Mutations in ROGDI Cause Kohlschütter-Tönz Syndrome

Kohlschütter-Tönz syndrome (KTS) is an autosomal-recessive disease characterized by the combination of epilepsy, psychomotor regression, and amelogenesis imperfecta. The molecular basis has not yet been elucidated. Here, we report that KTS is caused by mutations in ROGDI. Using a combination of autozygosity mapping and exome sequencing, we identified a homozygous frameshift deletion, c.229_230del (p.Leu77Alafs(∗)64), in ROGDI in two affected individuals from a consanguineous family. Molecular studies in two additional KTS-affected individuals from two unrelated Austrian and Swiss families revealed homozygosity for nonsense mutation c.286C>T (p.Gln96(∗)) and compound heterozygosity for the splice-site mutations c.531+5G>C and c.532-2A>T in ROGDI, respectively. The latter mutation was also found to be heterozygous in the mother of the Swiss affected individual in whom KTS was reported for the first time in 1974. ROGDI is highly expressed throughout the brain and other organs, but its function is largely unknown. Possible interactions with DISC1, a protein involved in diverse cytoskeletal functions, have been suggested. Our finding that ROGDI mutations cause KTS indicates that the protein product of this gene plays an important role in neuronal development as well as amelogenesis.

Folsäure – Freiwilliger Zusatz bei diversen Lebensmitteln oder obligate Anreicherung eines Grundnahrungsmittels?

Eine normale, landesübliche Mischkost reicht nicht aus, um den von wissenschaftlichen Gremien definierten Tagesbedarf von 400 μg Folsäure zu decken. Das Angebot diverser Folsäure-angereicherter Lebensmittel scheint deshalb berechtigt. Ob damit eine prophylaktische Wirkung auf die verschiedenen Homocystein-assoziierten Krankheiten der zweiten Lebenshälfte erwartet werden kann, ist allerdings nicht bewiesen, sondern nur fundierte Hypothese. Für die Verhütung von Neuralrohrdefekten und andern embryonalen Missbildungen und frühkindlichen Malignomen ist eine medikamentöse Prophylaxe mit 0,4–0,8 mg Folsäure notwendig, oder die generelle, d.h. obligate Anreicherung von Backmehl. Die Problematik dieser im Ausland erfolgreich erprobten Maßnahme wird diskutiert.

Folic acid: a public-health challenge

Despite worldwide public-health campaigns recommending periconceptional daily supplementation of synthetic folic acid to reduce the risk of neural tube defects, many women are not following these recommendations. At the same time, in most European countries no decline in defects has been recorded in recent years. Vulnerable groups are those with a low standard of education, young people, and women with unplanned pregnancies. Furthermore, in most countries without mandatory fortification, the general population is not consuming the recommended 0.4 mg of food folate per day. Voluntary fortification improves the situation, but does not reach all parts of the population. In the USA, Canada, and Chile, mandatory fortification of flour substantially improved folate and homocysteine status, and neural tube defects rates fell by between 31% and 78%. Nevertheless, many countries do not choose mandatory folic acid fortification, in part because expected additional health benefits are not yet scientifically proven in clinical trials, in part because of feared health risks, and because of the issue of freedom of choice. Thus, additional creative public-health approaches need to be developed to prevent neural tube defects and improve the folate status of the general population.

Stirbt die Schweiz aus?

In the last decades, the birthrates in most European countries have fallen considerably below the target value needed for the maintenance of a constant population. In Switzerland, the total fertility is 1.37 children per woman between 15 and 48 years of age (target 2.1), and in Swiss women along-excluding foreigners-it has reached the historical low of 1.21 children. The birth excess of the native population has been negative since 1998, which means that the number of inhabitants in Switzerland is only kept constant by immigrants. If the low birthrate continues for another 200 years, the native population-without immigration-will melt down to 2% of today's size, in other words: it will become extinct. The reasons for this deplorable evolution and possible countermeasures will briefly be discussed.

