Early growth delay in diabetic pregnancy: relation to psychomotor development at age 4

Ninety nine consecutive insulin dependent and 101 non-diabetic pregnant women were examined by ultrasonograph to assess early fetal growth. In 42 of the diabetic mothers and three of the non-diabetic mothers the scan showed early intrauterine growth delay. At 4-5 years of age all children available for study were evaluated by the Denver developmental screening test. Only 23 of the 34 children of diabetic mothers with early intrauterine growth delay had normal test scores compared with 46 of the 50 children of diabetic mothers with normal intrauterine growth. The children failed in personal-social development, gross motor development, and particularly in language and speech development. Children of diabetic mothers with normal early fetal growth had scores very similar to those of the children of non-diabetic mothers, of whom 76 of the 86 tested had normal scores. This study suggests that children with a history of growth delay in early diabetic pregnancy should be screened for possible developmental impairment.

Omeprazole and ranitidine in treatment of reflux oesophagitis: double blind comparative trial

One hundred and sixty two patients with endoscopically proved reflux oesophagitis stratified for severity, 66 with grade 1 disease (erythema and friability) and 96 with grade 2 or 3 disease (including erosions or ulcerations), were allocated at random to double blind treatment with omeprazole 40 mg in the morning or ranitidine 150 mg twice daily for up to 12 weeks. A patient could be evaluated sooner if symptomatic relief and endoscopically normal mucosa (grade 0) were noted after four to eight weeks' treatment. Patients treated with omeprazole responded significantly more rapidly than those treated with ranitidine (p less than 0.0001), cumulative healing rates at four, eight, and 12 weeks being 90%, 100%, and 100% respectively for those with grade 1 disease and 70%, 85%, and 91% respectively for those with grade 2 or 3 disease in the omeprazole group. Corresponding rates in the ranitidine group were 55%, 79%, and 88% (grade 1) and 26%, 44%, and 54% (grade 2 or 3). Relief of the major symptoms of heartburn, regurgitation, and dysphagia and improvements in the histological appearance of the mucosa occurred earlier and were again more pronounced during treatment with omeprazole than with ranitidine. This observed superiority of omeprazole 40 mg in the morning over ranitidine 150 mg twice daily in the short term treatment of reflux oesophagitis was obtained without major clinical or biochemical side effects, but further research is needed into longer term use of omeprazole and the effects of the acid inhibition it induces.

Infantile hypertrophic pyloric stenosis: the changing trend in treatment in a Danish county

From 1950 to 1984, 679 patients were treated for infantile hypertrophic pyloric stenosis (IHPS) in the County of Funen, Denmark. Medical treatment was performed in 114 patients and pyloromyotomy in 565. A pyloric tumor was palpated in 80% and a barium meal examination was performed in 24% of the patients. A shift toward intravenous fluid and general anesthesia is seen during the study period. Complications occurred in 17% of medically treated patients and in 8% of surgically treated patients. Six deaths occurred among the medically treated and four among the surgically treated patients. During the study period, a shift toward centralization and surgical treatment took place.

The effects of morphine on biliary dynamics. A scintigraphic study with 99mTc-HIDA

The effect of morphine on biliary dynamics was studied by cholescintigraphy with 99mTc-HIDA. Among 30 normals without morphine injection 3 did not demonstrate intestinal radioactivity after 1 h, whereas all visualized the gallbladder. Eight normals with morphine injection did not demonstrate intestinal radioactivity after 2 h, but all had gallbladder visualization very early. Variables of the time-activity curves from liver areas did not point to impaired uptake or excretion. Morphine-induced increase in resistance to passage from the common duct to the intestines in normals is of a magnitude that forces the total amount of bile to accumulate in the gallbladder. Results from 11 patients after cholecystectomy indicate that the increase in pressure is less than the maximal secretory pressure of the liver. The resorptive capacity and the compliance of the gallbladder enable these events to take place without signs of secondary liver impairment.

The effects of omeprazole on gastro-oesophageal sphincter pressure, intragastric pH, and the migrating motor complex in fasting healthy subjects

Placebo and omeprazole (80 mg) were administered by intravenous injection in a random, double-blind, cross-over manner. Phase I and phase II of the MMC were divided into segments, and phase III constituted a single segment. The highest and lowest sphincter pressures were recorded in each segment. In the placebo group only one of the lowest values was significantly different from phase I,1. Among the highest values all means from phase II,1 to phase III were significantly higher. In the omeprazole group all means from phase II,4 to phase III in the upper demarcation were significantly higher. When the pressure profiles of placebo and omeprazole in each segment were compared, no differences were found. An unchanged pressure profile in all segments of the MMC in connection with a substantial reduction of acid secretion indicates that omeprazole shows great promise for use in patients with oesophagitis.

