may be limited by poor tolerance but play an important role in establishing the diagnosis.

A retrospective review of X-linked Charcot-Marie-Tooth disease in childhood

OBJECTIVE

X-linked Charcot-Marie-Tooth disease (CMTX) is infrequently diagnosed in childhood, and its clinical and neurophysiologic features are not well-described. We reviewed clinical, neurophysiologic, and pathologic findings in 17 children with CMTX.

METHODS

This was a retrospective review of children with CMTX from 2 tertiary pediatric hospitals. The diagnosis of CMTX was based on an identifiable connexin 32 mutation (CMTX1) or a consistent pedigree and neurophysiologic features in children without a connexin 32 mutation (CMTX-other).

RESULTS

Six boys and 2 girls from 8 kindreds had CMTX1, and 8 boys and 1 girl from 5 kindreds had other forms of CMTX (CMTX-other). Fifteen children, including males and carrier females, were symptomatic from infancy or early childhood (younger than 5 years). In addition to the typical Charcot-Marie-Tooth disease clinical phenotype, some patients had delayed motor development, sensorineural hearing loss, tremor, pathologic fractures, or transient CNS disturbances. Eleven children underwent nerve conduction studies. Median nerve motor nerve conduction velocities were in the intermediate to normal range (30-54 m/s) in all children older than 2 years. Axon loss, reflected by low-amplitude compound muscle action potentials, was present in all patients. A pattern of X-linked dominant inheritance, with carrier females showing an abnormal neurologic or neurophysiologic examination, correlated with the presence of a connexin 32 mutation in all but 2 pedigrees.

CONCLUSIONS

The clinical phenotype of CMTX is broader than previously reported. Onset in males and carrier females is most often in early childhood. Families with an X-linked dominant inheritance pattern are likely to have CMTX1.

Determinants of reduced health-related quality of life in pediatric inherited neuropathies

OBJECTIVE

We have shown that health-related quality of life (QOL) in children with inherited neuropathies (Charcot-Marie-Tooth disease [CMT]) is significantly reduced compared to population norms, thus establishing its utility as an outcome measure in therapeutic trials. However, the Australian ascorbic acid trial in children with CMT type 1A (CMT1A) identified no change in QOL scores despite a trend toward improvement in nerve conduction velocities in the treated group. The objective of this study was to identify clinical, electrophysiologic, and functional correlates of QOL in children with CMT1A, to guide future investigations of strategies to improve QOL and reduce disability in these patients.

METHODS

In this cross-sectional study, a series of multivariate regression models were developed to determine whether QOL scores could be explained by demographic and symptom data, standardized measures of gross motor function, foot/ankle and hand/finger involvement, electrophysiology, and gait characteristics in 70 children aged 5-16 years with CMT1A.

RESULTS

Independent determinants of reduced QOL in children with CMT1A, from strongest to weakest, were leg cramps, hand tremor, short step length, reduced long jump distance, ankle inflexibility, poor agility and endurance, advancing age, and foot drop. Many of the standardized clinical and electrophysiologic measures used as endpoints in clinical trials of CMT correlated poorly with QOL.

CONCLUSION

QOL is negatively affected by CMT1A in children. Multivariate modeling suggests that interventions designed to improve leg cramps, tremor, agility, endurance, and ankle flexibility might have a substantial effect on QOL in children with CMT1A.

Autosomal dominant congenital spinal muscular atrophy--a possible developmental deficiency of motor neurones?

We describe a kindred with an unusual congenital lower motor neuron disorder with significant but static muscle weakness predominantly affecting the lower limbs. The proband had talipes equinovarus and congenital hip contractures and did not walk until 19 months of age. Lower-extremity predominant, primarily proximal weakness was identified on assessment at three years. Over a 20 year follow-up there has been no clinical progression. The proband has a four-year-old daughter with very similar clinical findings. Electromyography and muscle biopsy suggest reduced numbers of giant normal duration motor units with little evidence of denervation or reinnervation. Dominant congenital spinal muscular atrophy predominantly affecting the lower limbs is rarely described. It is possible that the disorder is due to a congenital deficiency of motor neurons.

Live-born infants of 24 to 28 weeks' gestation: survival and sequelae at two years of age

The survival rate of infants born alive between 24 and 28 weeks of gestation has increased significantly in this tertiary care centre, from about 9% in the first cohort studied (1966-1970), to 19.5% in the second cohort (1971-1974) and 50.3% in the third cohort (1977-1982); the borderline of practical viability decreased from 27 to 24 weeks over the years of the study. The number of mothers with a history of prior termination of pregnancy increased about sixfold from the second to the third cohorts but the rate of premature births increased by only 50%. The augmented survival rate was accompanied by an increase in the prevalence and total number of children with cerebral palsy, but bilateral blindness due to retinopathy of prematurity and severe sensorineural deafness were reduced. When 96% of children in the third cohort were assessed at two years of age. 13% had severe handicaps, 59% were considered normal and in 24% some handicap was suspected. The serious handicap rate was 28% for children born at 24-26 weeks compared with 8.5% for those born at 27-28 weeks of gestation.

Severe early-onset axonal neuropathy with homozygous and compound heterozygous MFN2 mutations

Objective: Severe early-onset axonal neuropathy (SEOAN) is a heterogeneous phenotype first delineated by Ouvrier et al., characterized by progressive axonal degeneration with gait problems often progressing to wheelchair requirement and later respiratory involvement. Most cases are sporadic single cases. Some have heterozygous mitofusin 2 (MFN2) mutations, many of which are de novo dominant mutations. The aim of this study was to investigate the mode of inheritance in three individuals with severe early-onset axonal neuropathy and homozygous or compound heterozygous MFN2 mutations.

Methods: The clinical and molecular findings in the parents of three individuals with SEOAN with homozygous or compound heterozygous MFN2 mutations were examined.

