Prognosis and evolution of bilateral grade III intraventricular - hemorhages (III-III-IVH)

OBJECTIVE: To describe the evolution of bilateral III IVH so as to define optimal dates for therapeutic moves.METHODS: Longitudinal study of brain ultrasound scans from day 1 over the first three months of life. Our team calls "massive III" a hemorrhage with an intraventricular clot diameter >8mm on the coronal view at the level of Monro's foramina of the day of maximal hemorrhage. The 90 neonates were divided into four groups. Group I included 29 premature neonates who died in the first seven days after birth (birthweight (BW), 1,114 -/+253 g, gestational age (GA), 28 weeks 3 days); with 21 massive uni/bilateral grade III PIVH, and early filling of the whole ventricular system and cisterna magna. Group II included seven premature neonates who died in the second week after birth (similar in BW and GA, but more heterogeneous group). Two groups of infants survived for more than 14 days. Group III included 30 premature neonates (BW, 1,299 -/+260 g, GA, 29 weeks 1 day), with 20 classical grade III PIVH, who had post-hemorrhagic dilatation regressed spontaneously in 13 cases and regressed after acetazolamide treatment in 17 cases (five deaths due to three bronchopulmonary dysplasias and two periventricular leucomalacias). Group IV included 24 premature neonates (BW, 1,344 -/+289 g, GA, 29 weeks 5 days) with 15 massive grade III PIVH, who suffered posthemorrhagic hydrocephalus through obstruction of the Sylvius aqueduct (15) and/or of the cisterna magna (21), 12 blocks affecting both levels. Blocks were observed from day 8, and 35 in the quasi totality of cases (17 deaths).CONCLUSIONS: From 1,183 consecutive peri-intraventricular hemorrhages (PIVH) diagnosed by brain ultrasound studies (01/01/81-12/31/94), 90 were grade (III-III) PIVH, with a 36% overall survival. The massive volume of grade III PIVG plays a heavy role in early deaths of extremely low birthweight neonates and it heralds a blocked hydrocephalus in more vigorous infants who survive PIVH.     

Outcome at 10 years of severe vesicoureteric reflux managed medically: Report of the International Reflux Study in Children.

OBJECTIVE: To study the progress of vesicoureteric reflux (VUR) grade III or IV in children followed up prospectively over 10 years. STUDY DESIGN: One hundred forty-nine children (33 boys and 116 girls) with VUR were recruited for the International Reflux Study in Children and were treated with a medical regimen and monitored by means of serial cystograms. VUR disappearance was based on negative findings on 2 consecutive cystograms. RESULTS: At 5 years, VUR with dilatation was seen in 72 (48%) children and VUR without dilatation, in 55 (37%); 22 (15%) children had no reflux. At 10 years, VUR with dilatation was seen in 34 (23%) children and VUR without dilatation, in 37 (25%); 78 (52%) children had no reflux. Grade IV VUR persisted in 8 children. Absence of VUR was significantly associated with grade III versus grade IV VUR (P = .007), unilateral versus bilateral reflux (P = .0002), and age > or = 5 years at entry versus age < 5 years (P = .001). Neither sex nor renal scarring at entry individually affected resolution of VUR. Among 43 (29%) children with intermittent VUR, only 6 had reflux with dilatation at 10 years. CONCLUSION: Continuing reduction in the severity of VUR in children receiving careful medical treatment was observed over 10 years. On the basis of negative findings on 2 consecutive cystograms, VUR was absent in half of the children.     

Mid-term and long-term outcome in newborn infants with periventricular leukomalacia (53 cases)]

During the period 1983-1987, 53 neonates (30 boys, 23 girls, mean birth weight 1,438 +/- 317 g, mean gestational age 30 +/- 2 weeks) were found to have cystic periventricular leukomalacias (CPVL) detected by brain ultrasonography. The neuro-developmental follow-up was 3-7 years. Seventeen CPVL were isolated and CPVL were associated with minor peri-intraventricular hemorrhage (0-1 to II-II) in 36 cases. CPVL included 16 minor forms (11 normal children; 2 minor, 3 moderate sequelae), 29 moderate forms (15 normal children; 4 minor, 7 moderate, 3 major sequelae) and 8 major forms (7 major sequelae, one moderate mental retardation without motor deficit). According to reverse analysis, a normal evolution (26 cases) followed CPVL which were sometimes widely, but thinly spread over the ventricles (thickness 1/5-1/3 of the cerebral mantle); minor sequelae (6 cases) were associated with a 1/4-1/3 thickness, moderate sequelae (11 cases) with a 1/3-1/2 thickness, major sequelae (10 cases) with a 1/2-2/3 thickness of CPVL. The thickness of the lesions appeared to be more predictive of sequelae than the sagittal extent, in particular that of the posterior CPVL which played a major role in the severity of sequelae, and mainly in the presence of motor deficits.     

