Ventricular dysfunction in children with obstructive sleep apnea: radionuclide assessment

Ventricular function was evaluated using radionuclide ventriculography in 27 children with oropharyngeal obstruction and clinical features of obstructive sleep apnea. Their mean age was 3.5 years (9 months to 7.5 years). Conventional clinical assessment did not detect cardiac involvement in 25 of 27 children; however, reduced right ventricular ejection fraction (less than 35%) was found in 10 (37%) patients (mean: 19.5 +/- 2.3% SE, range: 8-28%). In 18 patients wall motion abnormality was detected. In 11 children in whom radionuclide ventriculography was performed before and after adenotonsillectomy, right ventricular ejection fraction rose from 24.4 +/- 3.6% to 46.7 +/- 3.4% (P less than 0.005), and in all cases wall motion showed a definite improvement. In five children, left ventricular ejection fraction rose greater than 10% after removal of oropharyngeal obstruction. It is concluded that right ventricular function may be compromised in children with obstructive sleep apnea secondary to adenotonsillar hypertrophy, even before clinical signs of cardiac involvement are present.

Predicting ability to drive after stroke

OBJECTIVE

To determine the ability of perceptual testing to predict on-road driving outcome in subjects with stroke.

STUDY DESIGN

Historical cohort study of 84 individuals with stroke who completed both the perceptual testing and the on-road driving evaluation conducted in a driving evaluation service.

MEASURES

Perceptual tests, such as the Motor Free Visual Perception Test (MVPT) and Trail Making B test, and an on-road driving evaluation. Based on driving behaviors, a pass or fail outcome was determined by the examiners.

RESULTS

Subjects who passed the on-road evaluation had better average scores on the majority of perceptual tests compared with those who failed. The MVPT was the most predictive of on-road performance (positive predictive value=86.1%; negative predictive value=58.3%). The combination of tests resulting in the most predictive and parsimonious model was the MVPT plus Trail Making B, such that those who scored poorly on both were 22 times more likely to fail the on-road evaluation.

CONCLUSION

A screening process is useful in identifying persons who are not ready to undergo an on-road driving evaluation.

Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections

We prospectively examined whether febrile infants younger than 2 months of age who were defined as being at low risk for having bacterial infection could be observed as outpatients without the usual complete evaluation for sepsis and without antibiotic treatment. A total of 237 previously healthy febrile infants were seen at the Pediatric Emergency Room over 17 1/2 months. One hundred forty-eight infants (63%) fulfilled the criteria for being at low risk: no physical findings consisting of soft tissue or skeletal infections, no purulent otitis media, normal urinalysis, less than 25 white blood cells per high-power field on microsopic stool examination, peripheral leukocyte count 5000 to 15,000/mm3 with less than 1500 band cells/mm3. One infant appeared too ill to be included, and had sepsis and meningitis. None of the 148 infants at low risk had bacterial infections, versus 21 of 88 (24%) of those at high risk (P less than 0.0001); eight of 88 (9%) had bacteremia. Of the 148 infants classified as being at low risk for having bacterial infection, 62 (42%) were discharged to home, and 72 (49%) were initially observed for less than or equal to 24 hours and then discharged. Seventeen infants (11%) were hospitalized: in six, low risk became high risk; six had indications other than fever; and five because the study physicians could not be found. The 137 nontreated infants were closely observed as outpatients. The duration of fever was less than 48 hours in 42%, and less than 96 hours in 91%. All infants were observed for at least 10 days after the last examination. The fever resolved spontaneously in all infants but two, with otitis media, who were treated as outpatients. Our data suggest that management of fever in selected young infants as outpatients is feasible if meticulous follow-up is provided.

