Nachweis erniedrigter Flußgeschwindigkeiten in der Arteria cerebri anterior bei Früh- und Neugeborenen sowie älteren Säuglingen mit Hirnblutungen mit Hilfe der gepulsten Dopplersonographie = Detection of reduced flow velocities in the anterior cerebral artery in premature and newborn infants and in older infants with cerebral hemorrhages using pulsed Doppler sonography

34 infants with intracerebral haemorrhage (intraventricular haemorrhage 26; subdural haemorrhage 2; epidural haemorrhage 2; subarachnoidal haemorrhage 4) were investigated by pulsed Doppler-sonography. Absolute flow velocities were measured in the anterior cerebral arteries in infants with intracranial haemorrhage and compared with the flow velocities of a healthy control group of identical gestational age, actual age and weight. All flow velocities were significantly reduced in premature and full-term infants with intracranial haemorrhage, whereas the pulsatility-index was significantly increased. 10 infants with severe intracranial haemorrhage developed a shunt-depending posthaemorrhagic hydrocephalus. These children showed a significant reduction of all flow velocities in the anterior cerebral arteries in comparison to the healthy control group. The diastolic forward flow was more reduced than the maximal systolic velocity resulting in a significant increase of the pulsatility index. In rapidly progressive hydrocephalus, often no diastolic flow or even a retrograde diastolic flow could be found. After shunt-implantation normalisation of the flow velocities could be observed. Reduced flow velocities could be observed. Reduced flow velocities in the anterior cerebral arteries in infants with subdural, epidural and subarachnoidal haemorrhage were associated with a bad outcome: 1 infant died, 1 infant developed severe leucomalacia, and 1 infant showed atrophy of one cerebral hemisphere. Normal flow velocities in the intracranial arteries in subdural, epidural and subarachnoidal were associated with a favourable prognosis. Absent or even retrograde diastolic flow indicates a dramatic decrease of cerebral perfusion. The longer the pathologic flow patterns were demonstrable the worse was prognosis

Surfactant bolus instillation: effects of different doses on blood pressure and cerebral blood flow velocities

Fifteen preterm infants suffering from respiratory distress syndrome were randomly allocated to receive either high-dose (200 mg/kg) or low-dose (100 mg/kg) surfactant treatment. Retreatments were done with the low dose. Blood pressure, blood gases and cerebral blood flow velocities were determined before and after 24 bolus instillations. With the high dose mean blood pressure and mean cerebral blood flow velocity dropped significantly. With the low dose only mean cerebral blood flow velocity decreased; the course was unrelated to blood pressure or PCO2 fluctuations. The mechanisms leading to the observed circulatory changes after surfactant instillation remain unclear

Die Bedeutung von Serumglukose, Uringlukose und HbAlc bei der Langzeitüberwachung juveniler Diabetiker = The value of serum glucose, urine glucose and hbAIc for long term metabolic information in juvenile diabetics (author's transl.)

In 43 insuline dependent diabetics postprandial serum glucose concentrations as 24-hour glucose excretions have been determined. Their value for a long term metabolic information was compared to that of HbAIc concentrations. A correlation between postprandial serum glucose concentration of the partial correlations. Those excluded the influence of an interrelationship among the individual serum glucose concentrations, at the time of different presentations for metabolic control, on the serum glucose to HbAIc relationship. There was no correlation between the concentrations of HbAIc and the amount of glucose excreted into the urine. The study shows that single determinations of postprandial serum glucose concentrations, as the excretion of small amounts of glucose into the urine are of no use for a long term metabolic information in juvenile diabetics

Surfactantsubstitution beim sehr kleinen Frühgeborenen= Surfactant substitution in very small premature infants

In addition to the established treatment of neonatal respiratory distress syndrome by oxygen supplementation, artificial ventilation and thermoneutrality, substitution of surfactant offers a new therapeutic perspective. Up to now, either artificial mixtures of surface active components or surfactant extracts from minced animal lungs, lung lavage fluid, or human amniotic fluid have been used in controlled trials of prophylactic and rescue surfactant treatment. Meta-analysis of controlled prevention trials including about 2,400 preterm infants shows decreased mortality (21% in controls, 9.5% in infants treated with natural preparations, p less than 0.001; 17% in controls, 11% in infants treated with artificial preparations, p less than 0.001) and fewer complications of artificial ventilation (pneumothorax: 24 vs. 7.2% with natural preparations, p less than 0.001; 20 vs. 15% with artificial preparations, p less than 0.05). In rescue studies on more than 1,900 preterm infants, natural surfactant preparations decreased complications of artificial ventilation such as pulmonary interstitial emphysema and pneumothorax (32 vs. 13%, p less than 0.001). Although the immediate effect of artificial preparations is mild, the incidence of pneumothorax also could be reduced (30 vs. 19%, p less than 0.001). Mortality could be reduced by 1/3 with natural (31 vs. 20%, p less than 0.001) and with artificial preparations (23 vs. 16%, p less than 0.01). The incidence of bronchopulmonary dysplasia and intracerebral hemorrhage, however, did not drop significantly. Severe adverse side effects of this treatment seem to be rare. There are, however, potential hazards of surfactant substitution. Its use should be restricted to fully staffed and equipped neonatal intensive care units