Serum creatine kinase BB as predictor of periventricular haemorrhage in preterm infants

Serum creatine kinase BB (CK-BB) determinations were performed daily in 49 newborn infants of less than 34 weeks gestation to evaluate its usefulness in predicting the occurrence of periventricular-intraventricular haemorrhage (PIVH). Using ultrasound PIVH was detected in 20 infants (41%); five grade I, seven grade II, two grade III, six grade IV (grading according to Papile et al.). Infants who developed severe PIVH (grade IV) during the study period had significantly higher serum CK-BB activities immediately after birth when compared with infants who developed less severe haemorrhages (grades I, II and III) or no PIVH. We postulate that these high serum enzyme activities are caused by perinatal brain cell damage which is an important antecedent of severe PIVH. Therefore, serum CK-BB activities at birth can be used as predictor of severe PIVH.     

Serum creatine kinase BB as predictor of periventricular haemorrhage in preterm infants

Serum creatine kinase BB (CK-BB) determinations were performed daily in 49 newborn infants of less than 34 weeks gestation to evaluate its usefulness in predicting the occurrence of periventricular-intraventricular haemorrhage (PIVH). Using ultrasound PIVH was detected in 20 infants (41%); five grade I, seven grade II, two grade III, six grade IV (grading according to Papile et al.). Infants who developed severe PIVH (grade IV) during the study period had significantly higher serum CK-BB activities immediately after birth when compared with infants who developed less severe haemorrhages (grades I, II and II) or no PIVH. We postulate that these high serum enzyme activities are caused by perinatal brain cell damage which is an important antecedent of severe PIVH. Therefore, serum CK-BB activities at birth can be used as predictor of severe PIVH.     

Background patterns and sleep-wake cycles on amplitude-integrated electroencephalography in preterms younger than 30 weeks gestational age with peri-/intraventricular haemorrhage

AIM: The objective of this prospective study was to evaluate the influence of peri-/intraventricular haemorrhage (PIVH) grades I-IV on amplitude-integrated electroencephalographic (aEEG) activity in preterm infants<30 weeks gestational age (GA). METHODS: The aEEG tracings of the first 2 weeks of life of 56 preterm infants younger than 30 weeks GA (2 groups: group A=23-26 weeks GA, group B=27-29 weeks GA) born during a 4-year period with PIVH grades I-IV were assessed for the relative duration of four background aEEG activity patterns (continuous pattern, discontinuous high-voltage pattern, discontinuous low-voltage pattern and nearly isoelectric pattern), the presence of seizure activity and the appearance of sleep-wake cycles and compared to the tracings of 75 neurologically healthy preterms without PIVH. RESULTS: Analysis of aEEG background activity showed a decrease of continuous activity whereas discontinuous activity increased in both groups with larger haemorrhages (grades III and IV) and when compared to controls. Suspected seizure activity was more common with increasing degree of bleeding in group A (50% with PIVH I or II, 75% with PIVH III or IV) and when compared to controls and was the same with increasing degree of bleeding in group B (47% with PIVH I or II, 45% with PIVH III or IV). Sleep-wake cycles were less common with larger haemorrhages in both groups (group A: 41% with PIVH I or II, 25% with PIVH III or IV; group B: 52% with PIVH I or II, 9% with PIVH III or IV) and when compared to controls. CONCLUSIONS: The aEEG characteristics of severe PIVH consist in a combination of a more discontinuous background pattern, a lack of sleep-wake cycles and a higher likelihood of seizure activity when compared to age-matched controls.     