Intestinal malrotation without volvulus in infancy and childhood

Intestinal malrotation without volvulus in infants and children is often difficult to diagnose because of less dramatic clinical features, e.g. failure to thrive and intermittent bile stained vomiting, compared to the patients with volvulus. A plain x-ray of the abdomen may show the characteristic "double bubble sign", otherwise a barium meal will give the diagnosis. A follow-up study of 18 patients of whom 14 had an operation showed that all but one were free of symptoms after a median observation period of 205 months (range 20-317). It is concluded that any patient presenting with a symptomatic intestinal malrotation should be offered an operation except for the type with a mobile caecum.

Rectal prolapse in infancy: conservative versus operative treatment

In infancy there are two types of rectal prolapse. One type is less pronounced and intermittent. This type occurred in 9 out of 17 children referred for rectal prolapse and ceased after a few weeks' conservative treatment. The other type is a more pronounced prolapse occurring at nearly each defecation and lasting several weeks or months. These patients may need an operation, especially when ulceration of the mucosa occurs. In our patients, a Lockhart-Mummery operation was used successfully in all but one patient. No complications were observed. Though less extensive treatment, such as submucosal injection of sclerosing agents, is recommended to be the first method of choice because pathoanatomically the prolapse in infancy is frequently a prolapse of the mucosa, in patients where this therapy does not succeed, a Lockhart-Mummery operation may be an alternative.

Cirrhosis and bleeding ileal varices without previous intraabdominal surgery. A case report

A case is reported in which gastrointestinal bleeding was caused by ruptured ileal varices in a patient without previous intraabdominal surgery. Shunting took place via veins in adhesions which were the results of a previous periappendicular abscess. This implies that the clinical entity has to be extended to bleeding from the gastrointestinal tract, cirrhosis of the liver, and previous intraabdominal surgery or previous intraabdominal inflammatory disease.

Development of infantile hypertrophic pyloric stenosis in patients treated for oesophageal atresia. A case report

Two cases of infantile hypertrophic pyloric stenosis (IHPS) developed in 74 patients treated for oesophageal atresia. Treatment of oesophageal atresia is frequently followed by vomiting and failure to thrive due to gastrooesophageal reflux or anastomotic stricture. The diagnose of IHPS must be considered in such patients under the age of 8 weeks as symptoms of IHPS are similar to those of gastrooesophageal reflux. The diagnose of IHPS is strongly supported by the presence of a non-carbonic alkalosis. Contrast studies including oesophagus, stomach and duodenum are to be made early in the course, as clinical signs of IHPS are often masked.

Status at two years in 121 very low birth weight survivors related to neonatal intraventricular haemorrhage and mode of delivery

All 121 infants with birthweight less than or equal to 1500 g (VLBW) discharged from our department through an 18-month period were followed up at two years of age. All but 10 infants were examined by cranial ultrasound scanning in the neonatal period. Six had died after discharge; and of these two had severe brain damage following neonatal intraventricular haemorrhage. Twelve children had definite neuromotor abnormality; of these, the nine children with spastic types of cerebral palsy had all been delivered vaginally. Of the remaining children, one half had at least one neurodevelopmental symptom suggesting perinatal brain damage. Outcome was associated to neonatal intraventricular/subependymal haemorrhage when complicated by ventricular dilatation. Outcome in children with simple haemorrhage was similar to that in children without haemorrhage. The association between outcome and haemorrhage was considerably reduced by simultaneously considering the associations of gestational age at birth and the use of mechanical ventilation in the neonatal period. Head circumference at follow-up was greatest in those children with haemorrhage complicated by ventricular dilatation, when adjusted for actual body weight, birth weight, and gestational age at birth.

Long-term study of gamma-vinyl GABA in the treatment of epilepsy

The purpose of this study was to investigate the long-term efficacy and tolerability of gamma-vinyl GABA (GVG) in the treatment of epilepsy. 36 patients with severe therapy resistant epilepsies participated, the majority exhibiting complex partial seizures. The mean follow-up period was 9.3 months. GVG was administered as add-on therapy, to keep serum levels of concomitant treatment constant. The mean dose of GVG was 2.6 g's per day. Fifty-six per cent of the patients, including three patients with juvenile myoclonic epilepsy, experienced more than a 50% reduction in seizure frequency. No signs of tolerance development to the antiepileptic effect of GVG was demonstrated. Two patients were withdrawn from GVG treatment due to increased seizure frequency, and two due to side effects in the form of vomiting and nausea. Incidentally, the side effects observed were harmless and transient. Fifty per cent of the patients experienced no side effects at all. GVG seems to be a valuable antiepileptic compound. The results of this long-term study confirm observations from several short controlled trials.