Results: All parents were asymptomatic or mildly symptomatic with some signs of peripheral neuropathy indicating a minimal phenotype. Two had hearing problems. All parents carried the relevant single base (heterozygous) MFN2 variations.

Conclusion: Severe early-onset axonal neuropathy due to MFN2 mutations can present as an apparently recessively inherited neuropathy but the minimal phenotype in the parents suggests a semi-dominant mechanism.

Interventions for the prevention and treatment of pes cavus

BACKGROUND

People with pes cavus frequently suffer foot pain, which can lead to significant disability. Despite anecdotal reports, rigorous scientific investigation of this condition and how best to manage it is lacking.

OBJECTIVES

To assess the effects of interventions for the prevention and treatment of pes cavus.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (April 2007), MEDLINE (January 1966 to April 2007), EMBASE (January 1980 to April 2007), CINAHL (January 1982 to April 2007), AMED (January 1985 to April 2007), all EBM Reviews (January 1991 to April 2007), SPORTdiscuss (January 1830 to April 2007) and reference lists of articles. We also contacted known experts in the field to identify additional published or unpublished data.

SELECTION CRITERIA

We included all randomised and quasi-randomised controlled trials of interventions for the treatment of pes cavus. We also included trials aimed at preventing or correcting the cavus foot deformity.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, assessed trial quality and extracted data.

MAIN RESULTS

Only one trial (custom-made foot orthoses) fully met the inclusion criteria. Two additional cross-over trials (off-the-shelf foot orthoses and footwear) were also included. Both studies assessed secondary biomechanical outcomes less than three-months after randomisation. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The one trial that fully met the inclusion criteria investigated the treatment of cavus foot pain in 154 adults over a three month period. The trial showed a significant reduction in the level of foot pain, measured using the validated 100-point Foot Health Status Questionnaire, with custom-made foot orthoses versus sham orthoses (WMD 10.90; 95% CI 3.21 to 18.59). Furthermore, a significant improvement in foot function measured with the same questionnaire was reported with custom-made foot orthoses (WMD 11.00; 95% CI 3.35 to 18.65). There was also an increase in physical functioning of the Medical Outcomes Short Form - 36 (WMD 9.50; 95% CI 4.07 to 14.93). There was no difference in reported adverse events following the allocation of custom-made (9%) or sham foot orthoses (15%) (RR 0.61; 95% CI 0.26 to 1.48).

AUTHORS' CONCLUSIONS

In one randomised controlled trial, custom-made foot orthoses were significantly more beneficial than sham orthoses for treating chronic musculoskeletal foot pain associated with pes cavus in a variety of clinical populations. There is no evidence for any other type of intervention for the treatment or prevention of foot pain in people with a cavus foot type.

Oropharyngeal dysphagia in juvenile dermatomyositis (JDM): an evaluation of videofluoroscopy swallow study (VFSS) changes in relation to clinical symptoms and objective muscle scores

OBJECTIVE

To determine if objective, validated scores of muscle weakness and function [manual muscle testing (MMT), childhood myositis assessment scale (CMAS)] or scores of general disease activity or function [childhood health assessment questionnaire and physician global assessment of disease activity visual analogue scale (VAS)], can predict children at risk of swallow abnormalities in juvenile dermatomyositis (JDM) measured by videofluoroscopic swallow studies (VFSS).

METHODS

Patients were referred for speech and language dysphagia assessment upon diagnosis of JDM or flare of disease. VFSS was used to document a swallow score indicating severity of swallow dysfunction. Clinical symptoms, examination findings and objective scores of disease activity were analysed. Any correlation was looked for using chi-squared Fisher exact test and linear regression models.

RESULTS

Fourteen patients with inflammatory myopathy (age 2-16 years) had clinical assessments and VFSS. VFSS was abnormal in 11 children (79%). Only two children were asymptomatic at assessment, but both had swallow dysfunction, including aspiration, on VFSS. In contrast, three of the symptomatic children had a normal VFSS. No relationship was found between objective disease severity scores and VFSS swallow score.

CONCLUSIONS

This study failed to show any correlation between swallow score and objective measures of muscle strength and function (MMT/CMAS) or general disease activity and function [physician VAS/childhood health assessment questionnaire (CHAQ)]. In the absence of a more accurate assessment method to determine which children with active JDM are most at risk of swallow dysfunction and aspiration, all children with active dermatomyositis should be referred for speech and language assessment and VFSS.

Outcome of noninvasive ventilation in children with neuromuscular disease

OBJECTIVE

To assess the effect of institution of noninvasive ventilation (NIV) on clinical outcome and quality of life (QOL) in a cohort of children with severe neuromuscular disorders.

METHODS

We reviewed records and obtained clinical data from the year prior to commencing NIV and annually thereafter. Data obtained included diagnosis, patient symptoms, mortality, NIV adverse effects, pulmonary function tests, polysomnographic data, length of hospitalizations, and health care costs. Patients and parents completed questionnaires assessing QOL with NIV and recalling QOL before NIV.

RESULTS

Fourteen of 17 (82%) suitable patients were enrolled. Follow-up ranged from 6 to 84 months (median 30). Symptoms of daytime sleepiness (p = 0.003) and headache (p = 0.046) improved after initiation of NIV. Sleep quality assessed by polysomnography also improved. Hospitalization rates (p = 0.002) and health care costs (p = 0.003) decreased. QOL remained stable after NIV, despite disease progression.

CONCLUSION

Treatment of respiratory failure, in children with neuromuscular disease, with noninvasive ventilation results in a reduction in symptoms, hospitalizations, and health care costs without adverse effects on quality of life.

