The effect of dexamethasone on respirator-dependent very-low-birth-weight infants is best predicted by chest X-ray

BACKGROUND

Chronic lung disease (CLD) in premature infants shows a variable clinical course with different radiological manifestations.

OBJECTIVE

To evaluate the correlation between parameters of trans-membrane permeability [albumin/secretory component (SC)] and oxidative stress [malondialdehyde (MDA)/SC] in tracheal aspirate fluid (TAF) and radiological findings with the effect of a 5-day course of dexamethasone (0.5 mg/kg per day).

MATERIALS AND METHODS

Fifty ventilator-dependent premature infants with birth weights < 1,500 g (gestational ages 23-31 weeks) and radiological signs of early chronic lung disease (CLD) were treated with dexamethasone at day of life 5-27 (median 10 days) because of respiratory deterioration. TAF was collected serially. Chest X-rays taken before and 8-10 days after dexamethasone were scored for changes of opacification, consolidation and hyperinflation/emphysema, and classified into three groups.

RESULTS

Twenty-four infants had a positive response to dexamethasone, defined as a reduction of the ventilation index FiO2 x mean airway pressure > 40% at day 5, compared to pretreatment values. About 80% of the responders showed homogeneous lung opacification on chest X-ray, reflecting leaky lung syndrome. In contrast, seven of eight infants with predominantly emphysema on radiology were non-responders; 80% of infants with a mixed radiological picture characterized by predominance of consolidations alternating with regions of emphysema were also non-responders. Ratios of albumin/SC and MDA/SC in TAF decreased significantly within 3 days after the onset of dexamethasone. However, MDA/SC was persistently higher in non-responders compared to responders. Opaque lungs were largely improved by dexamethasone, in contrast to streaky or patchy consolidations and emphysema. In a logistic regression model, radiographic classification was the most important factor influencing the response to dexamethasone with a positive predictive value of 86%, followed by albumin/SC ratio.

CONCLUSIONS

The optimum timing of dexamethasone treatment may be determined by the stage of developing CLD and radiological findings rather than by the age of the premature infant.

Acute lymphoblastic leukemia with severe skeletal involvement: a subset of childhood leukemia with a good prognosis

Skeletal radiographic abnormalities are common in children with acute lymphoblastic leukemia (ALL). The impact of severe skeletal involvement (SI) on survival and the correlation between SI and biological markers were analyzed. Therefore, radiographs and medical charts of 106 ALL patients who received a skeletal survey at the time of diagnosis and were treated at the University Children's Hospital Würzburg between 1974 and 1995 were reviewed. On the basis of the skeletal survey, SI was quantified using a score. Fifty-nine patients (55%) showed radiographic abnormalities defined as metaphyseal banding (48%), periosteal reactions (11%), osteolysis (33%), osteosclerosis (31%), or osteopenia (22%). Children with severe SI (n = 32) presented with a higher rate of severe radiographic abnormalities such as geographic destructive osteolysis (37%; P < .001) and periosteal reactions (28%; P < .05) compared with children with moderate SI (0% and 4%, respectively). Patients with severe SI showed a lower peripheral blast count (P < .05) at diagnosis, a more frequent "prednisone good response" (P < .05), and a higher survival rate (83 +/- 7%; P < .05) than patients without SI (54 +/- 9%). Patients with moderate SI (n = 27) showed a higher hemoglobin concentration (P < .05), an enlargement of liver (P < .05) and spleen (P < .01), a higher BFM risk factor (P < .01), but still a higher survival rate (73 +/- 11%) than patients without SI (NS). Patients with severe SI had a higher (P < .001) DNA content of leukemic cells as measured by DNA index (DI) than patients without SI. Thirty-one percent of patients with severe SI, 22% of patients with moderate SI, and no patient without SI had a DI > 1.16. No patient with a DI < 1.0 presented with severe SI. The number of radiographic abnormalities in patients with SI correlated with the DI (rho: 0.46; P < .001). However, patients with euploidy (DI = I) and severe SI also had a higher (P = .05) survival rate (70 +/- 18%; n = 15) than euploid patients without SI (49 +/- 11%; n = 24). Of the patients with severe SI, 78% had common ALL and 22% had an ALL type other than common ALL (P < .05). In patients with ALL types different from common ALL, severe SI was also associated with higher survival rates. We conclude that on the basis of clinical features, two distinct subgroups could be identified in terms of SI. Patients with clinically relevant severe SI had a better prognosis, a higher DI, and more frequently a common ALL than patients without SI. However, the impact of severe SI on prognosis was independent of DI and type of leukemia.

[Indirect genotype analysis in 2 families with early manifestation of autosome dominant polycystic nephropathy]

Autosomal dominant polycystic kidney disease (ADPKD) is one of the commonest dominantly inherited disease with an estimated incidence of 1 in 1000. In the majority of cases the ADPKD gene locus is linked to chromosome 16p13.3-markers (PKD1). It has been estimated that approximately 2 percent of PKD1 gene carriers already present with severe clinical manifestation in childhood. In two families with early manifestation of ADPKD, DNA studies with markers of chromosome 16p allowed the determination of carrier status. A preclinical (predictive) DNA analysis of possible PKD gene carriers in childhood should not be performed as a routine examination. However, children of PKD gene carriers should be examined by pediatric nephrologists in order to allow early treatment of possible complications.

Intraarticular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth

OBJECTIVES

To assess the efficacy and effects on cartilage and statural growth of intraarticular corticosteroid (IAS) therapy for chronic arthritis in children and adolescents.

METHODS

We examined 21 children and adolescents with chronic arthritis (median duration, 8 months) that did not respond to nonsteroidal antiinflammatory drugs. The 21 joints injected with triamcinolone-hexacetonide were examined before and 7 weeks after IAS therapy by gadolinium-enhanced magnetic resonance imaging; 14 joints were also examined 13 months after IAS therapy.

