Rigorous science demands support of transgender scientists

To build a just, equitable, and diverse academy, scientists and institutions must address systemic barriers that sex and gender minorities face. This Commentary summarizes (1) critical context informing the contemporary oppression of transgender people, (2) how this shapes extant research on sex and gender, and (3) actions to build an inclusive and rigorous academy for all.

Multivariate Models of Animal Sex: Breaking Binaries Leads to a Better Understanding of Ecology and Evolution

"Sex" is often used to describe a suite of phenotypic and genotypic traits of an organism related to reproduction. However, these traits-gamete type, chromosomal inheritance, physiology, morphology, behavior, etc.-are not necessarily coupled, and the rhetorical collapse of variation into a single term elides much of the complexity inherent in sexual phenotypes. We argue that consideration of "sex" as a constructed category operating at multiple biological levels opens up new avenues for inquiry in our study of biological variation. We apply this framework to three case studies that illustrate the diversity of sex variation, from decoupling sexual phenotypes to the evolutionary and ecological consequences of intrasexual polymorphisms. We argue that instead of assuming binary sex in these systems, some may be better categorized as multivariate and nonbinary. Finally, we conduct a meta-analysis of terms used to describe diversity in sexual phenotypes in the scientific literature to highlight how a multivariate model of sex can clarify, rather than cloud, studies of sexual diversity within and across species. We argue that such an expanded framework of "sex" better equips us to understand evolutionary processes, and that as biologists, it is incumbent upon us to push back against misunderstandings of the biology of sexual phenotypes that enact harm on marginalized communities.

Sex and Biology: Broader Impacts Beyond the Binary

What are the implications of misunderstanding sex as a binary, and why is it essential for scientists to incorporate a more expansive view of biological sex in our teaching and research? This roundtable will include many of our symposium speakers, including biologists and intersex advocates, to discuss these topics and visibilize the link between ongoing reification of dyadic sex within scientific communities and the social, political, and medical oppression faced by queer, transgender, and especially intersex communities. As with the symposium as a whole, this conversation is designed to bring together empirical research and implementation of equity, inclusion, and justice principles, which are often siloed into separate rooms and conversations at academic conferences. Given the local and national attacks on the rights of intersex individuals and access to medical care and bodily autonomy, this interdisciplinary discussion is both timely and urgent.

Comparative phylogeography reveals widespread cryptic diversity driven by ecology in Panamanian birds

Widespread species often harbor unrecognized genetic diversity, and investigating the factors associated with such cryptic variation can help us better understand the forces driving diversification. Here, we identify potential cryptic species based on a comprehensive dataset of COI mitochondrial DNA barcodes from 2,333 individual Panamanian birds across 429 species, representing 391 (59%) of the 659 resident landbird species of the country, as well as opportunistically sampled waterbirds. We complement this dataset with additional publicly available mitochondrial loci, such as ND2 and cytochrome b, obtained from whole mitochondrial genomes from 20 taxa. Using barcode identification numbers (BINs), we find putative cryptic species in 19% of landbird species, highlighting hidden diversity in the relatively well-described avifauna of Panama. Whereas some of these mitochondrial divergence events corresponded with recognized geographic features that likely isolated populations, such as the Cordillera Central highlands, the majority (74%) of lowland splits were between eastern and western populations. The timing of these splits are not temporally coincident across taxa, suggesting that historical events, such as the formation of the Isthmus of Panama and Pleistocene climatic cycles, were not the primary drivers of cryptic diversification. Rather, we observed that forest species, understory species, insectivores, and strongly territorial species-all traits associated with lower dispersal ability-were all more likely to have multiple BINs in Panama, suggesting strong ecological associations with cryptic divergence. Additionally, hand-wing index, a proxy for dispersal capability, was significantly lower in species with multiple BINs, indicating that dispersal ability plays an important role in generating diversity in Neotropical birds. Together, these results underscore the need for evolutionary studies of tropical bird communities to consider ecological factors along with geographic explanations, and that even in areas with well-known avifauna, avian diversity may be substantially underestimated.

LAY SUMMARY

- What factors are common among bird species with cryptic diversity in Panama? What role do geography, ecology, phylogeographic history, and other factors play in generating bird diversity?- 19% of widely-sampled bird species form two or more distinct DNA barcode clades, suggesting widespread unrecognized diversity.- Traits associated with reduced dispersal ability, such as use of forest understory, high territoriality, low hand-wing index, and insectivory, were more common in taxa with cryptic diversity. Filogeografía comparada revela amplia diversidad críptica causada por la ecología en las aves de Panamá.