Gene expression analysis of bipolar disorder reveals downregulation of the ubiquitin cycle and alterations in synaptic genes

Bipolar affective disorder is a severe psychiatric disorder with a strong genetic component but unknown pathophysiology. We used microarray technology to determine the expression of approximately 22,000 mRNA transcripts in post-mortem tissue from two brain regions in patients with bipolar disorder and matched healthy controls. Dorsolateral prefrontal cortex tissue from a cohort of 70 subjects and orbitofrontal cortex tissue from a separate cohort of 30 subjects was investigated. The final analysis included 30 bipolar and 31 control subjects for the dorsolateral prefrontal cortex and 10 bipolar and 11 control subjects for the orbitofrontal cortex. Differences between disease and control groups were identified using a rigorous statistical analysis with correction for confounding variables and multiple testing. In the orbitofrontal cortex, 393 differentially expressed transcripts were identified by microarray analysis and a representative subset was validated by quantitative real-time PCR. Pathway analysis revealed significant upregulation of genes involved in G-protein coupled receptor signalling and response to stimulus (in particular the immune response), while genes relating to the ubiquitin cycle and intracellular transport showed coordinated downregulation in bipolar disorder. Additionally, several genes involved in synaptic function were significantly downregulated in bipolar disorder. No significant changes in gene expression were observed in the dorsolateral prefrontal cortex using microarray analysis or quantitative real-time PCR. Our findings implicate the orbitofrontal cortex as a region prominently involved in bipolar disorder and indicate that diverse processes are affected. Overall, our results suggest that dysregulation of the ubiquitin pathway and synaptic function may be central to the disease process.

Sec14p-like proteins regulate phosphoinositide homoeostasis and intracellular protein and lipid trafficking in yeast

The major PI (phosphatidylinositol)/PC (phosphatidylcholine)-transfer protein in yeast, Sec14p, co-ordinates lipid metabolism with protein transport from the Golgi complex. Yeast also express five additional gene products that share 24–65% primary sequence identity with Sec14p. These Sec14p-like proteins are termed SFH (Sec Fourteen Homologue) proteins, and overexpression of certain individual SFH gene products rescues sec14-1ts-associated growth and secretory defects. SFH proteins are atypical in that these stimulate the transfer of PI, but not PC, between distinct membrane bilayer systems in vitro. Further analysis reveals that SFH proteins functionally interact with the Stt4p phosphoinositide 4-kinase to stimulate PtdIns(4,5)P2 synthesis which in turn activates phospholipase D. Finally, genetic analyses indicate that Sfh5p interfaces with the function of specific subunits of the exocyst complex as well as the yeast SNAP-25 (25 kDa synaptosome-associated protein) homologue, Sec9p. Our current view is that Sfh5p regulates PtdIns(4,5)P2 homoeostasis at the plasma membrane, and that Sec9p responds to that regulation. Thus SFH proteins individually regulate specific aspects of lipid metabolism that couple, with exquisite specificity, with key cellular functions.

Mitochondrial dysfunction in schizophrenia: evidence for compromised brain metabolism and oxidative stress

The etiology and pathophysiology of schizophrenia remain unknown. A parallel transcriptomics, proteomics and metabolomics approach was employed on human brain tissue to explore the molecular disease signatures. Almost half the altered proteins identified by proteomics were associated with mitochondrial function and oxidative stress responses. This was mirrored by transcriptional and metabolite perturbations. Cluster analysis of transcriptional alterations showed that genes related to energy metabolism and oxidative stress differentiated almost 90% of schizophrenia patients from controls, while confounding drug effects could be ruled out. We propose that oxidative stress and the ensuing cellular adaptations are linked to the schizophrenia disease process and hope that this new disease concept may advance the approach to treatment, diagnosis and disease prevention of schizophrenia and related syndromes.

Functional genomics and proteomics: application in neurosciences

The sequencing of the complete genome for many organisms, including man, has opened the door to the systematic understanding of how complex structures such as the brain integrate and function, not only in health but also in disease. This blueprint, however, means that the piecemeal analysis regimes of the past are being rapidly superseded by new methods that analyse not just tens of genes or proteins at any one time, but thousands, if not the entire repertoire of a cell population or tissue under investigation. Using the most appropriate method of analysis to maximise the available data therefore becomes vital if a complete picture is to be obtained of how a system or individual cell is affected by a treatment or disease. This review examines what methods are currently available for the large scale analysis of gene and protein expression, and what are their limitations.

Clinical course correlates poorly with muscle pathology in nemaline myopathy

OBJECTIVE

To report pathologic findings in 124 Australian and North American cases of primary nemaline myopathy.

METHODS

Results of 164 muscle biopsies from 124 Australian and North American patients with primary nemaline myopathy were reviewed, including biopsies from 19 patients with nemaline myopathy due to alpha-actin (ACTA1) mutations and three with mutations in alpha-tropomyosin(SLOW) (TPM3). For each biopsy rod number per fiber, percentage of fibers with rods, fiber-type distribution of rods, and presence or absence of intranuclear rods were documented.

RESULTS

Rods were present in all skeletal muscles and diagnosis was possible at all ages. Most biopsies contained nemaline bodies in more than 50% of fibers, although rods were seen only on electron microscopy in 10 patients. Rod numbers and localization correlated poorly with clinical severity. Frequent findings included internal nuclei and increased fiber size variation, type 1 fiber predominance and atrophy, and altered expression of fiber type specific proteins. Marked sarcomeric disruption, increased glycogen deposition, and intranuclear rods were associated with more severe clinical phenotypes. Serial biopsies showed progressive fiber size variation and increasing numbers of rods with time. Pathologic findings varied widely in families with multiple affected members.

