Clinical practice guidelines for prevention and treatment of postoperative gastrointestinal disorder with Integrated Traditional Chinese and Western Medicine (2023)

Postoperative gastrointestinal disorder (POGD) was a common complication after surgery under anesthesia. Strategies in combination with Traditional Chinese Medicine and Western medicine showed some distinct effects but standardized clinical practice guidelines were not available. Thus, a multidisciplinary expert team from various professional bodies including the Perioperative and Anesthesia Professional Committees of the Chinese Association of Integrative Medicine (CAIM), jointly with Gansu Province Clinical Research Center of Integrative Anesthesiology/Anesthesia and Pain Medical Center of Gansu Provincial Hospital of Traditional Chinese Medicine and WHO Collaborating Center for Guideline Implementation and Knowledge Translation/Chinese Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Center/Gansu Provincial Center for Medical Guideline Industry Technology/Evidence-based Medicine Center of Lanzhou University, was established to develop evidence-based guidelines. Clinical questions (7 background and 12 clinical questions) were identified through literature reviews and expert consensus meetings. Based on systematic reviews/meta-analyses, evidence quality was analyzed and the advantages and disadvantages of interventional measures were weighed with input from patients' preferences. Finally, 20 recommendations were developed through the Delphi-based consensus meetings. These recommendations included disease definitions, etiologies, pathogenesis, syndrome differentiation, diagnosis, and perioperative prevention and treatment.

Sinusoidal transmission grating spectrometer for extreme ultraviolet measurement

Spectral measurements play a vital role in understanding laser-plasma interactions. The ability to accurately measure the spectrum of radiation sources is crucial for unraveling the underlying physics. In this article, we introduce a novel approach that significantly enhances the efficiency of binary sinusoidal transmission grating spectrometers . The grating was tailored especially for Extreme Ultraviolet (EUV) measurements. The new design, High Contrast Sinusoidal Transmission Grating (HCSTG), not only suppresses high diffraction orders and retains the advantageous properties of previous designs but also exhibits a fourfold improvement in first-order efficiency. In addition, the HCSTG offers exceptional purity in the first order due to effectively eliminating half-order contributions from the diffraction pattern. The HCSTG spectrometer was employed to measure the emission of laser-produced Sn plasma in the 1-50 nm spectral range, achieving a spectral resolution of λ/Δλ = 60. We provide a comprehensive analysis comparing the diffraction patterns of different STGs, highlighting the advantages offered by the HCSTG design. This novel, efficiency-enhanced HCSTG spectrometer opens up new possibilities for accurate and sensitive EUV spectral measurements.

Clinical trial of insulin-like growth factor-1 in Phelan-McDermid syndrome

Background

Phelan-McDermid syndrome (PMS) is caused by haploinsufficiency of the SHANK3 gene and is characterized by global developmental delays and autism spectrum disorder (ASD). Based on several converging lines of preclinical and clinical evidence supporting the use of insulin-like growth factor-1 (IGF-1) in PMS, this study aims to follow-up a previous pilot study with IGF-1 to further evaluate this novel therapeutic for core symptoms of ASD in children with PMS.

Methods

Ten children aged 5–9 with PMS were enrolled. Participants were randomized to receive IGF-1 or placebo (saline) using a 12-week, double-blind, crossover design. Efficacy was assessed using the primary outcome of the Aberrant Behavior Checklist—Social Withdrawal (ABC-SW) subscale as well as secondary outcome measures reflecting core symptoms of ASD. To increase power and sample size, we jointly analyzed the effect of IGF-1 reported here together with results from our previous controlled trail of IGF-1 in children with PMS (combined N = 19).

Results

Results on the ABC-SW did not reach statistical significance, however significant improvements in sensory reactivity symptoms were observed. In our pooled analyses, IGF-1 treatment also led to significant improvements in repetitive behaviors and hyperactivity. There were no other statistically significant effects seen across other clinical outcome measures. IGF-1 was well tolerated and there were no serious adverse events.

Limitations

The small sample size and expectancy bias due to relying on parent reported outcome measures may contribute to limitations in interpreting results.

Conclusion

IGF-1 is efficacious in improving sensory reactivity symptoms, repetitive behaviors, and hyperactivity  in children with PMS.

