Home visits in the Danish High Risk and Resilience Study - VIA 7: assessment of the home environment of 508 7-year-old children born to parents diagnosed with schizophrenia or bipolar disorder

OBJECTIVE

The home environment provided by the caregivers of a child is an influential single factor for development and well-being. We aimed to compare the quality of the home environment of children at familial high risk of schizophrenia or bipolar disorder with population-based controls.

METHODS

Danish nationwide registers were used to retrieve a cohort of 522 7-year-old children of parents diagnosed with schizophrenia (N = 202), bipolar disorder (N = 120) or none of these diagnoses (N = 200). The home environment was assessed using the Middle Childhood-Home Observation for Measurement of the Environment Inventory (MC-HOME Inventory).

RESULTS

The proportion of children living in home environments that were evaluated not to meet the needs of a 7-year-old child was significantly larger in the two familial high-risk groups. This was true for 21% of the children with familial predisposition for schizophrenia and 7% of children with familial disposition for bipolar disorder.

CONCLUSION

Children born to parents diagnosed with schizophrenia and to a lesser extent bipolar disorder are at an increased risk of growing up in a home environment with an insufficient level of stimulation and support. Identifying families with inadequate home environments is a necessary step towards specialized help and support to at-risk families.

Association of the missense variant p.Arg203Trp in PACS1 as a cause of intellectual disability and seizures

Graphical abstract key: ADHD, attention deficit hyperactivity disorder; ASD, atrial septal defect; DD, developmental delay; EEG, electroencephalogram; Ht, height; ID, intellectual disability; OCD, obsessive-compulsive disorder; OFC, open fontanelle; PDA, patent ductus arteriosis; PFO, patent foramen ovale; VSD, ventricular septal defect; Wt, weight.

The response of patients with phenylketonuria and elevated serum phenylalanine to treatment with oral sapropterin dihydrochloride (6R-tetrahydrobiopterin): a phase II, multicentre, open-label, screening study

This study aimed to evaluate the response to and safety of an 8-day course of sapropterin dihydrochloride (6R-tetrahydrobiopterin or 6R-BH4) 10 mg/kg per day in patients with phenylketonuria (PKU), who have elevated blood phenylalanine (Phe) levels, and to identify a suitable cohort of patients who would respond to sapropterin dihydrochloride treatment with a reduction in blood Phe level. Eligible patients were aged > or = 8 years, had blood Phe levels > or = 450 micromol/L and were not adhering to a Phe-restricted diet. Suitable patients were identified by a > or = 30% reduction in blood Phe level from baseline to day 8 following sapropterin dihydrochloride treatment. The proportion of patients who met these criteria was calculated for the overall population and by baseline Phe level (< 600, 600 to < 900, 900 to < 1200 and > or = 1200 micromol/L). In total, 485/490 patients completed the study and 20% (96/485) were identified as patients who would respond to sapropterin dihydrochloride. A reduction in Phe level was observed in all subgroups, although response was greater in patients with lower baseline Phe levels. Wide variability in response was seen across all baseline Phe subgroups. The majority of adverse events were mild and all resolved without complications. Sapropterin dihydrochloride was well tolerated and reduced blood Phe levels across all PKU phenotypes tested. Variability in reduction of Phe indicates that the response to sapropterin dihydrochloride cannot be predicted by baseline Phe level.

Urea cycle disorders

Deficiency of any of the five enzymes in the urea cycle results in the accumulation of ammonia and leads to encephalopathy. Episodes of encephalopathy and associated symptoms are unpredictable and, if untreated, are lethal or produce devastating neurologic sequelae in long-term survivors. Although these disorders do not produce liver disease, the consequences of hyperammonemia resemble those seen in patients with hepatic failure or in a transient interference with the urea cycle, as seen in some forms of organic acidemias. Therefore, investigation for hyperammonemia in any infant or child with altered mental status (in the absence of obvious causes, such as trauma, infection, or poisoning) is essential for prompt diagnosis of urea cycle disorders and institution of treatment to avoid brain damage and death. This article addresses the function of the urea cycle and the diagnosis and management of urea cycle disorders.

Mosaic trisomy 7 in a patient with pigmentary abnormalities

Somatic chromosomal mosaicism may present as isolated pigmentary abnormalities or multiple congenital anomalies with mental retardation. Pigmentary lesions are visually dramatic and are differentiated based on appearance when the underlying pathogenesis is not known. It is now clear that mosaicism is responsible for the pigmentary findings in hypomelanosis of Ito (HI) and linear and whorled nevoid hypermelanosis (LWH). Both hypopigmentation and hyperpigmentation have been noted in the same individual, and both LWH and HI can be caused by similar chromosomal abnormalities. Both of these conditions exhibit similar systemic involvement. We present a case of LWH associated with mosaic trisomy 7 and review the relevant literature.