CONCLUSIONS

Very numerous nemaline bodies, glycogen accumulation, and marked sarcomeric disruption were common in nemaline myopathy associated with mutations in skeletal alpha-actin. Nemaline myopathy due to mutations in alpha-tropomyosin(SLOW) was characterized by preferential rod formation in, and atrophy of, type 1 fibers. Light microscopic features of nemaline myopathy correlate poorly with disease course. Electron microscopy may correlate better with disease severity and genotype.

Nemaline myopathy: a clinical study of 143 cases

We report 143 Australian and North American cases of primary nemaline myopathy. As classified by the European Neuromuscular Centre guidelines, 23 patients had severe congenital, 29 intermediate congenital, 66 typical congenital, 19 childhood-onset, and 6 adult-onset nemaline myopathy. Inheritance was autosomal recessive in 29 patients, autosomal dominant in 41, sporadic in 72, and indeterminate in 1. Twenty-two patients had skeletal muscle actin mutations and 4 had mutations in the alpha-tropomyosin(slow) gene. Obstetric complications occurred in 49 cases. Seventy-five patients had significant respiratory disease during the first year of life, and 79 had feeding difficulties. Atypical features in a minority of cases included arthrogryposis, central nervous system involvement, and congenital fractures. Progressive distal weakness developed in a minority of patients. Thirty patients died, the majority during the first 12 months of life. All deaths were due to respiratory insufficiency, which was frequently underrecognized in older patients. Arthrogryposis, neonatal respiratory failure, and failure to achieve early motor milestones were associated with early mortality. Morbidity from respiratory tract infections and feeding difficulties frequently diminished with increasing age. Aggressive early management is warranted in most cases of congenital nemaline myopathy.

Anterior horn cell disease and olivopontocerebellar hypoplasia

To date, fewer than 30 cases of anterior horn cell disease with associated olivopontocerebellar hypoplasia have been reported. We describe five patients and review the literature on this uncommon disorder. In addition to a syndrome of progressive spinal muscular atrophy similar to that seen in Werdnig-Hoffmann disease, this disorder is characterised by hypoplasia of the olivary nuclei, pons, and cerebellum. Additional clinical features may include dysmorphism, abnormal eye movements, stridor, congenital joint contractures, and enlarged kidneys. Pontocerebellar hypoplasia may be associated with posterior fossa cystic malformations, cerebral atrophy, and a demyelinating neuropathy.

Childhood chronic inflammatory demyelinating polyneuropathy: clinical course and long-term outcome

We reviewed the clinical history, electrophysiologic and pathologic findings, and response to therapy of 16 children with chronic inflammatory demyelinating polyneuropathy. The majority presented with lower limb weakness. Sensory loss was uncommon. The illness was monophasic in seven children, relapsing in six, and three had a slowly progressive course. All patients were treated with immunosuppressive agents. In 11, the initial treatment was prednisolone. All had at least a short-term response but five went on to develop a relapsing course. Intravenous immunoglobulin was the initial treatment in four patients. Three responded rapidly, with treatment being stopped after a maximum of 5 months. In resistant chronic inflammatory demyelinating neuropathy, in addition to prednisolone and immunoglobulin, plasma exchange, azathioprine, cyclosporine, methotrexate, cyclophosphamide and pulse methylprednisolone were tried at different times in different patients. On serial neurophysiologic testing slowing of nerve conduction persisted for long periods after clinical recovery. Follow-up was for an average of 10 years. When last seen 14 patients were asymptomatic, two having mild residual deficits. Childhood chronic inflammatory demyelinating neuropathy responds to conventional treatment and generally has a favourable long-term outcome.

Persistent or severe back pain and stiffness are ominous symptoms requiring prompt attention

BACKGROUND

Children with severe or persistent back pain and stiffness often have an underlying organic cause but there is a large differential diagnosis, examination may be difficult and the problem is relatively rare in general paediatric practice. These difficulties appeared to lead to delays in diagnosis and management of children with this problem.

OBJECTIVES

To provide an approach to the diagnosis and management children with severe or persistent back pain or stiffness based on our clinical experience and the literature.

METHODOLOGY

The case histories of 10 children with severe back pain seen by the authors over a 5-year period were reviewed. They were chosen as illustrative examples of the diagnostic and management problems and did not represent a systematic review of all cases seen by the authors over that time.

RESULTS

Underlying causes included infection, inflammation, neoplasm, trauma and vascular malformation. Four of the children had spinal cord compression which required urgent decompression. There was one child with a conversion disorder but three children with organic disease were initially felt to have a conversion disorder. Investigations generally proceeded relatively slowly and the problem was not regarded as a semi-urgent situation carrying the risk of permanent paraplegia. Magnetic resonance imaging (MRI) scan of the spine was the investigation of choice.

CONCLUSION

Children with severe or persistent back pain and stiffness have a wide variety of underlying causes. The possibility of underlying spinal cord compression should always be considered in children with this presentation. If the diagnosis is not obvious, MRI scan of the spine should be arranged without delay.

Cerebral vasculitis in a case of Sydenham's chorea

A 10-year-old girl with acute-onset hemichorea had multiple areas of abnormal signal seen on magnetic resonance imaging of the brain, associated with middle and anterior cerebral artery vasculitis seen on cerebral angiography. Her serology and clinical course were supportive of the diagnosis of Sydenham's chorea. Other causes of cerebral vasculitis were excluded. Follow-up studies revealed resolution of changes seen on magnetic resonance imaging and partial resolution of angiographic abnormalities. This is the first report of abnormal cerebral angiography in Sydenham's chorea.

Influenza A encephalitis with movement disorder

Influenza A is an uncommon but well-recognized cause of viral encephalitis in childhood, occurring most commonly during community influenza outbreaks. The authors report four cases of influenza A encephalitis that occurred during an Australian epidemic in 1997-1998. Choreoathetosis during the acute phase of infection or basal ganglia involvement on neuroimaging was observed in three of the four patients. These findings in pediatric encephalitis are suggestive of influenza A infection and may guide investigation and early diagnosis.

