Clinical manifestations of sleep apnea

Obstructive sleep apnea (OSA) may manifest in a number of ways from subtle intrusion into daily life to profound sleepiness, snoring, witnessed apneas and other classic symptoms. Although there is increasing evidence suggesting OSA can adversely affect health in a variety of ways, this disorder remains underdiagnosed. The most well-escribed health consequences of OSA relate to the cardiovascular system. Hypertension and arrhythmias have a strong association with OSA, and evidence suggests that treatment of OSA in patients with refractory hypertension and in patients planning cardioversion for atrial fibrillation may be of particularly importance. Significant associations between heart failure and OSA as well as complex sleep apnea have also been well-described. Cerebrovascular insult, impaired neurocognition, and poorly controlled mood disorder are also associated with in OSA. Therapy for OSA may ameliorate atherosclerotic progression and improve outcomes post-cerebrovascular accident (CVA). OSA should be considered in patients complaining of poor concentration at work, actual or near-miss motor vehicle accidents, and patients with severe sleepiness as a component of their co-morbid mood disorders. The metabolic impact of OSA has also been studied, particularly in relation to glucose homeostasis. Also of interest is the potential impact OSA has on lipid metabolism. The adverse effect untreated OSA has on glucose tolerance and lipid levels has led to the suggestion that OSA is yet another constituent of the metabolic syndrome. Some of these metabolic derangements may be related to the adverse effects untreated OSA has on hepatic health. The cardiovascular, neurocognitive, and metabolic manifestations of OSA can have a significant impact on patient health and quality of life. In many instances, evidence exists that therapy not only improves outcomes in general, but also modifies the severity of co-morbid disease. To mitigate the long-term sequela of this disease, providers should be aware of the subtle manifestations of OSA and order appropriate testing as necessary.     

A comparison of pneumogram recordings in infants in the hospital and at home

It is not known how environment affects the ventilatory pattern of infants during sleep. Pneumogram recordings of ventilatory pattern and electrocardiograms are performed both in the hospital and at home. However, it is not known if the data obtained in these two settings are comparable. Therefore, 12-hour overnight PNGs were recorded in the hospital and at home within 10 days on 64 infants in three diagnostic categories: apnea of infancy, apnea of prematurity, and siblings of victims of sudden infant death syndrome. Pneumograms were quantitated for total sleep time (TST in minutes), longest apnea (in seconds), periodic breathing, and the total duration of apneas lasting 6 seconds or longer. TST was longer at home for the total group (p less than 0.001) and for the apnea of infancy group (p less than 0.005). No other differences were found between hospital and home recordings for any parameter. There was no difference in the number of abnormal pneumograms recorded in the hospital and at home. Therefore, hospital and home pneumogram recordings are equally sensitive and accurate.     

How infants and toddlers react to antisocial others

Although adults generally prefer helpful behaviors and those who perform them, there are situations (in particular, when the target of an action is disliked) in which overt antisocial acts are seen as appropriate, and those who perform them are viewed positively. The current studies explore the developmental origins of this capacity for selective social evaluation. We find that although 5-mo-old infants uniformly prefer individuals who act positively toward others regardless of the status of the target, 8-mo-old infants selectively prefer characters who act positively toward prosocial individuals and characters who act negatively toward antisocial individuals. Additionally, young toddlers direct positive behaviors toward prosocial others and negative behaviors toward antisocial others. These findings constitute evidence that the nuanced social judgments and actions readily observable in human adults have their foundations in early developing cognitive mechanisms.     

