Acute valproate intoxication with fatal outcome in an infant

A healthy twenty-month-old boy ingested a maximal dose of valproate from which about 750 mg/kg were absorbed. Cerebral coma, which lasted for twenty hrs, was followed by an undisturbed period of approximately sixteen hrs. Death from cardiorespiratory failure due to severe bronchopneumonia occurred 46.5 hrs after the ingestion of the drug. The serum valproic acid concentration reached a peak of 1061 micrograms/ml within three hours, and fifteen minutes before death it had fallen to 187 micrograms/ml. The half-life of 16.6 hrs was within the range usually found. Metabolic acidosis, hypernatraemia and hyperosmolarity could be corrected, unlike the hypocalcaemia, which developed later. Bilirubin, GOT, GPT, gamma-GT, alkaline phosphatase, blood glucose, diastase, urea, creatinine, haemoglobin as well as PT and PTT and the platelet count were all normal. Leucopenia with 1,600 per microliter developed only during the bronchopneumonial stage. The histo-pathological findings were acute hypoxic damage of the myocardium, kidneys and certain neurones of vulnerable areas of the brain (neuronal microvesiculation and tigrolysis) in addition to a severe cerebral oedema in the final stage. A morphological substrate of an acute valproate encephalopathy was not demonstrable. The liver showed no necrosis or cholostasis. The vertebral marrow was inconspicuous. All the results indicate that liver function was not impaired in spite of the initial maximal concentration of valproic acid. In all probability the patient might have survived the acute valproate intoxication had it not been for the bronchopneumonia.

[Prognosis of surviving children with neurologic complications in the intensive phase of leukemia treatment]

32 children survived neurological complications during the treatment of ALL, AML or NHL (intracranial bleeding, convulsions, infections, severe neuropathy, severe EEG-slowing). Neurological, electroencephalographic and psychological examinations were performed 6 months to 6 years after the end of maintenance therapy. Findings were normal or borderline in about 70% of the patients. 20% presented with neurological signs, due to localised cerebral or peripheral lesions. However, these generally did not interfere to high degree with the daily living skills. The frequencies of school problems and of abnormal psychological findings were similar to these found in ALL patients without neurological complications.

Ureteral stenosis after kidney transplantation: true incidence and long-term followup after surgical correction

Between March 1965 and December 31, 1982, 421 kidney transplantations were performed in our department. The over-all incidence of ureteral stenosis was 5.5 per cent. However, when the number of patients at risk at various times after transplantation was considered the probability for ureteral stenosis to develop was 4.6 per cent at 1 year, 7.7 per cent at 2 years and 9.7 per cent at 5 years. Preoperative and postoperative complications were frequent. The wound infection rate was 21.9 per cent and 2 of the 24 patients died of septic shock. Graft survival rate after definitive surgical correction of ureteral stenosis was 71 per cent at 1 and 2 years, and 65 per cent at 3 years. Late results justify the efforts to re-establish correct urinary drainage of the graft.

Islet-cell antibodies (ICA-CFICA) and HLA genotypes in 107 IDD patients and their first-degree relatives

The prevalence of ICA and CFICA in relation to HLA-DR genotypes was analyzed in 107 insulin-dependent diabetic (IDD) patients with a duration of IDD ranging from onset to 30 years, and 247 nondiabetic first-degree relatives. In 46 patients tested at onset of IDD, the prevalence of ICA and of CFICA was 61 and 50%, respectively; with the longer duration of IDD, the prevalence of CFICA decreased more rapidly than that of ICA. No significant association was observed between ICA and any HLA allele in patients tested from onset till 2 years after onset. However, a higher prevalence of ICA was found in DR3 positive patients with a duration of IDD of more than 2 years (p less than 0.02). Among the healthy relatives, the prevalence of ICA was 7% in parents and 13% in siblings; one out of 101 siblings had CFICA. No association was found between ICA and any HLA marker. The presence of ICA in sibs was independent of the number of haplotypes they shared with the IDD proband: among the 13 ICA-positive healthy sibs, one shared 2 haplotypes, nine shared 1 haplotype and three shared no haplotype with the proband, which is not different from the random distribution.

Elbow arteriovenous fistula (EAVF) for chronic hemodialysis in small children

Elbow arteriovenous fistulae (EAVF) were constructed in 10 children aged 27 mo to 10 yr. There were no operative failures. Follow-up ranged from 5 to 22 mo. Three episodes of thrombosis occurred in a single child. The fistula was recanalized each time. The creation of an EAVF is a simple surgical procedure. Children weighing as little as 10 kg were efficiently dialysed for prolonged periods of time with this vascular access device.

