[Cerebral palsy in the light of old and new research results--in what direction does the pendulum swing?]

Cerebral palsy is reviewed from Little's first description of spastic diplegia in 1843 to the results of the most recent studies. One central question concerns whether prenatal or perinatal causes are the most important for the development of cerebral palsy. Current research indicates that conditions prior to and during pregnancy probably play a more important role than earlier thought. For years it has been the belief that cerebral palsy is caused by mismanagement in the perinatal period. At the same time, it has been suggested that improved perinatal care would reduce the incidence of cerebral palsy. This has not been the case, and many studies indicate that, despite proper perinatal care, the incidence of cerebral palsy is increasing. Much research remains to be done to obtain an overall picture of the etiology of cerebral palsy before we can establish measures to prevent this complex and serious condition.

[Fall-related injuries among elderly at home]

The aim of this study was to describe the extent of the problem of injuries from falling among elderly people at home. The study is based on data from the National Injury Register, which contains information on all inpatients and outpatients treated for injuries by hospitals and emergency clinics in four Norwegian towns. This study included 594 cases of accidental fall-related injuries which occurred at home in 1992 among a total population of 23,942 persons aged 65 years and over living in two towns, Drammen and Stavanger. The incidence of fall-related injuries at home was 25 per 1,000. The incidence was higher among women than men (32 and 13 per 1,000 respectively). The ratio between falls to the same level and falls to lower levels was 2:1 in the age group 65-79 year and 4:1 in the age group over 80 years. The most common mechanisms causing injuries were loss of balance (46%), stumbling (19%) and sliding (12%). 60% of all patients sustained fractures (15 per 1,000). 50% of all patients were hospitalised. The findings show that possibilities exist for preventing these injuries. The strategies must be directed both at the home environment and at individual factors among the elderly population.

[In the beginning was the child...Is health and course of life determinated already in utero and during early childhood?]

This question has been asked in many medical journals in recent years. The British research group, DJP Barker and co-workers, has performed a series of studies where the delayed effects of the early environment have been documented. The studies comprise ecological, individual follow-up and case control studies, as well as studies of trends over time. They show associations between different measures of children's living conditions at birth and during the first year of life, and the prevalence of different diseases among adults, especially ischaemic heart disease. The Norwegian researchers Forsdahl and Waaler have also done early fundamental work in this field. The Barker group interprets their findings by suggesting that nutrition in foetal and early life is crucial. However, alternative interpretations of their findings have been suggested. The most important objection is perhaps that socio-economic conditions at birth tend to persist throughout life, and that these conditions are more decisive for adult health than the conditions associated with foetal life and birth. Longitudinal, prospective studies which could provide conclusive evidence are lacking.

["The patient slipped on the ice...". Non-traffic related fractures among pedestrians, occurrence and seasonal variations]

The epidemiology of non-traffic-related fractures among pedestrians in three Norwegian towns (Drammen, Harstad and Stavanger, 515,602 person years) during the period 1 January 1988 to 31 December 1990 was studied on the basis of data form The Norwegian Injury Register. 1,104 such fractures occurred during the study period (21 per 10,000). The incidence increased with age from 12 per 10,000 in the age group < or = 14 years, to 47 per 10,000 in the group > or = 65 years. 57% of all patients with fractures were under the age of 65. Higher incidence during the winter months was observed in all three towns during the whole period. The increase occurred in the age groups 25-64 and > or = 65 years, both in males and females, but not in the age groups < or = 14 or 15-24 years. In 1990 we obtained more accurate information on the injury incident. 39% of all the fractures were caused by slipping on ice or snow. 45% of these were fractures of the elbow or lower arm. There seems to be a substantial potential for targeted preventive measures.

Prevalence and persistence of stomach ache and headache among children. Follow-up of a cohort of Norwegian children from 4 to 10 years of age

Results from a prospective cohort of 136 children, from 4 to 10 years of age, indicated that stomach ache was almost as prevalent among preschool children as children of school age. Headache was almost absent among 4-year-olds but prevalent at 10 years of age. Generally, early pain complaints were persistent. The co-occurrence of stomach ache and headache increased from 4% of children at 4 years of age to 20% when they reached 10 years of age.

["Rough pleasures"--and the good outdoor life. Physicians as pioneers of the outdoor life]

From the middle of the last century, mountain tourism has become an important part of our national tradition and culture. The physical activity and the pleasure and relaxation achieved by walking in wild areas is believed to have beneficial effects on health. Several colleagues in the medical profession were early pioneers in mountain walking and in the discovery and description of former "white spots" on maps. They communicated their feeling and love for nature, and the pleasure gained from their eventful expeditions. They taught us respect and concern for our special environment, with its great opportunities for a variety of leisure time adventures.