Trial registration NCT01525901.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-022-00493-7.

A randomized controlled trial of intranasal oxytocin in Phelan-McDermid syndrome

Background

Phelan-McDermid syndrome (PMS) is a rare neurodevelopmental disorder caused by haploinsufficiency of the SHANK3 gene and characterized by global developmental delays, deficits in speech and motor function, and autism spectrum disorder (ASD). Monogenic causes of ASD such as PMS are well suited to investigations with novel therapeutics, as interventions can be targeted based on established genetic etiology. While preclinical studies have demonstrated that the neuropeptide oxytocin can reverse electrophysiological, attentional, and social recognition memory deficits in Shank3-deficient rats, there have been no trials in individuals with PMS. The purpose of this study is to assess the efficacy and safety of intranasal oxytocin as a treatment for the core symptoms of ASD in a cohort of children with PMS.

Methods

Eighteen children aged 5–17 with PMS were enrolled. Participants were randomized to receive intranasal oxytocin or placebo (intranasal saline) and underwent treatment during a 12-week double-blind, parallel group phase, followed by a 12-week open-label extension phase during which all participants received oxytocin. Efficacy was assessed using the primary outcome of the Aberrant Behavior Checklist-Social Withdrawal (ABC-SW) subscale as well as a number of secondary outcome measures related to the core symptoms of ASD. Safety was monitored throughout the study period.

Results

There was no statistically significant improvement with oxytocin as compared to placebo on the ABC-SW (Mann–Whitney U = 50, p = 0.055), or on any secondary outcome measures, during either the double-blind or open-label phases. Oxytocin was generally well tolerated, and there were no serious adverse events.

Limitations

The small sample size, potential challenges with drug administration, and expectancy bias due to relying on parent reported outcome measures may all contribute to limitations in interpreting results.

Conclusion

Our results suggest that intranasal oxytocin is not efficacious in improving the core symptoms of ASD in children with PMS.

Trial registration NCT02710084.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13229-021-00459-1.

Measurement of L-shell emission from mid-Z targets under non-LTE conditions using Transmission Grating Spectrometer and DANTE power diagnostics

In this work, we present the measurement of L-band emission from buried Sc/V targets in experiments performed at the OMEGA laser facility. The goal of these experiments was to study non-local thermodynamic equilibrium plasmas and benchmark atomic physics codes. The L-band emission was measured simultaneously by the time resolved DANTE power diagnostic and the recently fielded time integrated Soreq-Transmission Grating Spectrometer (TGS) diagnostic. The TGS measurement was used to support the spectral reconstruction process needed for the unfolding of the DANTE data. The Soreq-TGS diagnostic allows for broadband spectral measurement in the 120 eV-2000 eV spectral band, covering L- and M-shell emission of mid- and high-Z elements, with spectral resolution λ/Δλ = 8-30 and accuracy better than 25%. The Soreq-TGS diagnostic is compatible with ten-inch-manipulator platforms and can be used for a wide variety of high energy density physics, laboratory astrophysics, and inertial confinement fusion experiments.

Using L-shell x-ray spectra to determine conditions of non-local thermal dynamic equilibrium plasmas

K-shell x-ray spectra of Li- to H-like ions have long been used to determine plasma conditions. The ratio of integrated line intensities is used to determine the temperature. At the density of non-local thermal dynamic equilibrium (NLTE) plasmas (n _e ≈ 10²¹ cm^-3), the K-shell spectrum is not very sensitive to density. We propose using the L-shell emission of open L-shell ions (C- to Li-like) as an alternative to determine both temperature and density of NLTE plasmas. First, the L-shell models of a mid-Z material need to be verified against the temperatures obtained using a K-shell spectrum of a low-Z material. A buried layer platform is being developed at the OMEGA laser to study the open L-shell spectra of NLTE plasmas of mid-Z materials. Studies have been done using a 250 μm diameter dot composed of a layer of 1200 Å thick Zn between two 600 Å thick layers of Ti, in the center of a 1000 μm diameter, 13 μm thick beryllium tamper. Lasers heat the target from both sides for up to 3 ns. The size of the emitting volume vs time was measured with x-ray imaging (face-on and side-on) to determine the density. The temperature was measured from the Ti K-shell spectra. The use of this platform for the verification of atomic L-shell models is discussed.