Provision of supplementary fluids to breast fed infants and later breast feeding success

It has been shown that altering hospital policies in a way to avoid interference of routine prescriptions with initiation of breast feeding and to provide active encouragement to mothers and personnel can result in significant benefit for later breast feeding success. It is less clear, however, which of the elements of a promotional programme such as UNICEF/WHO's "ten steps to successful breast feeding" are absolutely essential and which can be adapted to local cultural habits. We performed an open randomized multicenter study in Switzerland to evaluate, whether restriction of supplementary fluids for breast fed infants in the first week of life and strict avoidance of artificial teats and pacifiers affects later breast feeding success. Follow up to 6 months was ensured by mailed questionnaires. 602 mother infant pairs were enrolled. Of 294 infants in the intervention group 39% were excluded from the final analysis because of protocol violations, mainly maternal request for the use of pacifiers or bottles. Though the number of dextrin maltose supplements during the first two days (1.7 vs. 2.2 on day 1, 2.2 vs. 2.6 on day 2) and the percentage of infants receiving any supplement (85% vs. 96.6%) was significantly smaller in the intervention group, the difference was disappointingly small. The prevalence of breast feeding was 100% vs. 99% at day 5, 88% vs. 88% at 2 months, 75% vs. 71% at 4 months and 57% vs. 55% at 6 months, none of the differences being significant. We conclude that rigorous adherence to all of the ten steps may encounter obstinate resistance from cultural habits even in a population highly favourable to breast feeding. An improvement in adherence does not necessarily lead to better breast feeding success. The results of the few comparable studies in the literature show also that cultural practices during the first months of life may influence profoundly the long term effects of interventions during the first days of life.

Effect of growth hormone and oxandrolone treatment on glucose metabolism in Turner syndrome. A longitudinal study

In 18 girls with Turner syndrome, glucose tolerance was studied before treatment and after 6 and 24 months of growth-promoting treatment with recombinant human growth hormone (24 IU/m(2)/week; 8 mg/m(2)/week) and oxandrolone (0.06 mg/kg/day), as well as after termination of the treatment. One girl developed an overt non-ketotic diabetes mellitus 50 months after termination of treatment. The results of the remaining 17 girls in whom the effect of treatment on glucose metabolism was reversible are presented as a group. Their median age at the beginning of the treatment was 10.4 years (range 6.9-15.9), and 15.0 years (range 12.1-19.9) at the final assessment. There was a moderate, but not significant rise in fasting glucose throughout the course of the longitudinal study. At oral glucose tolerance testing (oGTT), the area under the curve for glucose rose significantly (p = 0.013) during the period of treatment and returned to the basic value thereafter. Fasting insulin and especially the integrated insulin values (AUCi; area under the curve for insulin) during oGTT increased continuously during treatment, declined after termination of treatment but were still significantly (p = 0.04) higher than before treatment. Considering the fact that in untreated girls with Turner syndrome the fasting insulin and the AUCi increase with age, one can conclude that the insulinaemia returned to age-specific norm after termination of treatment. Thus the effect of a combined growth hormone and oxandrolone growth-promoting treatment on glucose metabolism was fully reversible in these 17 girls with Turner syndrome.

UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Neonatal Study Group

To promote breastfeeding, UNICEF/WHO have launched the "baby-friendly hospital initiative" focusing on hospital care routines during delivery and the first days of life. In industrialised countries, two aspects of the initiative have raised controversy: how do restriction of supplemental feedings and ban of bottles and pacifiers affect long-term breastfeeding performance? From ten centres 602 healthy newborns were randomly assigned either to a UNICEF group with restrictive fluid supplements and avoidance of bottles and pacifiers during the first 5 days of life, or to a standard group with conventional feeding practice. Breastfeeding was encouraged in both groups. The main study endpoints were the prevalences of breast-feeding on day 5, and after 2, 4 and 6 months. Of the newborns 46% violated the UNICEF protocol, mostly because of maternal requests to give a pacifier or supplements by bottle. In the standard group, the drop-out rate was 9.7%. No significant differences in breastfeeding frequency and duration could be found: (UNICEF vs standard) day 5: 100% vs 99%; 2 months: 88% vs 88%; 4 months: 75% vs 71%; 6 months: 57% vs 55%. Inclusion of drop-outs due to pacifier use did not alter the results.

CONCLUSION

In our study population fluid supplements offered by bottle with or without the use of pacifiers during the first 5 days of life were not associated with a lower frequency or shorter duration of breastfeeding during the first 6 months of life.