Plasma noradrenaline and adrenaline in newborn infants of diabetic mothers: relation to plasma lipids

No significant differences in plasma noradrenaline and adrenaline concentrations were found between 14 infants of diabetic mothers (IDMs) and 7 infants of non-diabetic mothers at birth or at 2 hours of age, although the mean values were higher in the IDMs. The mean blood glucose concentration declined from birth to 2 hours of age and it was lower at 2 hours of age in the IDMs although only one IDM became hypoglycaemic. Plasma non-antibody bound insulin concentrations were approximately 12 fold higher at birth and at 2 hours of age in the IDMs than in the control infants. Similar increases in plasma free fatty acids and free glycerol concentrations from birth to 2 hours of age were observed in the 2 groups. At 2 hours of age positive correlations were found between plasma noradrenaline and free fatty acids (r = 0.85, p less than 0.01) and free glycerol (r = 0.65, p less than 0.05) and between plasma adrenaline and free glycerol (r = 0.71, p less than 0.05) and the rise in free glycerol from birth to 2 hours of age (r = 0.65, p less than 0.05) in the IDMs. At birth positive correlations between plasma free fatty acids and plasma noradrenaline (r = 0.69, p less than 0.02) and plasma adrenaline (r = 0.88, p less than 0.01) were found in the IDMs. No correlations were found in the control infants. These findings indicate that the catecholamines counteracts the inhibitory effect of insulin on lipolysis in IDMs.

Gallbladder emptying and gastrointestinal cyclic motor activity in humans

The purpose of the present work was to answer two questions: does the human gallbladder empty in the fasting state, and, if so, is the emptying related to a specific phase of the activity in the gastrointestinal tract? The material consisted of nine healthy volunteers and the motility recordings were done with a perfused low-compliance system. Gallbladder emptying was recorded by the use of scintigraphy with 99mTc-HIDA. Eleven activity fronts were observed, and seven periods of gallbladder emptying were recorded. Reduction in counts over the gallbladder ranged from 8% to 32%. All emptyings took place in connection with phase-II activity in the intestine. Three were in close proximity to the following phase-III activity, and the other four occurred early in a phase II. Four activity fronts were not accompanied by output of bile.

CONCLUSIONS

bile output from the gallbladder occurs in fasting humans, and gallbladder emptying takes place in connection with phase-II activity in the intestine but not always in close connection with the following phase-III activity.

Congenital chylothorax: management by ligature of the thoracic duct

Congenital chylothorax in a male infant persisted for 10 weeks despite repeated thoracocenteses and dietary regimens which included total parenteral nutrition for 37 days and a peroral semielementary diet with medium-chain triglyceride content for 19 days. Thoracotomy disclosed a small leak in the thoracic duct. The duct was ligated above and below the leak, as attempted repair was unsuccessful. There was no recurrence of pleural effusion after the operation and no distal lymphoedema was observed.

Suppression of B lymphocytes in mature newborn infants

The ability of cord blood lymphocytes to secrete immunoglobulins during in vitro culture was investigated by means of a reverse hemolytic plaque forming cell (PFC) assay. Mononuclear cord blood cells did not differentiate into immunoglobulin-secreting cells after stimulation with the polyclonal B lymphocyte activator pokeweed mitogen (PWM), contrary to the findings in normal adults. Mononuclear cord blood cells were then separated into T-enriched and T-depleted blood lymphocyte subsets. When these were co-cultured, the PWM-induced immunoglobulin secretion was still low; following irradiation of the T-enriched cells, the numbers of IgM-PFC but not of IgG- or IgA-PFC increased considerably. The effect of irradiation of the T-enriched cells on the PWM-induced IgM response was dose-dependent, with maximal effect at 2500 rad. It is concluded that the low PWM responses obtained using cord blood lymphocytes are in part due to suppression by radiosensitive T suppressor cells. Following removal of this suppression by means of irradiation, B lymphocytes can be induced to secrete IgM, but not IgG or IgA.

Plasma noradrenaline and adrenaline in infants of diabetic mothers at birth and at two hours of age

Plasma noradrenaline and adrenaline in the umbilical artery were very high in many infants of both diabetic mothers (IDM) and non-diabetic mothers (controls) compared to values obtained in adults. Blood pH was slightly but significantly lower in IDM than in controls at delivery. There was a significant negative correlation between plasma noradrenaline and blood pH in IDM at birth, but no correlation between plasma noradrenaline and blood glucose, birth weight and Apgar scores. Plasma noradrenaline decreased significantly from birth to two hours of age both in IDM and controls. At two hours of age plasma noradrenaline and adrenaline were significantly greater in IDM compared to controls whereas blood glucose concentration was lower in the former group. There was a close inverse correlation between plasma noradrenaline and adrenaline, respectively, and blood glucose in IDM at two hours of age but not in controls. The elevated plasma noradrenaline at delivery in IDM may be explained by clinically undetectable acidosis whereas elevated plasma catecholamines at two hours are probably due to hypoglycaemia.