Enhanced accuracy of x-ray spectra reconstruction from filtered diode array measurements by adding a time integrated spectrometer

A new approach for the spectral reconstruction of time-dependent emission of soft x-ray sources based on the measurement of filtered x-ray diode array systems is suggested. Two reconstruction methods, based on this approach, are demonstrated using both simulated and measured data. The methods use the filtered x-ray diode measurement together with a co-aligned, time-integrated, spectrally resolved measurement, such as transmission grating spectroscopy. The additional experimental information allows for high accuracy spectral reconstruction, even for plasmas far from local thermodynamic equilibrium where the traditional reconstruction methods may miss some important source spectral features. For the demonstrated cases, the accuracy of the new reconstruction methods is better than 10% for the energy dependent flux and 1% of the total flux, which is higher than the accuracy of previous methods and better than the accuracy of the measurement itself.

Measurements of laser generated soft X-ray emission from irradiated gold foils

Soft x-ray emission from laser irradiated gold foils was measured at the Omega-60 laser system using the Dante photodiode array. The foils were heated with 2 kJ, 6 ns laser pulses and foil thicknesses were varied between 0.5, 1.0, and 2.0 μm. Initial Dante analysis indicates peak emission temperatures of roughly 100 eV and 80 eV for the 0.5 μm and 1.0 μm thick foils, respectively, with little measurable emission from the 2.0 μm foils.

Brain imaging in neurobehavioral disorders

Neuroimaging studies of neurobehavioral disorders are using new imaging modalities. In dyslexia, anatomic imaging studies demonstrate an abnormal symmetry of the planum temporale. Functional imaging supports the hypothesis that developmental dyslexia is frequently the result of deficits in phonologic processing and that normal reading requires a patent network organization of a number of anterior and posterior brain areas. In autism, anatomic imaging studies are conflicting. Functional imaging demonstrates temporal lobe abnormalities and abnormal interaction between frontal and parietal brain areas. In attention-deficit-hyperactivity disorder, imaging studies suggest an abnormality in the prefrontal and striatal regions. Neuroimaging studies are often contradictory, but trends, especially with functional imaging analysis, are evolving. Because neurobehavioral disorders seem to be a result of a dysfunction in brain circuits, no one region will be abnormal in all patients studied. Further studies with well-defined patient populations and appropriate activation paradigms will better elucidate the pathophysiology of these conditions.

Correlation of basal ganglia magnetic resonance spectroscopy with Apgar score in perinatal asphyxia

BACKGROUND

Brain metabolite levels are measured by proton magnetic resonance spectroscopy (1H MRS) and include N-acetylaspartate (NAA), creatine (Cr), choline (Cho), and lactate and the ratios NAA to Cho and Cr (NAA-ChoCr), NAA-Cr, NAA-Cho, and Cho-Cr. Brain metabolite levels may correlate with the degree of neonatal asphyxia.

OBJECTIVE

To determine which brain metabolite ratios have the strongest correlation with the Apgar scores in infants with possible asphyxia; whether the correlation is stronger with basal ganglia (BG) or anterior border-zone metabolites; and whether a combined approach using routine MR imaging (MRI), diffusion-weighted MRI, and MRS can be used to evaluate the severity of neonatal asphyxia.

METHODS

Twenty infants with 1-minute Apgar scores of 6 or less were studied at 2 to 28 days of age. The MRS variables were compared with routine and diffusion-weighted brain MRI. Clinical variables and MRS findings were subjected to factor analysis and stepwise multiple regressions to determine interrelationships.

RESULTS

The BG region NAA-Cho and NAA-ChoCr ratios correlated with the 1-minute (P<.001) and 5-minute (P = .01 for NAA-Cho; P = .006 for NAA-ChoCr). There was no correlation between metabolite levels and the 10-minute Apgar scores. The stongest predictions exist between the 1-minute Apgar scores and the NAA-Cho and NAA-ChoCr ratios. In the anterior border zone, the only correlation was between the 1-minute Apgar score and the NAA-Cho ratio, but there was a strong age effect in these data. Lactate was found in the BG of 3 infants, all of whom had 5-minute Apgar scores of 6 or less. Three patients had focal lesions on MRI; 2 of these had elevated lactate levels in the abnormal region; and the third, who had an intrauterine stroke, had no lactate in the region.

