Chiari Malformation Presenting as Headaches Associated with Laughter

Presentation We describe the case of a 5 year old boy, referred to our outpatient department with a one year history of headaches associated with laughter. Diagnosis Investigation with MRI Brain revealed Chiari Type 1 Malformation (CM-1), with cerebellar tonsillar descent of 19mm below the foramen magnum. Treatment He is being managed conservatively with serial neuroimaging and symptom monitoring. Discussion CM-1 is a hindbrain malformation characterised by ≥5mm herniation of the cerebellar tonsils.1,2 It is diagnosed radiographically, and is increasingly being detected incidentally.3,4 The natural history of asymptomatic patients is usually to remain asymptomatic, and symptomatic patients often show symptom improvement, particularly in paediatric populations.3,5 Neurosurgical interventions may be offered based on symptoms and radiographic findings, but carries a complication rate of 8.2%.6.

Development, preliminary validation and reliability of the colourful 'My Feelings Form' self-report for young children

BACKGROUND

Patient-reported outcome measures place the patient at the centre of his/her care. There are calls to introduce child-reported outcome measures to mental health services. We aimed to (a) develop an age-appropriate patient-reported outcome measure for children's mental health, and (b) validate this in a primary school and Child and Adolescent Mental Health Service (CAMHS).

METHODS

A list of items to measure children's mental health was proposed (Draft 1) and revised to 14 items following focus group and user consultation (Draft 2). A colourful, cartoon and emoji version was created in consultation with children (Draft 3); a professional cartoon artist created the final 'My Feelings Form' (MFF), with usability feedback (Draft 4). The MFF was tested by 317 children aged 4-13 years from one mixed-gender primary school at two time points in 1 day, and 25 children aged 4-13 years from CAMHS. Results were analysed using test-retest reliability and exploratory factor analysis; a receiver operator characteristic curve was constructed.

RESULTS

The CAMHS group scored significantly higher than the school group for the mean total score (23.5 ± 11.3 vs. 16.1 ± 6.2) and for 10 items. Test-retest reliability was acceptable (correlation = 0.74, p < .001). Exploratory factor analysis using 10 informative items identified two factors - emotional factor (Cronbach's alpha = 0.74) and function factor (Cronbach's alpha = 0.59). The revised 10-item form has a Cronbach's alpha of 0.77; a cut-off of 12 has a sensitivity of 80% and specificity of 60%, indicating that it correctly identified 80% of those who were attending CAMHS and gave 60% of the schoolchildren a negative result.

CONCLUSIONS

The colourful MFF was co-produced with children, and preliminary data suggest that it is a useful patient-reported outcome measure for children's mental health.

The impact of having a sibling with an intellectual disability: parental perspectives in two disorders

BACKGROUND

The potential effects on other children when there is a child with intellectual disability (ID) in the family are being increasingly recognized. This study describes the impact of having a sibling with Down syndrome or Rett syndrome using a questionnaire completed by parents.

METHODS

The parents of 186 Western Australian children with Down syndrome and 141 Australian girls and women with Rett syndrome participated in the study. Patterns of reporting disadvantages and/or benefits were compared across a number of child and family variables (age, functional ability and birth order of the affected child, number of siblings and number of parents in the family home) and by socio-economic status as measured by the index of relative socio-economic disadvantage and by area of residence. Parents' responses to open-ended questions about the benefits and/or disadvantages for siblings of their child were analysed for themes.

RESULTS

The majority of parents in the Rett syndrome and Down syndrome groups reported both disadvantages and benefits for siblings. In the Rett syndrome group, families from outer regional areas were the least likely to mention disadvantages and those with a smaller family more likely to note disadvantages. In both groups, more socio-economically advantaged families were more likely to report disadvantages. In the Down syndrome group, benefits were also more commonly reported by parents who were socio-economically advantaged, and by larger and two-parent families. Major disadvantages for siblings centred around parental and personal time constraints, relationships and socializing, restrictions, parental emotion and burden of helping. Major benefits were related to personality characteristics.