RESUMEN

Especies extendidas frecuentemente tiene diversidad genética no reconocida, y investigando los factores asociados con esta variación críptica puede ayudarnos a entender las fuerzas que impulsan la diversificación. Aquí, identificamos especies crípticas potenciales basadas en un conjunto de datos de códigos de barras de ADN mitocondrial de 2,333 individuos de aves de Panama en 429 especies, representando 391 (59%) de las 659 especies de aves terrestres residentes del país, además de algunas aves acuáticas muestreada de manera oportunista. Adicionalmente, complementamos estos datos con secuencias mitocondriales disponibles públicamente de otros loci, tal como ND2 o citocroma b, obtenidos de los genomas mitocondriales completos de 20 taxones. Utilizando los números de identificación de código de barras (en ingles: BINs), un sistema taxonómico numérico que proporcina una estimación imparcial de la diversidad potencial a nivel de especie, encontramos especies crípticas putativas en 19% de las especies de aves terrestres, lo que destaca la diversidad oculta en la avifauna bien descrita de Panamá. Aunque algunos de estos eventos de divergencia conciden con características geográficas que probablemente aislaron las poblaciones, la mayoría (74%) de la divergencia en las tierras bajas se encuentra entre las poblaciones orientales y occidentales. El tiempo de esta divergencia no coincidió entre los taxones, sugiriendo que eventos históricos tales como la formación del Istmo de Panamá y los ciclos climáticos del pleistoceno, no fueron los principales impulsores de la especiación. En cambio, observamos asociaciones fuertes entre las características ecológicas y la divergencia mitocondriale: las especies del bosque, sotobosque, con una dieta insectívora, y con territorialidad fuerte mostraton múltiple BINs probables. Adicionalmente, el índice mano-ala, que está asociado a la capacidad de dispersión, fue significativamente menor en las especies con BINs multiples, sugiriendo que la capacidad de dispersión tiene un rol importamente en la generación de la diversidad de las aves neotropicales. Estos resultos demonstran la necesidad de que estudios evolutivos de las comunidades de aves tropicales consideren los factores ecológicos en conjunto con las explicaciones geográficos. Palabras clave: biodiversidad tropical, biogeografía, códigos de barras, dispersión, especies crípticas.

Iron deficiency anemia in children with exstrophy of the cloaca

The clinical records of twenty-five children with exstrophy of the cloaca (EC) were retrospectively reviewed to evaluate the prevalence and the clinical characteristics of iron deficiency anemia (IDA). Five of the 25 children with EC (20 %) exhibited IDA at some point. Their ages at the time of diagnosis were between 1.9 and 13.0 years. In the four cases where IDA was thought to be related to iron malabsorption secondary to short-bowel syndrome, its treatment required longer periods of iron supplementation to correct the anemia and to restore the total body iron stores. Physicians caring for children with EC should monitor for and treat IDA as part of a comprehensive management plan.

The measurement of health-related quality of life (HRQL) in children with cerebral palsy

The measurement of health-related quality of life (HRQL) in children with cerebral palsy is part of an emerging discipline. Theoretical models of disability and chronic illness developed by the World Health Organization, the National Center for Medical Rehabilitation Research and others are being adapted for children. Development of HRQL measures in paediatrics lags behind the work completed with adults due to challenges unique to children, such as what domains to measure, whose perspective to address and the developmental changes inherent to children. The descriptive HRQL studies of children with moderate to severe cerebral palsy and comparisons of children with quadriplegia vs. diplegia and hemiplegia are presented. Consistent with the functional measures, no significant difference in HRQL by treatment was documented in children with spastic diplegia participating in a randomized clinical trial of selective dorsal rhizotomy. HRQL measures that are specifically tailored to cerebral palsy need to be developed. Generic and individualized measures of HRQL are currently available and while limited, may be useful for evaluating the effect of different treatments for spasticity on the quality of life in children with cerebral palsy.