CONCLUSIONS

Correlations between NAA-Cho and NAA-ChoCr ratios and the 1- and 5-minute Apgar scores are stronger in the BG region than in the frontal border zone. The presence or absence of lactate may indicate the severity of the brain insult, and the combination of MRS, MRI, and diffusion-weighted MRI may assist in localizing and predicting a long-term brain injury.

Hypertensive encephalopathy, reversible occipitoparietal encephalopathy, or reversible posterior leukoencephalopathy: three names for an old syndrome

Children with hypertension, seizures, lethargy, encephalopathy, headache, and occipital blindness are reviewed. After undergoing antihypertensive therapy, most children improve. Some patients have a similar syndrome associated with chemotherapy, transplantation, transfusion, or human immunodeficiency virus-1 (HIV-1) infection. These latter children can develop symptoms with only minimal or no discernible elevations in blood pressure and improve, in the case of cancer-associated encephalopathy, after discontinuing chemotherapy. The reported children with this distinctive clinical condition are compared to adults with reversible posterior leukoencephalopathy syndrome. Since both gray and white matter are involved, we had suggested previously that the name be changed to (reversible) occipitoparietal encephalopathy syndrome. However, reversible posterior leukoencephalopathy has been used in the adult population and probably should be employed in children for the sake of uniformity, since both children and adults have the same clinical presentation and presumably a similar pathophysiology for the encephalopathy syndrome. The diagnosis is confirmed by reversible posterior abnormalities seen on T2-weighted brain magnetic resonance imaging, and by the presence of either headache, altered mental status, seizures, or visual disturbances.

Neuropsychological testing in adult attention deficit hyperactivity disorder: a pilot study

Diagnosing adult ADHD is frequently problematic because behavioral information from the patient's childhood, and multiple informants who can delineate the patient's current behavior, are often unavailable. This preliminary study was designed to explore whether objective neuropsychological testing may be a useful adjunct in the diagnosis of adult ADHD. Nineteen adults diagnosed with ADHD according to DSM-IV criteria, along with 10 controls, were assessed using a neuropsychological battery which comprised tests assessing linguistic, visual-spatial perceptual, academic, attentional and inhibitory control, mnestic and executive functions. Following preliminary analyses, designed to determine which variables best discriminated the groups, receiver operating characteristic (ROC) curves were constructed to determine the sensitivity and specificity of the best measures both alone and in combination. Only three measures significantly (p < 0.01) distinguished the groups; Digits Backwards from the WAIS-R and two reaction time measures from a computerized task modeled after Luria's Competing Motor Programs. ROC curve analyses indicated that in combination these measures had greater than 90% accuracy for classifying ADHD and non-ADHD patients. While further research is necessary these preliminary findings suggest that neuropsychological testing may be a useful adjunct in the differential diagnosis of adult ADHD.

Electrophysiological changes in children with learning and attentional abnormalities as a function of age: event-related potentials to an "oddball" paradigm

This study investigated age-related electrophysiological differences between children diagnosed with Learning Disabilities (LD), Attention Deficit Hyperactivity Disorder (ADHD), LD-ADHD and Conduct Disorder, using Event-Related Potentials recorded during a two-tone discrimination test. Although age-related (N1 and N2 amplitude), as well as diagnostic group-related (P3 latency and amplitude) ERP changes were found, there was no significant interaction between the diagnostic groups and age grouping. We conclude that: 1) Electrophysiological abnormalities in LD and ADHD do not significantly change with age during childhood. This study does not, therefore, support a hypothesis of age-related brain abnormalities in LD and ADHD. 2) Significant group differences for P3 latency and amplitude were found between normal children and the LD groups (LD and LD-ADHD), but not between normal children and those with ADHD alone, suggesting that main correlates of P3 abnormalities in these children are "processing" and not attentional problems.