Preverbal infants expect members of social groups to act alike

The short ontogenetic time courses of conformity and stereotyping, both evident in the preschool years, point to the possibility that a central component of human social cognition is an early developing expectation that social group members will engage in common behaviors. Across a series of experiments, we show that by 7 months of age preverbal infants differentiate between actions by individuals that are and are not consistent with the actions of their social group members. Infants responded to group-inconsistent actions only in a social context: they failed to distinguish the same behavioral differences when presented with collections of nonsocial agents or inanimate objects. These results suggest that infants expect social group membership and behavior to covary, before extensive intergroup experience or linguistic input. This expectation is consistent with the socially motivated imitation and stereotyping evident in toddlers and preschoolers, and may play a role in the early emergence of one or both of these aspects of social behavior and cognition.Human behavior is often tied to the social affiliations of the actor. These ties are evident both in the ways we choose to act and the way we predict and perceive others’ actions. Individuals are biased to conform to the conventions of their social groups, maintaining cultural variations in behavior even in the face of intergroup contact and migration (1, 2). More transiently, we tend to mimic the actions and expressions of our partners in social interaction, especially when we want to be liked (3, 4). Stereotypes lead us to expect that others will act like their own social affiliates as well. We perceive social groups as sharing behavioral tendencies and traits that we use to predict and explain the behavior of individual group members (5, 6).Socially motivated imitation or conformity and stereotyping share an early developmental onset (7, 8). Many cultural behaviors, including social gestures and language, are acquired in the first few years, suggesting early biases for adopting the typical behaviors of one''s own social group. In the laboratory, preschool-aged children adopt labels for objects endorsed by the majority of informants and conform to consensus perceptual judgments and actions, and they copy the actions of ingroup over outgroup members when group membership is conveyed by native vs. foreign speech (9–13). Children even show an understanding of group-based social norms in their reactions to others’ behavior, protesting when ingroup members, although not outgroup members, break conventions (14, 15). Stereotyping is similarly robust at early ages; within North American populations, for example, preschool children are influenced by the gender and racial stereotypes of their culture (7, 16). In fact, in laboratory studies young children often rely on social category membership more than older children or adults when making predictions about individuals (17–19).Conformity, imitation, and stereotyping differ in some respects. Stereotypes are beliefs about stable attributes of group members, often thought to be inherent in the individual members themselves (19, 20). Although conformity can be constituted by long-term adherence to group norms, it also occurs in the context of temporary situations and transient judgments, as does socially motivated mimicry (3, 4, 21). Especially in these latter cases, the actions engaged in during conformity and imitation are not determined by the actor’s own traits or values but rather by the presence and actions of his social partners. Still, despite these differences, stereotyping and conformity both center on an expectation that social group members will or should act alike.Understanding how children come to make these connections between social categories and common behavior will be critical in determining why human groups develop and maintain conventional behaviors and stereotypes. By the preschool years, parents and other adults have begun to instruct children in the conventional behavior of their own groups, and they talk about the behaviors of social groups in generic terms (22). Children may generalize from this input and come to expect that groups are likely to be characterized by particular behaviors and that adherence to those behaviors is normative (23). Children might also learn from interacting with others that conventional behaviors can be socially rewarding, correct, or useful. Such a trajectory of acquisition would imply that the social-learning mechanisms that underlie cumulative culture are themselves the product of learning from instruction, experience with the success of past learning strategies, or both (24). Alternatively, the early development of socially motivated imitation and stereotyping may be predicated on an inherent sensitivity to shared behavior as a feature of social group membership. The latter view predicts that even preverbal infants, presented with novel social groups, may expect the group members to engage in common actions.One complication in designing an experiment to test for this expectation is that little is known about how, or even whether, infants represent social groups. Research on face perception has established that, by 4–6 months of age, infants categorize faces along a variety of dimensions, including sex, age, and race, and prefer to look at faces from more familiar instances of these categories (25–28). This research demonstrates infants’ ability to use perceptual information to distinguish some of the categories recognized by children and adults, but it is not clear whether infants endow these categories with social meaning. Although people can be categorized in many ways, we generally expect social groups to be characterized by affiliation between their members rather than solely by shared attributes (29). It is an open question whether infants under a year of age can represent such social relationships and use cues to affiliation to define social groups that can then be used in the service of inference about their members.The current research simultaneously asks whether infants recognize social groups on the basis of affiliative cues and, if so, whether they expect social group members to engage in the same actions and make the same choices. Infants were presented with animated depictions of two novel social groups, delineated via the spatial proximity and synchronous movements of their members, and were provided with information about the covariation of behavior with group membership for two of the three members of each group. Then we used two preferential-looking methods—a violation of expectancy method (Experiments 1–4) and a habituation method (Experiment 5)—to probe whether infants expected the remaining individuals to engage in the same behavior as the other members of their groups.To investigate whether infants'' expectations of within-group consistency apply both to shared behavior and shared choices or preferences, separate experiments tested infants'' inferences about groups that performed different actions (Experiment 1) and groups that directed similar actions toward different objects and locations (Experiments 2–5). To investigate whether infants'' expectations are specific to social groups, we compared infants’ responses to social characters and interactions with responses to similar events presented in the context of groups of inanimate entities (Experiments 2 and 5) and of animate agents stripped of information about social relationships (Experiment 3). We tested for the role of shared appearance in establishing and maintaining social groups by varying the presence of appearance cues to group membership (Experiments 4 and 5). Across these experiments, we tested for the robustness of infants’ reasoning about the shared actions of social groups by testing infants'' inferences at different ages and with different experimental designs.     

