Wigher Mortensson

Severe Neonatal Respiratory Distress Syndrome Treated with the Isolated Phospholipid Fraction of Natural Surfactant

Ten newborn infants (795–1680 g) with severe respiratory distress syndrome (RDS) were treated with the isolated phospholipid fraction of bovine or porcine surfactant, which was administered via the airways (dose 200 mg/kg), at a median age of 10.5 h. Before receiving surfactant, all the infants were on artificial ventilation (FiO2 0.6–1.0). Within 2 h after surfactant replacement, the arterial‐to‐alveolar PO2 ratio increased from 0.1 to 0.35. There was a concomitant improvement in lung aeration on the chest roentgenograms and a significant reduction in the right‐to‐left shunt. Four patients died of cerebral hemorrhage; two of them also had a patent ductus arteriosus. One surviving infant developed bronchopulmonary dysplasia, and another succumbed 8 months later to the sudden infant death syndrome. No antibodies against surfactant were detected in the sera of the survivors. Since our results show a significant improvement in lung function after replacement therapy, the efficacy of this new surfactant preparation should be further tested in randomized clinical trials.

Radiologic Observations in Severe Neonatal Respiratory Distress Syndrome Treated with the Isolated Phospholipid Fraction of Natural Surfactant

Ten newborn babies with severe respiratory distress syndrome, all dependent on artificial ventilation, were treated via the airways with the isolated phospholipid fraction of bovine or porcine surfactant. After treatment with surfactant at a median age of 10.5h, there was in all patients a striking improvement of lung aeration in chest films, with a decrease in parenchymal fluid retention and in distension of bronchioli. These radiologic findings were associated with a dramatic improvement of oxygenation and a significant reduction of the right-to-left shunt. In spite of the rapid therapeutic response, four patients died from cerebral hemorrhage. One of the surviving patients developed bronchopulmonary dysplasia. Our findings document efficacy of this new surfactant preparation in the neonatal respiratory distress syndrome, but the long-term effects need to be further tested in randomized clinical trials.

Diagnosis of intracranial lesions in very‐low‐birthweight infants by ultrasound: incidence and association with potential risk factors

This study was designed to determine the frequencies of germinal matrix and ventricular haemorrhages as well as lesions in the white matter diagnosed by ultrasonography. In subsequent studies the effects of perinatal brain lesions on the cognitive and motor development of preterm children will be presented. Lesions of the white matter are probably more damaging than intraventricular and subependymal bleeds. Therefore, a modified classification of the lesions was used, clearly separating bleeds from white matter pathology. The study includes 291 infants with a body weight of ≤1500 g consecutively admitted to the neonatal intensive‐care unit at Karolinska Hospital from 1988 to 1993. Fifty‐four (18.9%) died before 6 months. Two hundred and sixty‐three infants were examined using ultrasound. Pathology due to bleeding was classified into three grades (B1–3) similar to Papiles first three grades. Pathology in periventricular white matter was classified into four groups (W1–4): W1 = subtle and W2 = distinctive white matter echodensities; W3 = cyst formation; W4 = large, intense echodensity. Forty‐nine patients had abnormalities in the periventricular white matter (15 W1, 12 W2, 11 W3 and 11 W4) and 58 had subependymal (B1 = 29) or ventricular bleeding without (B2 = 13) or with dilatation (B3 = 16). Ventilator treatment was significantly associated with both B and W lesions. Low gestational age, low birthweight, small for gestational age, pre‐eclampsia and caesarean section were significantly associated with B lesions whereas asphyxia, surfactant treatment, male patient sex and outborn were associated with W lesions; B1–3 and W1–4 lesions were thus partly associated with different potential risk factors. The pre‐ and perinatal potential risk factors could only partly explain the variance in the frequency of B and W lesions, indicating that there are yet unidentified risk factors for intracranial ultrasonographic pathology.

Neonatal Skeletal Maturation in Congenital Hypothyroidism and Its Prognostic Value for Psychomotor Development at 3 Years in Patients Treated Early

Neonatal skeletal maturation was assessed by different methods based on the bone centres in the knee and ankle region in 46 infants with true-positive (patients) and 17 infants with false-positive screening tests (controls). The patients and controls did not differ in mean age at X-ray examination and age at the start of treatment (14.5 +/- 5.7 days). One of the methods used to score the size of femoral and tibial epiphyses was just as good as the other ones tested, but has the advantage of being the easiest to use and therefore clinically most suitable. Skeletal maturity assessed by this method correlated best with serum T4 (r = 0.62, p less than 0.01). Griffiths tests were performed in 37 of the 46 patients at 28-48 months of life. The best correlation obtained between neonatal skeletal maturity and Griffiths global developmental quotient at 3 years of age was r = 0.58 (p less than 0.001). Although statistically significant, it was too weak to be of clinical value in identifying individual patients at risk. We conclude that an assessment of skeletal maturation is not useful for the prognosis of psychomotor development in individual patients with congenital hypothyroidism receiving treatment within the first 2 weeks of life.