Plasma guanosine 3',5'-cyclic monophosphate and severity of peri/intraventricular haemorrhage in the preterm newborn

A poorly controlled cerebral circulation, caused by excessive production of nitric oxide, has been suggested as predisposing to peri/intraventricular haemorrhage (PIVH) in the immature neonate. It is hypothesized that a relation exists between plasma cyclic GMP (cGMP) as an effector of endogenous vasodilatory nitric oxide production and severity of PIVH. In 83 consecutively admitted preterm neonates, nitric oxide production was assessed by measuring plasma cGMP at 0, 24, 48, 72 and 168 h of age. Simultaneously, cranial ultrasound investigations were performed and haemodynamic parameters registered. The investigations showed that 60 neonates (72%) had no PIVH; 18 neonates (22%) had mild to moderate PIVH; and 5 neonates (6%) had severe PIVH. At 48 and 72 h of age, cGMP levels of infants with severe PIVH were significantly higher than those of infants with no or only mild PIVH, whereas at 72 and at 168 h, infants with moderate PIVHs had significantly higher cyclic cGMP levels than infants without PIVH. Finally, at 168 h of age infants with mild PIVH also had higher cyclic cGMP values than those of infants without PIVH. Maximal cGMP values preceded the final extension of PIVH in moderate and severe PIVHs. Blood pressure support was necessary significantly more often in infants with moderate and severe PIVH. A logistic regression model revealed that cGMP was significantly associated with PIVH, irrespective of gestational age, mean arterial pressure or severity of infant respiratory distress syndrome. Conclusion: Increased cGMP levels are associated with the development of PIVH. It is suggested that vasodilatory nitric oxide-induced impairment of cerebral autoregulation plays a role here.     

Primary vesicoureteric reflux--how useful is postnatal ultrasound?

The presence or absence of pelvicalyceal dilatation on postnatal ultrasound continues to appear within diagnostic algorithms to select patients for micturating cystourethrography (MCU) in the investigation of antenatally diagnosed hydronephrosis. Postnatal ultrasound findings were assessed in a population diagnosed as having antenatal hydronephrosis due solely to primary vesicoureteric reflux (VUR) to see whether this is justified. The postnatal ultrasound and MCU findings in 177 patients with primary VUR detected as antenatal hydronephrosis were reviewed retrospectively. A total of 132 (75%) were boys. Reflux was unilateral in 103 cases and bilateral in 74 (42%). Altogether 37% of boys and 33% of girls with a renal pelvic diameter of < or = 10 mm had grade III-V VUR. Calyceal and/or ureteric dilatation had specificities of 87-96% for grade III-V VUR, but sensitivities of only 37-54%. Fifty eight per cent of male and 75% of female renal units with grade III VUR and 17% of male units with grade IV-V VUR were normal on ultrasound. Approximately 25% of ultrasonically normal renal units had grade III-V VUR on MCU. Postnatal ultrasound criteria correlate poorly with the presence and degree of VUR in children with antenatally diagnosed hydronephrosis and should not be used to direct the use of cystography.     

Grade and laterality of intraventricular haemorrhage to predict 18-22 month neurodevelopmental outcomes in extremely low birthweight infants

Aim: To determine whether extremely low‐birthweight (ELBW) infants with bilateral compared to unilateral intraventricular haemorrhage (IVH) have worse neurodevelopmental outcomes at 18–22 months. Methods: A total of 166 ELBW infants (<1000 g) admitted to a Cincinnati NICU from 1998 to 2005 with a head ultrasound showing Grade I–IV IVH and neurodevelopmental assessment at 18–22 months corrected age were included. Multivariable linear and logistic regression models were developed to determine the impact of laterality and grade of IVH and other clinical variables to predict scores on the Bayley Scales of Infant Development, Second Edition, Mental Development Index and Psychomotor Development Index and the combined outcome of neurodevelopmental impairment (NDI). Results: Infants with bilateral grade IV IVH had lower adjusted mean Bayley scores compared with infants with unilateral grade IV IVH. For grades I, II and III IVH, bilaterality of IVH was not associated with lower mean Bayley scores. Infants with grade IV IVH had the highest odds of NDI. The probability of NDI increased with sepsis and postnatal steroid use. Conclusion: ELBW infants with bilateral compared to those with unilateral grade IV IVH had worse neurodevelopmental outcomes. Infants with grades I–III IVH had similar outcomes whether they had unilateral or bilateral IVH.     

