Randomized comparison of high-frequency ventilation with high-rate intermittent positive pressure ventilation in preterm infants with respiratory failure.

OBJECTIVE: In a randomized, controlled, multicenter trial, we tested the hypothesis that high-frequency ventilation (HFV) with a high lung volume strategy results in fewer treatment failures than intermittent positive pressure ventilation (IPPV) with high rates and low peak inspiratory pressures. STUDY DESIGN: Infants with a gestational age between >/=24 weeks and <30 weeks, requiring mechanical ventilation within 6 hours of birth, were randomly assigned to receive either IPPV or HFV until 240 hours after randomization, extubation, or meeting treatment failure criteria. Treatment failure, the primary end point, was determined when air leaks, an oxygenation index >35 to 45 (depending on gestational age), death, or chronic lung disease occurred. Chronic lung disease was defined as persistent requirement of mechanical ventilation, continuous positive airway pressure, or supplemental oxygen at a postmenstrual age of 36 weeks. Secondary end points included the incidence of intracranial hemorrhage. RESULTS: The third scheduled interim analysis led to termination of the trial after recruitment of 284 infants. Treatment failure criteria were met by 46% of infants receiving IPPV and 54% of infants receiving HFV (1-tailed primary hypothesis, P =.92; 2-tailed chi2 test, P =.15). Air leaks occurred in 31% and 42% (P =.042), CLD in 23% and 25%, and grade 3-4 intracranial hemorrhage in 13% and 14% of IPPV-treated and HFV-treated patients, respectively. The mortality rate before discharge was 10% in both groups. CONCLUSION: HFV with a high lung volume strategy did not cause less lung injury in preterm infants than IPPV with a high rate and low peak inspiratory pressures.

Bacterial tracheitis caused by Corynebacterium diphtheriae.

UNLABELLED: Diphtheria has become a rare disease in Germany. We report on an unimmunized 3.5-year-old German girl with a 7-day history of respiratory distress and fever, presenting a clinical picture mimicking typical bacterial tracheitis without pharyngeal and laryngeal manifestation. Diagnosis of diphtheria was not made until culture of tracheal secretions yielded growth of a toxigenic strain of Corynebacterium diphtheriae. The patient died from toxic cardiac failure despite treatment with diphtheria antitoxin. This is the second reported case of isolated bacterial tracheitis caused by Corynebacterium diphtheriae. CONCLUSION: The observation of a lethal course of diphtheric tracheitis emphasizes the paramount importance of immunization against diseases like diphtheria.

[Hypoplastic left heart syndrome--clinical and pathologico-anatomic findings]. / Das hypoplastische Linksherzsyndrom--klinische und pathologisch-anatomische Befunde.

In twenty-two cases with hypoplastic left heart syndrome the anamnestic criterias and the clinical features were analysed. The pathologic specimens were examined in thirteen cases. The relations of the left heart to the right heart were measured. The same information is to be measured by two-dimensional echocardiography intra vitam. It should be discussed whether it is possible to perform an operative procedure in some rare cases of hypoplastic left heart syndrome.

[Transfusion-induced acid load caused by erythrocyte concentrates in the newborn]. / Transfusionsbedingte Säurebelastung durch Erythrozytenkonzentrate im Neugeborenenalter.

Erythrocyte concentrates are preferred increasingly to whole-blood transfusions in treatment of neonatal anemias. By means of their application even very important restorations of hematocrit are possible without the risk of fluid overload. A possible side-effect of these erythrocyte suspensions is a transfusion mediated acidosis, which depends on the used buffer solution, temperature and storage conditions before and during use. The case report of a preterm infant with Rh-Erythroblastosis and postpartal shock demonstrates the problem of an additional acidosis caused by the ACD-adenin stabilised erythrocyte concentrate. The impression of a transfusion mediated acidaemia is confirmed by 30 comparative pH-measurements in ACD-adenin and heparin stored erythrocytes. We conclude that erythrocyte transfusions in very ill neonates with severe disturbances of metabolism and reduced organ functions should be done with heparin erythrocyte preparations.

Dysplastic features, growth retardation, malrotation of the gut, and fatal ventricular septal defect in a 4-month-old girl with ring chromosome 15.

A 20-day-old female neonate was admitted with symptoms caused by a large ventricular septal defect which was subsequently confirmed angiographically. Other clinical findings were pre- and postnatal growth retardation, microcephaly, dysmorphism of ears, fingers and feet. Cytogenetic analysis revealed a ring chromosome 15. Despite a palliative banding operation of the pulmonary artery, the infant succumbed to complications of her congenital heart disease in the 4th month of life.

[Leprechaunism (Donohue's syndrome). Clinical and pathologico-anatomical findings]. / Leprechaunismus (Donohue-Syndrom). Klinische und pathologisch-anatomische Befunde.

Leprechaunism is a very rare condition of obscure aetiology. At the age of three weeks the neonate described in this report lost all subcutaneous fat in spite of additional parenteral nutrition. He acquired purulent pneumonia, and finally died of septicaemia. The typical stigmata were a prominent nose, broad mouth with putty lips, and large, hypertrophic , backwards rotated ears, cutis laxa, atrophy of adipose tissue and gynaecomastia with hirsutism. Since the first report (1948), 32 patients have been described in detail. Compared with these reports of dysendocrinism we observed an excessive proliferation of various tissues, e.g. of the epithelia of the epidermis, bronchi, collecting tubules of kidneys, bile-ducts, and pancreatic ducts. Moreover, almost complete atrophy of lymphoid tissue was remarkable.

Congenital aortic thrombosis with complete obliteration of the aortic arch and the great vessels.