Coordination of two-joint rectus femoris and hamstrings during the swing phase of human walking and running

It has been hypothesized previously that because a strong correlation was found between the difference in electromyographic activity (EMG) of rectus femoris (RF) and hamstrings (HA; EMG(RF)-EMG(HA)) and the difference in the resultant moments at the knee and hip (Mk-Mh) during exertion of external forces on the ground by the leg, input from skin receptors of the foot may play an important role in the control of the distribution of the resultant moments between the knee and hip by modulating activation of the two-joint RF and HA. In the present study, we examined the coordination of RF and HA during the swing phase of walking and running at different speeds, where activity of foot mechanoreceptors is not modulated by an external force. Four subjects walked at speeds of 1.8 m/s and 2.7 m/s and ran at speeds of 2.7 m/s and 3.6 m/s on a motor-driven treadmill. Surface EMG of RF, semimembranosus (SM), and long head of biceps femoris (BF) and coordinates of the four leg joints were recorded. An inverse dynamics analysis was used to calculate the resultant moments at the ankle, knee, and hip during the swing phase. EMG signals were rectified and low-pass filtered to obtain linear envelopes and then shifted in time to account for electromechanical delay between EMG and joint moments. During walking and running at all studied speeds, mean EMG envelope values of RF were statistically (P<0.05) higher in the first half of the swing (or at hip flexion/knee extension combinations of joint moments) than in the second half (or at hip extension/knee flexion combinations of joint moments). Mean EMG values of BF and SM were higher (P<0.05) in the second half of the swing than in the first half. EMG and joint moment peaks were substantially higher (P<0.05) in the swing phase of walking at 2.7 m/s than during the swing phase of running at the same speed. Correlation coefficients calculated between the differences (EMG(RF)-EMG(HA)) and (Mk-Mh), taken every 1% of the swing phase, were higher than 0.90 for all speeds of walking and running. Since the close relationship between EMG and joint moments was obtained in the absence of an external force applied to the foot, it was suggested that the observed coordination of RF and HA can be regulated without a stance-specific modulation of cutaneous afferent input from the foot. The functional role of the observed coordination of RF and HA was suggested to reduce muscle fatigue.

Hysterectomy: social and psychosexual aspects

Studies of the psychological and sexual outcome of hysterectomy have often arrived at conflicting conclusions and this has resulted in some confusion among health professionals as well as among women themselves. This situation should cause concern, since the incidence of this surgery is high in most countries of the western world. The confusion about outcome arises out of the methodological problems that plagued earlier research. Some of the more recent studies using prospective design, standardized measures and appropriate statistical analysis have not implicated hysterectomy with increased psychological or sexual disorders. However, both before and after hysterectomy in samples studied, the rate of psychological disorder was higher than would have been expected in a normal population, although a clearer picture has emerged from the most recent study. In this paper, risk factors are identified, and the need to include women's own evaluation of the procedure is emphasized.

Antenatal HIV antibody testing in Australia

OBJECTIVE

To evaluate the role of voluntary antenatal testing in HIV surveillance and prevention by examining antenatal HIV antibody testing practice and policy in Australia.

DESIGN

Cross-sectional study using a self-administered questionnaire.

SUBJECTS AND SETTING

Specialist obstetricians and gynaecologists and general practitioners (GPs) affiliated with the Royal Australian College of Obstetricians and Gynaecologists and Australian public hospital antenatal clinics, August-November 1992.

MAIN OUTCOME MEASURES

The percentage of public hospital antenatal clinics and specialist and GP obstetricians in Australia who tested pregnant women for HIV antibody as part of their antenatal care, and the proportion of pregnant women in Australia who had an antenatal HIV antibody test in the 1991-92 financial year.

RESULTS

Questionnaires concerning antenatal HIV antibody testing were completed by 90% (993/1108) of specialists, 87% (2134/2461) of GPs and 93% (215/230) of public hospitals surveyed. Of the 706 specialists and 1503 GPs who reported that they were currently engaged in obstetric care, approximately 60% (430/706) and 935/1503, respectively) offered antenatal HIV testing either to all pregnant women or to selected groups at risk. There were significant differences in testing patterns between States and Territories. For the 95 public hospitals with antenatal clinics, 81% (77) offered the HIV antibody test to all or selected groups of pregnant women; these percentages did not differ significantly between States and Territories. It was estimated that 25% of pregnant women seen by specialists, 29% seen by GPs and 9% seen in public hospital clinics were tested for HIV antibody as part of their antenatal care in 1991-92.

CONCLUSIONS

In Australia approximately one in five pregnant women were tested for HIV antibody as part of their antenatal care in 1991-92. Voluntary HIV testing in pregnancy may provide unrepresentative data for measuring the prevalence of HIV infection in pregnant women.

The polyurethane nasotracheal tube

An uncuffed nasotracheal tube for use in minor maxillofacial surgery has been developed using polyurethane. The suitability of this tube as an alternative to the existing soft red rubber and harder polyvinyl chloride materials has been assessed at four centres during anaesthesia for routine oral surgery. The tube was found to be satisfactory.

Communication development in Angelman's syndrome

The communication development in 11 children with Angelman's syndrome is described. The clinical observation that these children appear to have a greater ability with receptive rather than expressive language is investigated and these skills assessed using published communication schedules. In addition the understanding and the use of nonverbal communication such as natural gesture was studied. The data collected highlight the fact that these children have developed very few words and have difficulty in using gestural or sign systems. This has implications for speech and language therapists and the children's remedial programmes. Possible future longitudinal studies are suggested.

Reproductive health: knowledge, attitudes and needs of adolescents

OBJECTIVE

To determine the knowledge and attitudes of adolescents with respect to reproductive health, with particular emphasis on their knowledge of the symptoms and transmission of sexually transmitted diseases (STDs), preventive strategies and sources of information.