RESULTS

All joints treated with IAS had improvement. Magnetic resonance imaging showed long-lasting suppression of inflammation and pannus without evidence of toxic effects on cartilage. Statural growth was not affected.

CONCLUSION

In experienced hands, IAS therapy may be a safe and effective tool in the treatment of chronic arthritis in childhood. Long-term follow-up is mandatory.

[Intra-articular steroid therapy in treatment of chronic arthritis in childhood and adolescence]

OBJECTIVE

Steroids are among the most potent antirheumatic drugs, but carry unacceptable adverse effects during long-term systemic application. In children with pauciarthritis intra-articular steroids have been recommended.

METHODS

We assessed the effect of intra-articular triamcinolone-hexacetonide in 16 joints of 12 children and adolescents with chronic arthritis unresponsive to non-steroidal anti-inflammatory agents.

RESULTS

All joints improved and no side effects were observed by clinical and roentgenographic means. After a follow-up of 12 months after a single injection 9 joints were without arthritis and 3 joints showed minimal effusion without limitation of motion. In 4 joints arthritis reappeared after 1, 6, 7 and 7 months.

CONCLUSION

Intra-articular steroid therapy is a highly effective alternative in the treatment of children and adolescents with chronic arthritis.

[Interstitial lung diseases. A comparative study between a film-screen combination and a digital storage phosphor technic]

Chest examinations were carried out in 60 individuals using film-screen and digital storage phosphor techniques and identical radiation doses. 29 of these individuals were patients with interstitial pulmonary disease; 31 were normals. Postprocessing of the digital images was carried out with filtering using an unsharp mask and identical parameters for all patients. An ROC analysis using 10 observers showed no significant difference in the evaluation of the interstitial lung disease. Correlation analysis showed a significant positive correlation (p less than 0.001) for the findings in both techniques. Under the present circumstances, film-screen and digital storage phosphor technique are of equal value in the diagnosis of interstitial pulmonary disease.

[A ROC analysis for comparing contrast perception in grey scale reversal of digital images]

Based on ROC (receiver operating characteristic) analysis, contrast perception by eight physicians engaged in x-ray diagnostics for different lengths of time was examined in respect of inversion of grey scale values of digital x-ray film images. The ROC analysis showed a significantly superior contrast perception for imaging by the negative mode (bones white) than by the positive mode (bones black). With r* = + 0.61 a positive correlation was obtained between the period of the physicians' activity in x-ray diagnostics and the difference between the areas below the ROC curves for both imaging modes. Hence, the negative mode is to be preferred for diagnostic work based on digital x-ray film images.

Alexander's disease: cranial MRI and ultrasound findings

Cranial ultrasound (US) findings and magnetic resonance imaging (MRI) are presented in an infant with Alexander's disease. Both methods may help the clinician with the early diagnosis of this rare disease.

[Intraoperative ultrasound in pediatric neurosurgery]

Intraoperative sonography is a useful tool for the neurosurgeon to achieve rapid orientation. This is of particular importance, since planning of an operation is usually based on standard cuts obtained via CT or MR, whereas surgical approach is governed by the prevailing anatomico-topographical conditions. The article reports on experience collected in the operation of intracranial tumors and cysts and in shunt implants effected in children and adults.

[The effect of maternal dexamethasone treatment after the 12th week of pregnancy on fetal genital development in adrenogenital syndrome with 21-hydroxylase deficiency]

Prenatal treatment with dexamethasone starting with gestation week 5 has been proposed to prevent virilization of female fetuses with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency. We report dexamethasone treatment in a mother during her third pregnancy; this treatment could not be started before the 12th week of gestation. The second child (index case) had a simple virilizing 21-hydroxylase deficiency CAH and Prader IV genitalia. Because after amniocentesis a normal female karyotype and HLA identity with the index case were found, the dexamethasone treatment (3 x 0.5 mg/die) was continued until delivery.-In contrast to patients with salt-wasting CAH, the 17-alpha-hydroxyprogesterone level in the amniotic fluid was within the normal range. Decreased maternal plasma and urine estriol concentrations, as well as the plasma cortisol values, demonstrated adequate suppression of the fetal and maternal adrenal gland. No side effects were found in the mother as a result of the dexamethasone treatment. The newborn had virilization of the external genitalia according to Prader III but without hypertrophy of the clitoris. The degree of rugated scrotum was less marked in relation to the index case and the sinus urogenitalis was more distally shifted. Thus, surgery on the clitoris could be avoided. The conditions for further surgery (vaginoplasty) could probably be improved. Therefore, dexamethasone treatment of a mother with a female CAH fetus due to 21-hydroxylase deficiency seems to be justified starting at the 12th week of gestation. However, the optimal beginning of therapy is in early pregnancy.

[Aortic dissection in childhood. Occurrence and diagnostic procedure]

Aortic dissections of the aorta thoracalis are rare in childhood, and mostly cause a life-threatening situation in which an immediate diagnosis is the key for survival. Main causes are an aortic vitium or a traumatic disruption. The conclusive diagnosis can only be obtained by a chest-X-ray, the two-dimensional echocardiography and the dynamic computed tomography scanning of the thorax. It must be taken into account, that patients with a polytrauma could possibly suffer from a traumatic aortic dissection, which sometimes can only be diagnosed at a later date.

[Gangrene of the intestine with pneumatosis intestinalis in a child with meningomyelocele]

A 13-year-old girl with meningomyelocele and a cauda-equina-paraplegia-syndrome, with resulting long-standing ileus, developed an extensive gangrene of the stomach, the small bowel and parts of the colon. As pathogenesis a non-occlusive-ischemia is suspected; the exceptional neurological situation is discussed.