OMENTAL AND MESENTERIC CYSTS IN CHILDREN

ABSTRACT. Six children with omental or mesenteric cysts are reported. The cysts usually gave rise to an uncharacteristic clinical picture and deceptive findings, which lead to misconception of the nature of the lesions. The primary step to correct diagnosis is to include the disease among the differential possibilities; ultrasonography may offer conclusive information.

SERUM α‐FETOPROTEIN—A BIOCHEMICAL INDICATOR OF PRENATAL HYPOTHYROIDISM

ABSTRACT. Serum α‐fetoprotein (AFP) was analysed at 10–30 days of age in infants with positive TSH screening tests for congenital hypothyroidism. These levels were significantly higher in infants with true positive screening tests than in those with false positive tests; 27 of 43 infants with congenital hypothyroidism had serum AFP levels above the age‐related reference range. The postnatal rate of elimination of AFP from serum did not differ in hypothyroid and euthyroid infants, indicating that the difference in serum AFP was due to more extensive synthesis in hypothyroid individuals. The level of serum AFP was inversely correlated with the roentgenological skeletal maturation index. It is postulated that increased serum AFP is caused by prenatal hypothyroidism and that analysis of serum AFP is a valuable tool to identify those infants with congenital hypothyroidism who are at risk of neuropsychological sequelae.

Radiation exposure to children in diagnosing and at hydrostatic reduction of intussusception.

The energy imparted to the children in diagnosing and hydrostatic reduction of intussusception was measured in 45 children by means of an area-dose measurement device and the mean absorbed dose was estimated. The device was provided with data on tube kVp, mAs and shutter positions and the results were presented as dGy × cm2. The device had been calibrated against a 30 cm3 ionisation chamber at the relevant kVp range. The median energy imparted and mean absorbed dose were 10.8 mJ and 0.94 mGy, respectively. 70% of the total dose was delivered during fluoroscopy. The complex irradiation situation with varying field collimation, tube voltage and amount of photon absorbing barium sulphate in the intestines renders organ dose and hazards estimations less reliable. However, even leaving the radiation shielding effect of the barium sulphate out, the radiation load is justifiable for a combined diagnostic and interventional procedure.

Scintigraphic evaluation of traumatic splenic lesions in children

Ninety-eight children with recent blunt abdominal trauma which initially evoked clinical suspicion of splenic injury were examined with colloid scintigraphy of the spleen and the liver using multiple imaging views and with abdominal survey. Nineteen children were, in addition, examined with tomographic scintigraphy. The clinical findings and the course of the disorder were reanalyzed. Scintigraphy indicated splenic injury in 56 children and hepatic injury in another 5 children. The left lateral and the left oblique were the optimum imaging views for detecting splenic ruptures. Tomographic scintigraphy did not improve the diagnostic yield. Abdominal survey failed to indicate almost every second case of splenic rupture and provided no additional information of significance. The clinical review agreed with the scintigraphic diagnosis of splenic lesions but, in addition, it suggested possible splenic lesions in another 10 children with normal scintigraphy. This discrepancy cannot be explained as surgery was not employed; the occurrence of splenic lesions too small to become detectable at scintigraphy or to provoke clinically evident symptoms may be supposed.

Contrast Medium Injected into Juvenile Bone Cysts to Analyze Interior Morphology and Guide Intracavity Corticosteroid Treatment

In connection with treating juvenile bone cysts with intracavital corticosteroid injections, the interior cyst anatomy was analyzed at cystography in 13 children aged 4 to 15 years. Only 4 children had a true unicameral cyst; the others had 2 or more cysts or had compartments with free or restricted communication to the main cyst. Cysts and compartments which had not been reached by steroids may continue to grow. Optimum treatment may therefore require injections at different sites guided by cystography. Neither conventional criteria of cyst activity nor repeated bone scintigraphy 3 months after treatment could predict whether the treatment would lead to final healing.

The Value of Neonatal Serum Thyroglobulin Determinations in the Follow‐up of Patients with Congenital Hypothyroidism

ABSTRACT. Serum thyroglobulin was determined in 68 newborn infants with positive screening tests for congenital hypothyroidism. In 38 infants the diagnosis was confirmed (patients), but the remaining 30 were euthyroid at follow‐up (controls). The mean thyroglobulin concentration at the age of 2 weeks did not differ significantly between the patients and the controls (179 vs. 125 μg/l). Thyroid scintigraphy was performed in 15 patients. All seven with thyroid aplasia, based on 99mTc pertechnetate scintigraphy, had measurable thyroglobulin (> 2 μg/l) and thyroid hormones in their serum. This indicates that total absence of thyroid tissue is very rare in Swedish patients with congenital hypothyroidism. Scintigraphy based on 99mTc does not permit detection of small amounts of thyroid tissue. The neonatal concentrations of thyroglobulin did not correlate with the results of Griffiths test at 3 years and are therefore not useful for prognosis of psychomotor development. We conclude that neonatal measurement of thyroglobulin is of limited value in the follow‐up of patients with congenital hypothyroidism.