Water intoxication with seizures

Presented is the case of a normal two-month-old girl who developed seizures secondary to water intoxication. The infant had been fed 20 to 30 oz of water daily for three days, while her usual formula was withheld because of vomiting and diarrhea. On the day of admission, the infant exhibited signs of water intoxication in the form of lethargy, vomiting, and seizures. Hyponatremia, hypothermia, and hyperglycemia were noted on admission, and are common features of the syndrome. The patient responded well to fluid restriction and salt replacement. Previous reports have attributed water intoxication to feeding mismanagement, vigorous hydration, dilute formulas, and swimming lessons.     

婴儿持续性高胰岛素血症性低血糖症研究进展

婴儿持续性高胰岛素血症性低血糖症(PHHI)是婴儿持续性低血糖最常见原因,其发病机制涉及影响胰岛β细胞胰岛素分泌的多个基因突变,表现为2种组织学类型(弥漫型和局灶型病变),是一大类病因各异的遗传性疾病.临床表现为婴儿期低血糖伴胰岛素不适当地过度分泌及低酮体、低脂肪酸血症,可造成严重的低血糖脑损伤及继发糖尿病.二氮嗪作为一线治疗药物可以抑制胰岛素分泌,在部分患者中有效.药物治疗无效可行胰腺次全或局部切除术以减缓脑损伤,术前或术中确定病理类型对决定手术方式和判断预后十分重要.     

Improved survival for acute lymphoblastic leukaemia in infancy: the experience of EORTC-Childhood Leukaemia Cooperative Group

Summary Out of 744 newly diagnosed ALL children under the age of 18 years treated according to the EORTC-CLCG protocols 58831 and 58832, 28 (4%) were infants less than 1 year of age. An elevated risk factor, which takes into account the sizes of the liver and spleen and the number of circulating blasts, was present in 25 cases.
Most patients had non-common ALL. Among 15 patients studied by cytogenetics, nine present chromosonal abnormalities, six of them having a t(4:11) translocation.
Complete remission was achieved in 86% of cases. One patient died in complete remission of therapy-related infection. The overall EFS is 43%. It is not statistically different in very young infants as compared to infants older than 6 months. Except for patients with AUL or with t(4:11) translocation, a continuous complete remission rate above 50% can be achieved with a median follow-up of 4 years.
The results obtained in infant ALL with EORTC-CLCG protocols are currently better than those obtained with some other protocols, but remains inferior when compared to the ones obtained in older children. Thus, further improvements are needed and should be evaluated in large cooperative trials.     

The Prevalence of Atopy and Asthma among University Freshmen in Seoul,Korea: Association with Obesity

Hospitalization of children with asthma declined at our institution between 1996 and 2000, before stabilizing for the past 5 years. The ages of children hospitalized since 2000 were examined to see if the demographics of the hospitalized population have changed to better understand why the hospitalization rate has remained the same despite continued, aggressive screening and education efforts. Data were gathered for our hospital through the Department of Defense Medical Health System Management Analysis and Reporting System (M2). The mean age (± SD) of children hospitalized in 2003 (2.84 ± 2.53) was less than the mean age for 2000 and 2002 (4.85 ± 3.7 and 4.61 ± 4.45), respectively (p < 0.05), and more infants less than 2 years of age were hospitalized in 2003 (33/60, 55% p < 0.01) and 2004 (32/68, 47% p < 0.05) than in 2000 (19/70, 27%). The diagnosis of asthma in hospitalized infants and young children has increased over the past 5 years, suggesting better recognition and providing a new target population for intervention with early asthma controller therapy.     