Correction of ureagenesis after gene transfer in an animal model and after liver transplantation in humans with ornithine transcarbamylase deficiency

We report effects of gene transfer and liver transplantation on urea synthesis in ornithine transcarbamylase deficiency (OTCD). We measured the formation of [15N] urea after oral administration of 15NH4Cl in two girls with partial OTCD before and after liver transplantation. Ureagenesis was less than 20% of that observed in controls before transplantation, and was normalized afterward. Studies performed on the OTCD sparse fur (spf/Y) mouse showed discordance between OTC enzyme activity and ureagenesis with modest increases in OTC enzyme activity after gene transfer resulting in significant improvement in ureagenesis. This study suggests that both liver transplantation and gene therapy may be effective in improving ureagenesis in OTCD.

Effect of long-term beta-blockade on aortic root compliance in patients with Marfan syndrome

BACKGROUND

This study was undertaken to assess the effect of long-term beta-blockade on the aortic root stiffness index and distensibility in patients with Marfan syndrome.

METHODS

Aortic root stiffness index and distensibility were calculated according to the formulas of Stefanadis and Hirai, respectively, with 2-dimensional guided M-mode echocardiogram before and after an average of 26 months of atenolol administration.

RESULTS

Twenty-three asymptomatic patients were studied (11 men and 12 women, aged 31 +/- 14.2 years). The follow-up was 4 +/- 2.2 years. The dose of atenolol was individualized (mean 43.5 +/- 21.6 mg/d). Heart rate decreased from 79 +/- 9 beats/min to 64 +/- 9 beats/min (P =. 01), and systolic blood pressure decreased from 124 +/- 13 mm Hg to 114 +/- 2 mm Hg (P =.01). Distensibility increased from 1.85 +/- 0. 70 x 10(-6) cm2/dynes-1 to 2.21 +/- 0.76 x 10-6 cm2/dynes-1 (P =.02), and the stiffness index decreased from 9.68 +/- 3.78 to 8.85 +/- 3. 15 ( P =.2). Two groups of responses to treatment were identified. Compared with baseline values 15 (65%) patients who responded to treatment had increased distensibility and decreased stiffness index of the aortic root (P =.05). Eight patients (35%) who did not respond to treatment had no significant change. Body weight >91 kg and baseline end-diastolic aortic root diameter >40 mm were significantly associated with no response (P =.05). Two patients in the nonresponding group had echocardiographic progression of aortic insufficiency.

CONCLUSIONS

There was a heterogeneous response in the aortic root elastic properties after long-term treatment with atenolol in asymptomatic patients with Marfan syndrome. Stiffness index and distensibility are more likely to respond when the baseline end-diastolic aortic root diameter is <40 mm.

Inborn errors of metabolism in infancy: a guide to diagnosis

Recent advances in the diagnosis and treatment of inborn errors of metabolism have improved substantially the prognosis for many of these conditions. This makes it essential that the practicing pediatrician be familiar with the clinical presentation of these disorders. A practical clinical approach to the recognition of inborn errors of metabolism in the young infant is presented in this review. Indications for specific laboratory studies are discussed. Guidelines are provided for the stabilization and emergency treatment of critically ill infants. This approach will identify those infants who will benefit from additional evaluation and specific treatment. Many of the inborn errors of metabolism, including urea cycle defects, organic acidemias, and certain disorders of amino acid metabolism, present in the young infant with symptoms of an acute or chronic metabolic encephalopathy. Typical symptoms include lethargy, poor feeding, apnea or tachypnea, and recurrent vomiting. Metabolic acidosis and/or hyperammonemia are observed in many of these conditions, but there are notable exceptions, including nonketotic hyperglycinemia and molybdenum co-factor deficiency. Therefore, appropriate laboratory testing for metabolic disorders should be performed in any infant who exhibits these findings. Although sepsis may be the initial consideration in a neonate with these symptoms, inborn errors of metabolism should always be in the differential diagnosis, particularly in a full-term infant with no specific risk factors. Hypoglycemia may be the predominant finding in a number of inborn errors of metabolism, including glycogen storage disorders, defects in gluconeogenesis, and fatty acid oxidation defects. The latter disorders, among the most common encountered, exhibit marked clinical variability and also may present as a sudden death, a Reye's-like episode, or a cardiomyopathy. Jaundice or other evidence of hepatic dysfunction is the mode of presentation of another important group of inborn errors of metabolism including galactosemia, hereditary tyrosinemia, neonatal hemochromatosis, and a number of other conditions. A subset of lysosomal storage disorders may present very early with coarse facial features, organomegaly, or even hydrops fetalis. Specific patterns of dysmorphic features and congenital anomalies characterize yet another group of inherited metabolic disorders, such as Zellweger syndrome and the Smith-Lemli-Opitz syndrome. Each of these symptom complexes, and the appropriate evaluation of the affected infants, is discussed in more detail in this review.