Frontal systems dysfunction in children with attention-deficit/hyperactivity disorder and learning disabilities

Tests of attention, inhibition, working memory, motor learning, and problem solving--functions associated with the brain's frontal systems--were administered to 26 children with attention-deficit/hyperactivity disorder and learning disabilities (ADHD + LD), 22 children with LD only, and 10 with ADHD only. Percentages of abnormal test results and significantly impaired scores were higher for the two groups with LD than for the ADHD-only group. The groups differed significantly on some tests of attention-inhibition-cueing, working memory, and problem solving, with the ADHD + LD and LD groups performing worse than the ADHD-only group. Abnormalities of frontal systems tests are not exclusive ADHD characteristics and are also present in LD children, implying a strong connection between centers of "processing" and centers of "executive" functions.

Brain lactate and N-acetylaspartate in pediatric AIDS encephalopathy

Two children with acquired immunodeficiency syndrome (AIDS) and progressive encephalopathy underwent MR spectroscopy before and after antiretroviral therapy. Initial MR spectroscopy of the basal ganglia region showed decreased N-acetylaspartate (NAA)/creatine (Cr) and a lactate peak. After therapy, there was improvement in NAA/Cr and an absence of the abnormal lactate peak. We suggest that decreased NAA/Cr in AIDS is reversible, that brain lactate might correlate with inflammation, and that MR spectroscopy can be useful in treatment trials.

Evaluation of pharmacokinetics, safety, tolerance, and activity of combination of zalcitabine and zidovudine in stable, zidovudine-treated pediatric patients with human immunodeficiency virus infection. AIDS Clinical Trials Group Protocol 190 Team

A double-blind phase II trial compared zalcitabine (0.03 mg/kg/day) in combination with zidovudine (720 mg/m2/day) and zidovudine monotherapy in 250 clinically stable, previously zidovudine-treated, human immunodeficiency virus-infected children. The combination was well-tolerated except for an increased incidence of neutropenia (14%) compared with that in children receiving monotherapy (5%). No differences were noted for time to first AIDS-defining illness or death, neuropsychologic status, or weight Z scores. In patients in the combination arm, the CD4 cell count decline was slower (13% per year) than in patients receiving monotherapy (25% per year) (P = .03), and quantitative peripheral blood mononuclear cell virus load remained lower at all time points (P = .08). Deaths were fewer in patients receiving combination therapy (4) compared with those in patients receiving monotherapy (10) (P = .083). Thus, administration of zidovudine with zalcitabine to children with prior zidovudine treatment did not result in a significant increase in toxicity compared with that resulting from zidovudine monotherapy and demonstrated improvement in immunologic and virologic surrogate markers.

Occipital-parietal encephalopathy: a new name for an old syndrome

A boy presented with hypertension, seizures, lethargy, headache, and occipital blindness. He improved with antihypertensive therapy. Other reported children with a similar distinctive clinical condition are compared with adults with a syndrome termed reversible posterior leukoencephalopathy. Because both gray and white matter are involved, we suggest that the name be changed to occipital-parietal encephalopathy syndrome.

Visual event related potentials and reaction time in normal adults, normal children, and children with attention deficit hyperactivity disorder: differences in short-term memory processing

Visual Event Related Potentials were recorded during a memory search paradigm in 30 normal adults, 17 normal children, and 14 children with Attention Deficit Hyperactivity Disorder (ADHD). Group differences were found in P3 latency and amplitude, Reaction Time and number of errors. The findings indicate a different information processing pattern for ADHD children who possibly use a "self-terminating" as opposed to "exhaustive" search strategy.

Central brain atrophy in childhood AIDS encephalopathy

OBJECTIVE

To determine differential patterns of brain atrophy in pediatric AIDS encephalopathy.

DESIGN

We measured the bicaudate, bifrontal, and ventricle-brain ratio in brain magnetic resonance imaging scans of 42 control children, nine children with progressive AIDS encephalopathy, 25 AIDS children without progressive encephalopathy, and 23 children with cerebral atrophy of other causes.

RESULTS

When compared with controls, encephalopathy patients showed significantly increased bicaudate and ventricle-brain ratios, but no significant increase in bifrontal ratio, whereas children with brain atrophy from causes other than AIDS showed increases in all three ratios.

CONCLUSION

Children with AIDS encephalopathy demonstrate a specific pattern of brain atrophy distinct from other etiologies: a central atrophy, primarily affecting the subcortical white matter or the basal ganglia regions.