Lung ultrasound—a new diagnostic modality in persistent tachypnea of infancy

Lung ultrasound (LUS) has been increasingly used in diagnosing and monitoring of various pulmonary diseases in children. The aim of the current study was to evaluate its usefulness in children with persistent tachypnea of infancy (PTI). This was a controlled, prospective, cross‐sectional study that included children with PTI and healthy subjects. In patients with PTI, LUS was performed at baseline and then after 6 and 12 months of follow‐up. Baseline results of LUS were compared to (a) baseline high‐resolution computed tomography (HRCT) images, (b) LUS examinations in control group, and (c) follow‐up LUS examinations. Twenty children with PTI were enrolled. B‐lines were found in all children with PTI and in 11 (55%) control subjects (P < .001). The total number of B‐lines, the maximal number of B lines in any intercostal space, the distance between B‐lines, and pleural thickness were significantly increased in children with PTI compared to controls. An irregularity of the pleural line was found in all patients with PTI and in none of the healthy children. There were no significant changes in LUS findings in patients with PTI during the study period. The comparison of HRCT indices and LUS findings revealed significant correlations between the mean lung attenuation, skewness, kurtosis and fraction of interstitial pulmonary involvement, and the number of B‐lines as well as the pleural line thickness. LUS seems to be a promising diagnostic tool in children with PTI. Its inclusion in the diagnostic work‐up may enable to reduce the number of costly, hazardous, and ionizing radiation‐based imaging procedures.     

Heterogeneity in disease severity in a family with a novel G68V GCK activating mutation causing persistent hyperinsulinaemic hypoglycaemia of infancy.

BACKGROUND/AIM: Glucokinase (GCK)-activating mutations cause persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI). GCK-PHHI patients have regulated insulin secretion and can usually be treated with diazoxide. The six reported cases suggest that the severity of the mutation predicts the clinical phenotype. The aim of this study was to relate genotype to phenotype [clinical phenotype, glucose-stimulated insulin release (GSIR) and GCK functional analysis] in a large pedigree with eight affected individuals. METHODS: The genes encoding B-cell GCK and the K(ATP) channel subunits (ABCC8 and KCNJ11) were sequenced to identify mutations for functional analysis. Genetic variants influencing B-cell function were genotyped in affected individuals. Islet secretory capacity was determined by oral glucose tolerance test RESULTS: A novel GCK mutation (G68V) co-segregating with hypoglycaemia was identified in eight family members. Kinetic analysis revealed that G68V-GCK activity is ~16 times more than wild-type-GCK with an increased affinity for glucose [concentration at half maximal activation (S(0.5)) 1.94 +/- 0.16 vs. 7.43 +/- 0.12, mutant vs. wild type, mean +/- sem]. Mathematical modelling predicted a threshold for GSIR of 1.9 mmol/l in the mutant. Oral glucose tolerance tests showed regulated insulin secretion. The severity of hypoglycaemia and related symptoms in affected subjects were heterogeneous. Clinical presentations were asymptomatic (n = 1), extreme hunger (n = 3), seizures (n = 2) and loss of consciousness (n = 2); 7/8 were managed with diet but the proband was treated with diazoxide and octreotide. Phenotypic modification by a second mutation in the K(ATP) channel genes (ABCC8, KCNJ11) or by common genetic variants in KCNJ11, GCK and TCF7L2 was excluded. CONCLUSION: The novel activating GCK mutation G68V is associated with variable phenotypic severity, supporting modification of GSIR by genetic and/or environmental factors.     