Malignant ventricular dysrhythmias in a patient with isovaleric acidemia receiving general and local anesthesia for suction lipectomy

We report the occurrence of severe ventricular arrhythmias in a patient with isovaleric acidemia during general anesthesia for suction lipectomy. The timing of events and character of the ECG changes are most consistent with bupivacaine toxicity after subcutaneous injection of tumescence solution containing this local anesthetic. The patient had previously documented carnitine deficiency, a condition which, we speculate, may lower the threshold for bupivacaine induced cardiotoxicity. We review clinical considerations in isovaleric acidemia and conclude that the use of bupivacaine in these patients probably should be avoided.

Altered newborn gender distribution in patients with low mid-trimester maternal serum human chorionic gonadotropin (MShCG)

OBJECTIVE

to determine if the sex ratio (male/female) is altered in infants born to patients with low mid-trimester maternal serum human chorionic gonadotropin (MShCG).

STUDY DESIGN

Between 2/1/90 and 1/3/91, 3,116 patients underwent prenatal screening using second-trimester maternal serum alpha-fetoprotein (MSAFP), MShCG, and maternal serum unconjugated estriol (MSuE3). Among these, there were 132 patients with low second-trimester MShCG (< 0.4 MoM), normal MSAFP and MSuE3. The gender distribution of these term, normal newborns was compared to that of 237 controls, matched for race, maternal age, and referral source and delivered at term to mothers with normal mid-trimester MSAFP, MSuE3, and MShCG. The gender distribution of these two groups of newborns was also compared to that of 78 term newborns from the same obstetrical population delivered to mothers with second-trimester MShCG > 2.5 MoM and normal MSAFP and MSuE3. All patients had a complete obstetrical history.

RESULTS

Forty-nine percent of the controls were male vs. 62% of the group with slow second-trimester MShCG (P < .01). Within the group with low MShCG, 59% of infants were male when the MShCG was between 0.19 and 0.4 MoM (A) and 80% when the MShCG was < 0.2 MoM (B) (control vs. A vs. B P < .005). The sex ratio in the high-MShCG group was similar to control.

CONCLUSION

The data suggest that gender distribution is different from normal in patients with low mid-trimester MShCG.

Pregnancy outcome in women with low midtrimester maternal serum unconjugated estriol

OBJECTIVE

To determine if unexplained low second-trimester maternal serum unconjugated estriol (MSuE3) is a useful predictor of complications of pregnancy.

STUDY DESIGN

Between February 1, 1990, and January 3, 1993, 10,492 patients underwent prenatal screening using second-trimester maternal serum alpha-fetoprotein (MSAFP), maternal serum human chorionic gonadotropin (MShCG) and MSuE3. One hundred ninety-five patients with complete obstetric history/delivery records and with < 0.4 multiples of the median (MoM) second-trimester MSuE3 values were matched with 261 controls with complete obstetric history/delivery records and normal second-trimester MSAFP, MSuE3 and MShCG.

RESULTS

The relative risk of pregnancy loss, as compared to that in controls, was 3.7 (1.4-9.1 confidence interval [CI], P < .0001) in patients with 0.2-0.4 MoM MSuE3 and 19.3 (6.1-60.5 CI, P < .0001) in patients with < 0.2 MoM MSuE3. After exclusion of patients with low and high MSAFP and MShCG, the relative risk of pregnancy loss for the remaining patients with low MSuE3 was 3.3 (1.3-8.5 CI, P < .008).

CONCLUSION

The data suggest that patients with unexplained low second-trimester MSuE3 have an increased risk of pregnancy loss that may not be associated with a high or low MSAFP, MShCG or higher incidence of pregnancy-induced hypertension, gestational diabetes, premature rupture of membranes or premature onset of labor.

Opitz syndrome is genetically heterogeneous, with one locus on Xp22, and a second locus on 22q11.2

Opitz syndrome (OS, McKusick 145410) is a well described genetic syndrome affecting multiple organ systems whose cardinal manifestations include widely spaced eyes and hypospadias (Fig. 1). It was first reported as two separate entities, BBB syndrome, and G syndrome. However, subsequent reports of families in which the BBB and G syndrome segregated within a single kindred suggested that they were a single clinical entity. Although the original pedigrees were consistent with X-linked and autosomal dominant inheritance, male-to-male transmission in subsequent reports suggested that OS was inherited as an autosomal dominant trait. Here we report that OS is a heterogeneous disorder, with an X-linked and an autosomal locus. Three families were linked to DXS987 in Xp22, with a lod score of 3.53 at zero recombination. Five families were linked to D22S345 from chromosome 22q11.2, with a lod score of 3.53 at zero recombination. This represents the first classic multiple congenital anomaly syndrome with an X-linked and an autosomal form.

