Positional asphyxia in individuals with severe cerebral palsy

The authors report the accidental death by positional asphyxia of three individuals with cerebral palsy occurring after they had been placed in bed for the night. During the five-year period between 1984 and 1989, 12 per cent of deaths from positional asphyxia in King County, Washington, involved individuals with cerebral palsy. Such accidents are similar to those occurring among healthy young children, perhaps because both groups have limited motor skills. Further research into accidents among disabled persons may clarify their special risks and possibly lead to modifications in bed design.

Severe gastric distension in seven patients with cerebral palsy

This is a report of two children who had severe recurrent gastric distension and vomiting, and five who experienced severe gastric distension without vomiting. Two of the five died during an episode of acute gastric distension. All had marked nutritional depletion, and severe spastic quadriplegia due to either cerebral palsy or acquired brain injury. None of the patients had significant gastroesophageal reflux. Positioning the patients in the left lateral decubitus position temporarily relieved their obstructions. Complete resolution of the distension and/or vomiting did not occur until after adequate weight gain. Loss of fat stores may lead to this type of recurrent gastric distension.

Quantitative measurement of spasticity in children with cerebral palsy

Spasticity was quantified in nine children with spastic diplegia, using a sinusoidal displacement of the foot at frequencies from 3 to 12Hz. Ankle-joint stiffness was separated into elastic (energy-storing) and viscous (energy-dissipating) components. 'Path length' was used to represent the variation in stiffness over this frequency range. Compared with 11 unaffected children, a significant difference in path lengths was demonstrated for the children with spasticity. An age-dependent effect was demonstrated when path lengths of unaffected children were compared with those of 10 unaffected adults. A modified path-length measure is proposed which minimizes age dependency, yet enables detection of spasticity. Passive stiffness properties of unaffected adults showed higher elastic stiffness, viscosity and friction than unaffected children. A method was developed to evade the need for temporary nerve blocks to calculate inerital properties of the foot in persons with spasticity.

Central ventilatory dysfunction in myelodysplasia: an independent determinant of survival

Central ventilatory dysfunction (CVD) is a significant complication of myelodysplasia with Arnold-Chiari type II defect. The records of 616 patients with myelodysplasia were reviewed and CVD was documented in 35 cases (5.7 per cent): it was the single most common cause of death in this population. There was no significant association between CVD and level of lesion, severity of hydrocephalus, hemorrhage or infection. The effects of CVD may be variable, with some patients having spontaneous remission and others having severe, often fatal, disruption of ventilation.

Recurrent hypothermia and thrombocytopenia after severe neonatal brain infection

Two children with multiple severe disabilities due to brain destruction by neonatal infection had recurrent hypothermia (less than 34 degrees C) with associated thrombocytopenia (less than 50,000), and clinical hemorrhage. They also had milder, less consistent erythroid and myeloid cell line abnormalities. The hypothermia was presumed to be due to hypothalamic dysfunction. Rewarming was always followed by correction of hematologic problems, but normal temperature was difficult to maintain. Recognition of this entity may improve long-term management of some severely disabled children.

Effects of 'tone-reducing' vs. standard plaster-casts on gait improvement of children with cerebral palsy

The relative effects of 'tone-reducing' (inhibitive) and standard casts on the gait patterns and functional motor activities of two children with cerebral palsy were examined in a repeated measures (single-subject) design. Both children's stride length improved in the tone-reducing casts, compared with standard casts, but there were no significant difference between the two casts in step length ratio, base of support or foot progression angle. From videotapes, clinicians noted mildly improved gait and function over baseline levels for one child during the tone-reducing cast phase. They also consistently rated this child's performance as being better with the tone-reducing casts than with the standard casts. Parents and therapists also favoured the tone-reducing casts. However, further evidence is needed for the efficacy of tone-reducing casts in the management of children with cerebral palsy.

Influence of prognosis on decisions regarding the care of newborns with myelodysplasia

Treatment of newborns with myelodysplasia (meningomyelocele and related disorders) continues to be a controversial subject. We have used a consistent plan of care and have employed the same prognostic criteria over the period from 1965 to 1982 to address the needs of 212 affected newborns. A good prognosis and early surgical care were given to 42 per cent of 53 newborns during the period 1965 to 1970, to 58 per cent of 65 newborns from 1971 to 1976, and to 71 per cent of 94 newborns from 1977 to 1982. Of the newborns with an initially poor prognosis, 19 per cent of 31 received early surgery between 1965 and 1970, as compared with 33 per cent of 27 between 1971 and 1976 and 52 per cent of 27 between 1977 and 1982. Life-table analyses of survival in the three periods revealed significant improvement over time in the survival of newborns receiving early surgical care, regardless of the initial prognosis (log-rank statistic = 8.240, P = 0.016) and in comparison to recipients of supportive care alone (log-rank statistic = 5.975, P = 0.05). We conclude that early surgery permits the survival of an increasing percentage of patients with myelodysplasia.