Respiratory failure in children following envenomation by the scorpion Leiurus quinquestriatus: hemodynamic and neurological aspects

Nine children, hospitalized for severe respiratory failure following scorpion envenomation, were a part of a group of 61 youngsters and infants admitted to the Pediatric Intensive Care Unit of the Soroka Medical Center, Beer-Sheva during the years 1983-87 because of scorpion venom intoxication. Four out of the nine had cardiogenic shock, three had severe systemic hypertension and one had severe airway obstruction. All nine patients had central nervous system manifestations, including lethargy, confusion and agitation (three cases), and markedly reduced level of consciousness (six cases). Hemodynamic studies performed in two patients showed 'high pressure' (cardiogenic) pulmonary edema. Seven patients recovered completely, one died and another one was left severely handicapped. Hydralazine i.v. showed a remarkable effect on the systemic blood pressure and central nervous system disturbances in addition to mechanical ventilation. Based on our own experience and previous clinical and experimental studies, the possible pathogenetic mechanisms underlying the respiratory and central nervous system dysfunction following scorpion sting are discussed.

The cardiovascular system after scorpion envenomation. A review

Scorpion envenomation is a common medical problem and life hazard in many countries of the world. Scientific investigations have addressed the interrelationship between the stimulatory effects of the venom on the autonomic nervous system and adrenals and the subsequent effects of released transmitters on the cardiovascular system. A number of clinical cardiovascular syndromes may dominate the initial clinical presentation after envenomation: the syndromes usually vary with the age of the victim, the size of the offender and the season. Central nervous system dysfunction is seen in children but rarely observed in adults; if accompanied by severe hypertension the clinical picture is consistent with acute hypertensive encephalopathy. Heart failure, pulmonary edema or a shock-like syndrome has been observed in 25% and hypertension in 30% to 77% of our patients. The electrocardiographic abnormalities recorded in the majority of the patients after envenomation include an "acute myocardial infarction-like pattern." Rhythm disturbances are frequent but conduction abnormalities are rare. Echocardiographic, radionuclide and experimental hemodynamic observations have provided evidence that heart failure and pulmonary edema after envenomation are multifactorial with diminished systolic performance following the initially increased left ventricular contractility and decreased ventricular diastolic compliance. Clinical laboratory data reporting increased catecholamine metabolite excretion and elevated plasma renin and aldosterone are consistent with the stimulatory effects of the venom on the autonomic nervous system. Treatment, including our experience with vasodilators and calcium channel blockers, is reviewed.

Echocardiographic and radionuclide angiographic observations following scorpion envenomation by Leiurus quinquestriatus

The echocardiographic and radionuclide angiographic abnormalities in children after scorpion envenomation with L. quinquestriatus, were evaluated. Five children were severely hypertensive, one of them in respiratory failure and another had pulmonary edema. The results revealed poor global contractility 12-15 hr after the sting in three patients. The radionuclide angiograms also revealed poor contractility with low ejection fraction. There was enzymatic evidence of myocardial damage. The changes observed in the echocardiograms and radionuclide angiograms were attributed to catecholamine induced myocardial ischemia. The abnormalities observed suggest that systolic dysfunction plays a role in the pathogenesis of heart failure in scorpion envenomation, in addition to a decrease of left ventricular compliance and increased impedance to left ventricular emptying. The beneficial effects of nifedipine in hypertension and other cardiovascular manifestations justify the routine use of afterload reduction in children with cardiovascular manifestations after scorpion envenomation.

Carbamate and organophosphate poisoning in young children

OBJECTIVE

Retrospective evaluation of the clinical course of carbamate and organophosphate poisoning in young children.

DESIGN

The records of 36 children intoxicated with carbamate and 16 children intoxicated with organophosphate (age range: 2 to 8 years, median: 2.8 years) were examined retrospectively. The carbamate agents were identified as methomyl or aldicarb, and the organophosphate as parathion, fenthion, malathion, and diazinon. The causes of poisoning were accidental ingestion in 46 children and inhalation in six children.

CLINICAL SETTING

Pediatric Intensive Care Unit of a teaching hospital.

INTERVENTIONS

Gastric lavage was performed, and activated charcoal was administered to all children who had ingested poisonous pesticides. Atropine sulphate was administered intravenously in repeated doses to all children with bradycardia, diarrhea, salivation, and miosis. Obidoxime chloride was administered to patients with organophosphate poisoning and to those in whom the ingested material was unidentified on admission.

RESULTS

Predominant symptoms were related to central nervous system depression and severe hypotonia. Other clinical signs such as miosis, diarrhea, salivation, bradycardia, and fasciculation were less frequent, while tearing and diaphoresis were not observed. Pulmonary edema developed in six patients with organophosphte poisoning. Three children required mechanical ventilation for several hours. One child (organophosphate poisoning) died shortly after arrival at the emergency department. All other children recovered completely.

