Haemophilus influenzae and Streptococcus pneumoniae infections in children with cerebrospinal fluid shunts

OBJECTIVE

This paper reviews the frequency of central nervous system infections due to Haemophilus influenzae and Streptococcus pneumoniae associated with cerebrospinal fluid (CSF) shunts in pediatric patients. The need for immunizations in this patient population is also evaluated.

PATIENTS

All patients with cerebrospinal fluid shunts except those with brain tumors seen in our clinics.

METHODS

We reviewed data in three computer databases, kept prospectively recording details of CSF shunt procedures and CSF shunt-related infections.

RESULTS

1,226 patients underwent 3,889 shunt placements between 1957 and 2007. Twelve patients had 14 episodes of Haemophilus or pneumococcal infections.

CONCLUSIONS

Children with CSF shunts are at high risk for infection with H. influenzae and S. pneumoniae. Routine immunizations during infancy in addition to the 23-valent polysaccharide pneumococcal vaccine should be highly and actively encouraged by health care providers caring for children with CSF shunts. Additional expanded-coverage vaccines should be utilized if and when they become available.

Myelodysplasia: the natural history of kyphosis and scoliosis. A preliminary report

The results of this study support the concept that the levels of the bifid vertebral arch and of functional motor activity are significant influences on the development of scoliosis and kyphosis in patients born with myelodysplasia. 'Significant' degrees of scoliosis and kyphosis may appear at any time during life, but most frequently occur during late childhood or adolescence. Not all 'significant' curvatures require treatment, nor do all children with myelodysplasia and factors predisposing to kyphosis and scoliosis develop these complications. It is believed that the preliminary cumulative percentage curves presented in this study will be of value in counselling parents of afflicted newborn infants, and in planning the management of patients born with myelodysplasia.

Assessing the development of daily living skills in patients with spina bifida

The development of independence in daily living skills of 256 patients with spina bifida was assessed by means of a new Functional Activities scoring system. The score was derived from nine categories of activity; five are to do with self-care, three with locomotion and one with social interaction. The reasons for the variation in achievement between individuals with the same degree of paralysis are discussed, as are the differences in learning curves for single activities. The scoring system enables a quantitative assessment to be made of the current status of an individual patient, and enables more realistic therapeutic goals to be set.

Meningomyelocele: management in utero and post natum

We report a four year follow-up of 39 of 47 infants born after pre-labour Caesarean section and 68 of 79 born vaginally. Loss of motor function due to late complications was more frequent in the Caesarean section group (Fisher's Exact; P = 0.004). However, the means of the differences between the X-ray levels (measured as the last intact vertebral arch seen on standard anteroposterior roentgenograms of the spinal column) subtracted from the motor levels still favour Caesarean section (mean = 3.24; SD = 2.7) over vaginal delivery (mean = 1.2; SD = 2.7) (Student's t-test; P = 0.0003). The frequencies of other complications, death and neonatal meningitis, were not significantly different. Another 38 infants born by Caesarean section after labour were more paralysed (mean of X-ray and motor difference = 1.8, SD = 2.2) following rupture of amniotic membranes than those with intact amniotic membranes with or without labour (mean = 3.4; SD = 2.2) (Student's t-test; P = 0.0067). The differences between X-ray and motor levels for patients born by Caesarean section with intact amniotic membranes and without labour (mean = 3.6; SD = 2.4) were not significantly different from those with labour and intact amniotic membranes (mean = 2.89; SD = 1.5). The number of new cases of meningomyelocele presenting to our clinic has decreased from an average of 30 per year between 1970 and 1987 to 14 between 1988 and 1992.

Longevity of patients born with myelomeningocele

There are limited data concerning the life expectancy for individuals born with myelomeningocele (MM), with and without hydrocephalus. To ascertain such data was our first purpose. We have selected all patients with MM in our computer database, The Patient Data Management System (PDMS/fx). Data were transferred to Excel for primary and SPSS/PC for final analysis by Kaplan-Meier life survival curves. Of the 1,054 patients with MM in the Birth Defects Clinic and the University of Washington Medical Center (UWMC) of Seattle, 505 are now over the age of 21 (391) or have died (114). Follow-up information was available since 1994 for 132, 62% of whom we have had contact within the past 2 years. The second purpose was to identify potential health factors associated with long-term outcome of patients with MM. Patient variables chosen as relevant to survival included hydrocephalus, treatment before or after 1975, and health maintenance determined by outcome for those receiving care within the last 5 years or those last seen before. Age at last appointment and reason for visit were determined in order to identify age-specific health care needs of the adult population. Survival and medical needs were obtained from the UWMC's computer database, Mindscape, and by telephone survey for adult patients not seen in the last 2 years. Death is more frequent earlier in life for those MM patients with hydrocephalus. Ordinary degenerative disorders affect MM patients earlier in life than normals. Our data extend life expectancy for patients with MM and hydrocephalus to age 40 years with some reliability for those treated from 1957 to 1974, but only 24 years for those treated with modern techniques after 1974. More data is needed to determine long-term survival.