DESIGN

Questionnaire survey of a stratified random sample of Year 10 students followed by group interviews with volunteers from the sample.

SETTING

The study was carried out in 33 Victorian secondary schools.

PARTICIPANTS

The questionnaire was administered to a stratified random sample of 1351 Year 10 students. Group interviews were conducted with 533 volunteers from the sample.

MEASUREMENTS AND MAIN RESULTS

Considerable gaps were identified in knowledge of STDs and their short-term and long-term effects on reproductive health. An STD Knowledge Score was constructed based on responses to 46 items. The mean score for the full sample was 22.7 (49.3% correct) with a standard deviation of 6.4. As a group, country students scored better than city students (mean, 23.8 v. 22.2, t = 3.97, P less than 0.001) and females better than males (mean, 23.5 v. 21.9, t = 4.21, P less than 0.001). Medical practitioners were rarely identified as a source of preventive advice.

CONCLUSION

The deficiencies identified in knowledge about reproductive health suggest that young people need better access to health information. Schools and the medical profession need to work together both to provide information and to help young people develop the confidence to use available information sources.

Selective improvement in cognitive test scores of extremely low birthweight infants aged between 2 and 5 years

The cognitive development at 2 and 5 years of a cohort of extremely low birthweight (ELBW) children (birthweight 500-999 g) was compared with that of cohorts of larger very low birthweight (VLBW) children (birthweight 1000-1500 g) and normal birthweight (NBW) children (birthweight greater than 2500 g) to determine whether the improvements in cognitive function of ELBW infants between 2 and 5 years are apparent or real. At 2 years of age, ELBW children had a mean Mental Developmental Index (MDI) on the Bayley Scales of 90.4, significantly lower than the means of 100.3 for the larger VLBW children (P = 0.006), and 107.8 for the NBW children (P = 0.0002). However by 5 years the mean scores on the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full-scale for the ELBW and larger VLBW children were virtually identical (105.9 and 106.0 respectively)--but still lower than the mean WPPSI full-scale of 114.6 for the NBW children. After standardizing the MDI and WPPSI scores relative to the NBW children, the ELBW children improved between 2 and 5 years (paired t-test, t = 3.2, P = 0.004) whereas the larger VLBW infants did not. We postulate that ELBW children require more time than larger VLBW children after birth to compensate for perinatal and other stresses, and that developmental delay at 2 years may not always persist to 5 years.

Psychological aspects of hysterectomy. A prospective study

Sixty women aged between 30 and 55 years, having hysterectomy for benign conditions, were prospectively studied to investigate psychological adjustment to operation, and to explore social, psychological and physical factors associated with psychological outcome. A further 30 women were included for prospective research on psychological outcome. Investigations took place within two weeks of operation and after four months and 14 months. The findings indicated a high prevalence of pre-operative psychological morbidity (55%), which reduced to 31.7% afterwards. There was no evidence that hysterectomy led to a greater psychological distress. The principal risk factors of poor psychological outcome were the previous scores on the mental health measures and personality inventory. Involvement in the research process did not appear to affect psychological outcome.

Accelerated extractable studies of borosilicate glass containers

This article describes the use of an accelerated extractable procedure for borosilicate glass containers. The procedure, which is very similar to a protocol developed by a PDA Task Force, includes the monitoring of Si, Na, K, Al, Ba, Ca, Mg, Fe, and Zn in the extracts as well as measurements of pH change and total extractables. Unlike the PDA protocol, which uses H2O as the sole extraction solution, the procedure outlined in this report used a variety of unbuffered (pH congruent to 4, H2O, pH congruent to 6.5, pH congruent to 8.0, pH congruent to 9.5, and pH congruent to 10.4) and buffered (pH = 8 and pH = 10) aqueous extraction media. Studies were completed for several borosilicate glasses, including a mixture of tubing vials, molded vials, and ampoules from US and European suppliers. Results of these studies are presented in this article and are discussed in terms of the interactions between borosilicate glasses and aqueous solutions.

Diabetes in Western Australian children: descriptive epidemiology

The prevalence and incidence of diabetes mellitus in the age group zero to 14 years in Western Australia were determined from a survey by means of Schools Health Services. Additional information from the State's computer-linked hospital records system, the State's only children's hospital, diabetic clinics and physicians enabled virtually complete ascertainment of cases of childhood diabetes. Only 60% of school-age diabetic children were known to school nurses before the survey, but the nurses were able to identify two-thirds of the remainder during the survey. Among non-Aboriginal children, the prevalence of diabetes in the age group zero to 14 years was 0.59 per 1000 children and the incidence was 12.3 per 100,000 children per year. These rates are somewhat lower than those that have been reported from the United Kingdom and North America, and substantially lower than the rates that were reported from Scandinavia. All but one of the diabetic children who were identified required insulin and were assumed to be insulin-dependent. An excess of boys was found. None of 8715 Aboriginal or part-Aboriginal children had insulin-dependent diabetes mellitus, which indicates that this racial group has a low prevalence of this condition. In case--control studies, which used questionnaires for parents, no significant trends were found in relation to the history of immunizations or of specific viral illnesses except for a past history of varicella which was less frequent in diabetic children. A past history of established breast-feeding (of more than one week) was less frequent in diabetic children, as was the ingestion of vitamin C supplements before the onset of diabetes. Some evidence for a seasonality of onset was obtained. The diabetic children were absent from school for more days and had more admissions to hospital than did non-diabetic children. The majority of diabetic children were prescribed insulin twice a day or more often (84%); performed home blood-glucose monitoring (74%); and attended hospital diabetic clinics (91%).