Proton MR spectroscopy of the basal ganglia in healthy children and children with AIDS

PURPOSE

To evaluate proton magnetic resonance (MR) spectroscopy in children with the acquired immunodeficiency syndrome (AIDS) and to establish an age-dependent spectroscopic database of the normal basal ganglia in children.

MATERIALS AND METHODS

Eighteen healthy children and 45 children with AIDS underwent both brain MR imaging and single-voxel MR spectroscopy with a long-echo-time point-resolved technique. A large part of the region of interest studied at MR spectroscopy included the basal ganglia.

RESULTS

Seven patients with progressive encephalopathy and eight with static encephalopathy had significantly lower mean N-acetyl aspartate (NAA)/creatine (Cr) ratios than age-matched control subjects (P<.02). In determining the presence of progressive encephalopathy in children with AIDS, MR spectroscopy appears to be more sensitive and specific than MR imaging and immunologic testing. Thirty patients without encephalopathy had normal NAA/Cr ratios but significantly lower choline/Cr ratios than age-matched control subjects (P<.02).

CONCLUSION

Proton MR spectroscopy may be a more sensitive diagnostic technique than MR imaging in childhood AIDS encephalopathy.

Malignant rhabdoid tumor of the brain and kidney in a child: clinical and pathologic features

Malignant rhabdoid tumor (MRT) is most frequently found in the kidney, but can occur in other tissues including the brain. The simultaneous appearance of MRT in the brain and kidney has rarely been described. We report the first fully described case of simultaneous appearance of MRT in the kidney and cerebellum of an 8-month-old boy. Cytoplasmic inclusion-like masses, representing aggregates of intermediate filaments, positively stained by Vimentin and by epithelial membrane antigen, were abundant in the kidney tumor but rare in the cerebellar tumor, suggesting that this often-described characteristic of kidney MRT can be an infrequently observed feature of brain MRT, which consequently may be thought to represent another type of tumor.

Magnetic resonance spectroscopy in childhood AIDS encephalopathy

Twenty-five children with acquired immunodeficiency syndrome (AIDS) underwent cranial magnetic resonance imaging and proton magnetic resonance spectroscopy. Patients were divided into 2 groups based on clinical parameters: encephalopathy and nonencephalopathy. N-acetyl aspartate/creatine ratios were compared between the 2 groups and to control data. Spectra were obtained for 2 volumes of interest: the basal ganglia region and the white matter. The mean basal ganglia region ratio for the AIDS encephalopathy patients (n = 8) was 1.12 and the ratio for the AIDS nonencephalopathy patients (n = 17) was 1.48. The ratio for the 9 controls was 1.57. The encephalopathy group had a significantly lower ratio than both the control (P < .001) and the AIDS nonencephalopathy group (P < .002). The mean white matter ratio for the encephalopathy group (n = 8) was 1.47 and for the AIDS nonencephalopathy group (n = 13) was 1.82 with a control (n = 6) ratio of 1.82. The encephalopathy patients had a lower white matter ratio than the nonencephalopathy (P < .05) patients but the ratio was not different than controls (P < .11). It is concluded that N-acetyl aspartate/creatine ratios are reduced in childhood AIDS encephalopathy and proton magnetic resonance spectroscopy may be helpful in defining brain human immunodeficiency virus-1 infection. However, further longitudinal studies are necessary to determine the sensitivity and specificity of this technique.

Event-related potentials to an "oddball" auditory paradigm in children with learning disabilities with or without attention deficit hyperactivity disorder

Event Related Potentials (ERP) were recorded during a two-tone discrimination task in 18 children with Learning Disabilities (LD) and 36 children with Learning Disabilities and Attention Deficit Hyperactivity Disorder (LD-ADHD). Twenty-seven normal children served as a control group. P3 wave amplitude was significantly smaller in the LD and LD-ADHD groups compared with normal children. There was no difference between the LD and LD-ADHD groups. It is suggested that the smaller P3 amplitude in children with LD-ADHD syndromes reflects cognitive and processing difficulties, which frequently coexist with ADHD in these children and is not specifically related to an attention deficit.