Increased cerebral blood flow velocities in newborn infants of smoking mothers

Cerebral blood flow velocities (CBFV) were measured by the pulsed Doppler method in 41 infants of smoking mothers and in 59 apparently healthy control infants. Although gestational age, birth weight, and systolic blood pressure were lower in infants exposed to tobacco smoke prenatally, systolic (65 +/- 11 vs. 47 +/- 12 cm/s, mean +/- SD; P < 0.001), mean (36 +/- 6 vs. 25 +/- 6 cm/s; P < 0.001), and diastolic (17 +/- 4 vs 13 +/- 4 cm/s; P < 0.001) CBFVs in the anterior cerebral artery were significantly higher when compared to control infants. Similar differences were seen in the internal carotid and in the basilar arteries. Multiple regression analysis did not reveal differences other than maternal smoking to explain these observations. We conclude that prenatal tobacco smoke exposure is related to increased CBFVs in newborn infants. Further studies should determine whether this relation is not only statistical but causal and whether increased CBFVs are an indicator of prolonged effects of prenatal tobacco smoke exposure

Verhütung von Komplikationen bei congenitalen Zwerchfelldefekten = Prevention of complications in congenital diaphragmatic defects

The mortality rate from congenital diaphragmatic hernia is not much better than it was 25 years ago. Most children, who are more than 24 hours of age at operation, survive. On the first day of life postoperative mortality is about 47%. Pediatric surgical problems are stabilization of the diaphragm and abdominal decompression. Some risk patients may be brought out of the fatal zone by high frequency ventilatory support and pharmacologic reversal of the fetal circulation. The most important causes of death are pulmonary hypoplasia with abnormal pulmonary vascular reactivity and persistent fetal circulation, iatrogenic pneumothorax, interstitial emphysema, mediastinal shifting with subsequent pulmonary hypertension and right to left shunting, and associated cardiac malformations

Surfactant protein A in the course of respiratory distress syndrome

Surfactant-associated protein (SP-A) was measured in tracheal aspirates of ventilated infants with (n = 51) and without (n = 21) respiratory distress syndrome (RDS). SP-A concentrations in samples collected after birth were significantly lower in RDS than in infants ventilated for other reasons than RDS (median 0.03 vs. 1.60 micrograms/ml). As a biochemical test to diagnose RDS early after birth, the sensitivity of measuring SP-A in tracheal aspirates was 87% and specificity 81%. SP-A content in tracheal aspirates of infants with RDS was monitored during the first 7 days of life. A significant (P less than 0.001) increase within the first 4 days was found in those infants who survived, whereas no such change was found in those infants who died

Fibrinpleurodese eines beidseitigen Spannungspneumothorax bei Mukoviszidose = Fibrin pleurodesis of bilateral tension pneumothorax in mucoviscidosis

A bilateral recurrent tension pneumothorax in an 18-year-old patient with cystic fibrosis was treated by fibrin glue pleurodesis. Within the observation period of 20 months no relapse has occurred

Sonographischer Nachweis von Hirntumoren im Säuglingsalter = Ultrasonographic Demonstration of Brain Tumors in Infancy

Using the open fontanelle as an acoustic window brain tumours were diagnosed by gray scale ultrasonography in 3 infants aged 1 day to 5 months. The tumours were characterized by their echo dense structure and their good delimination from the surrounding brain. In 2 children the tumour was localized infratentorially (medulloblastoma and unclassified neuroectodermal tumour) and had caused an occlusive hydrocephalus. Both children died aged 3 and 5 months in central nervous dysregulation. One child suffered from plexus papilloma which had caused a hypersecretory hydrocephalus. After resection of the tumour the hydrocephalus decreased without any further treatment. Comparison with axial computed tomography and autopsy findings showed, that gray scale ultrasonography is equally efficient in diagnosing brain tumours and associated hydrocephalus

Zum Einfluß geburtshilflich-perinatologischer Maßnahmen auf die Mortalität und Frühmorbidität von Frühgeborenen der Gewichtsklasse 500 bis 1500 Gramm = Effect of obstetric-perinatal measures on mortality and early morbidity of premature infants weighing 500 to 1,500 grams

In a retrospective analysis of perinatal influencing factors in 186 premature newborns of the Department of Gynaecology of the University of Erlangen covering the period from 1982-1987 with birth weights between 500 and 1500 grams, the mortality and early morbidity were analysed, as characterised by cerebral haemorrhages, respiratory distress syndrome and infections insofar, as they had been connected with the obstetrical approach and paediatric intensive-care treatment, 45 infants born in 1982/83 were compared with 141 infants, who had been subjected to a different treatment approach during 1984 to 1987. During the second period, there was a marked drop both in mortality and in the incidence of asphyxia-induced severe cerebral haemorrhage and of the respiratory distress syndrome. A shortened latency period after premature rupture of the amnion, and a more pronounced presence of a neonatologically experienced team of paediatricians were found to be significant obstetric liberal influencing factors in determining the need to perform Caesarean section. The triplication of the frequency of Caesarean section observed resulted in a 50% reduction in perinatal mortality and morbidity. Infants with pelvic presentation benefited most from the more liberal performance of Caesarean section, as did infants with vertex presentation. Shortening of the latency phase in premature rupture resulted in a marked reduction in infection morbidity and mortality. Therefore we conclude, that the frequently practised procrastination with the aim to await an improvement in lung maturity should be replaced by a more active obstetric management, avoiding both infection and birth trauma. Obstetric decisions should be based rather on prenatal estimation of weight than on the calculated gestational age. At present, the lowest birth weight associated with the expectation of a healthy life is considered to be 750 grams