An increased incidence of haemangiomas in infants born following chorionic villus sampling (CVS)

The incidence of haemangiomas was ascertained by questionnaire in infants born to 578 consecutive CVS patients and 445 consecutive mid-trimester amniocentesis patients seen at a single institution between 1 January 1989 and 31 May 1991. The incidence of 7.4 per cent reported in the amniocentesis group was comparable to previous estimates of the incidence of haemangiomas in the general population. In contrast, a 21.1 per cent incidence, three-fold higher than that observed in the amniocentesis group, was observed among CVS-exposed infants (P < 0.001). This increased incidence was largely confined to patients undergoing a transcervical procedure. No correlation was observed between the incidence of haemangiomas and gestational age at sampling, sample size, number of sampling attempts, or a history of bleeding following the procedure.

Microcephaly, lymphedema, and chorioretinal dysplasia: report of two additional cases

In recent years, several patients with microcephaly, lymphedema and chorioretinal dysplasia have been described. We have studied two additional patients with similar findings. The question of whether microcephaly with lymphedema and microcephaly with chorioretinal dysplasia and lymphedema are distinct entities remains unanswered. Identification of other patients in the future may provide additional information.

Clinical significance of low levels of second-trimester maternal serum human chorionic gonadotropin

OBJECTIVE

To determine if unexplained low second-trimester maternal serum human chorionic gonadotropin (MShCG) is a useful predictor of complications of pregnancy.

STUDY DESIGN

Between 2/1/90 and 1/3/91, 3,116 patients underwent prenatal screening using second-trimester maternal serum alpha-fetoprotein (MSAFP), MShCG and maternal serum unconjugated estriol (MSuE3). Among these, there were 160 patients with complete obstetrical history who had second-trimester MShCG < 0.4 multiples of the median (MoM). These were compared to 261 controls with complete obstetrical history and a normal second-trimester MSAFP, MSuE3 and MShCG.

RESULTS

No differences were found in gestational age at delivery, neonatal weight, premature rupture of membranes or pregnancy loss. The relative risk of pregnancy-induced hypertension in the study group was 0.29 (p < 0.01) and that of gestational diabetes was 0.3 (p < 0.05). Only when low MShCG was associated with a high or low MSAFP or low MSuE3 was there a significantly increased loss of pregnancy (relative risk 11.7; p < 0.0001).

CONCLUSION

The data suggest that second-trimester MShCG < 0.4 MoM by itself has no influence on the outcome of pregnancy.

Oromandibular-limb hypogenesis syndrome following chorionic villus sampling

A female infant with hypoglossia-hypodactyly syndrome is presented. Her mother underwent chorionic villus sampling (CVS) at 9 weeks gestation. This is the seventh reported case of oromandibular-limb hypogenesis syndrome associated with maternal CVS, the first from the United States. These seven CVS-related cases represent a significant increase over this syndrome's 'natural' incidence of 1 per 175,000 live births. An excess of limb reduction deformities has also been seen following CVS. These seven cases are reviewed, and the possible etiology of this rare condition is discussed.

A prospective trial of prenatal screening for Down syndrome by means of maternal serum alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol

OBJECTIVE

Our purpose was to prospectively evaluate the effectiveness of prenatal screening for Down syndrome by means of multiple serum markers.

STUDY DESIGN

alpha-Fetoprotein, human chorionic gonadotropin, and unconjugated estriol were measured in 8233 midtrimester serum samples, including 7492 from women < 35 years old and 741 from women > or = 35 years old. Down syndrome risks were computed by means of age and all three markers. Further testing was recommended for patients with a risk > or = 1:270. Testing for trisomy 18 was recommended for patients with an alpha-fetoprotein < or = 0.70 multiples of the median, human chorionic gonadotropin < or = 0.50 multiples of the median, and unconjugated estriol < or = 0.55 multiples of the median.

RESULTS

Of women screened initially 10.4% had a Down syndrome risk > or = 1:270; 10 of 12 known cases of Down syndrome were identified. One abnormality was detected for every 33 amniocenteses performed in this group. Of 0.4% of patients at increased risk for trisomy 18, two cases of trisomy 18 and one of triploidy were found.

CONCLUSION

Multiple marker screening is effective in identifying the majority of fetal chromosome anomalies.

Limb anomalies associated with chorionic villus sampling

Data on outcome of pregnancy were obtained in 436 (94%) of 463 patients undergoing chorionic villus sampling (CVS) at Humana Hospital-Michael Reese between January 1, 1989 and November 30, 1990. There were 18 elective abortions, 27 fetal and neonatal losses, and 391 surviving infants. Of the 394 fetuses and infants who were adequately evaluated, a total of 13 (3.3%) had major congenital anomalies, including four with transverse limb reduction deformities, three with cleft lip with or without cleft palate, and one each with a nasal encephalocele, large port-wine stain, craniosynostosis, omphalocele with associated defects, ambiguous genitalia, and undescended testes. The limb malformations in the four affected infants were all very similar and were comparable to those described by others in association with CVS. Three of the cases of limb malformations followed transcervical CVS; one followed a transabdominal procedure. The procedures were performed at 9.5, 9.5, 10.5, and 11 weeks' gestation. An adequate sample was obtained with a single attempt in each case. These observations, in conjunction with others in the literature, suggest that there is an increased risk of limb anomalies associated with CVS. A vascular etiology, related to either decreased fetal perfusion or thrombosis of the sampling site with subsequent embolization, is suggested.

