Sub-clinical cerebral oedema does not occur regularly during treatment for diabetic ketoacidosis.

Fulminant cerebral oedema is an uncommon, fatal complication of diabetic ketoacidosis (DKA) in children. This study aimed to find out whether the sub-clinical compression of the brain ventricles found by an earlier study, is a general phenomenon during intravenous treatment for DKA. Four boys and four girls were examined. Blood glucose values ranged from 40 to 24.6 mmol/l, base excess -34.6 to -13.6 and capillary blood pH 6.89-7.22. The patients received fluids containing both glucose and electrolytes, and insulin intravenously. After about 10h, blood glucose was 8.7-21.8 mmol/l and base excess had decreased substantially (-9.5 to -2.9) in seven of the eight cases. Computerized tomography of the brain was then performed, and again after full recovery. Only two of the patients had an initial decrease in intercaudate distance, which exceeded the variability found in a reference group. Compression of the cerebral ventricles does not occur regularly during treatment for DKA.

Osteochondral lesions in the radiocapitellar joint in the skeletally immature: radiographic, MRI, and arthroscopic findings in 13 consecutive cases.

Radiography, magnetic resonance imaging (MRI), and arthroscopy were performed in 13 consecutive cases of osteochondral lesions of the radiocapitellar joint in 12 patients aged 11-16 years. Nine patients had a high activity level, and two patients had a significant trauma before the onset of symptoms. Symptoms were limited range of motion, pain, and catchings or lockings. Clinical findings were decreased range of motion and lateral elbow tenderness. Radiography revealed loose body, flattening of the humeral capitellum, or subchondral cysts (or a combination of these) in all cases but three. There was a good correlation between MRI and arthroscopic examination. Nine lesions were located in the humeral capitellum, one lesion in the radial head, and in three cases, lesions were found in both sites. Loose-body removal, shaving, or subchondral drilling (or a combination of these) was performed in 11 cases. All surgically treated patients improved in the short run. Awareness of the typical clinical and radiologic picture will allow identification of the cases suitable for arthroscopy and surgical treatment. In these cases, MRI can be omitted.

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 < or = 1500 g consecutively admitted to the neonatal intensive-case 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 Papile's first three grades. Pathology in periventricular white matter was classified into four groups (W1-4): W1 = subtle and We = 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 associate with W lesions; b 1-3 and W 1-4 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.

Perinatal risk factors and neuromotor behaviour during the neonatal period.

Preterm birth is associated with an increased risk for neurological handicaps. The purpose of the present study has been: to investigate the influence of perinatal risk factors on early neuromotor development during the neonatal period; to specify the neuromotor parameters particularly sensitive to perinatal complications; and to analyse whether the infant's age at test influences the results. Beside examination of passive/active muscle tone and automatic movements (22 parameters) was performed at 36 (101 infants) and 40 (153 infants) gestational weeks. Low birthweight and long treatment on a ventilator had a negative influence on the neuromotor behaviour at 36 weeks' gestation and white matter disturbances strongly affected the neuromotor parameters at 40 weeks. The development of rooting, sucking, swallowing and arm recoil after long-lasting ventilator treatment was affected by several neonatal risk factors. The development of passive muscle tone and several parameters measuring active muscle tone demonstrated individual consistency between tests, i.e. an infant's rank at 36 weeks' gestation was unchanged 4 weeks later, and some other parameters were not as consistent. The present study shows that several perinatal risk factors influence neuromotor behaviour already during the neonatal period. In addition, the present study provides data on the neuromotor behaviour during the neonatal period that will be related to later neurodevelopmental examinations in order to evaluate the prognostic value of testing neuromotor development.

Psychomotor development at 10 months as related to neonatal health status: the Stockholm Neonatal Project.

The psychomotor development of 171 preterm very-low-birthweight (VLBW) infants (birthweight < or = 1500 g) at 10 months of corrected age was assessed by the Griffiths' Mental Developmental Scale. The developmental score was related to the prenatal and obstetric risk factors and to the neonatal health status of each infant. These results, in turn, were compared to findings for a reference group of full-term infants. This analysis revealed that prolonged ventilator treatment, patent ductus arteriosus, bronchopulmonary dysplasia, brain haemorrhage with ventricle dilatation, white matter lesions, low birthweight and low gestational age influenced psychomotor development in an unfavourable manner. Multiple regression analysis confirmed most of these correlations. Preterm birth per se (when children with risk factors were excluded) in general had no significant effect on psychomotor development. However, the early development of preterm infants with several neonatal risk factors was adversely affected.

