Massive digoxin intoxication in childhood.

In a 10 year old boy 8 hours after taking about 16 mg beta-acetyl-digoxin a maximum serum digoxin level of 31.8 ng/ml was measured radioimmunologically. This is the highest digitalis level in childhood described to date. The serum potassium level rose to 7.4 mmol/l. Complete atrio-ventricular block, and salves of ventricular premature beats were the most serious rhythm disturbances. The absence of life threatening rhythm disturbances is attributed to the early use of diphenylhydantoin in small frequent doses.

The effect of nifedipine alone or combined with low dose acetylsalicyclic acid on endotoxin-induced pulmonary hypertension in the piglet.

Cardiovascular responses to the calcium antagonist nifedipine, alone and combined with low dose acetylsalicyclic acid (ASA), were evaluated in a piglet model of endotoxin-induced pulmonary hypertension. All animals were anesthetized, paralyzed and mechanically ventilated. Cardiac output (CO), pulmonary artery pressure (PAP), aortic blood pressure (SAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAPM) and arterial blood gases were measured before and after induction of pulmonary hypertension by E. coli endotoxin and after treatment. Results of treated groups were compared to a control group of piglets subjected to the same dose (0.15 micrograms/kg i.v.) of endotoxin. Control animals responded to a bolus injection of endotoxin within 15 min with an increase in mean PAP by 110%. Pulmonary vascular resistance (PVR) increased by 144%. Mean arterial pressure did not change significantly from baseline values. In animals treated with a single dose of 1 mg/kg ASA prior to endotoxin, the initial pulmonary response was not quantitatively different from control values, whereas ASA 20 mg/kg abolished the pulmonary vascular reaction. The increase of systemic vascular resistance (SVR) produced by endotoxin was aggravated by high dose ASA. In piglets treated with nifedipine (4 micrograms/kg/min) over 30 min after the application of endotoxin with and without additional infusion of nifedipine 60 min prior to endotoxin the PVR could be attenuated. The combination of nifedipine and low dose ASA showed synergistic effects compared to control. The increase of mean PAP was significantly reduced, the PVR remained in baseline range due to a marked elevation of cardiac output.

Continuous monitoring of mixed venous oxygen saturation in infants after cardiac surgery.

Continuous mixed venous oxygen saturation (SvO2c) was measured in 16 infants immediately after cardiac surgery. A polyurethane 4F, dual channel catheter (Opticath, Modell U440, Oximetrix) with fiberoptic filaments was introduced into the pulmonary artery during cardiothoracic surgery. The catheters were left in place for an average of 67.5 h (range 27 h -125 h) and there were no catheter-related complications. Correlation between continuous in vivo SvO2 values and in vitro values was satisfactory (r = 0.85), whereas a correlation between SvO2c and arterial oxygen saturation (SaO2) was not found (r = 0.07). The sampled arterial lactate values were inversely correlated to the simultaneously measured SvO2c, but the correlation coefficient was only r = -0.4. There was an inverse correlation between SvO2c and arteriovenous oxygen content difference (Ca-vDO2) (r = -0.82), and a marked inverse correlation to the calculated oxygen utilization ratio (r = -0.97). Therefore SvO2c continuously reflects the overall balance between oxygen consumption and delivery, but the use of SvO2 as a predictor of blood lactate levels is unreliable. A further purpose of the present study was to demonstrate the clinical applications and to show the usefulness of SvO2c-monitoring; particularly as a surveillance and early warning system, as a guide for assessing therapy and its relevance in interpreting other monitored parameters. In our opinion continuous SvO2 measurement is a reliable and valuable indicator of cardiopulmonary function in the immediate post-operative period, even in infants with complicated repair of cardiac malformations.

[The changing clinical pattern of rheumatic fever (author's transl)]. / Das klinische Bild des rheumatischen Fiebers heute

During the last years a remarkable change in the pattern of rheumatic fever has been observed. Severe carditis and polyarthritis have almost disappeared. Accordingly the mortality rate decreased considerably milder forms of rheumatic fever may become a diagnostical problem so that adequate therapy may be delayed. These cases may present as chronic heart disease with an unspecific history. The modified Jones criteria alone have limited value. Laboratory tests are increasingly important. Not only improvement of hygiene or therapy with Penicillin are causes for the declining incidence of rheumatic fever, but also the change in the behaviour of Streptococci. This assumption will be supported if the equally dranged course of scarlet fever and the uniform ASO-titers in children as a measure for contacts with Streptococci are taken into account.