[Folic acid in the prevention of neural tube defects]

Neural tube defects (spina bifida) imply a severe limitation of quality of life. 70 to 100% of these defects are preventable by additional intake of folic acid during the periconceptional period. In accordance with the recommendations of Anglo-Saxon and other authorities prevention of this grave malformation should be attempted not only after a first-affected child, but primarily in a general manner in Switzerland, too. All women of childbearing age not under contraceptives should be advised to consume a diet rich in folic acid and to take an additional daily dose of 0.4 mg folic acid as a monosubstance or with a multivitamin preparation. A supplement of folic acid to cereal grain products, mainly bread flours, is recommended. A generally elevated folic acid intake may have further beneficial effects, such as risk reduction for the occurrence of carcinoma and atherosclerosis.

Human ferrochelatase: a novel mutation in patients with erythropoietic protoporphyria and an isoform caused by alternative splicing

Erythropoietic protoporphyria (EPP), attributable to deficiency of ferrochelatase activity (FECH), is characterised mainly by cutaneous photosensitivity. To define the molecular defect in two EPP-affected siblings and their parents in a Swiss family, ferrochelatase cDNA was amplified by the polymerase chain reaction (PCR) and subjected to sequence analysis. A 5-bp deletion (T580-G584) was identified on one allele of the ferrochelatase gene in both patients and their mother. Screening of the mutation among family members of RsaI digestion of PCR-amplified genomic DNA revealed autosomal dominant inheritance associated with abnormal protoporphyrin concentration and enzyme activity. We also isolated ferrochelatase cDNAs containing a 18-bp insertion (part of the intron 2 sequence) between exons 2 and 3; this corresponded to six extra amino acids (YESNIR) inserted between Arg-65 and Lys-66 of the known ferrochelatase. This isoform was identified initially in mRNAs derived from both alleles of the ferrochelatase gene in one patient. Its existence was confirmed in six additional EPP patients, in five out of seven controls, and in four different cell lines (fibroblast, muscle, hepatoma and myelogenous leukaemia). This isoform, roughly 20% of the total ferrochelatase mRNA, was generated through splicing at a second donor site in intron 2 and its presence was not linked to EPP.

Imaging diagnosis and follow-up of infantile hepatic haemangioendothelioma: a case report

A 4-week-old male infant was admitted to the hospital with acute gastrointestinal bleeding and marked coagulopathy secondary to vitamin K malabsorption in the presence of cholestasis. Physical examination revealed hepatomegaly and cutaneous haemangiomas. Ultrasonography, CT, and MRI demonstrated a multifocal vascular process and allowed the diagnosis of infantile hepatic haemangioendothelioma to be made without the use of more invasive diagnostic procedures. To avoid high-output congestive heart failure, the patient was treated with oral corticosteroids. After 5 months, rapid involution of the vascular malformations ensued. At age 2 years, a magnetic resonance scan confirmed complete resolution of the hepatic haemangioendothelioma.

Vitamin K1 concentration in breast-fed neonates after oral or intramuscular administration of a single dose of a new mixed-micellar preparation of phylloquinone

The plasma disposition of a new mixed-micellar preparation (KONAKION MM, Roche) of phylloquinone (vitamin K1) has been studied in 25 healthy, fully breast-fed, newborn babies, randomized to receive a single dose of either 1.5 mg i.m. (11 babies) or 3 mg p.o. (14 babies). Venous blood samples were collected at 25 h, 4 days, and 24 days. After p.o. administration, the median plasma phylloquinone concentration increased to 89 ng/ml after 24 h, then decreased to 51 ng/ml after 4 days; the respective concentrations after i.m. injection were 146 ng/ml and 34 ng/ml. The higher plasma phylloquinone level in the i.m. group after 24 h was not statistically significant compared with that of the p.o. group, but the reversed higher concentration in the p.o. group after 4 days was significant (p < 0.01). After 24 days the median plasma phylloquinone had decreased to 0.44 ng/ml (range 0.19-1.44) and 1.05 ng/ml (range 0.37-1.87) in the p.o. and i.m. groups, respectively. There was a significant difference between these plasma concentrations (p < 0.01). They were within or above the reference adult fasting range (0.17-0.68 ng/ml). The narrow range of plasma concentrations at 24 h and 4 days suggests a greater consistency of absorption from this micellar preparation than from other emulsion-based preparations. Further studies are required to assess the long-term protection of a single oral dose against late hemorrhagic disease of the newborn. Until such time, breast-fed babies given this preparation orally should receive (an) additional dose(s).