CONCLUSION

Based on a relatively large group of young pediatric patients with carbamate and organophosphate poisoning, it is concluded that the clinical presentation differed from those described in adults. Absence of classic muscarinic effects does not exclude the possibility of cholinesterase inhibitor agents poisoning in young children with central nervous system depression.

Interleukin-6 release following scorpion sting in children

Interleukin-6 levels were measured in the serum of ten children following severe scorpion envenomation. Measurements were taken on arrival, at the emergency room, and 12 and 24 hr after arrival. Interleukin-6 was markedly elevated in the serum of eight out of ten children on arrival. Interleukin-6 levels gradually decreased toward normal values on 12 and 24 hr measurements, but remained above control levels on all measurements. These results imply that signs and symptoms following scorpion envenomation may in part be explained by release of cytokines. Human and experimental animal studies are required in order to verify the assumption that interleukin-6 and other cytokines are involved in the pathogenesis of scorpion envenomation.

Aplasia cutis congenita in two sibs discordant for pyloric atresia

We report two sibs who were the products of a consanguineous mating, and who had an extensive form of aplasia cutis congenita (ACC). In one of them the generalized skin disorder was manifested by slipping off of the epidermis and mucous membranes with the slightest trauma. This sib also had pyloric atresia and other congenital malformations. Two hypotheses are presented to explain the discordance between the siblings for the abnormalities other than the ACC. One hypothesis assumes varying degrees of severity of the same autosomal recessive disease. The second suggests linkage between the gene for ACC and the gene for an epidermolysis bullosa (EB)-like disorder and pyloric atresia. a recombination event involving the EB-pyloric atresia gene in one carrier parent would then lead to an offspring with only ACC. Prenatal diagnosis is suggested by monitoring alpha-fetoprotein levels in aminotic fluid.

Hypocomplementemic autosomal recessive hemolytic uremic syndrome with decreased factor H

We describe the clinical course, complement components, and pathological findings of 10 infants with autosomal recessive hemolytic uremic syndrome (HUS). All patients were members of one extended highly inbred Bedouin kindred. The median age of presentation was 2 weeks (range 1-20 weeks). Eight patients died, 2 patients are alive, on dialysis. Renal biopsies revealed thrombotic microangiopathy with a predominant early arteriolar involvement and subsequent development of ischemic glomerular changes. Immunofluorescence was positive for C3 in glomeruli. All patients had low complement components levels during and between relapses, and in some this was evident soon after birth and prior to the onset of symptoms. This deficiency could not be normalized by repeated plasma transfusions. Biosynthetic labelling of patients' fibroblasts demonstrated normal rates of C3 protein synthesis. Serum factor H levels were greatly decreased or absent in 4 patients tested and moderately decreased in 15 of 23 healthy unaffected siblings and patients. This defect may cause complement activation and consumption, possibly at the endothelial cell level.

Scorpion envenomation and antivenom therapy

The clinical course and outcome of scorpion envenomation in 52 children treated in a pediatric intensive care unit without specific antivenom were retrospectively evaluated and compared with those of scorpion envenomation in the 52 preceding cases treated with specific scorpion antivenom. The demographic, clinical, and laboratory features on hospital arrival were similar in the two groups. The lengths of stay in the pediatric intensive care unit and in the pediatric wards were comparable. Hypotension with pulmonary edema developed in four of the children who did not receive antivenom and in one child who did receive antivenom as a complication of the envenomation; all completely recovered. Cardiogenic shock occurred in one child who did not receive antivenom, but who recovered completely, and in three children who received antivenom, of whom two died and one survived with a major deficit. Our study did not demonstrate any beneficial effect of therapy with antivenom for scorpion envenomation in children. However, our "control" group (i.e., the treated group) was a historical one; thus a prospective, randomized study appears to be warranted. Such a study may define specific subgroups that may benefit from treatment with antivenom.

Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma

OBJECTIVE

To asses the yield and contribution of a routine predetermined repeat head computed tomographic (CT) scan within 24-36 hrs in pediatric patients with moderate to severe head trauma.

DESIGN

Records review.

SETTING

Five pediatric intensive care units.

PATIENTS

We reviewed the charts of 173 consecutive pediatric patients with moderate to severe head trauma (Glasgow Coma Scale score of < or = 11) that survived the first 24 hrs after being admitted to five Israeli trauma centers. Clinical data collected included status at admission, at the time between the first and second CT scans, and after the second scan. Head details of the first, second, and, if performed, third CT scan were collected. Treatment strategy during each period was recorded, including any change in treatment after each CT scan.

MEASUREMENTS AND MAIN RESULTS

A total of 47 (27%) of the second CT scans showed new lesions including six intracranial hemorrhages, 17 cases of worsening brain edema, and 18 newly diagnosed brain contusions. However, none of these findings necessitated surgical intervention or any change in therapy. Of the 67 patients who underwent a third CT scan, two cases required surgical intervention because of new findings in the third CT.

CONCLUSIONS

A second routine prescheduled head CT scan within 24-36 hrs after admission in pediatric patients with moderate to severe head trauma is unlikely to yield any change in therapy. Clinically and intracranial pressure-oriented CT scan may better select and diagnose patients who require changes in therapy, including surgery. Studies aimed to determine the ideal timing for the second are warranted.

Cor pulmonale due to adenoidal or tonsillar hypertrophy or both in children. Noninvasive diagnosis and follow-up

Four children, aged 1 to 3 1/2, were first seen with cor pulmonale, pulmonary edema and severe respiratory distress due to chronic upper airway obstruction secondary to adenoidal or tonsillar hypertrophy or both. Arterial blood gas values, electrocardiograms and chest x-ray films were compatible with cor pulmonale. Echocardiography (four cases) and radionuclide angiography (two cases) showed severe right ventricular and right atrial dilation with reduced right ventricular ejection fraction. Following surgery, all four children improved; their echocardiographic and radionuclide findings returned to normal. Cardiac catheterization, traditionally performed in such cases, was unnecessary. The diagnosis and follow-up of this syndrome are adequately performed noninvasively.

Vasodilators and hypertensive encephalopathy following scorpion envenomation in children

Twenty-three children were admitted to a pediatric intensive care unit for scorpion envenomation with severe hypertension. The hypertension responded to analgesics and sedatives in 15 (65 percent) of the 23. The remaining eight children required specific antihypertensive therapy, and their condition promptly responded to intravenous hydralazine and sublingual nifedipine; rebound hypertension was observed in one. Hypertension is a frequent complication of a scorpion's sting in children, and specific antihypertensive therapy is indicated in severe cases. Hydralazine and nifedipine are effective and safe in such instances.

Pulmonary edema following relief of upper airway obstruction

In six pediatric patients, pulmonary edema (PE) appeared on chest x-ray film following intubation for upper airway obstruction (UAO). In spite of the x-ray appearance of PE, there was generally no concomitant physiologic or clinical decline. Only one of the patients required positive airway pressure following intubation. We conclude that PE on chest x-ray film following intubation for UAO is not uncommon, and may not be a harbinger of clinical and/or physiologic deterioration.

Hydrocarbon poisoning in children: a 5-year retrospective study

OBJECTIVE

To investigate the demographics, incidence, and symptoms and signs of hydrocarbon poisoning in admitted children from the Negev Desert area of Israel.

METHODS

The medical records of all children admitted for hydrocarbon poisoning from 1995 to 1999 were reviewed retrospectively.

RESULTS

Of the 274 admitted children, 61% were boys and 39% were girls, with ages ranging from 6 months to 18 years (median, 1.58 years). Ninety-four percent of the patients were Moslem Arab Bedouins, and 6% were Jews. The largest group of patients (106) was admitted during the summer months (P < .003). Also, more patients were admitted in spring (63) and autumn (67) than in winter (38) (P < .013). Thirty-two percent of the cases were seen in the Pediatrics Ambulatory Unit and then discharged, while 68% were hospitalized. The most commonly observed symptoms were tachypnea (73.7%), fever (63.5%), vomiting (51.1%), and cough (38.0%). About one third of the patients showed signs of central nervous system (CNS) impairment, including drowsiness, restlessness, stupor, and convulsions. These symptoms were significantly correlated with pneumonia, hypoxemia, and fever (P < .001). Of 274 patients, 43% (118 children) had pneumonia--usually interstitial pneumonitis (90%). Vomiting was significantly correlated with pneumonia (P < .05).