儿童发育性髋关节脱位闭合复位术后髋关节恢复正常X线表现影响因素的多中心回顾性研究

目的探讨发育性髋关节脱位(developmental dislocation of the hip,DDH)闭合复位术后髋关节恢复正常影像学表现的概率及其影响因素。方法回顾性分析2004年1月至2015年12月采用闭合复位石膏固定治疗的507例(586髋)DDH患儿的病历资料。其中,男50例,女457例;左侧259髋,右侧164髋,双侧163髋。通过X线片评估T?nnis脱位程度分级、股骨头坏死(avascular necrosis of the femoral head,AVN)(Bucholz/Ogden分型)、髋臼指数(acetabular index,AI)和中心边缘角(center-edge angle,CEA)。尝试建立髋关节恢复正常X线的参考标准,并按该参考标准将患儿分为恢复组(200髋)和未恢复组(386髋),对比分析两组患儿的年龄、性别、侧别、T?nnis分级、骨化核出现、术前和末次随访的AI和CEA、AVN和Severin分级。采用Cox回归分析、t检验、卡方检验、方差分析研究影响DDH闭合复位术后髋关节恢复正常影像学的概率以及影响因素。结果末次随访时,200髋(34.1%)恢复正常髋关节X线,78髋(13.4%)出现了Ⅱ型及以上AVN。年龄≥24个月患儿恢复率为8.8%(3/34),显著低于<12个月患儿的44.3%(47/106)、12~18个月患儿的35.5%(98/276)和18~24个月患儿的30.6%(52/170),组间差异有统计学意义(P=0.001)。恢复组双侧髋关节脱位患儿的恢复率为27.0%(44/163),明显小于左侧髋关节脱位患儿的39.0%(101/259)和右侧髋关节脱位患儿的33.5%(55/164),差异有统计学意义(P=0.04)。恢复组术前AI(34.8°±4.2°)显著小于未恢复组(36.0°±4.6°),组间差异有统计学意义(P<0.01)。Cox回归分析显示,术后5.5年前累积恢复概率大致呈线性增长至56%,此后累积恢复概率的增速明显降低(年增长<5%)。复位年龄大于24个月、双侧脱位、术前AI≥40°和Bucholz/OgdenⅡ型以上AVN患儿的累积恢复概率明显降低,差异有统计学意义(P<0.05)。200髋的平均恢复时间为(36.5±14.9)个月,其中93%(186/200)的髋关节在术后5年内恢复。恢复组年龄≥24个月患儿的恢复时间为(55.2±28.0)个月,显著大于<12个月患儿的(32.2±18.0)个月、12~18个月患儿的(36.9±11.9)个月和18~24个月患儿的(38.6±15.1)个月,差异有统计学意义(P<0.05)。T?nnisⅡ级患儿的髋关节恢复时间(32.8±15.7)个月显著小于T?nnisⅢ、Ⅳ级患儿的40.2个月和40.7个月,差异有统计学意义(P<0.05)。结论DDH闭合复位术后5.5年内髋关节恢复正常X线表现的累积概率呈线性增长,此后到达平台期。年龄大于24个月、双侧脱位、术前AI>40°和AVN是影响DDH闭合复位术后髋关节恢复正常X线的风险因素。复位年龄大于24个月、T?nnisⅢ/Ⅳ度会显著增加髋关节恢复至正常的时间。     

Mortality and two year outcome of infants of birthweight 500-1500 g: relationship with neonatal cerebral ultrasound data

Cranial ultrasounds were performed on 218 (96%) of 227 liveborn infants of birthweight 500-1500 g delivered in the Royal Women's Hospital, Melbourne, Australia, in an 18-month period concluding in March 1982. Seventy-two (31.7%) of the children died; 28 children (38.9%) had cerebroventricular haemorrhage, 35 (48.6%) showed no bleeding and there were nine (12.5%) with no data. Paired necropsy and ultrasound data were congruent in 22 (88%) of 25 children. One hundred and forty-eight (95.5%) of 155 survivors were seen at 2 years of age. Forty-one (28%) had cerebroventricular haemorrhage; nine children (6%) had both ventricular dilatation and haemorrhage and two had ventricular dilatation alone. Apart from a marginal advance in gestation and higher number of immigrant and less educated mothers in children without cerebroventricular haemorrhage, all other perinatal, biographical and social variables between those with haemorrhage and those without were similar. The major handicap rate overall was 14.2% (21 patients). The children with cerebroventricular haemorrhage had a trend for greater prevalence of handicap and lower mean Bayley psychological scores. This was even more evident with ventricular dilatation being present. Of children with major handicap 57.1% (12/21) had normal serial ultrasound findings during their primary hospitalization. Major handicap occurred in 15% (3/20) of children with grade 1 haemorrhage, 23.5% (4/17) with grade 2 or 3 bleeds and 25% (1/4) of those with grade 4 haemorrhage. Laterality of cerebral palsy did not correlate with ultrasound findings. Ultrasound findings did not improve statistical prediction of deaths or major handicap.     

