Broken heart: a statistical study of increased mortality among widowers

A total of 4,486 widowers of 55 years of age and older have been followed up for nine years since the death of their wives in 1957. Of these 213 died during the first six months of bereavement, 40% above the expected rate for married men of the same age. Thereafter the mortality rate fell gradually to that of married men and remained at about the same leveLThe greatest increase in mortality during the first six months was found in the widowers dying from coronary thrombosis and other arteriosclerotic and degenerative heart disease. There was also evidence of a true increase in mortality from other diseases, though the numbers in individual categories were too small for statistical analysis.In the first six months 22.5% of the deaths were from the same diagnostic group as the wife's death. Some evidence suggests that this may be a larger proportion than would be expected by chance association, but there is no evidence suggesting that the proportion is any different among widows and widowers who have been bereaved for more than six months.

Comparative analyses of multi-species sequences from targeted genomic regions

The systematic comparison of genomic sequences from different organisms represents a central focus of contemporary genome analysis. Comparative analyses of vertebrate sequences can identify coding and conserved non-coding regions, including regulatory elements, and provide insight into the forces that have rendered modern-day genomes. As a complement to whole-genome sequencing efforts, we are sequencing and comparing targeted genomic regions in multiple, evolutionarily diverse vertebrates. Here we report the generation and analysis of over 12 megabases (Mb) of sequence from 12 species, all derived from the genomic region orthologous to a segment of about 1.8 Mb on human chromosome 7 containing ten genes, including the gene mutated in cystic fibrosis. These sequences show conservation reflecting both functional constraints and the neutral mutational events that shaped this genomic region. In particular, we identify substantial numbers of conserved non-coding segments beyond those previously identified experimentally, most of which are not detectable by pair-wise sequence comparisons alone. Analysis of transposable element insertions highlights the variation in genome dynamics among these species and confirms the placement of rodents as a sister group to the primates.

Minor congenital laryngeal clefts: diagnosis and classification

Cleft larynx is a rare congenital anomaly. Detection of an unsuspected minor cleft may be difficult, but the pediatric laryngologist should suspect the possibility of cleft larynx from the clinical features. Four minor clefts are reported, three cases of supraglottic interarytenoid cleft and one of partial cricoid cleft. The technique for endoscopic diagnosis and the distinctive features are described and a classification into four types is proposed.

Prolonged intubation injuries of the larynx: endoscopic diagnosis, classification, and treatment

Laryngeal trauma from prolonged endotracheal intubation occurs in patients of all ages. Most changes are superficial and heal quickly. Injuries that are found consistently during intubation include nonspecific changes, edema, granulation tissue, ulceration, and other miscellaneous injuries. In this paper significant, severe, and lasting trauma of the larynx has been classified on the basis of the known factors in pathogenesis, observations made at endoscopy, and photographic documentation. This classification has required introduction of new descriptive terminology: "tongues of granulation tissue," "ulcerated troughs," "healed furrows," and "healed fibrous nodule." During intubation the degree of injury can be precisely assessed under general anesthesia by using telescopes for image magnification, thus assisting a decision whether to continue intubation or perform tracheotomy to minimize long-term morbidity. Changes that are found after extubation result from granulation tissue, ulceration, or a combination of both and have been illustrated on flow charts; a knowledge and understanding of these sequelae allows them to be identified by both indirect and direct laryngoscopy so that treatment can be planned.

The demand for dental care: evidence from a randomized trial in health insurance

Using data from a randomized trial in health insurance, this paper examines the effect of cost sharing on use of dental services. The data come from a sample of the nonaged, noninstitutionalized civilian population of six urban and rural sites. We find that: reducing the level of cost sharing increases demand for dental services; and dental expenses rise 46% when the coinsurance rate falls from 95% to 0%, subject to a catastrophic limit on out-of-pocket expenses. Of this increase, two-thirds is attributable to an increase in the likelihood of visiting a dentist during the year. Moreover, there is a substantial surge in demand during the first year of more generous coverage. The first-year response to cost sharing is nearly twice the second-year response.