CONCLUSIONS

1) There is a higher risk of hydrocarbon poisoning during the hot months of the year; 2) the respiratory system is the main target organ affected; 3) pneumonia is in most cases interstitial and bilateral; 4) vomiting after hydrocarbon ingestion is related to the rate of development of pneumonia; 5) symptoms of CNS impairment were correlated with hypoxemia, pneumonia, and fever; and 6) CNS toxicity may occur without hypoxemia, concurrent pulmonary pathology, or other pathology.

Visual testing for readiness to drive after stroke: a multicenter study

OBJECTIVE

The purpose of this study was to determine the ability of a visual-perception assessment tool, the Motor-Free Visual Perception Test, to predict on-road driving outcome in subjects with stroke.

DESIGN

This was a retrospective study of 269 individuals with stroke who completed visual-perception testing and an on-road driving evaluation. Driving evaluators from six evaluation sites in Canada and the United States participated. Visual-perception was assessed using the Motor-Free Visual Perception Test. Scores range from 0 to 36, with a higher score indicating better visual perception. A structured on-road driving evaluation was performed to determine fitness to drive. Based on driving behaviors, a pass or fail outcome was determined by the examiner.

RESULTS

The results indicated that, using a score on the Motor-Free Visual Perception Test of < or =30 to indicate poor visual-perception and >30 to indicate good visual perception, the positive predictive value of the Motor-Free Visual Perception Test in identifying those who would fail the on-road test was 60.9% (n = 67/110). The corresponding negative predictive value was 64.2% (n = 102/159). Univariate logistic regression analyses revealed that older age, low Motor-Free Visual Perception Test scores and a right hemisphere lesion contributed significantly to identifying those who failed the on-road test.

CONCLUSIONS

The predictive validity of the Motor-Free Visual Perception Test is not sufficiently high to warrant its use as the sole screening tool in identifying those who are unfit to undergo an on-road evaluation.

Carbamate poisoning in early childhood and in adults

OBJECTIVE

Retrospective evaluation of the clinical course of carbamate poisoning in young children and adults.

DESIGN

Thirty-six children aged 1 to 8 years (median 2.5 years) and 24 adults aged 17 to 41 years (median 22 years) ingested rat poison resulting in carbamate poisoning. The ingested poisons in all cases were positively identified as methomyl or aldicarb by gas chromatography-mass spectrometry.

RESULTS

Symptoms of intoxication in children were compared to those in adults with similar depression of the serum cholinesterase. The predominant symptoms in young children were central nervous system depression and hypotonia. The most common muscarinic effect was diarrhea. In adults, the main signs were miosis and fasciculations. Fasciculations in children were less frequent. Central nervous system depression, hypotonia, and diarrhea were uncommon in adults.

CONCLUSION

Based on a relatively large number of carbamate poisonings in young children, we conclude that the clinical presentation differs from adult poisoning manifestations. The absence of classic muscarinic effects does not exclude the possibility of carbamate poisoning in young children with central nervous system depression.

Carbamate and organophosphate poisoning in early childhood

Twenty-five infants and young children intoxicated by carbamate and organophosphorus compounds are described. Presenting signs and symptoms in children differed from those described in adults and were mainly related to severe CNS depression, coma and stupor, dyspnea, and flaccidity. Other clinical signs such as miosis, excessive salivation and tearing, sweaty, cold skin, and gastrointestinal symptoms were less frequent, while fasciculations and bradycardia were quite uncommon on arrival. Only two patients presented with all typical signs of organophosphate poisoning as described in adults. Signs of carbamate poisoning were indistinguishable from those of organophosphate poisoning and included signs of myoneural and CNS cholinergic receptor involvement, in addition to parasympathetic muscarinic dysfunction. Atropine sulfate was found to have a clear beneficial CNS effect in addition to its known peripheral antimuscarinic effect. Our data suggest that the clinical presentation of carbamate and organophosphate poisoning in early childhood and its response to therapy are quite different from those of adults and older children.