First report of management and outcome of pregnancies associated with hereditary orotic aciduria

Two pregnancies in a 25-year-old woman with hereditary orotic aciduria who was managed prenatally on uridine therapy are described. The first pregnancy resulted in an infant with multiple congenital anomalies and a 47,xx,inv(4)(p12q25), +der(22)t(11;22)(p23;q11) karyotype. The proposita was found to be a carrier of a de novo 11;22 translocation and a pericentric inversion of chromosome 4. Subsequently, several carriers of orotic aciduria in this family were identified with the inverted chromosome 4. The second pregnancy resulted in a normal male with an inverted chromosome 4.

45,X/47,XYY mosaicism: clinical discrepancy between prenatally and postnatally diagnosed cases

45,X/47,XYY mosaicism is a rare chromosomal disorder with clinical information limited to 11 postnatal cases in the literature and with uncertainty regarding prenatal prediction of phenotype and prognosis. We report on 7 new cases of 45,X/47,XYY mosaicism, three detected prenatally and 4 diagnosed postnatally. A clinical comparison of the cases of 45,X/47,XYY mosaicism is presented together with a literature review.

Congenital nephrosis as a cause of elevated alpha-fetoprotein

Two cases of congenital nephrosis were detected through routine maternal serum alpha-fetoprotein (MSAFP) screening of 95,135 patients. No other cases of congenital nephrosis from this group were reported, resulting in an incidence of approximately one in 47,500 in this low-risk population. In both of these cases, similar to other reported cases of congenital nephrosis having MSAFP screening, the protein concentrations were greater than or equal to 10 multiples of the median (MOM). Therefore, in the case of an MSAFP over 10 MOM and a normal ultrasound examination, congenital nephrosis should be included in counseling regarding the possibility of undetected malformations. Furthermore, in the case of a pregnancy with elevated amniotic fluid AFP with negative acetylcholinesterase and normal ultrasound, the possibility of congenital nephrosis should be mentioned, regardless of family history or ancestry. When a pregnancy is terminated because of these biochemical findings, special and immediate attention to the fetal kidneys using electron microscopy is necessary to evaluate properly the possibility of congenital nephrosis.

Risk of fetal chromosomal anomalies in patients with elevated maternal serum alpha-fetoprotein

When elevated maternal serum alpha-fetoprotein (MSAFP) results lead to diagnostic amniocentesis, a decision of whether to karyotype fetal cells must be made. We examined our experience with MSAFP screening in 71,563 unselected pregnancies in which karyotyping was performed when amniocentesis was done because of MSAFP elevations. A total of 727 women (1.0%) underwent amniocentesis because of elevated MSAFP values and among this group, seven chromosomal anomalies (incidence one in 104) were detected. Of the 727 women, 658 (91%) had normal amniotic fluid AFP. In this group, there were six (one in 109) chromosomally abnormal fetuses: three with triploidy, two with 47,XXX, and one with 46,XX,1q-. Among the 69 pregnancies with elevated amniotic fluid AFP, one fetal chromosomal anomaly (trisomy 13) was diagnosed. The incidence of all chromosomal anomalies observed in women undergoing amniocentesis because of elevated MSAFP is comparable to that reported in women 36 years of age undergoing testing because of advanced maternal age. We believe that chromosome analysis should be performed on amniotic fluid samples obtained because of elevated MSAFP unless there are compelling financial circumstances that preclude this. Even in such cases, cell cultures should be established until the amniotic fluid AFP result is available. Chromosome analysis is essential when the amniotic fluid AFP is elevated because of the known association between open fetal defects (spina bifida, omphalocele, and scalp defects) and trisomies 13 and 18.

Maternal serum alpha-fetoprotein screening

Maternal serum alpha-fetoprotein screening should be offered to all patients as a routine component of prenatal care. The benefits of MSAFP screening have far exceeded early expectations. This technology not only provides an efficient and cost-effective method of screening for neural tube defects that is applicable to all pregnancies but also provides the physician with important information relevant to a number of other birth defects and complications of pregnancy. Our knowledge of variables affecting MSAFP levels measured during pregnancy is rapidly evolving, and further refinements in the application of MSAFP screening will almost certainly occur. Such refinements can serve only to extend the benefits of this new and very valuable technology in improving the health and well being of mothers and infants.

