- Email: [email protected]
CLUSTER OF TRISOMY 13 LIVE BIRTHS
613 CLUSTER OF TRISOMY 13 LIVE BIRTHS
SIR,-We saw 6 babies with a karyotype of 47, XY or XX, +13 in 10 weeks between Aug. 20, and Oct. 31, 1977. Parents of 5 of these infants were all under 30 years old, and none had a history of exposure to radiation, drugs, or illness during pregnancy. Previous reproductive histories were unremarkable. All the families live in Maryland, though2 of the deliveries were in Washington, D.C. The
frequency of trisomy-13 among live births is about
1 in
14000.’- There-were approximately 46 000 live births in so 3 or 4 cases of trisomy-13’ might be in expected a year. Lately the yearly average for trisomy-13 has been 0.54 at this institution. We are unaware of any change in the referral pattern of local physicians that would account for the increased frequency. Furthermore the incidence of trisomy-21 has not changed during the past 24 months.
Maryland (1976)
Warburton et al.3 reported an increased frequency of trisomies in New York City (not confined to trisomy-13) among spontaneous abortuses and fetuses subjected to prenatal diagnosis. There was a four-fold increase in both these groups, and all were conceived in December, 1976, or January, 1977. Last menstrual periods of the mothers of all our patients correspond to this time also. We have no clues as to a common denominator, and report this cluster to see if a similar increase in trisomy-13 live births during the same time period has been observed at other centres. Division of Genetics,
that in this small group of patients the duration of postoperative hospital stay was a valid index of morbidity; it was determined only by fitness for discharge.
Wright
Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, U.S.A.
G. S. PAI DAVID VALLE GEORGE THOMAS
Children’s Hospital National Medical Center, Washington, D.C.
KENNETH ROSENBAUM
We thank Professor Dudley (Jan. 28, p. 213) for his helpful comments but feel that selection of the right statistical technique for handling these data is difficult. Our series now comprises 47 comparable patients, and the median hospital stay of 21 nutritionally normal patients was 17 days (range 11-25) while that of the 26 nutritionally depleted patients was 27 days (range 12-60). A non-parametric (Wilcoxon) test reveals this difference to be significant (P<0-01). Increased hospital stay was characterised by delayed wound healing, sternal disintegration, and general debility in the depleted group only. More striking was the mortality: none of the 21 non-depleted patients have died while there have been 9 deaths in 26 nutri-
tionally depleted patients (Fisher’s exact p=0-009). We were trying to identify in the preoperative period patients who were at risk from cardiac surgery; further studies are in progress but results to date strongly suggest that this method identifies a subpopulation of patients who are at increased risk of operative mortality and morbidity. Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London W12
R. K. WALESBY A. W. GOODE H. H. BENTALL
M.R.C. Cyclotron Unit, Hammersmith Hospital
T. J. SPINKS
COMPLICATIONS ASSOCIATED WITH PROPHYLACTIC ORAL KANAMYCIN IN PRETERM INFANTS
SIR,-Prophylactic oral antibiotics may reduce the incidence necrotising enterocolitis (N.E.C.) in preterm infants.1,2 One possible complication of such therapy is the emergence of antibiotic-resistant bacteria.1.3 We have isolated a multiple-antiof
NUTRITION AND OPEN HEART SURGERY
SIR,-We read with interest the comments of Mr Rich and Wright (Feb. 4, p. 281) Our preliminary communication (Jan. 14, p. 76) was based on a pilot study in which we tried to confirm that a clinical impression that a patient was fit for
Mr
cardiac surgery was often misleading. Three regression formulas were used to assess the normality of the population; in one of them weight was excluded but the results (not given in our paper) were similar to those predicted by weight-sensitive formulm despite the degree of overhydration. Overhydration a mean was measured by tritium dilution technique and of The measured 14% potassium overhydration (range 0-30%). was related to the potassium concentration in the fat-free mass derived anthropometrically, and there was no reduction in concentration in unit mass, suggesting that the depletion represented loss of lean tissue mass and not lower cellular potassium concentrations.
gave
Rich and Wright agree that, because of an unknown degree of fluid retention, clinical signs are no guide to nutritional status. They refer to a paper by Abel et al .4 who stated that "triceps skinfold thickness, serum albumin concentration, and body weight had little value in separating patients in chronic congestive failure" and that "clinical separation of patients by history and physical examination was, in the final analysis, the only reasonable method of separating the patients on the basis of pre-operative nutritional state". We can assure Rich and 1. Hamerton, J. L., Canning, N., Ray, M., Smith, S. Clin. Genet. 1975, 8, 223. 2. Conen, P. E., Erkman, B. Am. J. hum. Genet. 1966, 18, 374. 3. Warburton, D., Kline, J., Stein, Z., Susser, M. Lancet, 1977, ii, 201. 4. Abel, R. M., Fischer, J. E., Mortimer, B. J., Barnett, G. O., Austen, W. G.