Bacterial tracheitis--an old disease rediscovered

During a 3-year period, seven children with bacterial tracheitis were admitted to the intensive care unit of the Winnipeg Children's Hospital. The illness was characterized by fever, toxicity, and stridor. Respiratory difficulty was secondary to copious thick purulent tracheal secretions. In the majority of patients the illness was caused by Staphylococcus aureus, and the rest had Hemophilus influenzae infection. Viral studies in five patients were negative. Most patients required endotracheal intubation and frequent tracheal toilet to prevent serious airway obstruction. In our ICU, bacterial tracheitis accounted for about 14 per cent of admissions with infectious upper airway obstructive illness, while epiglottis and croup accounted for 55 per cent and 31 per cent, respectively. Only 5 per cent of children with croup admitted to the hospital were admitted to the ICU. Bacterial tracheitis has reappeared, at least in North America, as an important and serious cause of obstructive upper airway disease in children and must be recognized early in order to prevent catastrophic airway obstruction.

Acute pancreatitis in children following envenomation by the yellow scorpion Leiurus quinquestriatus

Plasma immunoreactive cationic trypsin (ICT), which is a specific and highly sensitive indicator of pancreatic injury, was measured in 14 children with signs of systemic envenomation following a sting by the scorpion Leiurus quinquestriatus. High ICT levels were found in 13 children (93%), indicating that acute pancreatitis is a common complication of envenomation by this scorpion. The pancreatitis may account for the abdominal pain and vomiting commonly seen in scorpion envenomation and may also contribute to the agitation and discomfort noted in young children.

Myocardial injury without heart failure following envenomation by the scorpion Leiurus quinquestriatus in children

The enzymatic activity of creatine kinase-MB isoenzyme (CK-MB), a sensitive and specific marker of myocardial damage, was measured in 32 children following scorpion envenomation. CK-MB activity, total creatine phosphokinase (CPK) and serum glutamine oxalacetic transaminase (SGOT) levels were examined for relationship with electrocardiographic (ECG) results and the clinical state of the children. Twenty-seven out of the 32 children had signs of systemic intoxication ("symptomatic" cases), while the other five children had only local signs ("asymptomatic" cases). Thirteen out of the 27 symptomatic children had enzymatic myocardial involvement characterized by high total CPK level, elevated CK-MB level and a CK-MB/CK ratio exceeding 6%. Six of these 13 children had ECG changes consistent with myocardial damage, and only one child had clinical signs of myocardial injury. None of the asymptomatic children, nor five healthy control children, had any evidence of myocardial damage as judged by CK-MB levels, clinical signs and ECG. Our study suggests that CK-MB activity is specific and highly sensitive in detecting myocardial damage in children following scorpion envenomation, and appears superior to ECG and clinical parameters. We speculate that the myocardial lesions are too small to cause heart failure in most cases, but they may account for the cardiovascular changes frequently seen in scorpion envenomation.

Fatal familial infantile glycogen storage disease: multisystem phosphofructokinase deficiency

An infant girl of consanguinous Bedouin parents suffered from fatal early onset of progressive generalized muscle weakness. Her older brother suffered from similar weakness and cardiomyopathy, which led to his death at the age of 21 months. A muscle biopsy performed on the propositus at the age of 9 months was PAS-negative, and showed nonspecific myopathic changes. A second muscle biopsy, performed at 21 months of age, a few days before her death, and postmortem study of heart and liver, disclosed excessive extralysosomal glycogen storage and reduced phosphofructokinase-1 (PFK-1) activity. Because the genes encoded for PFK-1 in liver and muscle are located on separate chromosomes, the reduced enzyme activity in both tissues could not be related to a single mutation for this enzyme. Activity of 6-phosphofructose-2-kinase (PFK-2), a recently discovered physiological activator to all PFK-1 isozymes, was normal in the liver. The possibility that this multisystem PFK-1 deficiency may be related to the absence of a yet unknown activator, common to all PFK-1 isozymes, is discussed.