Translocation t(5;11)(q13.1;p13) associated with familial isolated aniridia

A father and daughter with isolated aniridia were observed to have an apparently balanced, reciprocal translocation involving chromosomes 5 and 11 [t(5;11)(q13.1;p13)]. No other clinical characteristics often associated with the deletion of 11p13 were observed in this family. This finding, in association with 3 other instances of single breaks at 11p13 and aniridia, supports the assignment of AN2 to 11p13.

False-positive acetylcholinesterase with early amniocentesis

Among 93 acetylcholinesterase determinations performed on amniotic fluid samples from pregnancies at 11-14 weeks' gestation, five unexplained false-positive results were observed. In four of the five cases, the ratio of acetylcholinesterase to pseudocholinesterase was compatible with that observed in association with open neural tube defects in later gestation. In contrast, no false-positive results were noted among 951 acetylcholinesterase determinations performed on samples from women at 15-20 weeks' gestation. Repeat amniocentesis was performed several weeks after the first procedure in four of the five cases of early amniocentesis and false-positive results; in each case, the acetylcholinesterase was negative on the second sample. All four pregnancies had a normal outcome. In the remaining case, trisomy 21 was diagnosed in the fetus and the pregnancy was terminated. Positive acetylcholinesterase results should be interpreted cautiously in samples from early amniocentesis, especially when the amniotic fluid alpha-fetoprotein level is not markedly elevated. The acetylcholinesterase-to-pseudocholinesterase ratio is not useful in identifying fetal neural tube defects before 15 weeks' gestation. Repeat amniocentesis may help in determining the significance of a positive acetylcholinesterase result from early amniocentesis when no fetal defect is identified by ultrasonography.

Nonketotic hyperglycinemia in a patient with the 9p- syndrome

We describe a newborn infant with 9p- syndrome and nonketotic hyperglycinemia. This unusual occurrence may not have been coincidental and suggests that there may be a gene for nonketotic hyperglycinemia located on the short arm of chromosome 9.

Outcome of pregnancy in patients with unexplained elevated or low levels of maternal serum alpha-fetoprotein

Data relating to the outcome of pregnancy were gathered prospectively on patients with elevations of maternal serum alpha-fetoprotein (MSAFP) or with unusually low MSAFP levels (0.25 or fewer multiples of the median) unexplained by ultrasonography. Patients with unexplained MSAFP elevations (2.5 or more multiples of the median, amniotic fluid AFP normal) exhibited a significantly increased incidence of fetal loss, low birth weight, neonatal death, and fetal congenital anomalies compared with controls with normal MSAFP. Patients with unexplained low levels of MSAFP had a significantly greater risk of fetal loss than controls, but there was no increase in the incidence of low birth weight, neonatal deaths, or congenital anomalies.

Elevated maternal serum alpha-fetoprotein (MSAFP): interpretation and follow-up

Maternal serum alpha-fetoprotein screening should be offered to all patients as a routine component of prenatal care. The benefits of MSAFP screening have far exceeded early expectations. This technology not only provides an efficient and cost-effective method of screening for neural tube defects that is applicable to all pregnancies but also provides the physician with important information relevant to other complications of pregnancy. Our knowledge of variables affecting MSAFP levels measured during pregnancy is rapidly evolving and further refinements in the application of MSAFP screening will almost certainly occur. Such refinements can only serve to extend the benefits of this new and very valuable technology in improving the health and well-being of mothers and infants.

Open spina bifida: does cesarean section delivery improve prognosis?

Records were reviewed retrospectively on 72 infants with open spina bifida followed from birth through one year of age. Thirty-two infants were born by cesarean section and 40 vaginally. The following variables were compared between the two groups: 1) mortality in the nursery and between nursery discharge and one year of age, 2) incidence of meningitis in the neonatal period, 3) length of initial hospital stay, and 4) neurologic and developmental status at one year. No significant differences were noted between the two groups. Although it has been suggested that cesarean section may improve the prognosis for infants with open spina bifida, our data do not support that conclusion.

Outcomes in patients with unusually high maternal serum alpha-fetoprotein levels

In a study group of 166 patients with unusually high maternal serum alpha-fetoprotein values greater than or equal to 5 multiples of the median, 110 (66%) patients had a condition affecting obstetric care compared with 14% in the 2.5 to 2.9 range, 26% in the 3.0 to 3.9 range, and 30% in the 4 to 4.9 range of multiples of median. Fetal anomalies composed a significantly greater proportion (p less than 0.0001) of positive findings in the study group than the group with maternal serum alpha-fetoprotein values of greater than or equal to 2.5 to 4.9 multiples of the median. Fetal death either before 20 weeks or of one twin occurred significantly more often in the study group (p less than 0.0001). Neural tube defects (21%) and fetal death before 20 weeks (19%) were the most common findings in the study group. There was not a statistically significant difference (p less than 0.53) in pregnancy complications or in late complications between the two groups although oligohydramnios and abdominal pregnancies occurred more often in the study group (p less than 0.029 and less than 0.011). Diagnosticians evaluating patients with unusually elevated maternal serum alpha-fetoprotein values must be aware of the usual differential diagnosis as well as rarer causes. One must recognize that finding an unaffected fetus does not preclude the subsequent development of a pregnancy complication.