[Patterns of blood pressure and pulse frequency in infants during Vojta therapy]. / Zum Verhalten von Blutdruck und Puls bei Vojta-Therapie im Säuglingsalter.

In twenty infants aged seven weeks on average blood pressure and pulse frequency were measured during physiotherapy according to Vojta. At one of the exercises ("reflex reversion") blood pressure increased at an average of 60 mm Hg compared with the basic value under rest conditions. At another exercise ("reflex supporting") blood pressure reached about 52 mm Hg higher values as under rest conditions. The pulse frequency, however, showed a less impressive increase: it corresponded approximately to the value measured during crying. As probable causes for the increase of blood pressure are discussed: sustained muscle contractions, varied intrathoracal pressure conditions, and the emotional irritations of the infants. In infants with cardiovascular disease the increased strain during physiotherapy according to Vojta should be taken into account as an additional risk.

Congenital sinus bradycardia combined with congenital total atrioventricular block.

Sinus bradycardia and total atrioventricular block were found at the age of seven months in a boy who is now 16 1/2 years old. According to Yaters (1929) criteria, these are likely to be congenital disorders. While the frequency of the ventricular impulse generator in the upper bundle of His only slowed in accordance with age during the period of observation, the sinus node activity deteriorated considerably. Finally potentials could only be sporadically demonstrated. Under heavy stress and with a simultaneous slight increase in ventricular frequency, a re-occurence of regular but slow sinus node activity came about. The cause of this binodal disorder of rhythm is unknown. There is no indication of family affliction or of myocarditis in early childhood. Congenital heart disease could also be excluded.

[Ballooning mitral valve in tricho-rhino-phalangeal syndrome (author's transl)]. / Ballonierende Mitralklappe bei Tricho-rhino-phalangealem Syndrom I

The ballooning mitral valve defect has been repeatedly found in hereditary disorders of connective tissue such as the Marfan syndrome, osteogenesis imperfecta and the Ullrich-Turner syndrome. The present report concerns a nine year old girl with tricho-rhino-phalangeal dysplasia type I and this peculiar anomaly of the mitral valve. Since a literature review disclosed two more cases with tricho-rhinophalangeal dysplasia I and mitral insufficiency, the association may be more than fortuitous. Apparently the mesenchymal changes in tricho-rhino-phalangeal dysplasia I are not limited to the skeletal system.

[Rheumatic fever: present status (author's transl)]. / Das rheumatische Fieber--eine Bestandsaufnahme.

In general, there is a falling incidence of rheumatic fever in the Federal Republic of Germany. Data from 1949 to 1977 at the University Children's Clinic Mainz indicate that in the last few years rheumatic carditis and arthritis occurred with the same severity and frequency in relation to the total number of cases as 20--25 years ago. Merely the number of recurrences has been significantly lowered since the introduction of penicillin prophylaxis. The reduction in recurrences is the main reason why acquired heart disease has become less common.

[Hemorrhagic pulmonary edema and cardiac failure following isolated head injury. Treatment with dobutamine and nitroglycerin (author's transl)]. / Hämorrhagisches Lungenäodem und Herzkreislaufinsuffizienz nach isoliertem Schädelhirntrauma. Kombinierte Behandlung mit Dobutamin und Nitroglycerin.

A 12 year boy with an isolated head injury and subdural hematoma developed neurogenic pulmonary edema and intraoperatively a low cardiac output syndrome. The postoperatively depressed cardiac function and hemorrhagic pulmonary edema were treated with Dobutamine and Nitroglycerin given intravenously. The beta-1-stimulating catecholamine was used because of its positive inotropic effect, to reduce pulmonary capillary pressure and to improve the afterload. Nitroglycerin applied in a low dosage with exclusive venodilator effect was added for treatment of pulmonary edema and left ventricular failure. About 2 1/2 h after the start of the treatment pulmonary edema had subsided and circulation was stabilized.

Echocardiographic diagnosis of Candida endocarditis of the tricuspid valve and of the right atrium in a young infant.