Changes in gait at 1 year post-selective dorsal rhizotomy: results of a prospective randomized study

We performed a prospective randomized trial to compare the effects of selective dorsal rhizotomy with intensive physical therapy to intensive physical therapy alone in a group of children with mild spastic diplegic cerebral palsy. Instrumented gait analysis was carried out upon enrollment into the study and after 1 year. Changes in ambulatory status, time/distance parameters, and gait kinematics were observed for both groups. Considerable variability was present in both groups. Changes in ankle dorsiflexion, foot progression angle, and hip and knee extension in stance were significantly better in the selective dorsal rhizotomy group compared to the physical therapy group at 1 year (p < 0.05). These differences were not associated with significant improvements in functional gait as determined by changes in time/distance parameters or ambulatory status.

Intrathecal baclofen for management of spastic cerebral palsy: multicenter trial

Intrathecal baclofen infusion has demonstrated effectiveness in decreasing spasticity of spinal origin. Oral antispasticity medication is minimally effective or not well tolerated in cerebral palsy. This study assessed the effectiveness of intrathecal baclofen in reducing spasticity in cerebral palsy. Candidates were screened by randomized, double-blind, intrathecal injections of baclofen and placebo. Responders were defined as those who experienced an average reduction of 1.0 in the lower extremities on the Ashworth Scale for spasticity. Responders received intrathecal baclofen via the SynchroMed System and were followed for up to 43 months. Fifty-one patients completed screening and 44 entered open-label trials. Lower-extremity spasticity decreased from an average baseline score of 3.64 to 1.90 at 39 months. A decrease in upper extremity spasticity was evidenced over the same study period. Forty-two patients reported adverse events. Most common reports were hypotonia, seizures (no new onset), somnolence, and nausea or vomiting. Fifty-nine percent of the patients experienced procedural or system-related events. Spasticity in patients with cerebral palsy can be treated effectively by continuous intrathecal baclofen. Adverse events, although common, were manageable.

Current practice of occupational therapy for children with autism

OBJECTIVE

The purpose of this study was to examine the current practice patterns of occupational therapists experienced in working with children with autism spectrum disorders.

METHOD

Occupational therapists experienced in providing services to 2-year-old to 12-year-old children with autism completed a mail questionnaire describing practice patterns, theoretical approaches, intervention techniques, and preferred methods of preparation for work with children with autism.

RESULTS

Of those contacted, 72 occupational therapists met the study criteria and returned completed questionnaires. Practice patterns included frequent collaboration with other professionals during assessment and intervention. Intervention services were typically provided in a one-to-one format with the most common techniques being sensory integration (99%) and positive reinforcement (93%). Theoretical approaches included sensory integration (99%), developmental (88%), and behavioral (73%). Evaluations relied heavily on nonstandardized tools and clinical observations. Educational methods identified as most helpful were weekend workshops (56%) and on-the-job training (52%).

CONCLUSION

This study clarified the nature of current occupational therapy practice patterns for 2-year-old to 12-year-old children with autism. Additional studies are needed to examine the efficacy of current evaluation and intervention methods, as well as to explore the relevance of available standardized assessments for this population.

Electrophysiological monitoring during selective dorsal rhizotomy, and spasticity and GMFM performance

The relation between abnormal electrophysiological responses to intraoperative stimulation during selective dorsal rhizotomy (SDR) and the degree of spasticity and motor dysfunction was explored in 92 children with spastic cerebral palsy (CP) who underwent SDR at a single center. The proportion of abnormally responding rootlets was compared with the degree of spasticity measured with the modified Ashworth Scale (MAS) and with the spasticity measurement system (SMS) at discrete segmental levels. Motor impairment measured with the Gross Motor Function Measure (GMFM) was also compared with the proportion of abnormally responding dorsal rootlets. A consistent relation between the proportion of abnormally responding rootlets and the degree of spasticity and gross motor abnormality at the corresponding muscles could not be demonstrated. There was also no consistent association between the proportion of rootlets ablated during SDR and the change in spasticity measured with the MAS and SMS, or to the change in motor function as measured with the GMFM. These data suggest that the intraoperative monitoring technique most commonly used for SDR is unlikely to identify accurately those neural elements which contribute to spasticity in children with CP.