Mortality and two year outcome of infants of birthweight 500-1500 g: relationship with neonatal cerebral ultrasound data

Cranial ultrasounds were performed on 218 (96%) of 227 liveborn infants of birthweight 500-1500 g delivered in the Royal Women's Hospital, Melbourne, Australia, in an 18-month period concluding in March 1982. Seventy-two (31.7%) of the children died; 28 children (38.9%) had cerebroventricular haemorrhage, 35 (48.6%) showed no bleeding and there were nine (12.5%) with no data. Paired necropsy and ultrasound data were congruent in 22 (88%) of 25 children. One hundred and forty-eight (95.5%) of 155 survivors were seen at 2 years of age. Forty-one (28%) had cerebroventricular haemorrhage; nine children (6%) had both ventricular dilatation and haemorrhage and two had ventricular dilatation alone. Apart from a marginal advance in gestation and higher number of immigrant and less educated mothers in children without cerebroventricular haemorrhage, all other perinatal, biographical and social variables between those with haemorrhage and those without were similar. The major handicap rate overall was 14.2% (21 patients). The children with cerebroventricular haemorrhage had a trend for greater prevalence of handicap and lower mean Bayley psychological scores. This was even more evident with ventricular dilatation being present. Of children with major handicap 57.1% (12/21) had normal serial ultrasound findings during their primary hospitalization. Major handicap occurred in 15% (3/20) of children with grade 1 haemorrhage, 23.5% (4/17) with grade 2 or 3 bleeds and 25% (1/4) of those with grade 4 haemorrhage. Laterality of cerebral palsy did not correlate with ultrasound findings. Ultrasound findings did not improve statistical prediction of deaths or major handicap.     

Lenticulostriate echogenic vessels: clinical and sonographic study of 70 neonatal cases

Background Neonatal branching echogenic streaks in the basal ganglia or 'lenticulostriate vasculopathy' (LSV) has no clear comprehensive aetiology.Objective To provide some clinical evidence, possibly relevant to aetiology, by analysis of a large series.Materials and methods Seventy cases (9 deaths, 3 post mortem) identified between 1981 and 2000 out of 9,138 neonates with routine brain sonograms (578 in a protocol for neonates from HIV+ mothers). Review of maternal/neonatal charts for clinical data and serologic status. Retrospective analysis of sonograms for grading and time course of LSV and coexistent abnormalities.Results LSV was unilateral in 31 cases (22 right), bilateral in 39. Grading separated 8 major, 27 moderate and 35 minor patterns. In 42 cases, LSV was isolated, and in 28 it was mixed with peri-intraventricular haemorrhage grades I or II and/or leucomalacia. LSV was detected in the first postnatal week in 56 instances and appeared later in 13. Disappearance occurred mostly within 2 months. Perinatal circumstances: 13 recipient monochorionic twins (polycythaemia from twin-twin transfusion syndromes), 20 HIV+ mothers (possible immunological disturbances; only 2 infected neonates), 10 congenital anomalies, 1 toxoplasmosis, 1 postnatal cytomegalovirus infection, 25 miscellaneous conditions. Numerous maternal and neonatal factors were non-contributory.Conclusions These results do not support congenital toxoplasmosis, rubella, cytomegalovirus, and herpes (TORCH) infections as the main causative factor. Polycythaemia and various immunological disturbances may be involved, as well as infectious agents not appropriately screened by routine serodiagnoses.     

Head ultrasound screening in premature neonates weighing more than 1,500 g at birth

During a 14-month period, 112 consecutively born neonates with a birth weight between 1,501 and 2,000 g were screened by cranial ultrasonography. Nineteen patients (17%) had abnormal scans. Of these abnormalities, 14 (13%) were germinal matrix hemorrhage and/or intraventricular hemorrhage. Although the incidence of hemorrhage in these larger premature neonates is less than that which has been described in neonates with a birth weight less than 1,500 g, the severity of the hemorrhage, mortality (21%), morbidity, and outcome were similar to those seen in smaller neonates. More than half of the hemorrhages identified were severe, ie, grades III and IV. The clinical picture in these neonates was striking in that each suffered severe birth asphyxia and/or required ventilation shortly after birth. Therefore, screening all larger premature neonates is probably not warranted and selective screening will be adequate to identify those neonates who need intervention or would benefit from developmental follow-up.     