Longitudinal study of very low birthweight infants: intelligence and aspects of school progress at 14 years of age

Consecutive surviving children weighing less than 1501 g when born in 1966-70 were followed prospectively: 87% (146/168) attended normal secondary schools, 4% (7/168) attended schools for those with special needs and 9% (15/168) were untraced. The psychologist assessed 140 children at a mean age of 14.5 years. The mean WISC-R Verbal Score of 89.7 was almost identical to that achieved by the children at 8 years of age (89.2). Thirty three children (24%) had delay in Reading Accuracy on the Neale Analysis of Reading Ability, whilst 66 children (48%) were delayed on the Comprehension Scale. Social class and duration of maternal education were significant predictors of the WISC-R Verbal Scores and Reading Comprehension at 14.5 years but the total variance explained was small. The Bayley Development Index (MDI) available for half of the children at 2 years often underestimated their potential as defined by the WISC-R Verbal Score at 14.5 years. The 8 year intelligence (WISC-R) and reading measures (Neale) were significantly and highly associated with the corresponding measures at 14.5 years. It was concluded that 8 years was an appropriate age to evaluate the outcome of the children and to identify many of those needing educational intervention. The spasmodic nature and sometimes short duration of the help received by many of the children underlines the need for more appropriate intervention for children with learning difficulties.

Longitudinal study of very low birthweight infants: impairments, health and distance growth to 14 years of age

Of 456 consecutive infants born in a tertiary maternity centre in 1966-70 and of birthweight under 1501 g, 171 (37.5%) survived their primary hospitalization. Subsequently three children died and the outcome of 142 (90.5%) of the remaining children presumably still alive were reviewed at a mean age of 14.5 years. Four children had cerebral palsy although only one child was legally blind, 31.6% (48/152) had an existing or corrected visual impairment; visual impairments occurred significantly more frequently in those of birthweight under 1251 g or those born before 29 weeks gestation. Six children required hearing aids and three others were still epileptic. Four children were chronic asthmatics and one had rheumatoid arthritis. None had disabling malformations and there was no delay in pubertal changes. The distributions of weight, height and head circumference percentiles were not significantly different from a standard Australian population. For children in the cohort, weights and heights were under the 10th percentile in 13.4% and 14.1%, respectively. Of the 30 children with birthweights under the 10th percentile and who were reviewed as teenagers, only eight (26.7%) were still in this weight category.

Children of birth weight less than 1000 g: changing outcome between ages 2 and 5 years

Of 55 consecutive long-term survivors of birth weight 500 to 999 g, complete psychologic and pediatric data were available for 54 children at 2 years corrected age and for 50 at age at least 5 1/2 years. At the latter age, 60% (30 of 50) were not impaired, 10% (five of 50) had severe sensorineural or intellectual impairments, 10% (five of 50) had mild to moderately impairment, and 20% (10 of 50) had minor neurobehavioural abnormalities. Sensorineural deafness in one child and bilateral blindness in one remained stable over time, but of six children with spastic cerebral palsy at 2 years, only three retained this diagnosis at 5 1/2 years. The mean Mental Developmental Index (MDI) on the Bayley Scales at 2 years was 91.1, significantly below the test mean; by 5 1/2 years the mean full scale of the Wechsler Preschool and Primary Scales of Intelligence (WPPSI) was 101.8. The MDI correlated highly with the full-scale WPPSI (r = 0.7), but for individual children it was not always an accurate predictor of 5-year ability. Between 2 and 5 1/2 years there was a substantial reordering within four categories of impairment: findings in 27 children were improved, four were judged to become more severely impaired over time, and 19 did not change. We conclude that our 2-year assessment often underrated the potential of the children as expressed at 5 1/2 years, and that 2 years is too early for reliable classification of children of birth weight 500 to 999 g.

Cerebral palsy in very low birthweight infants surviving to 2 years with modern perinatal intensive care

The rate of cerebral palsy and factors associated with its occurrence were determined in surviving 2-year-old very low birthweight (VLBW) infants born during an era of modern perinatal intensive care. Of the survivors, 12.5% (52/416) of those traced had spastic cerebral palsy. Motor handicaps were mild in 42%, moderate in 25%, and severe in 33% of children with cerebral palsy. The prevalence of cerebral palsy was similar in all birthweight groups up to the upper limit of 1500 gm, and was considerably higher than in survivors born in the same hospital a decade earlier. Although several perinatal variables were associated with the occurrence of cerebral palsy, either singly or in combination, little statistical or clinical confidence would be placed in these associations. Moreover, although 77% of children with cerebral palsy had one or more commonly recognized perinatal risk factors, almost identical rates of risk factors were present in normal children. The advent of cranial ultrasonography during the time of the study was associated with an increase in mortality but no effect on the prevalence of cerebral palsy. Cerebroventricular hemorrhage correlated poorly with the presence of cerebral palsy. The prevalence of cerebral palsy in surviving VLBW infants is unacceptably high; however, no obvious preventable factors in its etiology could be identified.

Improved outcome to two years of very low-birthweight infants: fact or artifact?

In 1966-70, the survival rate for very low-birthweight (VLBW) children born in a tertiary perinatal centre was 37.1 per cent but by 1980-82 it had increased to 68.3 per cent. The latter cohort had a significantly reduced prevalence of strabismus, myopia and a head circumference under the 10th percentile, but a significantly increased prevalence of cerebral palsy compared with the 1966-70 VLBW children. Survivors born in 1980-82 had a significantly increased mean Mental Development Index (MDI) on the Bayley Scales compared with the sub-group of survivors born in 1968-70 but there was also a significant improvement in mean MDI over time for a group of normal-birthweight children. No improvement of MDI scores of VLBW survivors in the 1980-82 cohort could be attributed solely to perinatal care. The two-year-old VLBW children in the 1980-82 cohort had similar rates of sensorineural impairments, disabilities and mean MDI to those who would have survived with the care available in 1966-70. It is concluded that survival of VLBW infants has improved in recent times but that neurodevelopmental outcome still lags behind that of normal-birthweight peers.