Crohn disease with sclerosing cholangitis and liver cirrhosis in adolescence

A 17-year-old patient suffering from Crohn disease (CD) and liver cirrhosis is presented. At an advanced stage of the disease, he died of a concomitant urosepsis. Autopsy showed that the liver cirrhosis was caused by sclerosing cholangitis. This very rare complication of CD in adolescence is discussed.

N-acetylglutamate synthetase deficiency: diagnosis, management and follow-up of a rare disorder of ammonia detoxication

We report the 9-year follow-up of a patient suffering from N-acetylglutamate synthetase deficiency, an urea cycle disorder leading to severe neonatal hyperammonaemia. Hitherto two patients from two families with this inborn error of metabolism had been observed. Our management consisted mainly of a protein-restricted diet and oral treatment with N-carbamylglutamate, an activator of carbamylphosphate synthetase, together with arginine or citrulline. The somatic development was normal whereas a moderate psychomotor retardation was diagnosed. The patient died after an episode of coma and prolonged generalized convulsions at the age of 9.5 years.

[Nutrition in the first days of life: how many infants need supplemental food?]

A prospective study of 280 consecutive newborns (birth weight greater than 2500 g) showed that on discharge from hospital 88.5% were fully and 8.6% partly breastfed. Only 8 children (2.9%) were weaned. In the group of the fully breastfed infants, 8.5% received no prelacteal food or fluid, 85.9% received a 10% dextromaltose (DM) solution and in only 5.6% of the children was there additional feeding with an adapted milk formula for some days. This restrictive attitude concerning supplemental feeding involved no observable drawbacks. The increasing incidence of atopic diseases--especially cow's milk allergy, the evolution of which is essentially promoted by the administration of foreign proteins in the first days of life--justifies a feeding policy on these lines. The elimination of bovine proteins in the newborn period is of considerable preventive significance. On the other hand, restriction of water supply (10% DM solution) is not advisable in our opinion.

[Chronic, fatal, neonatally-acquired cytomegalovirus disease with hypereosinophilia and multiple organ involvement]

The case is reported of a boy who died at age four from perinatally acquired persistent cytomegalovirus (CMV) infection associated with hypereosinophilia. Although no primary immunodeficiency was found he developed chronic CMV infection of the lungs, liver, bones, kidneys and finally brain. The clinical picture was dominated for a long period by asthmatic attacks due to severe obstructive bronchopulmonary disease. The possible immunological background to CMV infection and the clinical significance of the associated hypereosinophilia are discussed.

Hepatic capillariasis in a 1-year-old child

We described the 2nd European case of hepatic capillariasis. The diagnosis of this parasitosis caused by Capillaria hepatica was made by needle biopsy of the liver in a 1-year-old girl who presented with a triad of persistent fever, hepatomegaly and hypereosinophilia. The child recovered completely after treatment with thiabendazole (Mintezol, Merck, Sharp and Dohme, Hoddeston, UK).

Epidermolysis bullosa simplex with mottled pigmentation

A patient with epidermolysis bullosa simplex with mottled pigmentation is described. Clinical features include blistering of the skin, especially of the extremities; healing without scars; slight atrophy of the skin; and striking mottled pigmentation of the trunk. Histologic examination of a biopsy specimen from freshly frictioned, clinically uninvolved skin indicated a split inside the basal keratinocytes, focal hyperpigmentation of the basal cells, and pigment incontinence without an inflammatory infiltrate. Indirect immunofluorescence demonstrated focal discontinuity of the basement membrane zone. Electron microscopic examination revealed basal keratinocytes with few intact intracellular organelles, aggregated tonofilaments, and subnuclear splitting with the basal parts of the cells adhering to the basement membrane. Both normal basement membrane and zones of irregular and interrupted structures were seen. Hemidesmosomes and anchoring fibrils appeared to be normal.