19-year follow-up of fetal myelomeningocele brought to term

We conducted a 19-year follow-up study of 223 infants with myelomeningocele born by cephalic presentation, 68 born by pre-rupture of amniotic membranes cesarean section (PRAM C/S) and 155 born vaginally to determine outcome. We recorded radiographic level as the last intact vertebral arch at the cephalad end of the spinal defect from standard AP films of the spine. Protrusions of the lesions dorsal to the back were obtained from medical records or parental recall. Subsequent spinal cord abnormalities (hydromyelia, tethered cord and hypoplasia) were determined by patient's symptoms and verified by MRI. Data were from our Patient Data Management System and analyzed using Microsoft Excel and Epi Info 6. Flat lesions protruding less than 1.0 cm beyond the plane of the back and those associated with breech position or kyphus were not benefited by PRAM CIS (Fisher's Exact, p = 0.58 between the two types of delivery for motor level). Flat lesions were more common in the vaginally delivered group (p = 0.01). Lesions protruding equal to 1.0 cm or beyond were associated with less paralysis after PRAM C/S (p = 0.01). Although tethered cord syndrome was more common in the PRAM C/S group (p = 0.02), there was no difference in the muscle strength loss between the PRAM C/S and the vaginally delivered groups. Symptomatic hydromyelia was equally distributed but spinal cord hypoplasia was more common in the PRAM C/S group (p = 0.03). Due to the limited numbers of patients in each group available for analysis, we recommend further study to ascertain the appropriate management of fetal myelomeningocele diagnosed in utero and brought to term.

Anatomy of the spinal cord in patients with meningomyelocele with and without hypoplasia or hydromyelia

We compared the cross-sectional areas of spinal cords of patients with normal cords to the area of patients with meningomyelocele. The control group consisted of examinations of 27 patients with normal spinal cords providing 1547 axial images at 20 levels, C2-L2. The meningomyelocele group consisted of 67 MRI examinations of 41 patients, providing 4,095 axial images at 23 levels C2 to S1. Thirty-four examinations were of 21 patients with minimal hydromyelia, 7 examinations were of 3 patients with operable hydromyelia, and 26 examinations were of 17 patients without hydromyelia. In an additional analysis, we selected those meningomyelocele patients with cord tethering but without hydromyelia or hypoplasia (53 examinations of 30 patients) and compared them to symptomatic hypoplasia cases (9 examinations of 6 patients). The symptomatic hypoplasia cases were chosen because of progressive loss of muscle strength and worsening spasticity not relieved by surgical adhesiolysis. The test, retest error was 5.6% with differences between the means of repeated readings not being significant. All tests for significance were paired T test. The areas of spine levels C7-L2 for the controls were significantly larger than for the meningomyelocele patients (p = 0.000007). Including all levels C2-S1, the minimal hydromyelia cases were not significantly different from those without hydromyelia (p = 0.5). The areas C2-S1 of operable hydromyelia cases were larger than both non-shunted minimal hydromyelia (p = 0.00009) and of meningomyelocele patients without hydromyelia (p = 0.00003). The areas C7-L2, of hypoplasia cases were significantly smaller compared to the "normal" meningomyelocele cases (p = 0.0004). These data suggest that hydromyelia stimulates overgrowth of the cord, as does hydrocephalus of the brain, and that adhesiolysis procedures are of no value with hypoplasia of the spinal cord.

Epidemiology of tethered cord with meningomyelocele

This paper describes the epidemiology of tethered cord syndrome and its etiologies and co-morbidities following initial repair of both meningomyeloceles and lipomeningomyelocele. A review of the pertinent literature and data from 654 cases of meningomyelocele and 118 cases of lipomeningomyelocele has been drawn from a computerized database, Patient Data Management System/fx. Only cases born since 1964 were analyzed for the etiologies, co-morbidities, spinal cord abnormalities detected by contrast studies or MRI and for significant symptoms and signs. Tethered cord symptoms were related to an attachment to a rigid tether for all 31 cases following lipomeningomyelocele repair but 62 (75%) of the 83 post meningomyelocele repair patients developed the symptoms of tethered cord. Causes other than, or in addition to, tethering included an obstructed cerebrospinal fluid shunt, syringohydromyelia, benign tumor and spinal cord hypoplasia. Quantitative differentiation between asymptomatic thin spinal cords and symptomatic spinal cord hypoplasia as well as between central canal enlargement and symptomatic syringohydromyelia could not be demonstrated. Collaborative, multi-center studies of larger numbers of patients are recommended.

