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Coagulopathy following brain injury
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E d i t o r i a l correspondence
December 31, 1883. Philadelphia, 1884, Allen, Lane & Scott's Printing House. Eighth annual report of the Board of Managers of St. Christopher's Hospital for Children for the year ending December 31, 1884. Philadelphia, 1885, Allen, Lane & Scott's Printing House. Fourteenth annual report of the Board of Managers of St. Christopher's Hospital for Children for the year ending December 31, 1890. Philadelphia, 189 i, Press of Allen, Lane & Scott. Radbill SX: A history of children's hospitals. J Dis Child 90:411, 1955.
Coagulopathy following brain injury To the Editor." We read with interest the report by Miner et al. t on disseminated intravascular coagulation following head injury. It is surprising that coagulation studies have not been previously performed in children with brain damage, because tissue thromboplastins are very common in cerebral structures. We have done a study of neonatal brain damage in which fibrin split products were evaluated? Blood determinations did not show significant disturbances, but spinal fluid had a significant increase of fibrin split products in those infants who developed neurologic handicaps at one year of age. This and the report by Graeber and Stuart 3 inspired us to do a more complete study of clotting properties of cerebrospinal fluid after neonatal brain damage? Procedures derived from activated partial thromboplastin time and thrombelastography on the cerebrospinal fluid revealed significant disturbances in high-risk vs low-risk infants. We agree with Miner et ah, ~ and we hope that coagulation studies of blood and cerebrospinal fluid will become routine in children with either traumatic or nontraumatic episodes potentially able to threaten brain structures. Bernard Dalens, M.D. Marie-Josbphe Bezou, Ph.D. Hotel-Dieu, B.P. 69 Pavillon Gosselin University o f Clermont-Ferrand F-63003 Clermont-Ferrand France
REFERENCES 1.
2.
3.
Miner ME, Graham SH, Gildenberg PL: Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: Frequency and prognostic implications. J PEDIATR 100:687, 1982. Dalens B, Bezou M J, Coulet M, Raynaud E J: Fibrin-fibrinogen degradation products in cerebrospinal fluid as an indicator of neonatal brain damage. Acta Neurol Scand 64:81, 1981. Graeber JE, Stuart M J: Spinal fluid procoagulant activity:
The Journal o f Pediatrics January 1983
4.
A sensitive indicator of central nervous system damage. Lancet 2:285, 1978. Dalens B, Bezou M J, Coulet M, Haberer JP, Vanneuville G: Spinal fluid clotting activity: A new method of evaluating neonatal brain damage. Pediatr Res 16:412, 1982.
Diagnosis of Down syndrome To the Editor: Rex and Preus' diagnostic index for Down Syndrome ~ may be a useful tool for clinicians. I question, however, the appropriateness of using Brushfield spots as a diagnostic creterion in evaluating black patients. Although Brushfield spots have been reported to occur in brown eyes,2 a survey of my colleagues confirmed that none recalls seeing Brushfield spots in a black infant who had Down Syndrome. Using this feature as a diagnostic criterion in blacks would result in lower index scores; not only would all of the black patients receive a -0.31 for lacking Brushfield spots, but they would also be penalized by not being able to obtain a +.70 score for the feature, adding up to a loss of 1.01 on the log index scale. I suspect that the major effect of this loss would be to increase the number of black patients scoring in the "zone of doubt." Perhaps a different scoring nomogram should be constructed for black patients, excluding Brushfield spots as a criterion. David B. Flannery, M.D. Department o f Human Genetics Medical College of Virginia Virginia Commonwealth University P.O. Box 33 Richmond, VA 23298 REFERENCES 1. 2.
Rex AP, Preus M: A diagnostic index for Down syndrome. J PEDIATR 100:903, 1982. Donaldson DD: The significance of spotting of the iris in mongoloids: Brushfield's spots. Arch Ophthalmol 65:25, 1961.
To the Editor: The elegant paper by Rex and Preus ~ presents an "effective" diagnostic index for Down syndrome. The authors estimate that roughly 95% of patients suspected of having Down syndrome can be categorized with this index as having Down syndrome or not with 99.9% confidence. The diagnostic index contains eight "characters." The three most powerful discriminatory characters are, in order: (1) the dermal pattern on the hallucal area of the foot, (2) the dermal pattern on the second finger (forefinger), and (3) a dermal pattern feature on the palm the height of the palmar axial triradius. All three of the top features are dermal patterns. What proportion of pediatricians can read the dermatoglyphics on the hallucal area of the foot? 1 doubt that 2% of pediatricians have achieved this special skill, and would estimate the proportion
2.