[To put one's femininity at stake. Admission of women to medical studies; Marie Spångberg and other pioneers]

In 1993, 100 years have passed since the first woman graduated in medicine from the University of Oslo. Her name was Marie Spångberg. A long-lasting "battle" had previously taken place to allow women to enter the University and to study medicine in particular. The first proposal to the Storting (the Norwegian national assembly) on this matter was made by Mr. L. Smitt, who strongly argued for the admittance of women to medical studies at the University. The Storting agreed, but the Medical Faculty protested violently in a note which was regarded as one of the most reactionary statements of the time on the nature of women. However, on 23 June 1884, an Act allowing women to graduate in all University studies was finally passed. In spite of the earlier resistance from the Medical Faculty, the female students did not experience any discrimination of women during their studies. They did meet difficulties, however, after their graduation, both in continuing their education and in obtaining a position.

Immune-mediated hemolysis associated with the administration of a radiographic contrast medium

A female patient developed serious hemolysis in association with the injection of a radiographic contrast medium (RCM). Serologic investigation of her serum suggested complement-mediated hemolysis, induced by an RCM-dependent IgM antibody in her serum. The antibody was of high titer and low avidity. The antibody showed cross-reactions with related radiographic contrast media and reacted only with group I adult RBCs.

[Neonatal alloimmune thrombocytopenia. Serological studies]

Alloimmune neonatal thrombocytopenia is most often caused by immunization towards the platelet-specific, glycoprotein IIIa-associated antigen HPA-1a (previous nomenclature PlA1, Zwa), but other defined platelet-specific antigens may also be involved. An HPA-1a-negative mother carrying an HPA-1a-positive child occurs in 1/50 of all pregnancies. However, HPA-1a-immunization occurs only in 1/1000 of all pregnancies, and only a proportion of the children are clinically affected. If the mother is positive for HLA-B8/DR3 she is known to be at risk for immunization. The serological diagnosis of thrombocyte immunization requires careful typing and investigation of antibodies, and reliable typing reagents. The quantitation of the mother's antibody is of little predictive value for the child's outcome, but intrauterine cord sampling can be a useful tool for improving the prenatal diagnosis.

Gastric lymphoma causing granulocytopenia and cold intolerance, with recovery after treatment

A 34-year-old man was found to have granulocytopenia with a white blood count of 2.3 x 10(9) l-1, consisting of 10% segmented neutrophils, 50% monocytes and 40% lymphocytes. A bone marrow aspirate showed 20% promyelocytes and 10% blasts with monoblastic features, and a smouldering myelomonocytic leukaemia was considered to be a possible diagnosis. In cold weather the patient experienced cold intolerance with acrocyanosis and small ulcerations on the ears. The test for heparin-precipitable protein ('cryofibrinogen') was strongly positive. During the following year, these signs and symptoms persisted, and the patient also developed constant moderate pain in the epigastric region. Gastroscopy revealed a large lymphoma of the stomach, which was a high-grade malignant centroblastic type of non-Hodgkin's lymphoma. After successful removal of the tumour, and six courses of potent cytostatic combinations, the patient recovered completely, and the granulocytopenia and cold intolerance disappeared.

[Compatibility problems in transfusion. Special reference to the delayed hemolytic transfusion reaction]

During 1988, our laboratory (The National Blood Group Reference Laboratory) detected clinically significant alloantibodies (excluding anti-D and anti-C + D) in samples from 72 patients from 24 different hospitals, transfusing about 40,000 units of red cells in this period of time. The simultaneous presence of autoantibodies complicated the serological diagnosis in a number of cases. Two patients had suffered acute haemolytic transfusion reactions due to antibodies not being discovered in the pretransfusion testing (anti-c and anti-Fya). 13 showed serological evidence of delayed haemolytic transfusion reaction not noted in the local hospital. We believe that delayed haemolytic transfusion reaction is seldom recognized. We stress the importance of quality control programmes in blood group serology.

Antibody dependent cell mediated cytotoxicity against anti-D sensitized human erythrocytes. Influence of various effector cells and enzyme treatment of the target cells

Antibody dependent cell mediated cytotoxicity (ADCC) was measured against anti-D sensitized erythrocytes using various mononuclear cell populations from peripheral blood in a chromium release assay. Adherent effector cells gave stronger cytotoxicity than unseparated and non-adherent cells, and were less dependent on pretreatment of the target cells with papain. However, close correlations were found between the cytotoxicity obtained with the various effector cell populations, indicating that either of them might be used for the purpose of establishing in vitro methods to determine the clinical significance of erythrocyte antibodies. The optimal choice of effector cells is discussed.