Vertebral column and spinal cord malformation in children with exstrophy of the cloaca, with emphasis on their functional correlates

Exstrophy of the cloaca is a dramatic malformation whose embryology is poorly understood. While the management of this disorder has received significant attention in the urology and general surgery literature, the neurologic status of these children has been poorly addressed. In order to better characterize the spinal cord and vertebral column malformations found in children with exstrophy of the cloaca, we undertook a clinical review of 26 consecutive children with exstrophy of the cloaca who had been seen at a single institution over 28 years. The prevalence of vertebral malformations in the 25 children who could be evaluated was 25/25 (100%). Twenty (80%) of the children had at least one vertebral fusion, most frequently at T-7. Twenty-two (88%) of the children had at least one vertebra with deficient posterior elements, and the spinal levels most frequently involved were S-2, S-3, S-4 and S-5. Nine (36%) of the children had at least one vertebra with a narrowed interpedicular distance, most frequently at T-7. Nine (36%) of the children had at least one vertebra with atrophic facet anatomy, most frequently at L-3. The prevalence of myelodysplasia in the 19 children for whom spinal magnetic resonance imaging or intraoperative findings were available was 100%. Of these 19 children, 15 (79%) had myelocystocele, 2 (11%) had a lipomeningocele, 2 (11%) had a meningocele, 2 (11%) had hydromyelia, and 4 (21%) had a tethered cord. These data suggest that spinal cord and vertebral column malformations are very common in children with exstrophy of the cloaca.

Plasma homocysteine and methionine concentrations in children with neural tube defects

Mild to moderate homocysteinemia in women has been associated with an increased frequency of pregnancies with neural tube defects (NTD). Homocysteinemia is also an independent risk factor for premature vascular disease. In addition to folic acid, supplemental Vitamin B12, Vitamin B6 and betaine may normalize homocysteine metabolism, decrease the risk for NTD formation, and correct related metabolic imbalances in children with NTD. By means of automated amino acid analysis, we assessed total non-fasting homocysteine and methionine in plasma from 24 children with myelomeningocele. This study group (mean age 10.5 +/- 4.9 years) included 12 girls and 12 boys randomly selected from our Birth Defects Clinic. Homocysteine concentrations in our patients (4.7 +/- 1.8 mumol/L) did not differ from those of 20 randomly selected child controls (5.1 +/- 2.6 mumol/L). The mean homocysteine concentration for 36 adult controls (9.3 +/- 3.0 mumol/L) was significantly higher than the mean for either group of children (p < 0.0001). Linear regression analysis revealed negative correlation of total plasma homocysteine with serum folate (r = -0.53; p = 0.01), but not of homocysteine with either methionine or B12. Plasma methionine concentrations from our patients did not differ from adult reference values. Elevated homocysteine in some mothers of children with NTD has been attributed to defective methylation of homocysteine. These preliminary results do not indicate such a defect in the children themselves. A more comprehensive study of homocysteine, methionine and related metabolites in children with NTD and age-matched controls will be required to determine the clinical significance of these findings.

Comparison of erythrocyte antioxidant enzyme activities and embryologic level of neural tube defects

Increased exposure to oxidant-derived free radicals or inadequate systems for antioxidant defense could alter cellular response at critical points in development. We measured 5 antioxidant enzymes, glutathione peroxidase (GSH-Px), glutathione reductase, glutathione-S-transferase, catalase and superoxide dismutase in erythrocytes and their plasma cofactor trace elements (Se, Zn, Cu) in 37 children with myelomeningocele and in 37 age-matched controls. We placed the patients into 3 groups according to motor level of the lesion at birth. We found significantly lower GSH-Px activities (p = 0.007) in children with myelomeningocele. For paired comparisons among the 3 patient groups and controls, there were significant differences (p < 0.05) between controls and both high (thoracic) and raid (lumbar) level embryologic lesions. The finding of antioxidant enzyme variations in our patients with myelomeningocele may indicate a role for abnormal oxidative metabolism in the development of this defect. The contribution of oxidative stress to human birth defects warrants investigation. We discuss potential relationships between oxidative stress and energy metabolism during primary neurulation.