Evaluation of clinical and biological parameters in marastic Kwashiorkor children treated by parenteral nutrition

Reduction of hospital stay and mortality rate due to dehydration and electrolyte imbalance in children suffering from severe marasmic Kwashiorkor was attempted. A program of parenteral nutrition providing 70 to 100 milliliters water, 30 to 40 kilocalories, and 3 to 4 grams amino acids per kilogram daily was given. Seventy-seven African children suffering from protein deficiency and calorie deficiency were given an intravenous perfusion of casein hydrolysate or cristalloid amino acids for a mean period of 6 days. An oral supplement of tea and sugar, boiled rice, and palm oil was also given. The total mortality has not been modified in comparison with that in children given an oral diet (semi-liquid) consisting of low fat milk and locally available proteins. In more than half of the cases, the parenteral nutrition has favored water and salt retention and the development of cardiac failure possibly due to adynamic circulatory state. Weight curve, serum albumins, serum and urine amino acids were followed closely for 1 month. In eleven patients, nitrogen balance studies were done. All were positive independently of the coexisting infectious pathology. Correlating the increase in serum proteins with the cumulative nitrogen balance allowed us to consider casein hydrolysate as particularly useful for hepatic protein synthesis while cristalloid amino acids seem to favor muscular protein synthesis. The introduction of parenteral nutrition as a therapeutic regimen for standard use in the malnourished child seems less favorable than oral realimentation programs and does not seem desirable in developing countries.

Mobility of endogenous ecotropic murine leukemia viral genomes within mouse chromosomal DNA and integration of a mink cell focus-forming virus-type recombinant provirus in the germ line

Characterization of endogenous ecotropic Akv proviruses in DNA of low and high leukemic mouse strains revealed the presence of one to six copies of the Akv genome per haploid genome equivalent integrated in the germ line. Low leukemic strains analyzed so far contained only one complete copy of the Akv proviral DNA. The site of integration varied among strains, although genetically related strains often carried the Akv proviral gene in the same chromosomal site. The different substrains of the AKR mouse displayed the presence of variable numbers (two to six) of Akv genomes. In all substrains one Akv genome was present in an identical chromosomal site; this locus probably comprised the progenitor genome. Closely related substrains had several Akv proviral DNAs integrated in common sites. The accumulation of Akv genomes in the germ line of the AKR/FuRdA strain is likely the result of independent integration events, since backcross studies with the Akv-negative 129 strain showed random segregation of all six proviral loci. The AKR/Cnb strain carried a recombinant provirus in the germ line. This provirus resembled in structure the AKR mink cell focus-forming viruses, which are generated by somatic recombination during leukemogenesis. Therefore, the germ-line amplification of Akv proviral DNAs occurs most likely through infection of embryonic cells by circulating virus.

[Use of arterio-venous fistulas for hemodialysis in children (author's transl]

From September 1977 till December 31st 1977, 21 arterio-venous fistulas were created in 18 children aged 6 to 15 years. Four early failures occured. The probability of fistula survival is 93% at 2 years for children treated only with hemodialysis. At the end of this same period of time, 62% of patients submitted to a combined treatment of hemodialysis followed by kidney transplantation have a functioning fistula. Overgrowth of the involved extremity, infection episodes and cardiac failure were not observed. One arteriovenous fistula is still functioning after 8 years.

[Mesomelic dwarfism (author's transl)]

Mesomelic dwarfism of the Langer type is described. This is characterised by shortening and bending of the middle portions of the extremities. This is compared with three cases of "mesomelic" changes in the forearm. The classification of this condition is discussed.

[The differential diagnosis of the Meckel syndrome and the Ellis-van-Creveld syndrome with encephalocele (author's transl)]

The differential diagnosis of Meckel's syndrome and Ellis-van-Creveld's syndrome with encephalocele is summarized utilizing two own observations. Radiographic criteria are of special importance. In EvCS typical signs of chondrodysplasia are present whereas in MS we found pelvic changes similar to Down's syndrome and striking rhomboid deformities of the tibiae. Clinically relevant is ectodermal dyplasia in EvCS, especially, when cystic kidneys in MS are not palpable.

[Diseases caused by drug therapy in newborn babies]

A drug may reach the newborn indirectly from the mother via the umbilical cord or brest milk and by direct application. If the Apgar score after 5 or 10 min decreases in relation to the score of the 1st minute, a depression by drugs has to be considered if other causes are eliminated. Some drugs and typical symptoms are described as for instance diazepam, addiction causing drugs, reserpin and imidazol derivatives. With regard to the direct effect of drugs the danger of the simultaneous application of several remedia is especially pointed out.