The use of [99mTc](2,6-diethylacetanilide)-iminodiacetic acid ([99mTc]HIDA) in evaluating normal hepatobiliary dynamics

Scintigraphic examination with [99mTc]HIDA was used to investigate fasting hepatobiliary dynamics in thirty normal subjects, fifteen males and fifteen females. Ten were studied in duplicate. All subjects visualized the bile ducts and showed gallbladder filling within 60 min. All but three demonstrated excretion of bile to the duodenum. Only five subjects showed activity in the gut before gallbladder visualization. Twenty-one had one or more contractions of the gallbladder. A significant positive correlation was found between age and excretory liver function in males, signifying a lower excretory capability with advancing age. The median percentage deviation for gallbladder and gut visualization in repeat tests was 40% and 88%, respectively. It is concluded that the hepatic bile in the fasting state is delivered to the gallbladder as well as to the duodenum. Furthermore, the results suggest a cyclic function of the biliary tract based upon coordination between the gallbladder and the sphincter of Oddi.

Scintigraphy with 99mTc-(2,6-diethylacetanilide)-iminodiacetic acid as a diagnostic test in traumatic lesions of the liver and biliary tract

99mTc-HIDA scintigraphy was used as a diagnostic procedure in three patients with liver and biliary tract injuries following blunt abdominal trauma. The scintigraphic characteristics are illustrated and discussed. The application of this method is recommended in patients who are clinically stable and in whom the physical findings are equivocal. Furthermore, important information can be gained in patients who have an unsatisfactory course after operative treatment of liver and biliary tract injuries.

Hepatobiliary scintigraphy with 99Tcm-HIDA in patients with jaundice

In order to assess the clinical value of 99Tcm-HIDA for hepatobiliary scintigraphy 23 patients with hepatocellular disease and 44 patients with obstructive biliary tract disease were examined. Positive information was obtained in 14 and 23 patients, respectively. False results mainly depended on inadequate imaging of the liver in the case of severely impaired function, whatever the cause. Spontaneously ameliorated obstruction leaving an impaired hepatocellular function may give misleading results. A malignant tumour widely involving the liver and impressing the bile ducts may also create the appearance of obstruction. If HIDA scintigraphy be limited to patients with serum bilirubin levels between 40 and 250 mumol/l the diagnostic specificity and sensitivity of 90 per cent and 78 per cent, respectively, is reached in demonstrating obstruction, when the prevalence is 0.58.

The effect of carbachol on resting gastro-oesophageal sphincter pressure and serum gastrin in normal human subjects

With the purpose of investigating the mechanism of action behind the rise in gastro-oesophageal sphincter pressure induced by cholinergic activity, serum gastrin and sphincter pressure were recorded in 8 normal human subjects before and in relation to administration of carbachol. Carbachol was given subcutaneously in a dose of 4.5 mug per kg body weight. Mean sphincter pressure recorded 15, 30, and 45 minutes after administration of carbachol was significantly higher than the basal mean. The administration of carbachol did not lead to significant changes in serum gastrin and a relationship between serum gastrin and sphincter pressure was not demonstrable. It is concluded, that the carbachol-induced rise in the basal sphincter pressure is not dependent on an increase in serum gastrin, but probably attributable to either direct cholinergic stimulation of the receptors or a cholinergically enhanced sensitivity of the receptors for gastrin. Moreover, it is concluded that carbachol in individual dosages may be a suitable adjuvant in the medical treatment of patients with gastro-oesophageal reflux.

Effect of barium meal on resting gastro-oesophageal sphincter pressure in normal human subjects

The effect of ingestion of 250 ml X-ray contrast medium on resting gastrooesophageal sphincter pressure was studied in 10 normal human subjects. Twenty minutes after initiated intake of the contrast medium, a significant fall in sphincter pressure was recorded. In the light of studies on the neurogenic and hormonal regulation of the sphincter pressure it is attempted to account for this effect, and it is concluded that it must be a manifestation of a reflectory relaxation of the sphincter region. From a clinical point of view the consequence must be a demand for standardized conditions with regard to composition and pH of the contrast medium, time schedule and degree of abdominal compression in those cases in which radiological evaluation of the resistance against reflux is called for.