Erythrocyte antioxidant enzyme activities in children with myelomeningocele

Erythrocyte free radical scavenging enzyme activities and their cofactor trace elements in plasma were assessed in 26 selected patients with myelomeningocele, both parents from 10 selected families, and 14 healthy adult controls. All index children except one were deficient in erythrocyte glutathione peroxidase (GSH-Px). Nine of 10 parent pairs had at least one parent with deficient GSH-Px activity. Children with myelomeningocele had significantly lower GSH-Px activities than their parents; the group of 10 parent pairs had significantly lower GSH-Px activities than the control group; and glutathione reductase activities were significantly lower in parents and children with myelomeningocele compared with controls. A deficiency in one or more antioxidant enzymes may increase the risk for neural tube defects.

Epidemiology, etiologic factors, and prenatal diagnosis of open spinal dysraphism

The caudal neural tube closes late in the first month after fertilization and failure of it results in myelomeningocele. Epidemiologic studies have shown differences in prevalence at birth based on ethnic-racial backgrounds and geography. Etiologic factors include the drug valproic acid or carbamazepine. Periconceptional folic acid supplementation appears to decrease the prevalence of neural tube defects. Numerous modalities allow for prenatal diagnosis of myelomeningocele. A cesarean section, before rupture of amniotic membranes and onset of labor, decreases the degree of paralysis.

Fetal aqueductal stenosis diagnosed sonographically: how grave is the prognosis?

OBJECTIVE

Aqueductal stenosis is a common cause of fetal hydrocephalus. Published studies of neonates with aqueductal stenosis have noted variable outcomes, with normal development seen in 24-86% of cases. In an attempt to better assess long-term outcomes in cases diagnosed in utero and to determine what prenatal sonographic findings might be used to predict prognosis, a retrospective analysis of patients with aqueductal stenosis was done.

MATERIALS AND METHODS

Fifty-three consecutive cases of aqueductal stenosis discovered in utero at two high-risk obstetrical centers in Seattle between 1980 and 1993 were studied. Parents elected to continue pregnancy in 39 of these cases. Two months to 10 years of long-term follow-up was available in 30 patients, who form our study group. Prenatal sonograms, postnatal cranial ultrasound, and head CT and MR were evaluated. Prenatal sonographic data collected included the biparietal diameter, size of the lateral and third ventricles, the ratio of the two, and thickness of the frontoparietal cortical mantle. Medical records provided an assessment of development based on physical examination, meeting of major milestones, and neuropsychological testing. The in utero diagnosis of aqueductal stenosis was confirmed by postnatal CT, MR imaging, sonography, or autopsy.

RESULTS

Within the study group of 30 patients, eight died in the postnatal period and four died subsequently. Of the 22 patients with adequate postnatal follow-up, moderate or severe developmental delay was present in 16 (73%). Normal developmental milestones were met in only three (10%) of all 30 patients and in 14% of those surviving the neonatal period. Although size of the lateral and third ventricles was not a useful predictor of long-term prognosis, the ratio of the two, as well as thickness of the frontoparietal cortical mantle, was weakly associated with long-term prognosis. No correlation was found between biparietal diameter and outcome.

CONCLUSION

As compared with previous reports, prenatal diagnosis of aqueductal stenosis carries a grave prognosis. Twelve of the 30 patients died, for an overall mortality of 40%. Normal development was seen in only 10%, significantly less than in prior studies.

The outcome of fetal myelomeningocele brought to term

14 years experience with 354 infants born with myelomeningocele are reviewed in view of prelabor and pre-rupture of amniotic membranes vs vaginal delivery or delivery by cesarian section after labor and rupture of amniotic membrane. The apparent lack of effect of severity of impairment determined by prenatal diagnosis on parental decision to carry their baby to term, the negative effect on motor function of kyphos or congenital kyphoscoliosis, the equivocal effect of breech presentation with or without rupture of amniotic membranes and the beneficial effect of prelabor and prerupture of membranes delivery of selected infants is discussed. The need for further multiple center, collaborative study to identify the contribution of a number of factors influencing the outcome of fetuses diagnosed as having myelomeningocele is emphasized.

Cognitive abilities and lipomyelomeningocele

Ten children with lipomyelomeningocele were evaluated with the WISC--R, the Wide Range Achievement Test--Revised, the Developmental Test of Visual-motor Integration, and the Child Behavior Checklist. These children were consecutive referrals to a birth defects clinic. Unlike their meningomyelocele counterparts, as a group these children appear to be average in their intellectual, academic, and behavioral characteristics. However, they exhibited low average perceptual motor skills, a feature more commonly seen in meningomyelocele.