Elevated maternal serum alpha-fetoprotein levels and oligohydramnios: poor prognosis for pregnancy outcome

The outcome of 21 pregnancies with elevated maternal serum alpha-fetoprotein levels associated with oligohydramnios was studied. Seven of the 21 pregnancies ended in spontaneous abortion or intrauterine fetal death before week 24 of pregnancy. Five patients experienced premature labor between 24 and 26 weeks of gestation; each fetus was either stillborn or died in the immediate neonatal period. Four patients were delivered of infants after 32 weeks of gestation; each infant was either stillborn or died in the immediate neonatal period. Four patients electively had their pregnancies terminated. One patient was delivered at term of a healthy, growth retarded male infant who on follow-up at age 17 months was developmentally normal. Only three cases were associated with a fetal defect. Patients should be counseled that, even in the absence of a demonstrable cause for diminished amniotic fluid on ultrasonography, raised maternal serum alpha-fetoprotein levels coupled with oligohydramnios seem to carry a poor prognosis.

Walker-Warburg syndrome with cleft lip and cleft palate in two sibs

Two sibs are reported with Walker-Warburg syndrome including hydrocephalus, agyria, anterior chamber dysgenesis, and encephalocele. In addition, both had cleft lip and cleft palate and intrauterine growth retardation, findings not previously noted in this condition.

Sialidosis (neuraminidase deficiency) types I and II: neuro-ophthalmic manifestations

The clinical details and ophthalmologic findings of two siblings with neuraminidase deficiency (sialidosis) are presented. One patient is best classified as having sialidosis type I, while the younger sibling has features of type II. Both exhibited classic cherry-red macular abnormalities, and the patient who would permit complete ophthalmologic examination had both corneal and lenticular opacities. Markedly reduced neuraminidase activity was demonstrated in both patients. These two patients, and 48 others from the literature, were reviewed to determine the frequency of various ophthalmologic abnormalities with sialidosis. Macular cherry-red spots were present in all adequately described type I patients and all but three patients with type II disease. Visual field defects, diminished acuity, and optic atrophy, though less well documented, occurred in the majority of both type I and type II patients. Lenticular lesions were present in all but two of the 18 patients with detailed ocular examination, whereas corneal opacities were found more often in type II than type I disease.

Inborn errors of metabolism: the clinical diagnosis in early infancy

Major advances occurring in recent years in the recognition and treatment of inborn errors of metabolism have made it more essential than ever that the physician be familiar with the clinical presentation of these disorders. Although infants with inborn errors of metabolism will continue to be best cared for in centers with expertise in the treatment of inherited metabolic disease, the initial recognition of these disorders remains the responsibility of the practicing physician. A clinical approach to the diagnosis of inborn errors of metabolism in the young infant is presented as well as suggestions for the use of readily available laboratory studies that can serve to identify these infants who will benefit from further evaluation and treatment.

Positive amniotic fluid acetylcholinesterase: distinguishing between open spina bifida and ventral wall defects

The ratio of amniotic fluid acetylcholinesterase to pseudocholinesterase was determined by scanning densitometry on 43 amniotic fluid samples with positive acetylcholinesterase associated with open fetal defects. The mean ratio was 0.587 (range 0.204 to 0.979) in 21 amniotic fluid samples from pregnancies affected with open spina bifida and 0.052 (range 0.026 to 0.075) in 12 pregnancies affected with ventral wall defects. These data confirm previous observations and indicate that scanning densitometry of electrophoretic gels is a useful method for distinguishing between open spina bifida and ventral wall defects in the fetus.

A new skeletal dysplasia: clinical, radiologic, and pathologic findings

Two siblings, one male and one female, were noted to have a distinct skeletal dysplasia. The clinical and radiographic features resemble those observed in Kniest dysplasia and Rolland-Desbuquois syndrome, but important differences were noted. Specifically, these two patients have microstomia, "pursed" lips, and ectopia lentis, and their radiographs reveal no coronal clefts. Chondro-osseous features also differ from those observed in either of the other disorders. Scattered dense patches consisting of collagen fibers 10 to 30 times broader than normal are seen scattered throughout the cartilage matrix; the "Swiss cheese" appearance characteristic of Kniest dysplasia is not observed. These patients appear to have a new skeletal dysplasia, most likely inherited in an autosomal recessive fashion.