Serial brainstem auditory evoked responses in infants and children with AIDS

Fourteen infants and children with AIDS had serial BAER studies, with stimuli delivered at a frequency of 10 and 50 per second. The latencies of waves I, III, V and interpeak latencies I-III, III-V and I-V were measured, and their changes over time were calculated. A significant correlation was found between wave V latency and I-V interval on the left, obtained with a stimulation rate of 50/second, and the length of the follow-up period. There was a trend toward latency increases over time in 9 of the 14 patients. Two patients who had an increase of all wave latencies over time had the worst neurological involvement of all patients. There was no clear correlation between decrease of CD4/CD8 lymphocytes subset ratio and increase of BAER latencies. We conclude that serial BAER studies may be useful in the following of the progression of central nervous system involvement in infants and children with AIDS.

Visual event related potentials after methylphenidate and sodium valproate in children with attention deficit hyperactivity disorder

We divided a group of Attention Deficit Hyperactivity Disorder (ADHD) boys into two groups determined by the results of EEG and visual ERP tests--those who had excessive EEG background slowing, EEG epileptiform activity or abnormally high amplitude ERP waves (the "E-ADD" group), and those with normal EEG and ERP (the "ADD" group). The subjects of each group were then given either a dose of methylphenidate (Ritalin, MPH), sodium valproate (Depakene, VPA) or placebo, and repeated visual ERPs one hour later. Following both medications there was a significant suppression of the amplitude of the N3, the "slow negative" wave of the ERP, in the E-ADD group but not in the ADD group. The effect of VPA and MPH in ADHD children may be related to the electrophysiological (EEG, ERP) background. Both medications may have a similar effect on arousal processes in ADHD.

Brainstem auditory evoked responses in infants and children with AIDS

Brainstem auditory evoked responses were measured in 16 infants and children with acquired immunodeficiency syndrome (AIDS) and in 9 normal infants and children. Two stimulation rates were used: a conventional rate of 10 Hz and a high rate of 50 Hz. Latencies of waves III, IV, and V on the left were significantly longer in the AIDS group when a stimulation rate of 10 Hz was used. With a higher stimulation rate of 50 Hz, significant differences between the two groups occurred in the latencies of waves I, III, and V bilaterally, but there were no significant differences in the interpeak latencies. A measure of the differential effect of the increasing stimulus rate on the two groups was significant for wave I latency and for I-III and I-V interpeak latencies on the left, revealing that increasing stimulation rate prolongs these measures more in the AIDS group. Increased brainstem auditory evoked response stimulation rate may unmask abnormalities in infants and children with AIDS that are not observed when the lower stimulation rate is used.

Flash and pattern-reversal visual evoked potential abnormalities in infants and children with cerebral blindness

Visual evoked potentials (VEPs) were recorded of 60 infants and children with cerebral blindness, aged between six weeks and 10 years, and compared with age-matched normative data. Every patient had abnormal VEPs. 18 had absent flash and pattern VEPs and 13 had atypical or atypical and asymmetrical flash and pattern VEPs. Of the remaining 29, most had greater abnormality of pattern than of flash VEPs and greater abnormalities over parietal and temporal than occipital areas. Eight patients had normal occipital responses to flash and five others had delayed responses with normal morphology. One had normal occipital responses to pattern stimuli. All of these had abnormal late occipital responses or abnormal responses over the parietal and temporal areas. It is recommended that visual assessments using VEPs employ both flash and pattern stimuli, that pre-occipital as well as occipital recordings be made and that tracings be compared with age-specific normative data.

Multiple ischemic infarcts in a child with AIDS, varicella zoster infection, and cerebral vasculitis

A 4 1/2-year-old girl with acquired immunodeficiency syndrome and prolonged varicella zoster virus skin infection developed multiple ischemic strokes and radiologic and histopathologic evidence of central nervous system vasculitis. Typical features of acquired immunodeficiency syndrome encephalitis were not present and there was no evidence of vasculitis outside the nervous system. Central nervous system vasculitis probably resulted from varicella zoster virus infection that persisted because of immunodeficiency. This acquired immunodeficiency syndrome complication has only rarely been described in adults and to our knowledge has not been described in children.