The natural history of hip deformity in myelomeningocele

We studied 1061 children with myelomeningocele, reviewing 3184 pelvic radiographs from 802 patients. Hip dislocation had occurred by the age of 11 years in 28% of children with a thoracic neurosegmental level, 30% of those with an L1/2 level, 36% of L3, 22% of L4, 7% of L5 and only 1% of those with sacral levels. Hip dislocation was not inevitable even when there was maximal muscle imbalance about the hip. The average hip flexion contracture in children aged 9 to 11 years was significantly greater in those with thoracic (22 degrees) and L1/2 (33 degrees) levels than in those with L4 (9 degrees), L5 (5 degrees) or sacral (4 degrees) levels. Our findings indicate that muscle imbalance is not a significant factor in the production of flexion deformity or dislocation of the hip; both are commonly seen in the absence of imbalance. The restoration of muscle balance should no longer be considered to be the principal aim of the management of the hip in children with myelomeningocele.

Mobility aids for children with high-level myelomeningocele: parapodium versus wheelchair

The optimal method for providing mobility for children with myelomeningocele remains controversial. 39 children using a parapodium were compared with 29 children in wheelchairs. There were no significant differences between the two groups for medical complications, use of health-care services or activities of daily living, although there were differences in the patterns of complications. Children using the parapodium were more likely to develop lesions of the lower extremities, to have dislocated hips, to be more obese and to watch more television; children using wheelchairs were more likely to develop lesions of the gluteal region, to have knee-flexion contractures and to have fewer fecal accidents. The parapodium was judged by families to be less effective as a mobility aid; however, the upright posture it allows was considered extremely advantageous. A combined approach allowing upright posture and wheeled mobility would appear to be optimal.

Cognitive abilities and achievement status of children with myelomeningocele: a contemporary sample

Designed study as a conceptual replication of Shaffer, Friedrich, Shurtleff, and Wolf (1985). Intelligence, school achievement, and perceptual motor skill data from 73 children with uncomplicated myelomeningocele were examined to determine their deviation from test norms. The respective impact of shunting and functional motor level was also assessed. The sample as a whole functioned below WISC-R and VMI norms. On the WRAT, deviation from the norms was evident only for the Arithmetic subtest. Partial replication of the Shunt X Motor level interaction reported by Shaffer et al. (1985) was obtained. Limitations of small-sample studies are discussed.

Modifications to the traditional description of neurosegmental innervation in myelomeningocele

The consistency between patterns of lower-limb muscle strengths in children with myelomeningocele and Sharrard's classic description of segmental innervation was examined in 291 patients. Although it has been assumed that medial hamstring innervation was from a similar neurosegmental level as gluteus medius, and gluteus maximus was from a similar level as gastrocnemius-soleus, the authors found that medial hamstring strength more frequently correlated with iliopsoas and quadriceps, and glutei with anterior tibialis. It is proposed that children with myelomeningocele be grouped according to specific muscle strength rather than by neurosegmental level.

Ambulatory outcome of children with myelomeningocele: effect of lower-extremity muscle strength

The relationship between patterns of strength and mobility was studied in 291 children with myelomeningocele, graded as community ambulators, partial (household) ambulators and nonambulators. Iliopsoas strength was found to be the best predictor of ambulation, with the quadriceps, anterior tibialis and glutei also contributing significantly. Grade 0 to 3 iliopsoas strength was always associated with partial or complete reliance on a wheelchair. No patient with grade 4 to 5 iliopsoas and quadriceps function relied completely on wheelchairs and the majority were community ambulators. Grade 4 to 5 gluteal and anterior tibialis function was associated with community ambulation, without aids or braces. Deterioration in mobility was most common in those with strong iliopsoas/quadriceps and grade 0 to 3 gluteus medius, and was not age-related.

Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally

Background. Meningomyelocele can now be detected before birth. Few data are available on its natural history, however, and optimal management at the time of delivery is controversial, although it has been suggested that labor and vaginal delivery may cause pressure on exposed nerve roots, resulting in additional loss of neural function. Methods. To assess the effect of labor and the type of delivery on the level of motor function in fetuses with uncomplicated meningomyelocele, we identified 200 cases of this disorder, accounting for 95 percent of the cases that occurred in the state of Washington during our 10-year study period. We compared the outcomes of 47 infants delivered by cesarean section before labor began, 35 delivered by cesarean section after a period of labor, and 78 who were delivered vaginally (another 40 were ineligible for the study). In cases of meningomyelocele detected prenatally, cesarean section was performed before the onset of labor if isolated meningomyelocele without severe hydrocephalus was present. The infants delivered in this manner were compared with those who were delivered either vaginally or by cesarean section after labor began. Results. At two years of age, the infants who had been exposed to labor were 2.2 times more likely to have severe paralysis than those delivered by cesarean section without labor (95 percent confidence interval, 1.7 to 2.8). Infants delivered by cesarean section before the beginning of labor had a mean (+/- SD) level of paralysis 3.3 +/- 3.0 segments below the anatomical level of the spinal lesion at two years of age, as compared with 1.1 +/- 2.3 for infants delivered vaginally and 0.9 +/- 4.1 for infants delivered by cesarean section after the beginning of labor (P less than 0.001 for both comparisons). Exposure to labor did not affect the frequency of neonatal complications or later intellectual performance. Conclusions. For the fetus with uncomplicated meningomyelocele, delivery by cesarean section before the onset of labor may result in better subsequent motor function than vaginal delivery or delivery by cesarean section after a period of labor.

The outcome of pregnancies diagnosed as having a fetus with meningomyelocele

Forty-nine cases of meningomyelocele diagnosed in utero and another 10 cases delivered by prelabor cesarean section (N = 59) are compared to all other cases of meningomyelocele (N = 98) born following labor and seen during the same period. Prenatal diagnosis was established for 19 cases before and 30 cases after 24 weeks gestational age. Ten cases were delivered by prelabor cesarean section for maternal indications. Eight of 12 cases diagnosed before 24 weeks and given a guarded prognosis and one given a poor prognosis, elected cesarean section. One of the 8 was stillborn. Four of the 12 given a guarded prognosis and 6 an extremely poor prognoses elected termination of the pregnancy. Nineteen of the 30 cases diagnosed after 24 weeks were delivered by prelabor cesarean section and two by cesarean section after inadvertent labor. Of the 35 cases born by prelabor cesarean section, 48% have sacral levels or no loss of motor function compared to 14% of the 98 born after labor (P = 0.0001). We recommend prelabor cesarean section before onset of labor to preserve neural function of a baby with meningomyelocele and leg movement in utero when parents refuse termination or have a diagnosis made after 24 weeks gestational age.

Assessment of muscle strength in children with meningomyelocele: accuracy and stability of measurements over time

The strength of lower limb musculature, as determined by clinical muscle testing, influences assigned lesion levels, prognosis, and the subsequent orthopedic and rehabilitative management of children with meningomyelocele. The purpose of this study was to determine the accuracy of muscle testing at various ages based on clinical impressions of therapists; and to determine how the stability of measurements over time varies with age and muscle tested. A total of 3,084 examinations were performed on 825 children with meningomyelocele. Therapists coded the degree of accuracy of the last 1,282 examinations. Of these patients 177 with six or more serial examinations were studied by generating Spearman rank order correlation coefficients for comparison of strength measurements at given ages with median strengths during five-year follow-up periods. The percentages of patients who had examinations at a given age equal to, and within one grade of individual best estimates of ultimate muscle strength were also calculated. It was concluded that: therapists are markedly more confident about assessments in children five years and older; stability of muscle testing measurements over time generally increases from birth to age five or six when peak stability is approached; the probability that a single muscle test precisely predicts future muscle strength varies with age and muscle tested; and the probability that a muscle test will predict future strength to within one grade is not strongly influenced by age or muscle tested.

Meningomyelocele: a new or a vanishing disease?

I believe meningomyelocele is not vanishing, but is a new and diminishing disorder. Prenatal diagnosis will be accepted only by a portion of most communities if abortion is the only alternative to the delivery of an impaired child. I believe participation in neural tube screening programmes can be increased by offering improved pregnancy outcome with concomitant prelabor caesarean section in addition to termination. Regardless, the prevalence at birth of children with myelomeningocele will decrease both in total numbers and in the severity of the expressed lesion. The resultant rarity will require collaboration between centers to evaluate treatment. The developing International Myelodysplasia Study Group using a Patient Data Management System and computer-assisted analysis is a model of successful collaboration that allows better exploration of the multiple variables that contribute to the well-being of children with open neural tube defects of the spine.