CONCLUSION

Parents identified both benefits and disadvantages to the siblings of their child with either Rett syndrome or Down syndrome. It is important that these findings are incorporated into any discussion around the impact on the family of a child diagnosed with an ID.

Trends in mode of delivery during 1984-2003: can they be explained by pregnancy and delivery complications?

OBJECTIVES

To describe trends in mode of delivery, to identify significant factors which affected mode of delivery, and to describe how these factors and their impact have changed over time.

DESIGN

Total population birth cohort.

SETTING

Western Australia 1984-2003.

PARTICIPANTS

The analysis was restricted to all singleton infants delivered at 37-42 weeks of gestation with a cephalic presentation (n = 432,327).

METHODS

Logistic regression analyses were undertaken to estimate significant independent risk factors separately for elective and emergency caesarean sections compared with vaginal delivery (spontaneous and instrumental), adjusting for potential confounding variables.

MAIN OUTCOME MEASURES

Trends in mode of delivery, demographic factors, and pregnancy and delivery complications. Estimated likelihood of elective caesarean section compared with vaginal delivery and emergency caesarean section compared with vaginal delivery.

RESULTS

Between 1984-88 and 1999-2003, the likelihood of women having an elective caesarean section increased by a factor of 2.35 times (95% CI 2.28-2.42) and the likelihood of an emergency caesarean section increased 1.89 times (95% CI 1.83-1.96). These caesarean section rate increases remained even after adjustment for their strong associations with many sociodemographic factors, obstetric risk factors, and obstetric complications. Rates of caesarean section were higher in older mothers, especially those older than 40 years of age (elective caesarean section, OR 5.42 [95% CI 4.88-6.01]; emergency caesarean section, OR 2.67 [95% CI 2.39-2.97]), and in nulliparous women (elective caesarean section, OR 1.54 [95% CI 1.47-1.61]; emergency caesarean section, OR 3.61 [95% CI 3.47-3.76]).

CONCLUSIONS

Our data show significant changes in mode of delivery in Western Australia from 1984-2003, with an increasing trend in both elective and emergency caesarean section rates that do not appear to be explained by increased risk or indication.

Cardiovascular, skeletal, and renal defects in mice with a targeted disruption of the Pkd1 gene

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by cyst formation in the kidney, liver, and pancreas and is associated often with cardiovascular abnormalities such as hypertension, mitral valve prolapse, and intracranial aneurysms. It is caused by mutations in PKD1 or PKD2, encoding polycystin-1 and -2, which together form a cell surface nonselective cation ion channel. Pkd2-/- mice have cysts in the kidney and pancreas and defects in cardiac septation, whereas Pkd1(del34) -/- and Pkd1(L) -/- mice have cysts but no cardiac abnormalities, although vascular fragility was reported in the latter. Here we describe mice carrying a targeted mutation in Pkd1 (Pkd1(del17-21betageo)), which defines its expression pattern by using a lacZ reporter gene and may identify novel functions for polycystin-1. Although Pkd1(del17-21betageo) +/- adult mice develop renal and hepatic cysts, Pkd1(del17-21betageo) -/- embryos die at embryonic days 13.5-14.5 from a primary cardiovascular defect that includes double outflow right ventricle, disorganized myocardium, and abnormal atrio-ventricular septation. Skeletal development is also severely compromised. These abnormalities correlate with the major sites of Pkd1 expression. During nephrogenesis, Pkd1 is expressed in maturing tubular epithelial cells from embryonic day 15.5. This expression coincides with the onset of cyst formation in Pkd1(del34) -/-, Pkd1(L) -/-, and Pkd2-/- mice, supporting the hypothesis that polycystin-1 and polycystin-2 interact in vivo and that their failure to do so leads to abnormalities in tubule morphology and function.