Chronic dysphagia, vomiting and gastroesophageal reflux as manifestations of a brain stem glioma: a case report

Brain stem glioma is the third most common childhood brain tumor, comprising 10-15% of this group of neoplasms. Typical presenting symptoms include ataxia, diplopia and headache, while signs of increased intracranial pressure occur later in the clinical course. Although prolonged failure to thrive, characterized by cachexia and vomiting are rare manifestations of brain stem lesions, in this study we report a 9.5-year-old boy with failure to thrive since infancy which remitted after excision of a brain stem astrocytoma.

Toward a clinical subgrouping of hyperactive and nonhyperactive attention deficit disorder. Results of a comprehensive neurological and neuropsychological assessment

We studied 32 boys with attention deficit disorder (ADD)--21 with hyperactivity, and 11 without hyperactivity. The ADD group with hyperactivity had significantly more neurological and cognitive abnormalities and a higher frequency of prenatal and neonatal abnormalities. It seems that hyperactivity is an important determinant of the degree of neurological and cognitive involvement in children with ADD. It also seems that a cause of "early" brain insult is more likely when hyperactivity is present.

Neurological manifestations in abused children who have been shaken

Four infants with the 'shaken infant syndrome' are described. None had skull fractures and only one had a subdural hematoma. All had extensive retinal and pre-retinal hemorrhages. Follow-up computerized tomography showed severe brain atrophy, multiple hypodense areas and ventricular enlargement. Three of the patients suffered severe, permanent brain damage, with mental retardation, spasticity and blindness. It is suggested that the underlying pathogenesis of this syndrome is acutely increased intrathoracic pressure, transmitted into the head to cause multiple venous infarctions. Retinal and pre-retinal hemorrhages are cardinal features of this syndrome and their presence should raise the suspicion of this form of battering in the absence of the 'classical' signs of battering.

Obstructive sleep apnea and its therapy: clinical and polysomnographic manifestations

Obstructive sleep apnea syndrome was studied in 32 children, aged 2 to 14 years, in the sleep-wake disorders center at Montefiore Hospital and Medical Center during the years 1977 to 1980. All children underwent all-night polysomnograms; 17 of these children had surgery to relieve airway obstruction and seven had a repeat polysomnographic study 4 to 6 weeks following the surgery. There was a significant improvement in the number of obstructive apneas and in other apnea indices following surgery. There was no significant effect on the durations and the proportions of the various sleep stages, on sleep efficiency, or on the number of awakenings.

Sleep apnea and hypoventilation syndrome associated with acquired nonprogressive dysautonomia: clinical and pathological studies in a child

A 6-year-old girl had subacute onset of hypoventilation and apnea during sleep. Diffuse dysautonomic changes were identified, including dilated, nonreactive pupils, decreased tearing and sweating, and abnormal temperature and cardiovascular control. All-night polysomnographic studies revealed frequent obstructive and central sleep apnea episodes. Her serum contained cytotoxic antineuroblastoma immunoglobulins. She died two years later during sleep. The general pathological examination revealed a ganglioneuroma originating in the sympathetic ganglia. Abnormalities in the brain were confined to the brainstem and consisted of complete loss of neurons with severe fibrillary gliosis in the region of the Edinger-Westphal nuclei as well as loss of neurons with gliosis in the locus ceruleus and in the reticular formation bilaterally.

Visual evoked potentials in the evaluation of "cortical blindness" in children

Visual evoked responses (VERs) to brief light flashes were recorded from occipital regions in a group of 30 "cortically blind" children aged 4 months to 15 years and were compared with those of 31 children of similar age range who had the same type of central nervous system diseases but without signs or symptoms of blindness. The VERs were analyzed for amplitude, number of peaks, and morphology, following a method used previously by other authors. All the responses had some degree of abnormality, but there were no significant differences between the two groups. The findings suggest that recording of VERs is not always an accurate method for diagnosis of cortical blindness in children since the presence of abnormal responses is not incompatible with normal vision. Only 1 patient with coritcal blindness showed no response.

Fatal disseminated BCG infection. An investigation of the immunodeficiency

A 2-year-old boy had a fatal disseminated BCG infection. Immunologic assessment showed a normal humoral response and normal numbers of E rosettes, normal thymus weight and histological features, but an abnormal response of lymphocytes in vitro and negative skin tests. Histological examination showed the presence of Gram-negative acid-fast bacilli within the macrophages. The possible mechanisms of immunodeficiency in this patient are discussed.