Natural history of flexion deformity of the hip in myelodysplasia

For definition of the incidence and natural history of hip flexion contracture, 5,147 serial measurements of the range of hip extension in 966 patients with spina bifida were analyzed. Contractures were generally present in the first few months of life (physiologic flexion posture); this then diminished during the first 27 months in all but those with thoracic lesions. Hence, surgical management is seldom appropriate until after that age. In general, contractures reappear or worsen between the ages of 3 and 6 years, but few patients with sacral lesions develop this deformity. Our findings also demonstrate that hip flexion contracture is not merely due to muscle imbalance, sitting posture, or these factors in combination.

Hip flexion contractures: a comparison of measurement methods

Rater reliability characteristics of four positioning techniques used to measure hip extension (prone hip extension, Thomas, Mundale, and pelvifemoral angle) were compared. Two raters examined 45 children (90 hips), including patients with spastic diplegia and with meningomyelocele, who are prone to developing hip flexion contractures, and healthy subjects. Retests were performed on 21 children. The least reliable readings in the cerebral palsy group were found from tests using the Thomas technique, and in the meningomyelocele group using the Mundale technique. The pelvifemoral angle is more time consuming, and no more accurate than other methods. Considering the ease of measurement, reliability and reproducibility, we recommend use of the prone hip extension test for patients with cerebral palsy and for those with meningomyelocele, and recommend the Thomas test as an alternative for nonspastic patients.

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.

Experience with 1201 cerebrospinal fluid shunt procedures

This report of our experience with 1,201 cerebrospinal fluid shunt procedures over a 17-year period includes two time periods: from 1965 to 1974 and from 1975 to 1982. The overall operative infection rate fell from 10.7% in the former period to 3.6% in the latter period. The overall average number of revisions fell from 1.8 to 0.77. The number of revisions for patients with infected shunts in the latter period was 4.07. Three hundred and eighty-four shunts were studied in the latter period for the effects of prophylactic antibiotics. No significant difference was found between the infection rate of 5.6% in the nonantibiotic group and the infection rate of 2.1% in the group receiving intravenous and intraventricular methicillin and gentamicin. Differences in the operative infection rates for patients with and without meningomyelocele and those operated on by different surgeons were not significant. The only mortalities were from nonoperative and noncerebrospinal fluid shunt causes.

Toileting skills in children with myelomeningocele: rates of learning

Rates at which 173 children with myelomeningocele learned 20 different toileting skills were studied in an attempt to describe their acquisition of control over chronic urinary and stool incontinence. All had clinical or urodynamic evidence of neurogenic bowel and bladder dysfunction. Seventy-five other children were excluded because of intelligence quotients less than or equal to 70 points, uncontrolled hydrocephalus, spastic extremities, or other major disabilities. Inadequate follow-up or parent cooperation eliminated 27 other cases. Using a home inventory, parents recorded their child's accomplishments. An investigator contacted parents regularly to minimize inaccurate reporting and to screen data against preestablished criteria. The observation period lasted 2.5 years, but earlier achievements that met criteria were included in the cumulative data pool. Each child was categorized into one of four groups of motor paralysis (L2 and above, L3-4, L4-5, S1 and below), and calculations were made when 20%, 50%, and 80% of the children had attained each toileting skill. Intergroup and intragroup variances were often striking. Possible explanations for these variances include physical and psychosocial readiness as well as home and community support systems. For the child who meets the selection criteria, these specific learning rates can be used in evaluating treatment, describing current levels of bladder or bowel control, and setting realistic goals.

Survival after acute mercury vapor poisoning

An 8-month-old girl with acute mercury vapor intoxication experienced pneumonitis with respiratory failure, bilateral pneumothorax, pneumomediastinum, acute renal failure, hepatocellular dysfunction, and seizures. Treatment centered on intensive supportive care; her survival is exceptional among infants with severe mercury intoxication.

A longitudinal study of shunt function in 360 patients with hydrocephalus

Data from an eight-year clinical study of shunt-treated hydrocephalus indicated continued shunt dependency in 289 of 360 patients. 919 combined pressure-radionuclide clearance studies were performed. In 307 studies in which the shunt was identified as nonfunctional, 208 patients were symptomatic for increased intracranial pressure and had the shunt revised. Of the other 99 patients, 71 have remained asymptomatic for three to 60 months (mean 27 months) and 28 subsequently required shunt revision after one to 67 months (mean 24 months). Five other clinical patterns are described. Various methods of monitoring shunt function are recommended.