Selective dorsal rhizotomy: efficacy and safety in an investigator-masked randomized clinical trial

The objective of this single-center investigator-masked randomized clinical trial was to investigate the efficacy and safety of selective dorsal rhizotomy (SDR) in children with spastic diplegia. Forty-three children with spastic diplegia were randomly assigned on an intention-to-treat basis to receive SDR plus physical therapy (PT), or PT alone. Thirty-eight children completed follow-up through 24 months. Twenty-one children received SDR (SDR+PT group) and 17 received PT (PT Only group). SDR was guided with electrophysiological monitoring and performed by one experienced neurosurgeon. All subjects received equivalent PT. Spasticity was quantified with an electromechanical torque measurement device (spasticity measurement system [SMS]). The Gross Motor Function Measure (GMFM) was used to document changes in functional mobility. Primary outcome measures were collected at baseline, 6, 12, and 24 months by evaluators masked to treatment. At 24 months, the SDR+PT group exceeded the PT Only group in mean reduction of spasticity by SMS measurement (-8.2 versus +5.1 newton meters/radian, P=0.02). The SDR+PT group and the PT Only group demonstrated similar improvements in independent mobility on the GMFM (7.0 versus 7.2 total percent score, P=0.94). Outcomes on secondary variables were consistent with primary outcomes. There were no serious adverse events. We conclude that SDR is safe and reduces spasticity in children with spastic diplegia. SDR plus PT and equivalent PT without SDR result in equal improvements in independent mobility at 24 months. SDR may not be an efficacious treatment for children with mild spastic diplegia.

Comparison of functional outcomes from orthopedic and neurosurgical interventions in spastic diplegia

Selective dorsal rhizotomy (SDR) and orthopedic surgery, in the form of muscle-tendon (MT) lengthening surgery are commonly performed in ambulatory children with spastic diplegia to improve their level of motor function. This investigation is a post hoc comparison of the functional effects from each of these surgical options in 30 patients with spastic diplegia who underwent one of these interventions as their initial surgical procedure. Sixteen children underwent SDR and 14 underwent MT surgery in two separate prospective clinical trials. The same functional outcome measures preoperatively and approximately 1 year postoperatively were used in both studies including temporospatial parameters from three-dimensional gait analysis, the total score, and score on each of the five dimensions of the Gross Motor Function Measure (GMFM). Comparisons indicate that patients who underwent SDR had significant improvements in GMFM Dimensions 2, 4, and 5 as well as in total score, although 63% of those studied had a 10% or more reduction in gait velocity. Gait was more predictably improved in the MT group, with only 21% demonstrating reductions in velocity. Conversely, the change in GMFM scores in the MT group was not as pervasive and skewed toward higher skills with only GMFM Dimension 5 and total score improved significantly. Several important hypotheses are derived from these comparisons. Multicenter clinical trials are needed to define more clearly the indications for and to assess more comprehensively the outcomes from each intervention.

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.

Acquired hydrocephalus associated with superior vena cava syndrome in infants

We report observations on children with the unusual combination of superior vena cava syndrome in infancy followed by communicating hydrocephalus. Following retrospective review of hospital discharges at a tertiary children's hospital, three children were identified in a 13-year period. Two term infants were treated with extracorporeal membrane oxygenation for pulmonary failure associated with congenital diaphragmatic hernia. These infants had septic complications of central venous lines. A post-term infant required reconstruction of the superior vena cava following cannulation for cardiac bypass surgery to repair transposition of the great vessels. Thrombosis occurred and was followed by the sequential development of superior vena cava syndrome and communicating hydrocephalus. The findings in these patients suggest that communicating hydrocephalus may be caused by superior vena cava syndrome. This is an unusual complication of therapeutic manipulation of the heart and great veins. Cerebrospinal fluid shunting may be required.

Marinesco-Sjögren syndrome: clinical and magnetic resonance imaging features in three children

The authors describe clinical and MRI features of a girl and two boys, aged 9, 17 and 19 years, respectively, with Marinesco-Sjögren syndrome. The clinical findings included the major features of the syndrome, including growth deficiency, ataxia, cataracts, hypogonadism (in two) and seizures (in two). Truncal hypotonia (in three), microcephaly (in two) and leg spasticity (in two) were also present. MRI showed a very small cerebellar vermis in all three patients, various supratentorial abnormalities, an apparently small anterior pituitary gland in two and the absence of a posterior pituitary gland in all three. The MRI features are similar to the few reported pathologic findings for persons with Marinesco-Sjögren syndrome. MRI may be helpful in the early diagnosis of the disorder.