[Hepatitis B associated membraneous glomerulonephritis: healing following drug-induced reactivation of hepatitis]

We report on a 7-year-old boy with nephrotic syndrome due to a membranous glomerulonephritis. The disease was caused by a persistent hepatitis B antigenemia without formation of antibodies. It was possible to show diffuse deposits of HBs antigen in the glomerular basement membrane and the mesangium by immunohistology. Therapy with cyclophosphamide resulted in an acute exacerbation of the hepatitis and, consequently, in a seroconversion. Subsequently, the nephrotic syndrome and the HBs antigenemia disappeared, and the hepatitis healed.

[Neonatal vitamin K prophylaxis and vitamin k deficiency hemorrhages in Switzerland 1986-1988]

On the basis of an inquiry held in Switzerland in May 1988, over 99% of all newborn receive vitamin K prophylaxis, 59% orally and 41% intramuscularly. In the previous 2 1/2 years, ten cases of bleeding due to vitamin K deficiency had been observed, of which two were inadequately documented. In two children there was early haemorrhage and late haemorrhage in eight. The latter were all exclusively breast-fed and had received oral vitamin K prophylaxis. Seven presented with vitamin K deficiency due to cholestasis or chronic diarrhea. The only "idiopathic" case is insufficiently documented. The advantages and disadvantages of oral and intramuscular prophylaxis are discussed. A definite stand in favour of the one route or the other is not possible at present. However, the continuation of general prophylaxis is undoubtedly necessary.

[Familial Mediterranean fever. Study of a Swiss child]

Familial Mediterranean fever (FMF) has been observed in a Swiss child without ethnic predisposition. The case is analyzed and the current literature briefly reviewed. Recurrent attacks of fever, accompanied by abdominal pain, colic and arthritic symptoms, and often by pleuritic pain and a transitory skin rash, are the hallmarks of FMF, which is predominantly seen in ethnic groups of the Mediterranean area, notably Sephardic Jews, Turks and Armenians. However, it rarely occurs among individuals without an ethnic predisposition. Its most ominous manifestation is amyloidosis, which leads to chronic renal failure within a matter of years. Thanks to colchicine treatment, which is now widely accepted, patients often lead normal lives, and it appears that amyloidosis can be prevented.

[Varicella fetopathy]

A newborn boy, whose mother had suffered from varicella in her 15th week of gestation, showed at birth fresh skin ulcers and cicatricial skin lesions on the right side of his face. Ocular abnormalities (chorioretinitis) as well as persistent dysphagia were observed. Up to date, only 25 cases of congenital varicella have been reported. They frequently showed cutaneous scars in a segmental distribution, hypoplasia of the locomotor system and ocular defects. In view of the extreme rarity of this condition, we do not consider diagnostic and prophylactic measures compulsory in cases of varicella contact during pregnancy.

Feeding of very-low-birth-weight infants with breast-milk enriched by energy, nitrogen and minerals: FM85

Although human milk is the best tolerated nutrition for very-low-birth-weight infants, it does not cover the special requirements of premature babies. The protein content does not allow a growth rate comparable to the intrauterine weight gain, and the calcium and phosphorus supply is by far too small for a full mineralization of the growing skeleton. If a sufficient caloric supply should be achieved, the low energy/water ratio leads to a high volume load for stomach and circulation. We therefore searched for a solution with an enriched human milk. As main energy carrier, polydextrose (dextrinmaltose) is added; the protein content is raised to 2.5 g/100 kcal by the addition of amino acids and small peptides and the mineral content is supplemented by calcium salts and phosphates. These ingredients are premixed; addition of 5 g% of this mixture results in a human milk with 85 kcal/100 ml and an optimal concentration of calcium, phosphate, sodium, potassium, chloride and magnesium. This feeding procedure is simple, safe, and without any practical difficulties.

Benign migraine-like syndrome with CSF pleocytosis in children

Four children with symptoms consistent with complicated migraine had CSF pleocytosis, in three cases lymphocytic and in the fourth polymorphonuclear. In one case the CSF abnormality was found during two separate attacks of complicated migraine. On the basis of the 23 cases reported in the literature and these four personal cases, the authors conclude that, as a rule, pleocytosis is a secondary phenomenon of an attack of complicated migraine. However, in exceptional cases an infectious disease might produce both a migraine attack and CSF pleocytosis.