Developmental guidelines for children with myelodysplasia

A new inventory of 166 milestones and developmental tasks was designed and given to parents of 173 children with myelodysplasia to use over a 2 1/2-year period to record their children's development. The inventory included items in the categories of self-help (including independent toileting), personal-social development, and gross motor development. The children were placed in one of four subgroups according to their level of paralysis. For each motor-level group, the percentage of those performing each item at various ages was calculated. The ages of routine performance of selected self-help and personal-social items are reported for 20, 50, and 80 percent achievement for the children for whom the data were known. There was a tendency for the less paralyzed children to learn skills more quickly than their more paralyzed peers. However, the wide age ranges within groups for learning individual skills indicate that factors other than the level of paralysis affect the rate of development, and these factors need to be identified. The data provided represent a reasonable estimate of when children with varying degrees of paralysis can first be expected to perform developmental tasks. The tables can be used to establish learning objectives and programs so that more children with myelodysplasia can learn independence at an earlier age.

Skin breakdown in patients with myelomeningocele

An attempt was made to quantify longitudinal morbidity and identify risk factors associated with high rates of skin breakdown in patients with myelomeningocele. Based on annual evaluations, 227 of 524 patients accounted for 468 positive observations including classic decubiti, abrasions, burns, and ammoniacal dermatitis. Forty-two percent (196) of skin breakdown was attributed to excessive pressure; 57% (267) to other causes; and 1% (5) to unknown causes. Prevalence curve revealed a steady rise from infancy to age 10 years, at which point rates varied between 20-25%. Longitudinal morbidity curves of first skin breakdown showed a tendency of lesions over the perineum or gibbus to appear more frequently in the presence of higher paraplegia (generalized Savage or Mantel-Cox, p = 0.05). However, mildly paraplegic and partially insensate patients exhibited relatively higher rates of breakdown over the lower extremities compared to more paraplegic patients. Higher rates of breakdown were associated with other characteristics such as mental retardation, large head size, kyphoscoliosis, and chronic soiling. Data confirm the high prevalence of skin breakdown in patients with myelomeningocele and reflect an overall influence of growth and development.

Vesicoureteral reflux in children with uremia. Prognostic indicators for treatment and survival

To define factors related to renal prognosis in children with vesicoureteral reflux and renal insufficiency, we reviewed 908 children with vesicoureteral reflux. Twenty-five patients were found who had initial creatinine clearances of less than 60 mL/min/sq m and had five-year follow-up examinations. All had severely dilated ureters. Renal function improved in eight, remained stable in ten, and deteriorated in seven. Probability of deterioration of renal function in these children was related to factors measurable at clinical presentation: (1) a corrected creatinine clearance of less than 25 mL/min/sq m; (2) 2r greater reaction for protein on urinalysis that disclosed no infection; and (3) being in less than the fifth percentile of body length. The total number of the three factors present in each patient was more significantly related to prognosis than any one factor.

Combined pressure-radionuclide evaluation of suspected cerebrospinal fluid shunt malfunction: a seven-year clinical experience

A simple, safe radionuclide technique for evaluating the functional status of a cerebrospinal fluid shunt has been used in the clinical management of hydrocephalus in 306 patients over a seven-year period. Results of 526 studies showed greater than 99% sensitivity and accuracy in diagnosing distal shunt obstruction and 96% correct correlation with clinical outcome overall. Intrareservoir pressure measurements are especially valuable to diagnose proximal catheter shunt malfunction and to assess shunt dependency.

An autosomal dominantly inherited syndrome of facial asymmetry, esotropia, amblyopia, and submucous cleft palate (Bencze syndrome)

This is the second report of a dominantly inherited syndrome of facial asymmetry, esotropia, and amblyopia (Bencze syndrome). The phenotypic spectrum is expanded to include submucous cleft palate. The observation for the first time of male-to-male transmission seems to confirm an autosomal dominant mode of inheritance. The facial asymmetry in this family was mild and did not require surgical intervention. With the exception of one patient who had other abnormalities, intelligence was normal.

Bladder function in children with meningomyelocele: comparison of cine-fluoroscopy and urodynamics

We have assessed 60 children on an outpatient basis with cine-fluoroscopy combined with urodynamics. Bladder and rectal pressure together with sphincter electromyography were measured during bladder filling under fluoroscopy, which was followed by measurement of rectal pressure and sphincter electromyography during voiding under fluoroscopy. Comparison of the x-ray studies and urodynamics showed that the cystogram alone was not a reliable indicator of ray studies and urodynamics showed that the cystogram along was not a reliable indicator of detrusor function. The sphincter electromyogram during voiding must be interpreted in the face of intra-abdominal pressure changes owing to straining or Credé's maneuver. Residual urine estimations and the appearance of the bladder outflow on fluoroscopy were better parameters of outflow obstruction than sphincter electromyography.