Treatment of progressive posthemorrhagic hydrocephalus with temporary external ventricular drainage. Preliminary results

Peri-intraventricular hemorrhage (PIVH) is a major problem of preterm neonates: over 40% of infants with birth weight less than 1500 g have been found to experience this disorder. The posthemorrhagic hydrocephalus (PHH) is generally believed to occur secondary to obliterative posterior fossa arachnoiditis. Its management in critically ill premature infants with multiple medical problems has thus become quite significant. This paper reports the results of the placement of a temporary external ventricular drainage in three patients in whom progressive ventricular dilatation began within two weeks after severe neonatal PIVH. In all patients the hydrocephalus and increased intracranial pressure were controlled within three weeks of treatment. One infant died from other problems associated with his prematurity. Early demonstration of progressive ventricular dilatation by ultrasound and prompt external drainage has been found to be a safe initial method to treat PHH in preterm infants.     

Neonatal lenticulostriate vasculopathy. Mid and longterm outcome (70 cases)]

OBJECTIVES: If the pattern of neonatal lenticulostriate vasculopathies (NLSV) is well-known, the prognosis is unknown except in TORCH syndromes. This study was aimed to describe the short, mid and long-term outcome of NLSV of various origins. POPULATION AND METHODS: Of 9138 neonates (1981-2000) which were submitted to an early brain ultrasound study, 70 presented with a pattern of minor (35), moderate (27) or severe (8) NLSV, a single finding in 42 cases and in association with minor peri-intraventricular haemorrhage and/or leukomalacias in 28. The maternal and neonatal charts were reviewed, and the survivors were followed according to our usual policy. RESULTS: Of nine deaths, eight cases included severe congenital defects (metabolic or malformations or acquired: transfused monochorial twins). Of 61 survivors, eight were lost to follow-up within the first year, 53 were followed for 21 months to 9 years and 7 months (median 4 years 5 months). Of 53 children, 35 (66%) were strictly normal, eight had minor deviations, four had moderate and six had major neurodevelopmental deficits. Of 34 survivors with isolated NLSV and known follow-up, 27 were normal (79%) versus 8/19 (42%) in associated NLSV. CONCLUSIONS: Minor or moderate isolated NLSV generally have a good long-term prognosis. Associated forms of any severity depend mainly upon the severity of periventricular leukomalacias. Major forms of NLSV must be a warning sign of a possible underlying congenital anomaly which will rule the vital and functional prognosis.     

Contemporary results of balloon valvuloplasty and surgical valvotomy for congenital aortic stenosis.

The purpose of this study was to compare contemporary results of balloon dilatation and surgery for valvar aortic stenosis in infants and children in the five years between August 1988 and October 1993. Thirty four children underwent attempted balloon valvuloplasty (age 1 day-16 years, weight 1720 g-68 kg) (group 1), eight of whom were neonates with critical aortic stenosis. During the same period, 17 children underwent direct surgical valvotomy (group 2) (seven neonates). Successful balloon valvuloplasty was achieved in 33 (97%) with immediate reduction in the instantaneous systolic pressure gradient from 82 to 34 mm Hg (mean). There were two deaths in this group (both neonates), the second in a preterm neonate from necrotising enterocolitis. Complications requiring intervention in group 1 were aortic regurgitation in one and femoral artery injury in two. Follow up from four months to five years showed sustained results in most cases. There were two neonatal deaths in the surgical group. When the two groups were compared there was no significant difference in mortality, morbidity, or need for reintervention within 12 months. Deaths from both groups were attributed to small left ventricles. Hospital stay was significantly shorter in group 1. It is concluded that balloon dilatation for valvar aortic stenosis is effective and safe for the entire paediatric population. The results compare favourably with those of surgery.     