Tracheomalacia in infants and children

The clinical features of tracheomalacia depend on the location, length, and severity of the weakness of the tracheal wall. There is firm evidence that tracheomalacia in association with tracheoesophageal fistula is due to malformation and deficiency in the tracheal wall, but in other types of tracheomalacia the evidence is less conclusive. A classification is proposed, based on the known histopathologic and endoscopic changes. Endoscopy is considered the most reliable diagnostic examination.

Congenital tracheal stenosis

Twenty-one cases of congenital tracheal stenosis seen at the Royal Alexandra Hospital for Children 1971 through 1980 were reviewed with regard to the clinical features, associated anomalies, endoscopic findings and radiological evaluation. Congenital tracheal stenosis was usually a serious problem often associated with other major anomalies of the respiratory tract, esophagus, or skeleton. There was no set pattern of presentation. The presenting features included: persistent wheeze or stridor, atypical "respiratory distress," and atypical "croup" or "bronchiolitis." Documentation of the nature and extent of the stenosis by endoscopy and, if necessary, tracheobronchogram was important for prognosis and to direct treatment. Congenital tracheal stenosis must be considered in infants who present with atypical respiratory tract obstruction, especially where there is an H-type tracheoesophageal fistula, pulmonary hypoplasia or skeletal abnormalities such as hemivertebrae or a thumb abnormality.

Ten-year review of pediatric tracheotomy

One hundred sixty-four consecutive tracheotomies are reviewed over the 10-year period 1972-1981. Early in the series acute inflammatory airway obstruction was the major indication for tracheotomy, being 60% of cases in the first 3 years. In the last 3 years this fell to approximately 15%. After 1975 nasotracheal intubation replaced tracheotomy for acute epiglottis. More recently it has become the treatment of choice for acute laryngotracheobronchitis. Tracheotomy prior to reconstructive surgery for major craniofacial abnormalities is becoming more frequent. Acquired subglottic stenosis is not a problem in our hospital despite the use of long-term nasotracheal intubation in premature infants, and no tracheotomies were performed for this indication. There were few major complications. Decannulation difficulties were due to obstruction by stomal granulation tissue or displaced flap of anterior tracheal wall. There was no case of hemorrhage, no posttracheotomy stenosis, and no death was attributable to tracheotomy. These results demonstrate that in a major pediatric hospital tracheotomy is a relatively safe and effective procedure with minimal morbidity.

Management of airway obstruction in the Pierre Robin sequence

A 10-year retrospective study of the management of airway obstruction in 26 infants with Pierre Robin sequence was made. It was not possible when the infant was first seen to assess the future severity of the airway obstruction but later 3 distinct groups could be identified according to the airway management which had become necessary. The deaths from respiratory obstruction indicate the prime importance of airway management. Laryngoscopy for intubation or endoscopic evaluation was often difficult and sometimes could not be achieved. 'Awake intubation' without general anesthesia has proved to be safer and less difficult using a special purpose slotted laryngoscope. Airway management should be individualized following the progressive sequence of posturing in the prone position, nasopharyngeal tube, endotracheal intubation and tracheotomy until successful control is achieved as indicated by the clinical features and pulse oximetry.

Prevalence of behavior problems in US children with asthma

OBJECTIVES

To present national population-based estimates of the prevalence of parent-reported emotional and/or behavioral problems in children with asthma and the relationship of medical comorbidity and asthma severity with behavior problems.

DESIGN

Cross-sectional study of the 1988 National Health Interview on Child Health.

MAIN OUTCOME MEASURES

Parent responses to a checklist of child health conditions were used to assign school-age children (5 to 17 years old) into one of four groups: children without reported chronic conditions; children with asthma alone; children with asthma and additional reported chronic conditions; and children with the same chronic conditions, but without asthma. Parental responses to the Behavior Problem Index (BPI) were used for construction of an overall BPI score, as well as subscale scores. Cross-tabulation and linear and logistic regression were used to determine the relation of the different condition categories to emotional and/or behavioral problems expressed by relative values of the BPI.