Marinesco-Sjögren syndrome: clinical and magnetic resonance imaging features in three children

The authors describe clinical and MRI features of a girl and two boys, aged 9, 17 and 19 years, respectively, with Marinesco-Sjögren syndrome. The clinical findings included the major features of the syndrome, including growth deficiency, ataxia, cataracts, hypogonadism (in two) and seizures (in two). Truncal hypotonia (in three), microcephaly (in two) and leg spasticity (in two) were also present. MRI showed a very small cerebellar vermis in all three patients, various supratentorial abnormalities, an apparently small anterior pituitary gland in two and the absence of a posterior pituitary gland in all three. The MRI features are similar to the few reported pathologic findings for persons with Marinesco-Sjögren syndrome. MRI may be helpful in the early diagnosis of the disorder.

The role of selective dorsal rhizotomy in cerebral palsy: critical evaluation of a prospective clinical series

This is a prospective observational study of a consecutive series of 34 children with spastic cerebral palsy treated at a single center. 10 had spastic quadriplegia and 24 had spastic diplegia. All were followed for at least one year. After selective dorsal rhizotomy (SDR), all children received one month of physical therapy at the center and were prescribed a program of physical therapy in their community. The children were assessed before and one year after SDR and physical therapy, using the Ashworth Scale, deep tendon reflex response, range of motion and the Gross Motor Function Measure. The results show that there is often a decrease in lower-extremity spasticity and functional improvement after SDR with physical therapy, but that there is considerable variability in outcome. Randomized prospective clinical trials with masked objective outcome measures are needed to determine the efficacy of SDR.

Pain management for children following selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure used for treating lower extremity spasticity in patients with cerebral palsy. The purpose of this paper is to present a review of our institution's first three years' experience with postoperative pain and spasticity management in patients who have undergone SDR. The medical records of the 55 patients who had an SDR during the study period were reviewed. The basis of postoperative analgesia was morphine, with the majority of patients receiving continuous morphine infusions (20-40 micrograms.kg-1.hr-1 (n = 49), 60 micrograms.kg-1.hr-1 (n = 1)). Four patients used a patient-controlled delivery system. One patient had successful analgesia with epidural morphine. Ketorolac (1 mg.kg-1 i.v. loading dose followed by 0.5 mg.kg-1 i.v. every six hr for 48 hr) was used as an adjunct to morphine in six patients. For management of postoperative muscle spasm, an intravenous benzodiazepine was used (diazepam 0.1 mg.kg-1 (n = 2), or midazolam infusion 10-30 micrograms.kg-1.hr-1 (n = 51)). All patients were cared for on a ward where nurses were familiar with the use of continuous opioid and benzodiazepine infusions. All patients received continuous cardiorespiratory monitoring as well as frequent nursing assessment. There were no episodes of postoperative apnoea or excessive sedation. We have found the use of continuous infusions of morphine and midazolam, along with adjunct ketorolac, to be effective in treating postoperative pain and muscle spasms following SDR.

Prospective measurement of functional changes after selective dorsal rhizotomy

Selective dorsal rhizotomy (SDR) followed by intensive postoperative therapy is commonly performed to reduce spasticity in carefully selected children with cerebral palsy. Reduction in spasticity and improvement in range and quality of movements are frequently reported. Functional gains have also been indicated but have not often been examined in a systematic manner. Twenty-nine children with spastic diplegia or quadriplegia received SDR and postoperative physical and occupational therapy. Upper-limb movement, self-care, and functional mobility were evaluated prospectively through preoperative, 6-month, and 12-month follow-up examinations. Significant improvements in the Pediatric Evaluation of Disability Inventory scores for functional mobility and self-care domains were observed for children with spastic diplegia, but not spastic quadriplegia. Children's scores in upper-limb reach and coordination tasks did not consistently improve. When attributing improvements in self-care and mobility independence to SDR and specialized therapy, continued development, new goals, and positive beliefs about progress should also be considered as factors influencing outcome.

Mechanical efficiency of children with spastic cerebral palsy

In this feasibility study, the authors compared the mechanical efficiency of nine children with spastic diplegia with that of nine able-bodied children, matched for gender. They also compared resting energy expenditure in the two groups. The children with CP had significant reductions in mechanical efficiency at maximum stable work-load and marginally significant reductions when they were compared at 200 kg-m/min work-load. The efficiency of able-bodied children at 200 kg-m/min was unexpectedly reduced. There were no differences in resting energy expenditure. Mechanical efficiency may be a useful objective technique to assess the effects of interventions intended to improve the efficiency of the movement of children with CP.

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.