Thrombosis of the great arteries rarely occurs in the neonate. We report a case of thrombosis of the aortic arch, the brachiocephalic truncus, the left carotid and subclavian arteries, seen in a one-day-old neonate. The clinical findings were at first misdiagnosed as interrupted aortic arch syndrome, though, in retrospect echocardiography was very suggestive of the correct diagnosis. On the basis of the histological examination we assume, as the most likely cause for thrombosis, an aortitis in the prenatal period. Following thrombectomy and Gore-Tex bypass from the ascending to the descending aorta, combined with ligature of a PDA, the child developed a low output state and died on the table. The postmortem examination revealed that the latter was due to multiple infarcts of the left ventricular myocardium.

[The angiocardiographic image following determination of axial-oblique projection with 2-dimensional echocardiography]. / Kardioangiographische Darstellungen nach Bestimmung der axial-schrägen Projektionsrichtung mit zweidimensionaler Echokardiographie.

A precise prediction of axial-oblique angulation in cineangiocardiography by noninvasive investigation is possible. A simple method is described using two-dimensional echocardiography to determine the cross-sectional plane. The perpendicular X-ray beam presents the angiocardiographic feature related to the echocardiographically determined plane. The described method is most helpful in diagnosis of simple morphological changes (ASD, VSD) as well as in complex congenital heart defects. To our knowledge this is the first report of the application of two-dimensional echocardiography to cardioangiographic axial-oblique angulation.

Arterial occlusion in a preterm infant. Successful non-surgical treatment with urokinase and low-dose heparin.

Neonatal arterial occlusion is a rare condition of obscure aetiology, when not associated with catheterization of the umbilical artery. Embolic occlusion of the left iliac artery was diagnosed in a preterm baby weighing 1000 g, who presented with a cold, pale and pulseless left leg on the 6th day of life. Surgical embolectomy was contraindicated in this very small baby. Fibrinolytic therapy with urokinase and administration of low-dose heparin resulted in a complete recovery of skin colour, skin temperature and blood pressure. After three weeks of urokinase therapy, no pulse differences could be detected between right and left femoral and popliteal arteries by Doppler examination, and only minimal differences were present between right and left tibial arteries.

[The percutaneous cardiac catheterization in the diagnosis of congenital cardiac failure (author's transl)]. / Die perkutane Herzkathetereinführung in der Diagnostik kongenitaler Herzfehler.

The results of a modified percutaneous approach of 113 cardiac catheterizations will be reported. The success rate for the right heart catheterization from the unselected cases in 63% in infants, 84% in those one to five years old and 96% in those children older than five years. For the retrograde left heart catheterization, the percutaneous approach was successful in infants in 91% (except one patient with aortic coarctation) and successful in all patients older than one year.

[New angles of view in cineangiography of congenital heart disease (author's transl)]. / Neue Projektionsmethoden zur cineangiokardiographischen Darstellung angeborener Herzfehler.

Axial oblique views were performed during cineangiography of congenital heart disease on patients of a paediatric cardiological unit for a period of two years. The resulting angle-patterns are shown in a synoptical review, and indications for angiographic demonstration of morphological conditions in congenital heart disease are discussed. In comparison with the literature to date, this is the first report of experience with a biplane synchronised "C" arm cineangiographic system.

[Treatment of ALL in children. Results and side effects with a modification of protocol memphis VII (author's transl)]. / Zur Therapie der ALL. Modifikation des Behandlungsplanes Memphis VII.

42 patients with ALL were treated according to the following protocol: induction with vincristine + prednisone (+/- L-asparaginase), CNS-prophylaxis with cranial irradiation (2400 rads) and intrathecal methotrexate, maintenance for 3 years with 6-MP 50 mg/m2/d p.o. + MTX 75-150 mg/m2/2 wk i.v. X 4, alternating in a cyclic fashion with 6-MP 50 mg/m2/d p.o. + cyclophophshamide 600 mg/m2/2 wk i.v. X 4. The observation time is 24-67 (median 49) months. The actuarial complete remission curve shows 40% continuous complete remissions at 36 months and 30% at 60 months.--The frequency and temporal distribution of typical infectious complications are presented. The incidence of varicella was comparable to that in a southgerman normal control group (5,7% per year). During treatment there were two zoster manifestations per one varicella case, the incidence of zoster being 1 case per 106 patient-months, viz 11,4% per year.

Monocytopoiesis in normal man: pool size, proliferation activity and DNA synthesis time of promonocytes.

Monocytopoiesis was analyzed in the bone marrow of healthy individuals. Promonocytes were identified by simultaneous determination of sodium-fluoride-sensitive and resistent naphthol-AS-D-acetate esterases. DNA synthesis activity of enzyme-positive promocytes was determined by 3H-thymidine (3H-TDR) incorporation in vitro. DNA synthesis time of these cells was measured by a double labelling technique (3H-TDR in vivo, 14C-TDR in vitro) as well as by serial injections of 3H-TDR. The relative number of promonocytes in the myelogram averaged 2.9% corresponding to a medullar promonocyte pool of about 600 X 10(6) cells per kilogram body weight. The promonocytes were classified into 4 groups on the basis of nucleus morphology: type I promonocytes with small lymphocyte-like nuclei (mean frequency of occurence, F = 5%; mean 3H-TDR labelling index, LI = 7.1%; type II promonocytes with large round or oval nuclei (F = 31%; LI = 9.7%); type III promonocytes with large, slightly folded nuclei (F = 51%; LI = 10.1%); type IV promonocytes with large, distinctly folded nuclei (F = 13%; LI = 24.9%). LI of pooled promonocytes was 12.0%. Mean DNA synthesis times of the different types of promonocytes was similar and approximated 10 h (range 6.6-13.3 h). This was true under normal conditions as well as in septicaemia.