Systemic candidiasis developed in a seven-week-old premature baby after 6 weeks treatment with antibiotics for suspected septicemia. At that time the echocardiogram showed a dense layer of echoes posteriorly to the anterior tricuspid leaflet during atrial systole. The diagnosis of Candida endocarditis with vegetations on the tricuspid valve and with right atrial thrombus secondary to the Candida infection was verified by autopsy.

[Hemodynamic reactions to intraventricular hemorrhage]. / Hämodynamische Reaktionen bei Ventrikeleinbruchblutung.

In a 13-year girl with head injury the hemodynamic parameters during 2 episodes of intraventricular hemorrhage were monitored. There were hyperdynamic values for heart rate, Cardiac output, mean arterial and pulmonary artery pressures, systemic vascular and pulmonary vascular resistances. It is likely that centrogenic, sympathico-adrenergic reactions are the cause of pulmonary failure after isolated head injuries.

[Experiences with nifedipine in the treatment of acute hypertension in childhood]. / Erfahrungen mit Nifedipin bei der Behandlung akuter Hypertonien im Kindesalter.

The efficacy of Nifedipine (N) as an antihypertensive drug was assessed in 4 children aged 6-12 years with acute severe hypertension. In one child with a hypertensive encephalopathy N 10 mg administered sublingually in addition to other antihypertensive drugs caused a prompt fall in blood pressure followed by a rapid clinical improvement. In the other 3 children N 10 mg reduced systolic and diastolic blood pressure by 13.7% and 16.4% respectively. This antihypertensive action lasted for about 3-4 hours and was associated with an increase in heart rate by 11.5%. The antihypertensive effects of N are positively related to pretreatment blood pressure. These results provide support that N is a safe and effective drug for controlling blood pressure also in hypertensive emergencies of children.

Effects of dobutamine on left ventricular performance in newborns as determined by systolic time intervals.

To evaluate the effects of dobutamine on myocardial function in newborns, left ventricular systolic time intervals (STI) - normalized pre-ejection period (PEPI), normalized left ventricular ejection time (LVETI) and pre-ejection period to left ventricular ejection time ratio (PEP/LVET) - were assessed by echocardiography in 18 newborns treated with dobutamine for clinically diagnosed heart failure. Examinations were performed prior to and 30 min after starting dobutamine infusion (7.5 or 10 micrograms/kg per min). Patients were assigned to two groups according to their PEP/LVET prior to dobutamine administration: group I (n = 9) with pre-treatment PEP/LVET less than or equal to 0.35 and group II (n = 9) with pre-treatment PEP/LVET greater than 0.35. While there was no change of STI in group I, dobutamine infusion resulted in a significant decrease in PEPI (from 102 +/- 4.8 to 87.8 +/- 4.2; mean +/- SEM; P less than 0.01) and of PEP/LVET (from 0.56 +/- 0.05 to 0.45 +/- 0.05; mean +/- SEM; P less than 0.01) and in a significant increase of LVETI (from 237.6 +/- 5.6 to 253.3 +/- 5.2; mean +/- SEM; P less than 0.01) in group II. Heart rate increased significantly in both groups. Left ventricular end-diastolic dimension, also assessed by echocardiography, did not change in the eight studies performed. An increase in mean arterial pressure was found in three out of five newborns of group II and in one out of four patients in group I. It is concluded that dobutamine can improve cardiac performance in newborns with impaired left ventricular function. This effect is probably due to an improvement in myocardial contractility.

[Purpura fulminans associated with varicella and polyvalent protective inoculations (author's transl)]. / Purpura fulminans nach Varizellen und polyvalenter Impfung

We report about a 10 5/12 years old boy, who developed the rare disease of Purpura fulminans following Varicella, after having received the trivalent Poliomyelitis vaccine of Sabin and a diphtheria-tetanus booster during the incubation period of Varicella. The acute stage of the disease was overcome by symptomatic therapy; extensive skin necrosis especially in the lower extremities had to be treated surgically. The etiology of Purpura fulminans has not yet been established. Since diffuse intravascular clotting (DIC) plays an essential part in the pathogenesis of this disease. Heparintherapy is now used as the treatment of choice. At the present state of knowledge we believe that the protective inoculations given in the incubation period of Varicella possibly provoced Purpura fulminans as a rare complication of Varicella.