Fluorouracil (5-FU) induced acute immune haemolytic anaemia

A female patient on Fluorouracil (5-FU) therapy for rectal carcinoma developed acute intravascular haemolysis with her fifteenth drug injection; a similar episode occurred later after a controlled challenge with the drug. A 5-FU-dependent complement-activating IgM antibody, which reacted with RBC in an indirect antiglobulin test, was detected in her serum. The antibody did not react with cord RBC, but a blood group specificity could not be determined. An excess of 5-FU in the indirect antiglobulin tests resulted in inhibition of these reactions.

Hereditary thrombocytopenia with excessively prolonged bleeding time, corrected by infusions of platelet poor plasma

In a family with hereditary thrombocytopenia, transfused normal platelets as well as their own platelets had a shortened survival in the patients' circulation (11). On the other hand, the patients' platelets survived normally when transfused to a normal recipient. Platelet-associated immunoglobulins or circulating platelet antibodies were not detected (immunofluorescence method). About 200 ml platelet poor plasma (PPP) from each of 4 normal donors was infused daily for 5 consecutive d to 1 afflicted family member, causing a rise of platelet count from 65 X 10(9)/l to 163 X 10(9)/l and a decrease of bleeding time from 28 to 11 min 7 d after the PPP was discontinued. The platelet count then gradually decreased and was 65 X 10(9)/l with a bleeding time of 30 min 16 d after the PPP was discontinued. In a repeated PPP infusion experiment a similar response was evoked. It is concluded that the afflicted family members must have a deficiency of some plasma principle necessary to keep platelets fit and circulating.

Pulmonary reaction associated with transfusion of plasma containing anti-5b

A patient developed an acute respiratory distress syndrome with lung infiltrates during a transfusion of plasma. The transfused plasma was shown to contain a potent leucocyte agglutinating antibody of IgG type with anti-5b specificity, reactive with the patient's cells. A review of the literature on similar transfusion-related syndromes showed an association with more of less well-defined white cell antibodies, mainly in the donors' plasma. The majority of donors were multiparous women. The anti-5b in our donor was demonstrated only by granulocyte agglutination technique, as previously described antibodies in the five system. A long incubation procedure (20-25 h) seemed to be optimal for granulocyte agglutination.

Chloroquine removal of HLA antigens from platelets for the platelet immunofluorescence test

Chloroquine-treated platelets did not react with HLA antisera in a platelet suspension immunofluorescence test (PSIFT), while the reactions with platelet-specific antibodies (P1A1, Baka) seemed even stronger after treatment. The method might be useful in discerning HLA and platelet-specific antibodies without absorption procedures. The treatment causes death of a proportion of the cells, with nonspecific fluorescence making the reading difficult. This may be circumvented by using special phase-contrast lenses.

An international reference typing for Ch and Rg determinants on rare human C4 allotypes

Red cells, serum and plasma samples of 20 individuals, selected for their C4 allotypes, were distributed from Bonn to five laboratories, for investigation of their Chido (Ch) and Rodgers (Rg) determinants. One anti-Ch (M.H.) and one anti-Rg(Prest.) were distributed, but the individual laboratories also used their own reagents and their own typing methods. There was general agreement in interpretation of the majority of samples. Partial inhibition for Ch and Rg was detected. Two samples gave anomalous results; one sample with C4 A1,3 BQO, QO had Ch determinants on the red cells and in plasma (partial inhibition), and another sample with C4 A3,4 B5, QO apparently lacked Ch determinants on the red cells and in plasma. Heterogeneity of anti-Ch and anti-Rg was suggested in testing red cells, perhaps, reflecting a quantitative effect. This heterogeneity was confirmed by inhibition studies. The capacity of some reagents to detect partial inhibition probably reflects qualitative as well as quantitative differences.

Paroxysmal cold haemoglobinuria. The most frequent acute autoimmune haemolytic anaemia in children?

Paroxysmal cold haemoglobinuria (PCH) is a disease which today is met mainly in its acute form in children. The diagnosis is revealed by a careful serological examination. Case reports of four children with PCH are given in this paper. They all showed typical clinical pictures of PCH, and displayed the expected serological findings, including a bithermic autoantibody (haemolysin), the Donath-Landsteiner antibody. Children with PCH often require immediate transfusion therapy, but certain precautions should be taken regarding transfusion policy in these patients. When the acute phase is overcome, the prognosis is excellent.

Neonatal alloimmune thrombocytopenia. Case reports, diagnostic and therapeutic considerations

Two families are presented, where the mothers have given birth to children with neonatal alloimmune thrombocytopenia (NAITP) due to immunization towards the platelet specific antigen PIA1, which is responsible for most of the cases with NAITP. Anti-PIA1 has previously been difficult to demonstrate, but current techniques, such as the platelet suspension immunofluorescence test (PSIFT) used here, have made routine laboratory diagnosis possible. Both mothers in these families were HLA-B8 positive. This antigen shows strong association with PIA1 immunization.