RESULTS

Children with asthma and comorbid conditions had a mean BPI score of 7.3, compared with 5.4 for children without chronic conditions, and all subscale scores, except those for antisocial conduct and immature behavior, were significantly elevated. Using logistic regression to control for confounding variables, children with severe asthma alone had nearly three times the odds (odds ratio, 2.96; 95% confidence interval, 1.22 to 7.17) and children with asthma plus comorbid conditions nearly twice the odds (odds ratio, 1.86; 95% confidence interval, 1.20 to 2.90) of children without chronic conditions to have severe behavior problems.

CONCLUSIONS

Severe asthma and asthma with medical comorbidity represent significant risk factors for emotional and/or behavioral problems. Clinicians caring for children with asthma and their families should be aware of the relationship between asthma and emotional and/or behavioral problems and anticipate that a substantial number of their patients may have mental health services needs.

Recurrent laryngeal nerve injury caused by a laryngeal mask airway

Although there have been few reports of serious complications with the laryngeal mask airway, we record a case of permanent unilateral vocal cord paralysis following the use of a laryngeal mask airway and review the literature describing injuries, not only to the recurrent laryngeal nerves but also to the hypoglossal and lingual nerves.

Endoscopy in esophageal atresia and tracheoesophageal fistula

Between 1970 and 1979 152 infants born with the anomaly of esophageal atresia with or without tracheoesophageal fistula or of congenital tracheoesophageal fistula without atresia were treated at the Royal Alexandra Hospital for Children, Sydney. Recent developments in endoscopic equipment and new techniques of anesthesia allow detailed examination of the respiratory tract and esophagus with minimum trauma and maximum safety. Symptomatology relating to the airway and to the esophagus after surgical repair often occurs in patients who may have tracheomalacia, esophageal anastomotic stricture, esophageal reflux and sometimes recurrent or residual fistula. A definite diagnosis of tracheomalacia can be made by finding the typical triad of anteroposterior narrowing of the tracheal lumen, weakening of the semicircular-shaped cartilages and forward ballooning of the widened posterior membranous tracheal wall. Careful examination of the trachea and esophagus allows identification of an elusive recurrent fistula or an H-type fistula. As the primary results of surgery for esophageal atresia and tracheoesophageal fistula improve, long-term problems are becoming increasingly important. The role of the pediatric endoscopist is vital in the care of these patients.

Vocal cord granulomas

A series of 16 vocal cord granulomas in adults and children were studied; of these, seven occurred postintubation. All granulomas were removed at least once and the recurrence rate was high. On average, there were three removals, and some patients are still under observation. The recurrence rate did not seem to be related to removal by surgical excision or by laser. We postulate, contrary to conventional teaching, that vocal ulcer and vocal cord granuloma should be regarded as separate entities which occur at the same anatomical site.

Sheltered homeless children: their eligibility and unmet need for special education evaluations

OBJECTIVES

This study described the proportion of sheltered homeless children in Los Angeles, Calif, who were eligible for special education evaluations because of a probable behavioral disorder, learning disability, or mental retardation, and to explore their level of unmet need for special education services.

METHODS

This was a cross-sectional study of 118 parents and 169 children aged 6 through 12 years living in 18 emergency homeless family shelters in Los Angeles County, California. Parents and children were interviewed with standardized mental health and academic skill measures in English and Spanish.

RESULTS

Almost half (45%) of the children met criteria for a special education evaluation, yet less than one quarter (22%) had ever received special education testing or placement. The main point of contact for children with behavioral disorders and learning problems was the general health care sector.