Contemporary results of balloon valvuloplasty and surgical valvotomy for congenital aortic stenosis

The purpose of this study was to compare contemporary results of balloon dilatation and surgery for valvar aortic stenosis in infants and children in the five years between August 1988 and October 1993. Thirty four children underwent attempted balloon valvuloplasty (age 1 day-16 years, weight 1720 g-68 kg) (group 1), eight of whom were neonates with critical aortic stenosis. During the same period, 17 children underwent direct surgical valvotomy (group 2) (seven neonates). Successful balloon valvuloplasty was achieved in 33 (97%) with immediate reduction in the instantaneous systolic pressure gradient from 82 to 34 mm Hg (mean). There were two deaths in this group (both neonates), the second in a preterm neonate from necrotising enterocolitis. Complications requiring intervention in group 1 were aortic regurgitation in one and femoral artery injury in two. Follow up from four months to five years showed sustained results in most cases. There were two neonatal deaths in the surgical group. When the two groups were compared there was no significant difference in mortality, morbidity, or need for reintervention within 12 months. Deaths from both groups were attributed to small left ventricles. Hospital stay was significantly shorter in group 1. It is concluded that balloon dilatation for valvar aortic stenosis is effective and safe for the entire paediatric population. The results compare favourably with those of surgery.     

Surgical or conservative treatment of congenital hydronephrosis. Ten years' experience

BACKGROUND: Controversy exists concerning the ideal management of hydronephrosis diagnosed in the perinatal period. Different opinions depend on the absence of an accurate tool and of well-defined cut-off values for each test. For these reasons we retrospectively evaluated our management protocol. METHODS: Two-hundred and seventy-two patients with single system hydronephrosis were evaluated. Patients with bilateral hydronephrosis or with other renal or ureteral abnormalities were excluded. Diagnosis and grading of hydronephrosis were done by ultrasound. Before 1995, grade II or greater hydronephrosis was also evaluated with diuretic intravenous urography, but in cases studied afterwards, a functional evaluation of the obstruction was reached with well tempered diuretic renogram. Indications for surgery were considered: recurrent urinary tract infections, grade IV hydronephrosis, obstructive drainage pattern and differential renal function less than 40%. Patients managed non-operatively received serial re-evaluation with US-scan, urine test and functional tests if necessary. RESULTS: Hydronephrosis was on the right side in 98 cases (36%), and on the left side in the other 174 (64%). There were 129 grade I hydronephrosis (47%), 46 grade II (17%), 57 grade III (21%), 40 grade IV (15%). Fifty-seven (21%) cases of hydronephrosis underwent surgery: 49 (86%) showing obstructive pattern at functional tests, 40 (70%) presenting a differential renal function less than 40%, 5 (8%) because recurrent urinary tract infections, 40 (70%) affected by grade IV hydronephrosis. No children received nephrectomy. Average postoperative follow-up was 2.8 years: pelvic dilatation improved or remained unchanged but the obstructive pattern at functional tests always disappeared after surgery. The average follow up in the observational group of 163 patients (60%) was 4.1 years. In 149 (91%) pelvic dilatation improved, but in 14 (9%) it remained unchanged. CONCLUSIONS: The ideal management of congenital hydronephrosis is still debated since the natural history of these disease is not still completely understood and there is no accurate tool to assess these renal units. We believe that grade IV hydronephrosis always need surgery as well as those ones with recurrent urinary tract infections, longer drainage time or a differential renal function less than 40%. On the other hand grade I hydronephrosis never need surgery. Mild grade hydronephrosis can be safely managed non-operatively with a meticulous follow-up and undergoing surgery only when signs of deterioration occur.     

早产儿颅内出血振幅整合脑电图背景模式及睡眠觉醒周期的特点

目的 分析不同程度脑室周围-脑室内出血（PIVH）早产儿振幅整合脑电图（aEEG）背景模式及睡眠觉醒周期的特点。方法 选取56 例胎龄25~33 周的PIVH 早产儿及31 例同胎龄段无PIVH 早产儿,将PIVH 患儿按Papile 分级标准分为轻度出血组（Ⅰ、Ⅱ级）和中重度出血组（Ⅲ、Ⅳ级）,对各组早产儿aEEG的结果进行比较分析。结果 与轻度出血组及对照组比较,中重度出血组患儿的电压连续性降低,睡眠觉醒周期（SWC）缺失率高,aEEG 评分低（P 结论 aEEG 背景活动及SWC 的改变与早产儿PIVH 的严重程度有关。