OSAHS患者呼吸障碍的差异及SaO2检测的诊断价值

目的探索连续血氧饱和度(SaO2)检测是否对阻塞性睡眠呼吸暂停低通气综合症(OSAHS)有诊断价值,以及不同程度OSAHS患者之间的呼吸障碍的差异。方法对104例鼾症患者进行多导睡眠图(PSG)的检测,分为单纯鼾症、轻、中、重度OSAHS共4组,收集资料并分析。结果1各OSAHS组SaO2的基础值和最低值均小于单纯鼾症组(P均<0.05);2所有患者的SaO2的基础值和最低值均与睡眠呼吸暂停低通气指数(AHI)呈显著负相关(R=-0.478,-0.507;P均<0.05);3OSAHS患者的SaO2的基础值和最低值均与AHI呈显著负相关(R=-0.315,-0.334;P均<0.05);4所有患者的SaO2的基础值和最低值均与体重指数(BMI)呈显著负相关(R=-0.579,-0.601;P均<0.05);5若以SaO2基础值<95%和SaO2<85%作为诊断OSAHS的标准,敏感性分别是78.5%和73.8%;特异性均是100%;6各OSAHS组睡眠呼吸障碍在不同睡眠期的分布不同。结论OSAHS患者存在睡眠时SaO2下降,并与疾病的严重程度有关;连续检测SaO2是在鼾症患者中鉴别出OSAHS的一个有效的简易方法;各OSAHS组睡眠呼吸障碍在不同睡眠期的分布不同。     

Calgary睡眠呼吸暂停生活质量指数在阻塞性睡眠呼吸暂停低通气综合征诊治中的地位

目的 探讨Calgary睡眠呼吸暂停生活质量指数（SAQLI）在中国阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者诊断与治疗随访中的地位。方法 确诊为中重度OSAHS并接受无创持续正压通气（nCPAP）患者连续入选68例，设为治疗组；按年龄、性别、身高、体质量等因素进行均衡纳入中重度OSAHS且未接受任何针对OSAHS治疗的患者68例，设为对照组。治疗前、治疗后1个月、治疗后2个月分别采用SAQLI评估其生活质量，分析基础状态下SAQLI评分与病情的相关关系及治疗前后SAQLI变化水平；并统计平均CPAP使用时间，采用多元逐步回归分析其预测因素。结果 SAQLI总分与OSAHS病情存在弱相关关系；有效CPAP治疗后SAQLI评分改善（P〈0.01），而对照组SAQLI评分没有显著变化（P〉0.05）；多元逐步回归分析发现SAQLI基础评分及SaO2〈90%时间是平均CPAP使用时间的独立预测因素。结论 SAQLI量表可用于中国OSAHS患者病情评估及疗效判定；SAQLI基础评分及SaO2〈90%时间可作为OSAHS治疗指征制定的参考指标。     

Neonatal Apnea: What's New?

Apnea of prematurity (AOP) remains a major clinical problem in present day neonatology that warrants frequent evaluations and imposes challenges in therapeutic strategies. Although the pathogenesis of AOP is poorly understood, it is probably a manifestation of physiologic immaturity of breathing control rather than a pathologic disorder. Immature breathing responses to hypoxia, hypercapnia and exaggerated inhibitory pulmonary reflexes in preterm infants might also contribute to the occurrence or severity of AOP. Recent data suggest a role for genetic predisposition. Although typically resolve with maturation, the role of bradycardia and desaturation episodes associated with AOP in the development of sleep disorder breathing and neurodevelopmental delay needs further clarification. Pharmacological treatment with methylxanthines and CPAP remain the mainstay for treatment of AOP. However, recent studies have implicated central inhibitory neuromodulators including prostaglandins, GABA and adenosine in its pathogenesis, the fact that might provide future specific targets for treatment. This review will summarize new insights involving these issues as well as others involving the pathogenesis, treatment strategies and consequences of apnea in premature infants.     

Neural indicators of articulator-specific sensorimotor influences on infant speech perception

While there is increasing acceptance that even young infants detect correspondences between heard and seen speech, the common view is that oral-motor movements related to speech production cannot influence speech perception until infants begin to babble or speak. We investigated the extent of multimodal speech influences on auditory speech perception in prebabbling infants who have limited speech-like oral-motor repertoires. We used event-related potentials (ERPs) to examine how sensorimotor influences to the infant’s own articulatory movements impact auditory speech perception in 3-mo-old infants. In experiment 1, there were ERP discriminative responses to phonetic category changes across two phonetic contrasts (bilabial–dental /ba/-/ɗa/; dental–retroflex /ɗa/-/ɖa/) in a mismatch paradigm, indicating that infants auditorily discriminated both contrasts. In experiment 2, inhibiting infants’ own tongue-tip movements had a disruptive influence on the early ERP discriminative response to the /ɗa/-/ɖa/ contrast only. The same articulatory inhibition had contrasting effects on the perception of the /ba/-/ɗa/ contrast, which requires different articulators (the lips vs. the tongue) during production, and the /ɗa/-/ɖa/ contrast, whereby both phones require tongue-tip movement as a place of articulation. This articulatory distinction between the two contrasts plausibly accounts for the distinct influence of tongue-tip suppression on the neural responses to phonetic category change perception in definitively prebabbling, 3-mo-old, infants. The results showing a specificity in the relation between oral-motor inhibition and phonetic speech discrimination suggest a surprisingly early mapping between auditory and motor speech representation already in prebabbling infants.