3.
4.
E d i t o r i a l correspondence
December 31, 1883. Philadelphia, 1884, Allen, Lane & Scott's Printing House. Eighth annual report of the Board of Managers of St. Christopher's Hospital for Children for the year ending December 31, 1884. Philadelphia, 1885, Allen, Lane & Scott's Printing House. Fourteenth annual report of the Board of Managers of St. Christopher's Hospital for Children for the year ending December 31, 1890. Philadelphia, 189 i, Press of Allen, Lane & Scott. Radbill SX: A history of children's hospitals. J Dis Child 90:411, 1955.
Coagulopathy following brain injury To the Editor." We read with interest the report by Miner et al. t on disseminated intravascular coagulation following head injury. It is surprising that coagulation studies have not been previously performed in children with brain damage, because tissue thromboplastins are very common in cerebral structures. We have done a study of neonatal brain damage in which fibrin split products were evaluated? Blood determinations did not show significant disturbances, but spinal fluid had a significant increase of fibrin split products in those infants who developed neurologic handicaps at one year of age. This and the report by Graeber and Stuart 3 inspired us to do a more complete study of clotting properties of cerebrospinal fluid after neonatal brain damage? Procedures derived from activated partial thromboplastin time and thrombelastography on the cerebrospinal fluid revealed significant disturbances in high-risk vs low-risk infants. We agree with Miner et ah, ~ and we hope that coagulation studies of blood and cerebrospinal fluid will become routine in children with either traumatic or nontraumatic episodes potentially able to threaten brain structures. Bernard Dalens, M.D. Marie-Josbphe Bezou, Ph.D. Hotel-Dieu, B.P. 69 Pavillon Gosselin University o f Clermont-Ferrand F-63003 Clermont-Ferrand France
REFERENCES 1.
2.
3.
Miner ME, Graham SH, Gildenberg PL: Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children: Frequency and prognostic implications. J PEDIATR 100:687, 1982. Dalens B, Bezou M J, Coulet M, Raynaud E J: Fibrin-fibrinogen degradation products in cerebrospinal fluid as an indicator of neonatal brain damage. Acta Neurol Scand 64:81, 1981. Graeber JE, Stuart M J: Spinal fluid procoagulant activity:
The Journal o f Pediatrics January 1983
4.
A sensitive indicator of central nervous system damage. Lancet 2:285, 1978. Dalens B, Bezou M J, Coulet M, Haberer JP, Vanneuville G: Spinal fluid clotting activity: A new method of evaluating neonatal brain damage. Pediatr Res 16:412, 1982.
Diagnosis of Down syndrome To the Editor: Rex and Preus' diagnostic index for Down Syndrome ~ may be a useful tool for clinicians. I question, however, the appropriateness of using Brushfield spots as a diagnostic creterion in evaluating black patients. Although Brushfield spots have been reported to occur in brown eyes,2 a survey of my colleagues confirmed that none recalls seeing Brushfield spots in a black infant who had Down Syndrome. Using this feature as a diagnostic criterion in blacks would result in lower index scores; not only would all of the black patients receive a -0.31 for lacking Brushfield spots, but they would also be penalized by not being able to obtain a +.70 score for the feature, adding up to a loss of 1.01 on the log index scale. I suspect that the major effect of this loss would be to increase the number of black patients scoring in the "zone of doubt." Perhaps a different scoring nomogram should be constructed for black patients, excluding Brushfield spots as a criterion. David B. Flannery, M.D. Department o f Human Genetics Medical College of Virginia Virginia Commonwealth University P.O. Box 33 Richmond, VA 23298 REFERENCES 1. 2.
Rex AP, Preus M: A diagnostic index for Down syndrome. J PEDIATR 100:903, 1982. Donaldson DD: The significance of spotting of the iris in mongoloids: Brushfield's spots. Arch Ophthalmol 65:25, 1961.
To the Editor: The elegant paper by Rex and Preus ~ presents an "effective" diagnostic index for Down syndrome. The authors estimate that roughly 95% of patients suspected of having Down syndrome can be categorized with this index as having Down syndrome or not with 99.9% confidence. The diagnostic index contains eight "characters." The three most powerful discriminatory characters are, in order: (1) the dermal pattern on the hallucal area of the foot, (2) the dermal pattern on the second finger (forefinger), and (3) a dermal pattern feature on the palm the height of the palmar axial triradius. All three of the top features are dermal patterns. What proportion of pediatricians can read the dermatoglyphics on the hallucal area of the foot? 1 doubt that 2% of pediatricians have achieved this special skill, and would estimate the proportion