[Tick-borne meningoradiculitis--a form of spirochetosis]

Three pediatric cases of tick-borne meningoradiculitis are presented. This disease is characterized by a distinct sequence of symptoms: erythema chronicum migrans, localized pain, and eventually radicular asymmetric neurologic involvement (in particular facial palsy) associated with findings of aseptic meningitis. On the basis of specific serologic data in these three patients, it is suggested that the etiology of tick-borne meningoradiculitis is also spirochetal , as recently shown for the tick-associated Lyme disease. Analogue positive spirochetal antibody titers were found in additional patients with erythema chronicum migrans and in a child with B afverstedt cutaneous lymphadenosis (see addendum). 20% of tick specimens collected in the area of Lucerne (Ixodes ricinus) were infected by these spirochetes.

Varicella and herpes zoster in immunosuppressed children: preliminary results of treatment with intravenous immunoglobulin

Seven immunosuppressed children with varicella and two with herpes zoster were treated with large intravenous doses of polyvalent, intact immunoglobulin (IgG i.v.). In all patients the treatment was effective for controlling fever and skin lesions and for preventing progression and complications, even if this therapy was started late and/or if the patient was severely lymphopenic . More IgG was needed to control disseminated than less advanced varicella. No untoward effects of IgG therapy were observed. The preliminary results suggest that in future trials i.v. IgG should be used for comparison with antiviral agents.

[Perinatal and neonatal mortality and morbidity in central Switzerland in 1982. An analysis of all newborns in a geographically circumscribed region]

In assessment of the perinatal situation in Central Switzerland, all 5616 infants born in the geographically surrounding areas of the Children's Hospital Lucerne have been statistically evaluated, according to birth place, birth weight, gestational age, perinatal condition, and postnatal development. 76 infants (1.4%) were born at home, 417 births (7.5%) took place before the completed 37th gestational week. Only 5.8% of our newborns had weights below the 10th percentile according to the Winterthur percentile curves used in Switzerland. The perinatal mortality was 12.9%, the neonatal mortality 7.1%. 2/3 of the deaths concern either extremely premature babies or infants with severe congenital malformations. The recorded malformations coincide with the known incidence, with the exception of trisomy 21, which marked an incidence of 1:1400. 8% of all live-born babies (499) needed special neonatal care. Among the preterm infants, every 2nd, and among the full-term babies every 12th had to be transferred to the neonatal care unit. Most of the transferrals were due to simple disturbances of adaptation (6% of all live-borns), whereas 1% required intensive care because of severe disorders. In 50 babies (1% of all live-borns), the neonatal diagnosis allows to anticipate a reduction of the quality of life.

[Toxocariasis in Swiss children]

A report is presented on 6 clinical observations of toxocariasis in Swiss children and on an epidemiological study of toxocara infections conducted in an urban and a rural area. The ELISA test in 70 children from the city of Basel revealed no seropositive result. In contrast, 4 of 68 children tested in the village of Entlebuch were seropositive. All reported close and intensive contact with dogs (mainly puppies) or geophagia. The main presenting symptom in our 6 clinical observations was excessive and sustained eosinophilia. Additional clinical and epidemiological aspects, the clinical picture and current therapy are discussed.

[Superior sagittal sinus thrombosis is the newborn--diagnosis by computerized tomography]

The case of a newborn with a superior sagittal sinus thrombosis is reported. The clinical symptoms are difficult to differentiate from other cerebral conditions in the neonatal period. Sudden appearance of signs of raised intracranial pressure, however, is characteristic. Main predisposing factors are infection, dehydration and polycythemia. Before computed tomography (CT) became available, the diagnosis could be made only by means of invasive examination techniques. Today CT, in many cases, allows a rapid diagnosis of this condition.

[Herlitz, severe generalized atrophic epidermolysis bullosa. Description and genealogic clarification of 4 new cases from Unterwalden canton]

Four infants with congenital epidermolysis bullosa letalis Herlitz were admitted between 1971 and 1978 to the Children's Hospital, Lucerne. All four were from three related families from the same valley in the Canton of Unterwalden and died before the age of one year. Histological and ultrastructural examinations of skin specimens confirmed the diagnosis, but an attempt to detect heterozygous carriers by the same method failed. Genealogical analysis revealed a fourth affected family one generation back and multiple consanguinity among three of the four families, according to an autosomal-recessive inheritance. The pathogenesis, clinical findings, therapy and genetics in this disease are discussed, together with the particular population genetics of the area concerned.