Prospective management of exstrophy of the cloaca and myelocystocele following prenatal ultrasound recognition of neural tube defects in identical twins

We describe identical twins concordant for exstrophy of the cloaca and myelocystocele. Their management and subsequent course was strongly influenced by prenatal ultrasound recognition of neural tube defects in both twins and severe renal dysplasia in one of the fetuses. The genetic aspects of this case are consistent with existing causal theories of exstrophy of the cloaca.

Acetabular augmentation for progressive hip subluxation in cerebral palsy

Between 1969 and 1981, 20 acetabular augmentations were performed on 17 cerebral palsied patients with progressive hip instability. Average follow-up was 41.5 months, with a range from 24 to 147 months. Evaluation of results was based on assessment of hip stability, center edge (CE) angle, range of motion, and postoperative complications. Eighteen hips were rated good, one fair, and one poor. Stability was achieved in 19 hips. The CE angle was increased from a preoperative mean of -17 degrees to a follow-up mean of 50 degrees. There was no significant difference between preoperative and follow-up hip range of motion. The only complication encountered was a supracondylar femur fracture sustained after spica cast immobilization. Acetabular augmentation can be used effectively in the treatment of progressive hip instability in patients with cerebral palsy.

Birth complication reporting: the effect of birth certificate design

The completeness of reporting of selected birth complications and congenital malformations on the Washington State birth certificate was estimated by comparing the total occurrences reported on birth certificates to the totals reported in hospital records. Two time periods were studied (1977-78 and 1980-81 before and after changes in birth certificate design). The design change (inclusion of a series of check boxes for conditions) was found to provide more complete reporting of birth complications.

Developmentally disabled infants can be hard to trace

The purpose of this study was to determine how well the existing medical care system in a large geographic region communicates about and keeps track of the developmental problems of infants receiving tertiary inpatient care. Two hundred thirty-seven infants hospitalized in the first months of life were tracked, using a postal questionnaire at a mean age of 20 months. A discharge summary was present in 98 percent of charts, and a follow-up physician was identified in 95%. Questionnaires were returned by 116 physicians about 182 infants (77%). Seventy-one physicians had received a discharge summary. Current developmental information was obtained for 111 infants: 44 normal, 52 with known disabilities, and 15 with developmental delays. One hundred twenty-six infants could not be located at the time of the study. We conclude that many infants likely to have major disabilities are hard to track using simple retrospective techniques.

Neonatal mercury vapor exposure in an infant incubator

A healthy newborn infant acquired a substantial body burden of mercury by inhaling mercury vapor originating from a broken mercury expansion switch in the heating unit of an infant incubator. Highly toxic mercury vapor is produced in quantity by heating otherwise harmless metallic mercury. Switches and thermometers that contain mercury should be removed from infant incubators.

Developmental dyspraxia in a family with X-linked mental retardation (Renpenning syndrome)

This paper describes the existence of severe developmental speech dyspraxia in a member of a family that is typical of other reports of X-linked mental retardation without physical abnormality (Renpenning syndrome). Other family members have evidence of motor or speech dyspraxia. Other reports of X-linked mental retardation have mentioned "verbal disability", which suggests that developmental dyspraxia may be quite common in these families. Developmental dyspraxia of speech is amenable to specific types of intervention: after two years of such intervention our patient's adaptive skills reflect his normal non-verbal intellectual ability, despite persistent speech deficits. This functional improvement shows how important it is to identify dyspraxia in young children, who may otherwise be labelled mentally retarded.

Coarctation of the aorta in male cousins with similar maternal environmental exposure to insect repellent and insecticides

Two male infants, whose mothers are sisters and whose fathers are unrelated, were born within two weeks of each other. Both infants had coarctation of the aorta. Since both mothers were exposed to an insecticide while on a camping trip in the first trimester of pregnancy, it is unknown whether genetic or environmental factors caused the anomalies. Observations should be made on other patients with congenital heart defects to clarify the etiologic factors.

History of SO2 removal system at the Meramec plant of union electric

In line with the then emerging air pollution control regulations Union Electric installed a limestone injection wet scrubber sulfur dioxide removal system on an intermediate size coal-fired utility boiler at its Meramec Power Plant on an experimental basis in September, 1968. Approximately 3 years of operation many difficulties were encountered with plugging and scaling of various system components by calcium sulphate. As a result of this experience along with related experiences by other utilities employing similar systems, the experiment was terminated in June, 1971. As a result of the experiences gained, however, second generation experiments in sulfur dioxide removal have been initiated elsewhere with the hope of improved performance. A number of experimental projects are still under tests. Costs in resources, reliability, and disposal of residual by-products are matters of great concern. The ture cost of sulfur dioxide removal systems in dollars and resources is not well known and perhaps a reevaluation of current and future SO2 removal projects is in order at this time before additional resources are committed.