CONCLUSIONS

School-aged sheltered homeless children have a high level of unmet need for special education evaluations, the first step toward accessing special education programs. Interventions for homeless children should include integration of services across special education, general health care, and housing service sectors.

Chevalier Jackson Lecture. Congenital laryngeal webs

Congenital laryngeal web is not as common as has been previously believed, and thorough clinical, radiographic, and endoscopic assessment is needed before any form of surgical treatment is undertaken. It is important to detect associated anomalies in the larynx, the respiratory tract, or in other organ systems. The results of treatment with regard to voice quality are good only in thin, membranous, uncomplicated webs. Treatment for thick webs with or without associated congenital subglottic stenosis remains unsatisfactory.

Recurrent respiratory papillomatosis: a 10 year study

Sixty cases of recurrent respiratory papillomatosis in both children and adults treated over a 10 year period were reviewed. An unexpected finding was that nine of the 60 patients (15 per cent) had symptoms by two months of age; an earlier onset than previously described. The control rate was 66 per cent for paediatric onset patients and 44 per cent with adult onset; the former required more operations. No anaesthetic deaths or complications were encountered. Glottic webs were the only surgical complication. The findings confirm that there is no relationship between puberty and the rate of control or recurrence. The necessity for precise and comprehensive endoscopic examination of the upper aerodigestive tract using a range of endoscopes and rigid telescopes under general anaesthetic is emphasized.

Infant tracheotomy--endoscopy and decannulation

The records of 73 infants aged 24 months or less who underwent tracheotomy in a 10-year period were reviewed. Two common problems before decannulation were granulations and suprastomal collapse of the anterior tracheal wall above the internal stoma. There were no decannulation failures which could not be accounted for by the primary airway problem. There was no evidence of unexplained "dependence" on the tracheotomy. The results confirm that tracheotomy in the infant patient can be safe both short-term and long-term. There has been no similar long-term review of tracheotomy in small infants indicating the place of endoscopy and the technique of decannulation.

Mental health problems among homeless mothers: relationship to service use and child mental health problems

BACKGROUND

The purpose of this study was to describe the prevalence of psychological distress and probable lifetime mental disorders among homeless mothers, their use of services, and the relationship between maternal and child mental health problems.

METHOD

The study involved a cross-sectional assessment of 110 mothers and 157 children living in homeless shelters in Los Angeles County.

RESULTS

The majority (72%) of sheltered homeless mothers reported high current psychological distress or symptoms of a probable lifetime major mental illness or substance abuse. However, few mothers (15%) in need of services received mental health care, and the main point of contact for those with a mental health problem was the general medical sector. Mothers with a probable mental disorder were also significantly more likely to have children with either depression or behavior problems.

CONCLUSIONS

Homeless mothers have a high level of unmet need for mental health services. The relationship between maternal and child problems underscores the need for homeless family interventions that promote access to psychiatric care for both generations.

Primary retroperitoneal mucinous cystadenocarcinoma

A case of primary retroperitoneal cystadenocarcinoma is presented as the fourth reported case in the world literature to date. The cyst was removed intact and demonstrated an infiltrating malignant process with nuclear pleomorphism and mitotic activity. No ovarian tissue was identified and a cancer antigen 125 (CA 125) test was normal. The patient underwent a staging procedure subsequently that included peritoneal washings, hysterectomy, bilateral salpingoophorectomy, and iliac node dissection. No metastases were found and the patient is without recurrence 22 months postoperative. The literature is reviewed to better define the origin and prognosis of these tumors.

Idiopathic subglottic stenosis: diagnosis and endoscopic laser treatment

The records of 15 patients with idiopathic subglottic stenosis treated at Royal North Shore Hospital, Sydney, between 1980 and 1994 were reviewed. All were female and had similar characteristic clinical and histopathologic features. Endoscopic laser vaporization was the primary treatment in 12 patients and was successful in maintaining the airway of 8 of these 12; this outcome indicates that the disease can be managed, at least initially, by endoscopic laser treatment in most cases.