Archs. Surg. 1976, 111, 45.
biotic resistant strain of Staphylococcus epidermidis coincident with the use of prophylactic oral kanamycin. Oral kanamycin, 15 mg/kg/day, was used in the neonatal intensive-care unit of Hennepin County Medical Center, Minneapolis, in an effort to prevent N.E.C. Over a two-month period all premature infants who weighed less than 2000 g and were being fed received kanamycin for at least six days. Nine infants were treated. Two infants had N.E.C. despite prophylaxis. Grossly blood diarrhoea in two other neonates prompted stool cultures that revealed pure growth of Staph. epidermidis, resistant to kanamycin, as well as to gentamicin, oxacillin, and penicillin. Heavy growth of Staph. epidermidis with the same antibiotic-resistant pattern was isolated from the stools of eight of nine infants receiving oral kanamycin. A similarly resistant Staph. epidermidis was cultured from the blood and cerebrospinal fluid of one premature infant with meningitis who was present in the nursery at that time. Although routine bacteriological surveillance had not been done in this nursery, previous stool cultures indicate that the cluster of infants with a heavy growth of antibiotic-resistant Staph. epidermidis is unusual. Five months after routine oral kanamycin prophylaxis was stopped, the organism was not recovered from stool cultures of any infants in the nursery. We feel this experience illustrates the need for caution in the administration of oral antibiotic prophylaxis for N.E.C. until the aetiology and pathogenesis Of N. E. c. are better defined. Medical Center and Department of Pediatrics,
Hennepin County
University of Minnesota, Minneapolis, Minnesota, U.S.A. 1. 2. 3.
MARY MARGARET CONROY RENNER ANDERSON K. LYNN CATES
Egan, E. A. and others J. Pediat. 1976, 89, 467. Grylack, L., Scanlon, J. W. Lancet, 1977, ii, 506. Nelson, J. D. J. Pediat. 1976, 89, 471
SIR,-We saw 6 babies with a karyotype of 47, XY or XX, +13 in 10 weeks between Aug. 20, and Oct. 31, 1977. Parents of 5 of these infants were all under 30 years old, and none had a history of exposure to radiation, drugs, or illness during pregnancy. Previous reproductive histories were unremarkable. All the families live in Maryland, though2 of the deliveries were in Washington, D.C. The
frequency of trisomy-13 among live births is about
1 in
14000.’- There-were approximately 46 000 live births in so 3 or 4 cases of trisomy-13’ might be in expected a year. Lately the yearly average for trisomy-13 has been 0.54 at this institution. We are unaware of any change in the referral pattern of local physicians that would account for the increased frequency. Furthermore the incidence of trisomy-21 has not changed during the past 24 months.
Maryland (1976)
Warburton et al.3 reported an increased frequency of trisomies in New York City (not confined to trisomy-13) among spontaneous abortuses and fetuses subjected to prenatal diagnosis. There was a four-fold increase in both these groups, and all were conceived in December, 1976, or January, 1977. Last menstrual periods of the mothers of all our patients correspond to this time also. We have no clues as to a common denominator, and report this cluster to see if a similar increase in trisomy-13 live births during the same time period has been observed at other centres. Division of Genetics,
that in this small group of patients the duration of postoperative hospital stay was a valid index of morbidity; it was determined only by fitness for discharge.
Wright
Department of Pediatrics, Johns Hopkins Medical Institutions, Baltimore, Maryland 21205, U.S.A.
G. S. PAI DAVID VALLE GEORGE THOMAS
Children’s Hospital National Medical Center, Washington, D.C.