Low- and high-risk non-T and non-B and T-cell acute lymphoid leukemia (ALL) in childhood: different duration of remission and survival

In a prospective, nonrandomized trial clinical (initial WBC and chest film) and immunological (surface immunoglobulin and rosetting with pretreated sheep red blood cells) criteria were used to stratify 69 children with previously untreated acute lymphoid leukemia (ALL). Forty of 61 evaluable patients had low-risk ALL (initial WBC less than or equal to 20,000/mm3, no mediastinal mass) and were treated less intensively. Twenty-one of 61 patients had high-risk ALL (initial WBC greater than 20,000/mm3 and/or mediastinal mass) and were treated more intensively. Of the high-risk patients 15 had non-T non-B and 6 T ALL. Sixty of 61 patients went into complete remission. After a median observation period of 27 months, 32 of 40 low-risk, 7 of 14 high-risk non-T non-B, and none of 6 high-risk T ALL patients were in continuous first remission. Thirty-six of 40 low-risk, 9 of 15 high-risk non-T non-B, and none of 6 T ALL patients were alive. Despite more intensive treatment, the duration of remission and the survival were significantly shorter in the high-risk than in the low-risk patients. Among the high-risk ALL, non-T non-B ALL did better than T ALL.

[Convulsions after whooping-cough vaccination]

Convulsions or status epilepticus in 11 infants after pertussis vaccination are reported. In 3 cases grand mal epilepsy persisted and 2 children developed infantile epileptic encephalopathy (Lennox syndrome). On the basis of our own experience, the incidence of seizures approximates 1:4800 infants vaccinated or 1:12 800 vaccinations. According to a recent prospective study from the USA, the incidence of seizures may be closer to 1:600 infants. Since there is a significant difference between the incidence of spontaneous fits in children of the same age group and the incidence after vaccination, a causal relationship between the seizures and vaccination appears to be confirmed. The following conclusions are drawn from these observations: 1. In view of the usually benign course of whooping cough today, current vaccination against pertussis is hardly satisfactory. Improvement of the available vaccines is an urgent necessity. The protection should include the population most at risk, i.e. infants during the first few months of life. 2. Parents should be better informed about the risks involved in pertussis vaccination. 3. Booster inoculations should be abandoned. 4. Health authorities should decide whether the current pertussis vaccination program should be continued. 5. Complications following vaccination should be registered at a national centre.

[Infant nutrition in Switzerland 1978. A prospective study on feeding habits during the first 6 months. II. Artificial feeding]

The term "artificial feeding" includes a) the various infant formulas (including homemade formulas) substituting or supplementing mother's milk; b) the so-called "Beikost", i.e. minor additions to mothers milk or formula, such as fruit juices, fruit, meat and eggs; c) solid foods replacing part of the liquid food after a few weeks or months (weaning food). The use of these preparations in no- or partially-breastfed infants was studied and correlated with various socioeconomic parameters. The most striking observations were (1) during the first three months a decline in homemade formulas in favour of adapted readymade preparations; (2) a reduction in milk-cereal preparations with an increase in the use of yoghurt. Both trends reduce the carbohydrate content of the food. Except for breast-feeding, there are only minor differences in feeding habits between different socioeconomic classes. 96% of all infants received prophylactic doses of vitamin D, while 81% were given fluorides as prophylaxis against caries. On average the first gliadins were given after 16 weeks, in 10% earlier than the sixth week and in 16% after the sixth month only.