Very low birthweight and normal birthweight infants. A comparison of continuing morbidity

One hundred and forty-eight (95.5%) of 155 consecutive two-year survivors of 227 very low birthweight (VLBW, less than 1501 g) infants and 50 (83.3%) of 60 infants of normal birthweight who were selected at random, all of whom were born at the Royal Women's Hospital, Melbourne from October 1980 to March 1982, were seen at the age of two years. Social, psychological and health data were compared between the groups. The mean Bayley Mental Developmental Index scores of VLBW children were significantly lower; the prevalence of major handicaps and poor growth (height and weight below the 10th percentile), and the number of hospital readmissions, wheezing episodes, major and minor congenital anomalies and postnatally-acquired malformations (for example, abnormally shaped skull) were significantly greater in VLBW children. There was a trend for a greater number of episodes of otitis media, lower respiratory tract infections and surgical procedures per child in VLBW children. Extremely low birthweight children (birthweight less than 1000 g) contributed significantly to this morbidity. Parents of VLBW children perceived significantly more problems with infant vomiting and behavioural disturbances at two years of age. The children of mothers of limited education, or immigrant status and non-fee paying or lower socioeconomic families had lower mean Bayley Mental Developmental Index scores but similar handicap rates and health status in both weight cohorts.

Relationship of growth and psychoneurologic status of 2-year-old children of birthweight 500-999 g

There were 257 liveborn infants of birthweight 500-999 g born in one tertiary centre in the 5 1/4 years commencing January 1977; 86 (33.5%) survived to 2 years of age, corrected for prematurity and 83/86 (96.5%) were fully assessed. The prevalence of cerebral palsy was 10/83 (12%) and 17/83 (20%) had a major impairment. The distribution of weights and heights for 2-year-old boys and girls was significantly lower than for the standard population, as was the head circumference distribution for boys; the distribution of the Mental Developmental Index (Bayley Scales) was not related to the head circumference or body weight at two years or to head-circumference/bodyweight or height ratios. At birth measurements of weight, length and head circumference were under the 3rd percentile for 13/86 (15%), 9/86 (10.5%) and 9/86 (10.5%) respectively. By 2 years of age, weight, length and head circumference were under the 3rd percentile in 23/83 (27.7%), 26/83 (31.3%) and 4/83 (4.8%) respectively. 12 children who were SGA at birth were fully assessed at 2 years; the group of 6, who continued with poor postnatal weight gains (under the 3rd percentile) had the highest rate of major impairment but included were the only extremely SGA twins and the only two major malformations in the study. We found no association of other health problems or unfavourable social factors with poor postnatal growth or impaired outcome.

Effects of antenatal steroid therapy on mortality and morbidity in very low birth weight infants

A cohort of 678 consecutive very low birth weight infants, liveborn in one tertiary institution during a 63-month period, was studied to investigate whether antenatal steroid therapy had any beneficial or harmful effects on mortality or morbidity over the first 2 years of life. Comparing the 244 babies who received treatment with the 434 controls, 195 (79.9%) and 265 (61.1%), respectively, were discharged home (P less than 0.001). Mortality in the treated group remained substantially lower and was almost halved after adjustment for birth weight, extreme immaturity, lethal malformations, and confounding obstetric variables (P = 0.001). Fatal cases of respiratory distress syndrome were less common in the treated group (P = 0.044). Of in-hospital survivors, those in the treated group required less positive pressure respiratory support (P = 0.003) and fewer days in oxygen (P = 0.018), and the incidences of bronchopulmonary dysplasia (P = 0.003) and patent ductus arteriosus (P = 0.002) were lower. Two-year survivors who had received treatment were heavier (P = 0.016) and had larger head circumferences (P = 0.029). These beneficial associations in the treated group were not at the expense of increased rates of infection or adverse neurologic outcome. We did not detect any adverse effects of antenatal steroid therapy on any relevant aspect of mortality or morbidity in infancy under circumstances in which the chances of finding substantial differences were high.

Mortality and two year outcome of infants of birthweight 500-1500 g: relationship with neonatal cerebral ultrasound data

Cranial ultrasounds were performed on 218 (96%) of 227 liveborn infants of birthweight 500-1500 g delivered in the Royal Women's Hospital, Melbourne, Australia, in an 18-month period concluding in March 1982. Seventy-two (31.7%) of the children died; 28 children (38.9%) had cerebroventricular haemorrhage, 35 (48.6%) showed no bleeding and there were nine (12.5%) with no data. Paired necropsy and ultrasound data were congruent in 22 (88%) of 25 children. One hundred and forty-eight (95.5%) of 155 survivors were seen at 2 years of age. Forty-one (28%) had cerebroventricular haemorrhage; nine children (6%) had both ventricular dilatation and haemorrhage and two had ventricular dilatation alone. Apart from a marginal advance in gestation and higher number of immigrant and less educated mothers in children without cerebroventricular haemorrhage, all other perinatal, biographical and social variables between those with haemorrhage and those without were similar. The major handicap rate overall was 14.2% (21 patients). The children with cerebroventricular haemorrhage had a trend for greater prevalence of handicap and lower mean Bayley psychological scores. This was even more evident with ventricular dilatation being present. Of children with major handicap 57.1% (12/21) had normal serial ultrasound findings during their primary hospitalization. Major handicap occurred in 15% (3/20) of children with grade 1 haemorrhage, 23.5% (4/17) with grade 2 or 3 bleeds and 25% (1/4) of those with grade 4 haemorrhage. Laterality of cerebral palsy did not correlate with ultrasound findings. Ultrasound findings did not improve statistical prediction of deaths or major handicap.