KENNETH ROSENBAUM
We thank Professor Dudley (Jan. 28, p. 213) for his helpful comments but feel that selection of the right statistical technique for handling these data is difficult. Our series now comprises 47 comparable patients, and the median hospital stay of 21 nutritionally normal patients was 17 days (range 11-25) while that of the 26 nutritionally depleted patients was 27 days (range 12-60). A non-parametric (Wilcoxon) test reveals this difference to be significant (P<0-01). Increased hospital stay was characterised by delayed wound healing, sternal disintegration, and general debility in the depleted group only. More striking was the mortality: none of the 21 non-depleted patients have died while there have been 9 deaths in 26 nutri-
tionally depleted patients (Fisher’s exact p=0-009). We were trying to identify in the preoperative period patients who were at risk from cardiac surgery; further studies are in progress but results to date strongly suggest that this method identifies a subpopulation of patients who are at increased risk of operative mortality and morbidity. Department of Surgery, Royal Postgraduate Medical School, Hammersmith Hospital, London W12
R. K. WALESBY A. W. GOODE H. H. BENTALL
M.R.C. Cyclotron Unit, Hammersmith Hospital
T. J. SPINKS
COMPLICATIONS ASSOCIATED WITH PROPHYLACTIC ORAL KANAMYCIN IN PRETERM INFANTS
SIR,-Prophylactic oral antibiotics may reduce the incidence necrotising enterocolitis (N.E.C.) in preterm infants.1,2 One possible complication of such therapy is the emergence of antibiotic-resistant bacteria.1.3 We have isolated a multiple-antiof
NUTRITION AND OPEN HEART SURGERY
SIR,-We read with interest the comments of Mr Rich and Wright (Feb. 4, p. 281) Our preliminary communication (Jan. 14, p. 76) was based on a pilot study in which we tried to confirm that a clinical impression that a patient was fit for
Mr
cardiac surgery was often misleading. Three regression formulas were used to assess the normality of the population; in one of them weight was excluded but the results (not given in our paper) were similar to those predicted by weight-sensitive formulm despite the degree of overhydration. Overhydration a mean was measured by tritium dilution technique and of The measured 14% potassium overhydration (range 0-30%). was related to the potassium concentration in the fat-free mass derived anthropometrically, and there was no reduction in concentration in unit mass, suggesting that the depletion represented loss of lean tissue mass and not lower cellular potassium concentrations.
gave
Rich and Wright agree that, because of an unknown degree of fluid retention, clinical signs are no guide to nutritional status. They refer to a paper by Abel et al .4 who stated that "triceps skinfold thickness, serum albumin concentration, and body weight had little value in separating patients in chronic congestive failure" and that "clinical separation of patients by history and physical examination was, in the final analysis, the only reasonable method of separating the patients on the basis of pre-operative nutritional state". We can assure Rich and 1. Hamerton, J. L., Canning, N., Ray, M., Smith, S. Clin. Genet. 1975, 8, 223. 2. Conen, P. E., Erkman, B. Am. J. hum. Genet. 1966, 18, 374. 3. Warburton, D., Kline, J., Stein, Z., Susser, M. Lancet, 1977, ii, 201. 4. Abel, R. M., Fischer, J. E., Mortimer, B. J., Barnett, G. O., Austen, W. G.
Archs. Surg. 1976, 111, 45.
biotic resistant strain of Staphylococcus epidermidis coincident with the use of prophylactic oral kanamycin. Oral kanamycin, 15 mg/kg/day, was used in the neonatal intensive-care unit of Hennepin County Medical Center, Minneapolis, in an effort to prevent N.E.C. Over a two-month period all premature infants who weighed less than 2000 g and were being fed received kanamycin for at least six days. Nine infants were treated. Two infants had N.E.C. despite prophylaxis. Grossly blood diarrhoea in two other neonates prompted stool cultures that revealed pure growth of Staph. epidermidis, resistant to kanamycin, as well as to gentamicin, oxacillin, and penicillin. Heavy growth of Staph. epidermidis with the same antibiotic-resistant pattern was isolated from the stools of eight of nine infants receiving oral kanamycin. A similarly resistant Staph. epidermidis was cultured from the blood and cerebrospinal fluid of one premature infant with meningitis who was present in the nursery at that time. Although routine bacteriological surveillance had not been done in this nursery, previous stool cultures indicate that the cluster of infants with a heavy growth of antibiotic-resistant Staph. epidermidis is unusual. Five months after routine oral kanamycin prophylaxis was stopped, the organism was not recovered from stool cultures of any infants in the nursery. We feel this experience illustrates the need for caution in the administration of oral antibiotic prophylaxis for N.E.C. until the aetiology and pathogenesis Of N. E. c. are better defined. Medical Center and Department of Pediatrics,
Hennepin County
University of Minnesota, Minneapolis, Minnesota, U.S.A. 1. 2. 3.
MARY MARGARET CONROY RENNER ANDERSON K. LYNN CATES
Egan, E. A. and others J. Pediat. 1976, 89, 467. Grylack, L., Scanlon, J. W. Lancet, 1977, ii, 506. Nelson, J. D. J. Pediat. 1976, 89, 471