[Infant nutrition in Switzerland 1978. A prospective study on the nutritional habits during the first 6 months of life. I. Natural nutrition: breast feeding]

With the help of 55 nurses counseling young mothers in northern, central and eastern Switzerland the feeding habits of 371 infants born in March and April 1978 were studied during the first 6 months of life. Infants who were still breastfed at the end of the observation period were monitored for another 6 months. 92% of all infants were breastfed during the puerperium (62% receiving exclusively mother's milk). At the end of the second month some 60% of the infants were breast-fed (40% exclusively). At the end of the fourth month the numbers were 30% (15%) and after 6 months 18% (2%). The "mean corrected nursing period" was 10.25 weeks. The length of this period showed a direct correlation with the socioeconomic class of the family and especially with the educational status of the mother. A small difference in duration of the nursing period between male and female infants was not statistically significant, although during childbed there was a significant difference in favour of boys. There appeared to be a relationship between duration of nursing and age, parity and bodyweight of the mother. There were marked differences in frequency and duration of breast-feeding according to whether rooming-in was practiced during childbed or not. At the end of the first half year of life babies with a long nursing period had a significantly lower body weight than those with partial or no breastfeeding. A much smaller difference in body length resulted in a lower and probably more favourable weight/length ratio. There was no difference in head circumference. As compared with other industralized European countries, the authors regard current nursing habits in Switzerland as satisfactory.

Partial trisomy 7q and probable partial monosomy of 5p in the son of a mother with a reciprocal translocation between 5p and 7q

An underweight male newborn revealed a complex pattern of abnormal findings including severe neurologic dysfunction, a catlike cry, defective ossification of the calvarian bones, hypertelorism, downward slanting palpebral fissures, epicanthal folds, a short and flat nose with a flattened bridge, broad thumbs, clenched fingers 3--5 on the right hand, simian creases, a congenital heart defect, internal hydrocephalus, and bilateral hydronephrosis. He died on day 26 of his life. Chromosome examination disclosed a maternally inherited reciprocal translocation between 5p and 7q, resulting most probably in monosomy of 5p15 and trisomy of 7q32 leads to qter (46,XY,der(5), t(5;7)(p15;q32)mat).

[Juvenile pernicious anemia with congenital intrinsic factor deficiency and intermediate intrinsic factor secretion in the parents]

A 11 1/2-year-old girl of Turkish origin showed symptoms and signs of pernicious anaemia with low B12 level in blood but normal gastric acid secretion. There were no antibodies to mucosal cells or intrinsic factor. Quantitative determination of intrinsic factor in gastric juice, done by a RIA method, proved absence of the factor. Both parents had normal values for haemoglobin, normal B12-absorption tests and slightly decreased B12 blood levels. The gastric acid secretion was normal in both, but intrinsic factor in the gastric juice was decreased markedly. These findings support the hypothesis that congenital pernicious anaemia, e.g. congenital absence of intrinsic factor, is transmitted by an autosomal recessive trait.

[Vitamin E deficiency and anaemia in premature infants (author's transl)]

The effect of a prophylactic treatment with tocopherol, early iron substitution and administration of polyunsaturated fatty acids in different quantities on the plasma concentration of vitamin E, hemolysis in the peroxide test and hematological parameters during the first two months of life was determined in 23 premature infants with birth weights of less than 1800 gms. In no patient in any of the different treatment groups a tocopherol deficiency (plasma concentration less than 0.50 mg/100ml) was observed and accordingly no hemolytic anemia attributable to E hypovitaminosis was found. The mean concentration of tocopherol at birth (0.51 mg/100 ml) was already above the critical limit, and no single value was found below the latter after the 10th day of life. For that reason, the amount of vitamin E included in formulas generally used in this country and its intestinal absorption have to be considered as adequate even for small premature children. The different treatments of the test groups had no significant influence on the clinical state or the hematological findings. The infants with vitamin E substitution and those without had similar hemoglobin levels. Almost all children had a distinct reticulocytosis and thrombocytosis during the second month of their life. This seems to occur naturally. The peroxide test proved to be no reliable indicator of a tocopherol deficiency in the individual case. It is not yet clear which additional factors cause vitamin E deficiency, infrequently seen in small premature infants.

[Successful treatment of a severe drowning accident after 20 minutes submersion]

Report on successful post-drowning cardiopulmonary resuscitation of a 2-year-old boy who had lain for 20 min in cold water at 5-7 degrees C. Because of severe pulmonary complications after primary resuscitation--e.g. pulmonary edema, repeated mediastinal and subcutaneous emphysema, pneumoperitoneum and bilateral pneumothorax--spontaneous respiration remained insufficient for 36 days. Under appropriate treatment the patient recovered completely except for slight muscular hypotrophy of the left thigh. 14 months after the submersion no other neurological or pulmonary sequelae could be detected.