Outcome in infants born to mothers with unexplained elevations of maternal serum alpha-fetoprotein

The outcome in infants without fetal neural tube defect born to mothers with elevated maternal serum alpha-fetoprotein was studied. Elevated maternal serum alpha-fetoprotein with normal amniotic fluid alpha-fetoprotein was found to be associated with an increased incidence of intrauterine growth retardation and nonneural tube congenital anomalies. There was no increased incidence of developmental disabilities in infants born to mothers with elevated maternal serum alpha-fetoprotein. It is speculated that adverse events occurring early in gestation may simultaneously result in congenital anomalies and subsequently elevated maternal serum alpha-fetoprotein, perhaps through disruption of the normal placental barrier between the fetal and maternal circulations.

alpha-Fetoprotein screening

Maternal serum alpha-fetoprotein screening will soon be a routine component of prenatal care. The benefits of MSAFP screening have far exceeded early expectations. This technology not only provides an efficient and cost effective method of screening for fetal neural tube defects that is applicable to all pregnancies but also provides the physician with important information relevant to other complications of pregnancy. Maternal serum alpha-fetoprotein screening may also prove to be a significant tool for the early detection of Down's syndrome and other chromosomal abnormalities. Our knowledge of variables affecting MSAFP levels measured during pregnancy is rapidly evolving and further refinements in the application of MSAFP screening will almost certainly occur. Such refinements can only serve to extend the benefits of this new and very valuable technology in improving the health and well-being of mothers and infants.

Maternal serum alpha-fetoprotein screening: the effect of participation on anxiety and attitude toward pregnancy in women with normal results

The purpose of this study was to assess the psychological impact of maternal serum alpha-fetoprotein screening on pregnant women with normal results and their male partners. Assessments of anxiety (as measured by the state-trait anxiety inventory) and attitudes toward pregnancy (as measured by the maternal attitude to pregnancy instrument) were conducted sequentially beginning at 16 weeks' gestation in women participating in the maternal serum alpha-fetoprotein screening with normal results and in women without access to screening. Screened subjects exhibited similar or lower levels of anxiety at each point in time as compared to unscreened subjects. In addition, they exhibited a similar or more positive attitude toward pregnancy. No differences in anxiety were observed between male partners in the two groups. Participation in screening appeared to have no adverse psychological effect on the subjects studied.

The psychological impact of false positive elevations of maternal serum alpha-fetoprotein

The purpose of this study was to assess the psychological impact of maternal serum alpha-fetoprotein screening on pregnant women with false positive elevations of maternal serum alpha-fetoprotein and on their male partners. Subjects with maternal serum alpha-fetoprotein elevations and their partners exhibited significantly heightened anxiety as measured by the State-Trait Anxiety Inventory following notification of the elevation, and this anxiety persisted until normal results were obtained by further testing. Heightened anxiety was not alleviated by counseling prior to definitive testing. Once normal results were obtained, anxiety returned to control levels and heightened anxiety was not observed throughout the remainder of pregnancy. Maternal serum alpha-fetoprotein elevations had little effect on maternal attitudes toward pregnancy as measured by the Maternal Attitudes to Pregnancy Inventory. Similarly, no differences were observed between subjects with normal and elevated maternal serum alpha-fetoprotein levels with regard to depression, marital discord, work attendance, or work productivity.

Cholesterol ester and triglyceride metabolism in intact fibroblasts from patients with Wolman's disease and cholesterol ester storage disease

Cholesterol ester and triglyceride metabolism was examined in intact fibroblast monolayers from normal individuals and patients with Wolman's disease and cholesterol ester storage disease. Cholesterol esters were introduced into cells by incubation in medium containing [3H]cholesteryl linoleate (CL) bound to human low density lipoprotein. Triglycerides were introduced by incubation with glycerol tri[1-14C]oleate (triolein) bound to human very low-density lipoprotein. Both types of mutant cell lines accumulated the unhydrolyzed substrates to a greater extent than did normal cells with the greatest accumulation observed in Wolman's disease cells. Wolman's disease cells hydrolyzed CL at 10-22% and triolein at 11-19% the rate of normal cells; cholesterol ester storage disease cells hydrolyzed these substrates at 28-49 and 30-47% the normal rate, respectively. In contrast, assays of acid lipase activity in cell lysates revealed less than 1% of control activity in both disorders. The data suggest that the mutant acid lipase present in Wolman's disease and cholesterol ester storage disease is more active in the intact cell than assays of cell lysates would indicate. In addition, the differences observed between the two disorders provide a biochemical explanation for the different phenotypes associated with the two disorders.

Brief clinical report: prune belly syndrome: observations supporting the hypothesis of abdominal overdistention

We report on an infant with the prune belly syndrome who was unusual in that the typical manifestations of the disorder were accompanied by an anterior abdominal wall defect. We speculate that this defect may have occurred as a result of splitting of the abdominal wall secondary to massive bladder dilatation and stretching of the abdominal muscles. An alternative explanation is that the defect may have been the result of secondary pressure necrosis from stretching forces or from contact with another structure, such as the cervix. This case lends further support to the hypothesis that bladder distention with overdistention of the abdomen may be the primary event leading to the findings observed in the prune belly syndrome.