The polycystins: a novel class of membrane-associated proteins involved in renal cystic disease

Polycystin-1, polycystin-2 and polycystin-L are the predicted protein products of the PKD1, PKD2 and PKDL genes, respectively. Mutations in PKD1 and PKD2 are responsible for almost all cases of autosomal dominant polycystic kidney disease (ADPKD). This condition is one of the commonest mendelian disorders of man with a prevalence of 1:800 and is responsible for nearly 10% of cases of end-stage renal failure in adults. The cloning of PKD1 and PKD2 in recent years has provided the initial steps in defining the mechanisms underlying renal cyst formation in this condition, with the aim of defining pharmacological and genetic interventions that may ameliorate the diverse and often serious clinical manifestations of this disease. The PKD genes share regions of sequence similarity, and all predictintegral membrane proteins. Whilst the predicted protein domain structure of polycystin-1 suggests it is involved in cell-cell or cell-matrix interactions, the similarity of polycystin-2 and polycystin-L to the pore-forming domains of some cation channels suggests that they all form subunits of a large plasma membrane ion channel. In the few years since the cloning of the PKD genes, a consensus that defines the range of mutations, expression pattern, interactions and functional domains of these genes and their protein products is emerging. This review will therefore attempt to summarise these data and provide an insight in to the key areas in which polycystin research is unravelling the mechanisms involved in renal cyst formation.

Effects of gender and functional overload on plantaris muscle morphology in the dwarf (HsdOla:dw-4) Lewis rat

To investigate relationships between pituitary function and gender on skeletal muscle growth and hypertrophy, fiber cross sectional area (CSA) and type were assessed in the plantaris muscle of normal and dwarf (Dw) male and female Lewis rats after 6 weeks of functional overload (FO). Serum growth hormone levels were 70-80% less in Dw rats of both genders, and body mass was 62% greater in normal rats when compared to their Dw counterparts. Muscle weight was affected by gender, dwarfism, and FO as well as a significant gender*Dw*FO interaction. FO increased Type I, IIA, and IIX/B fiber CSA 120%, 102%, and 75%, respectively. Only type 1H fibers exhibited a reduction in CSA as a function of gender or dwarfism. Both type IIA and IIX/B fibers were affected by a significant gender*Dw*FO interaction. Our results suggest that the growth of type II fibers is sensitive to gender and pituitary function, while hypertrophy of type II muscle fibers is a function of the interaction between mechanical load, gender, and pituitary function.

The energy expenditure of normal and pathologic gait

Physiological energy expenditure measurement has proven to be a reliable method of quantitatively assessing the penalties imposed by gait disability. The purpose of this review is to outline the basic principles of exercise physiology relevant to human locomotion; detail the energy expenditure of normal walking; and summarize the results of energy expenditure studies performed in patients with specific neurologic and orthopedic disabilities. The magnitude of the disabilities and the patients' capacity to tolerate the increased energy requirements are compared. This paper also will examine the effectiveness of rehabilitation interventions at mitigating the energetic penalties of disability during ambulation.

Findings in post-poliomyelitis syndrome. Weakness of muscles of the calf as a source of late pain and fatigue of muscles of the thigh after poliomyelitis

The purpose of this study was to identify overuse of muscles and other alterations in the mechanics of gait in twenty-one patients who had muscular dysfunction as a late consequence of poliomyelitis. All of the patients had good or normal strength (grade 4 or 5) of the vastus lateralis and zero to fair strength (grade 0 to 3) of the calf, as determined by manual testing. Dynamic electromyography was used, while the patients were walking, to quantify the intensity and duration of contraction of the inferior part of the gluteus maximus, the long head of the biceps femoris, the vastus lateralis, and the soleus muscles. Patterns of contact of the foot with the floor, temporal-spatial parameters, and motion of the knee and ankle were recorded. The principal mechanisms of substitution for a weak calf muscle fell into three groups: overuse of the quadriceps (twelve patients) or a hip extensor (the inferior part of the gluteus maximus in eight patients and the long head of the biceps femoris in four), or both; equinus contracture (twelve patients); and avoidance of loading-response flexion of the knee (five patients). Most patients used more than one method of substitution. These observations support the theory that post-poliomyelitis syndrome results from long-term substitutions for muscular weakness that place increased demands on joints, ligaments, and muscles and that treatment--based on the early identification of overuse of muscles and ligamentous strain--should aim at modification of lifestyle and include use of a brace.