Glial fibrillary acidic protein is increased in the cerebrospinal fluid of preterm infants with abnormal neurological findings.

Glial fibrillary acidic protein (GFAP) is the structural protein of the intermediate filament of astroglia. The aims of the present study were to examine GFAP in the cerebrospinal fluid (CSF) of preterm infants at different postmenstrual ages and to evaluate the potential of GFAP to predict abnormal neurodevelopmental outcome. GFAP increased in correlation with postmenstrual age in preterm infants (n = 17) and full-term infants (n = 9). The levels were five times higher in preterm infants (n = 10) with an abnormal neonatal course and/or an abnormal neurological outcome than in healthy preterm infants. The positive predictive value of a GFAP higher than the 98th percentile of normal infants was 69%, while a GFAP level below this limit invariable predicted a good outcome. Simultaneously analysed noradrenaline, hypoxanthine and glutamate did not differ between the groups. We conclude that CSF GFAP increases with maturity and that CSF GFAP appears to be a promising marker for perinatal brain damage.

Gray-scale sonography in torsion of the testicular appendages.

The reliability of gray-scale ultrasonography in diagnosing torsion of the testicular appendages was studied in a series of 54 boys with acute non-traumatic scrotal pain. All boys were operated upon, and the appendages extirpated irrespective of their appearance at exploration; the final diagnosis was based on histological examination. Forty-two boys had appendicular torsion, 2 had testicular torsion and 10 had other diagnoses. Using the sign of appendicular torsion--an echogenic extratesticular structure situated between the head of the epididymis and the upper pole of the testis--as the criterion, 37 displayed a true positive, 9 a true negative, 3 a false positive and 5 a false negative diagnosis. Thus, the sensitivity was 88%, the specificity 75% and the positive predictive value 93% respectively. The echogenic mass varied in size from 3 to 17 mm in diameter. In 34 of the 42 cases of appendicular torsion extratesticular fluid was present, and 19 patients showed enlargement of the head of the epididymis. It is concluded that gray-scale sonography is an accurate and valuable tool in diagnosing torsion of the testicular appendages.

Generalized increase of arterial blood flow to the liver observed at visceral radiocolloid angiography.

Visceral radiocolloid angiography was performed in 1230 consecutive patients studied with scintigraphy of the reticuloendothelial system (RES). The hepatic arterial flow was considered increased if an early and obviously increased accumulation of the radiocolloid occurred in the liver during the visceral radionuclide angiography, i.e. that the early part of the liver time-activity curve coincided with the early parts of the kidney and spleen time-activity curves with respect to time and steepness. A generalized increase of arterial blood flow to the liver was found in 70 patients, of whom 54 per cent had alcoholic liver disease. 20 per cent metastatic liver disease, 19 per cent had various diagnoses, and in 7 per cent no certain diagnosis was found. Generalized increase of arterial blood flow to the liver gives a typical appearance in radiocolloid angiography and the corresponding time-activity curves. It may be a sign of severe disease, most often localized in the liver, but in some cases it may be of extrahepatic origin. In 27 per cent it was the only obvious pathologic finding. It was in a few cases a reversible condition. Generalized increase of arterial blood flow to the liver is a clinically important finding that could escape detection if radionuclide angiography is not included in the RES scintigraphy.

Relations between clinical signs of right and left cardiac decompensation and radiological signs thereof.

Ten consecutive patients arriving at the emergency department for severe systemic cardiac decompensation were investigated in respect of 17 clinical and laboratory parameters indicative of right or left heart failure. Investigations were made at arrival to the hospital and after completed in-hospital care. In respect of left heart failure the presence of rales and signs of interstitial oedema had a similar sensitivity. Both were of diagnostic value. Right heart failure was best diagnosed with clinical parameters such as pitting oedema, filling of the jugular vein, and liver enlargement. The laboratory parameters were less sensitive and appeared to have not a diagnostic but well a confirmatory value.