[Dobutamine in childhood]. / Dobutamin im Kindesalter.

The synthetic catecholamine Dobutamine has potent inotropic effects. It is frequently used in the management of adult patients with low cardiac output and elevated left ventricular enddiastolic pressure not yet associated with systemic hypotension. The few available informations on hemodynamic effects of Dobutamine in children emphasize the effectiveness of this sympathomimetic amine also in the treatment of children especially older than 12 months with acute low cardiac output states. Neonates and infants appear to respond to Dobutamine as well, but possible changes in cardiovascular structure and function accompanying growth which are discussed and which could cause a considerable variance in individual patient response, require an exceptionally close monitoring of the hemodynamic effects of Dobutamine in this age-group.

[Care of severely asphyctic preterm and term infants]. / Versorgung schwer asphyktischer Früh- und Termingeborener.

We present a complex monitoring procedure for preterm and term infants with severe perinatal asphyxia and/or shock. It includes arterial and central venous catheters and occasionally a pulmonary artery catheter. The monitoring system provides rapid information on a number of parameters which can be used to improve the quality of ventilation and drug treatment. Therapy induced side effects are more rapidly detected and corrected. Handling of the baby is reduced and thereby the otherwise resulting increase in blood pressure and ensuing danger of cerebral hemorrhage.

[Pubertal status of pupils in orientation classes with reference to school sports]. / Der Pubertätsstatus der Schüler in den Orientierungsstufen im Hinblick auf den Schulsport.

Tanner scores of pubertal development were determined in 194 girls and 190 boys of the fifth and sixth grades. There was a wide scatter of Tanner scores both within and between sexes, reflecting considerable variability of pubertal development in these age cohorts. Physical performance depends on muscle mass and muscle strength. Since these variables are related to pubertal development, training programs and training goals must take the stage of pubertal development into consideration. A comparison of Tanner scores and sport ratings showed that the factor "pubertal development" is usually accounted for in daily practice.

[Supravalvular pulmonary stenosis following anatomic correction of transposition of great vessels: report of a successful balloon dilatation]. / Supravalvuläre Pulmonalstenose nach anatomischer Korrektur bei Transposition der grossen Gefässe: Bericht über eine erfolgreiche Ballondilatation.

Primary anatomical repair of TGA has several theoretical advantages over conventional atrial baffle techniques. However, one of the most common postoperative complications of the new technique is the development of an obstruction at the arterial anastomosis to the pulmonary artery (PA). A supravalvular pulmonary stenosis developed progressively over the first months after an arterial switch operation of a simple TGA in a newborn infant. The diagnosis was easily performed by Doppler-echocardiographic follow-up studies. Hemodynamic assessment by cardiac catheterization performed when the patient was five months old revealed a systolic gradient of 76 mm Hg at the arterial anastomosis. Percutaneous balloon angioplasty was successfully performed.

Determination of cardiac output by an angle and diameter independent dual beam Doppler technique in critically ill infants.

OBJECTIVE: To compare cardiac output measurements in critically ill infants by the dual beam Doppler and thermodilution techniques. DESIGN: Prospective direct comparison of the two techniques. For statistical evaluation one randomly assigned paired measurement of every patient was used. SETTING: Paediatric intensive care unit in a university hospital. PATIENTS: 18 infants after open heart surgery aged 4-25 months (weight 4-10 kg). INTERVENTIONS: Cardiac output measurements by dual beam Doppler and thermodilution techniques were performed within 10 minutes of each other and without knowledge of the results of the other methods. Multiple measurements were performed on some patients with a pharmacological or electrophysiological intervention or with a minimum of six hours between each pair of measurements. MEASUREMENTS AND MAIN RESULTS: Three patients were excluded because of an inadequate Doppler signal or a significant residual shunt. Cardiac output measurements ranged from 0.4 to 2.2 l/min for the thermodilution technique and from 0.5 to 2.1 l/min for the dual beam Doppler technique. Agreement between both methods was acceptable. The mean difference between the two methods was 0.026 l/min with two standard deviations ranging from -0.20 to 0.26 l/min. CONCLUSION: The dual beam Doppler technique was shown to have promise for the non-invasive determination of cardiac output in critically ill infants.