Infants rapidly acquire robust representations of the native phonetic repertoire from the natural multisensory speech input of their environment. Multimodal speech signals are generated by a common underlying source—the vocal tract and the articulatory movements used during production (1, 2). Adult speech perception is influenced by synchronously occurring multimodal speech cues, including auditory, visual, motor, and sensorimotor signals (3). Recent advances reveal that speech production relies on both auditory and sensorimotor signals (4, 5), but also, sensorimotor input can affect the perception of auditory (6) and visual (7) speech. Indeed, neural evidence indicates bidirectional interaction between the speech perception and production systems in the adult brain (8). It has been widely assumed that the interactions between the articulator-specific sensorimotor information and acoustic phonetic perception would appear later in development after infants begin to babble and to produce speech themselves. This assumption is not surprising given that motor coordination is immature early in life and appears to have a protracted development. However, to fully understand how infants acquire their native speech sound repertoire, it is critical to examine whether sensorimotor/motoric dimensions of speech are relevant for auditory speech perception even in infants who are prebabbling. If so, then sensorimotor influences on speech perception may be part of the foundation that sets the stage for language acquisition in general and babbling in particular, rather than production experience driving the eventual auditory-sensorimotor/motor speech interaction.While the speech signal that infants experience and learn from is multimodal, speech perception research during the acquisition period has focused mainly on auditory speech perception, and to a modest extent, on audiovisual speech perception. Infants reliably match heard and seen speech at 2 mo of age by looking longer to the face that is articulating the syllable being played (9, 10). Remarkably, infants are also able to match audio and visual speech even for nonnative consonants and vowels, which they have not encountered in their linguistic environment (11). While some have suggested that audiovisual speech perception abilities in infants reflect a domain-general preference for synchronously occurring stimuli (12), there is neural evidence of multimodal phonetic representation already at 2 mo of age (13). In ref. 13, a phonetic mismatch response (MMR) was observed to the category change of an auditory vowel, both when the preceding stimuli were repetitions of visemes (a face articulating the same or a different vowel) or speech sounds. The consistency of the MMRs to the phonetic category change regardless of modality suggests that infants have access to an integrated intermodal representation (13).There is less experimental work investigating sensorimotor interactions with speech perception; however, several recent behavioral studies have addressed this question by experimentally manipulating infants’ own oral-motor movements. In the first such study, 4-mo-old infants’ labial configuration was manipulated (by gently holding an appropriately shaped object in their mouth) to either resemble the shape made for producing /i/ or /u/ vowels while they were tested in an audiovisual matching task. Results showed that infants’ matching of these same vowels was changed by the manipulation (14). The influence of sensorimotor cues on auditory-only speech perception was more recently tested, this time with infants aged 6 mo, who do not typically produce well-formed consonant–vowel (CV) syllables. Replicating previous work (15), English-learning infants this age discriminated a dental /ɗa/–retroflex /ɖa/ phonetic contrast that is nonnative to English speakers, but native to Hindi speakers’ contrast. These two consonants differ, in adult Hindi production, only on the placement of the tongue tip during articulation: The dental involves placement of the tongue tip behind the back front teeth, whereas retroflex production involves curling the tongue tip back and placing it against the roof of the mouth. However, when an infant’s tongue-tip movement was inhibited by having a caregiver gently hold a teether on the tongue, discrimination of this nonnative /ɗa/-/ɖa/ contrast was disrupted (16, 17). A control experiment showed that discrimination of this contrast was maintained when a different teether that does not interfere with tongue-tip movement was used, indicating that it was not the mere presence of a teething toy but rather the inhibition of the relevant articulator that accounted for the disruption of discrimination (16).These specific sensorimotor influences on auditory and audiovisual speech perception provide evidence that the relation between sensorimotor information and auditory speech perception is present in infants who have not had extensive speech production or babbling experience. Although preverbal infants this young have yet to gain the full articulatory control required to generate speech-like sounds, behavioral studies reviewed above suggest that a sensorimotor mapping of the articulators may be available to infants before babbling begins, possibly through spontaneously generated movement patterns during prenatal development (18). These patterns may be progressively refined through orofacial movements (e.g., sucking movements and nonspeech vocalizations) that help to shape the motor articulatory space that must be aligned with the phonetic perceptual space to ensure correct productions.Anatomically, the core neural pathways for speech including the cortical connections between the frontal (productive) and temporal (receptive) speech areas are in place before term birth (19). While the ventral pathway is more mature at birth, the dorsal pathway (i.e., the arcuate fasciculus) that functionally transforms auditory and motor speech codes rivals in maturity by 10 wk (20, 21). In ref. 21, the authors concluded that the functional connectivity, or cross-talk, between the suprasylvian part of the arcuate fasciculus, the posterior part of the superior temporal sulcus, and area 44 in the left inferior frontal region is established within the first few postnatal months based on a unique correlational pattern in the maturational indices across these regions, which also collectively form key nodes of the adult phonological loop. The early maturation and functional engagement of the arcuate fasciculus, which is a bidirectional tract between the productive and receptive areas, suggest that the necessary connectivity that subserves the sensorimotor influence on auditory perception is in place within several months after birth.     

Ulcerative Colitis in Infancy

Ulcerative colitis (UC) is a chronic idiopathic inflammatory disorder of colon. Frequency of UC is gradually increasing over few years worldwide. Prevalence is 35 to 100/100 000 people in USA, 1% of them are infants. UC develops in a genetically predisposed individual with altered intestinal immune response. An eight-month-old girl presented with loose bloody stool, growth failure, and moderate pallor. The girl was diagnosed as a case of UC by colonoscopy and biopsy. Treatment was thereafter started with immunosuppressive drugs. After initial induction therapy with parenteral steroid and infliximab, the patient is now on remission with azathioprine and mesalamine. UC is rare in Bangladesh, especially in children, and it is rarer during infancy. Several conditions like infective colitis, allergic colitis, Meckel''s diverticulitis, Crohn''s disease, etc. may mimic the features of UC. So, if a child presents with recurrent bloody diarrhea, UC should be considered as differential diagnosis.     

Prospective evaluation of an oral appliance in the treatment of obstructive sleep apnea syndrome

The purpose of this study was to investigate the effects of an oral appliance (OA), with and without mandible advance, in the treatment of obstructive sleep apnea syndrome (OSA). Twenty-four patients diagnosed with OSA agreed to participate in this study. The patients were treated for 3 months (with a removable soft elastic silicone positioner customized with thermoplastic silicone and with a 5-mm opening). Patients were selected, using a randomized design, to receive an OA model either with (12 patients) or without advance (12 patients). Before treatment, a snoring questionnaire, the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Functional Outcomes of Sleep Questionnaire (FOSQ), the Epworth Sleepiness Scale (ESS), and polysomnography were completed. Fifteen subjects completed the protocol (13 men, two women). With respect to basal values, the mandible-advanced OA group presented a decrease in the mean apnea–hypopnea index (AHI) (33.8±4.7 versus 9.6±2.1; p<0.01), number of arousals per hour (33.8±13.9 versus 16.0±1.5; p<0.05), ESS score (14.7±5.1 versus 5.1±1.9; p<0.05), snoring score (15.4±1.9 versus 10.1±3.2; p<0.05), and total FOSQ score (78.1±22.6 versus 99.3±14.4; p<0.05). After treatment, the non-advanced group presented a decrease in the mean AHI (24.0±12.2 versus. 11.7±7.9; p<0.05). However, no significant differences were found in the number of arousals per hour, ESS score, snoring, and total FOSQ score in the non-advanced group. Neither study group showed significant difference in mean SF36 scores. Oral appliances, especially those that advance the mandible, offer an effective treatment for OSA.