Assessment of abdominal lymph nodes in a normal paediatric population: An ultrasound study

During a 9 month period, 50 consecutive children were evaluated by ultrasound to determine the size, location (mesenteric vs para-aortic), number, shape and texture of abdominal lymph nodes in a normal paediatric population. High resolution linear array transducers were used with graded compression. Nodes ranging from 10 to 20 mm were recorded in the majority of subjects. In all cases mesenteric lymph nodes were larger and more numerous than para-aortic nodes. Para-aortic lymph nodes were not seen in isolation.     

USE OF ATRACURIUM OR VECURONIUM TO PROLONG THE ACTION OF TUBOCURARINE

Forty patients received tubocurarine in a dose greater thanED₉₀. When neuromuscular function had recovered to amplitudeof the first contraction of the train-of-four equals 10% ofcontrol, a small increment of atracurium or vecuronium was administered,repeating the same increment at each subsequent recovery to10%. The intensity and duration of the neuromuscular block followingthe first increment was always greater than that of subsequentincrements. The duration and intensity of the block was progressivelyreduced with subsequent increments until the responses to furtherincrements were unchanged. These final means at steady statewere: group 1 (atracurium 1.1 mg) 6.4 (0.3) min; group 2 (atracurium2.0 mg) 8.2 (0.9) min; group 3 (vecuronium 0.25 mg) 5.8 (0.4)min; group 4 (vecuronium 0.5 mg) 13.2 (0.4) min.     

Low-density lipoprotein subfraction profiles in dialysis patients

Summary: Uraemic dyslipidaemia is a major risk factor for cardiovascular disease in end-stage renal failure patients. In patients without renal failure, high levels and qualitative abnormalities of low-density lipoprotein (LDL) are known to be atherogenic. Recently, LDL subfraction analysis has associated premature coronary artery disease with a high prevalence of small, dense LDL particles characterizing the LDL subclass phenotype B. We therefore examined the lipid profiles, LDL subfraction distribution and phenotypes in our population of haemodialysis (HD; n = 30) and peritoneal dialysis patients (PD; n = 17), and compared them to 40 asymptomatic, non-uraemic volunteers. Dialysis patients had significantly higher triglyceride and VLDL cholesterol concentrations and lower HDL cholesterol and smaller LDL peak particle diameters. PD patients had significantly higher total cholesterol, glycated haemoglobin and fasting blood glucose levels with smaller LDL peak particle diameters (24.4 [0.1] vs 24.8 [0.1 nm] than HD. Both groups showed significant negative correlations between plasma triglyceride and LDL peak particle diameter, and positive correlations between HDL cholesterol and LDL peak particle diameter. All the PD patients expressed the B phenotype (LDL peak diameter ± 25.5 nm) compared to 73% of HD patients. This study demonstrates that HD and especially PD patients have atherogenic lipid profiles which are associated with a predominance of small dense LDL particles and the highly atherogenic LDL subclass phenotype B.     

Age-related changes in oxygen saturation over the first year of life: A longitudinal study

Stability of oxygen saturation depends on maturation and function of individual components of the respiratory system. The aim of this study was to record and analyse comprehensive oxygen saturation data in a longitudinal study over the first year of life. Detailed sleep studies were performed on 15 normal infants eight times in the first year of life. The accrued oxygen saturation data were analysed on a computerized oximetry data analysis system. Results show the mean sleep saturation levels trending upwards and stabilizing by 185 days. There was an inverse curvilinear relationship between mean age and median desaturation time and the median number of desaturations at ≥95, ≥92 and ≥90% saturation. The mean cumulative desaturation time ≥90% in the first 4 months was 11.08 min (range 2.5–36.57 min). This study demonstrates monotonic patterns of increasing saturation and decreasing number and time of desaturations ≥95% and ≥90% but a random pattern of desaturations ≥85% occurs across the first 6 months of life. Cumulative desaturation times over the first 4 months of life were high and could be important to the development of maturity of the respiratory system. After 6 months, all indices of saturation and desaturation point to a stable and mature respiratory system.     

Respiratory sinus arrhythmia: comparison with EEG indices during isoflurane anaesthesia at 0.65 and 1.2 MAC

Respiratory sinus arrhythmia (RSA) is a cyclical variation inheart rate during breathing, where the heart rate increasesduring inspiration and decreases during expiration. RSA andthe electroencephalogram (EEG) were monitored in 70 patientsundergoing elective surgery with isoflurane and nitrous oxidein oxygen anaesthesia after induction with propofol. All patientswere subject to controlled ventilation and recovery from competitiveneuromuscular block was facilitated by neostigmine and glycopyrronium(seven patients) or atropine (three patients). Median and spectraledge (95%) frequencies of the raw EEG were derived off-line.RSA and EEG indices were obtained during preinduction (baseline),induction, incision, 0.65 and 1.2 MAC of isoflurane maintenanceduring surgery and recovery. Significant decreases in the levelof RSA, median and spectral edge frequencies were observed duringinduction and significant increases in all indices were observedat recovery in all patients. Significant decreases in the medianand spectral edge EEG frequencies occurred in patients treatedwith atropine both to counteract bradycardia after propofolinduction and at antagonism of neuromuscular block (n = 3),compared with patients treated with glycopyrronium (n = 7).In contrast, the level of RSA did not decrease significantlywith atropine. It is concluded that measurements of RSA couldform the basis of a useful index of anaesthetic depth duringisoflurane anaesthesia, even during the use of pharmacologicallyappropriate doses of atropine. However, any effects of atropineon the raw EEG and on indices derived from the EEG, should becharacterized further so that these effects are not confusedwith changes in anaesthetic depth. (Br. J. Anaesth. 1994; 72:397–402)     

The use of magnetic resonance imaging in the assessment of malignant vaginal fistulas

The objective of this study was to determine whether magnetic resonance imaging (MRI) could reliably demonstrate fistulas and any associated mass and to see whether these findings were beneficial in the management of the fistula. Twelve consecutive patients presenting with suspected vaginal fistulas were examined prospectively with MRI, using a combination of sequences, for the presence, extent and configuration of fistulas and any associated mass. Comparison was made with CT when available. All patients underwent examination under anesthesia (EUA) and the findings compared. Of the 12 women presenting, seven had vesico-vaginal fistulas (VVF) and seven had recto-vaginal fistulas (RVF). Four women had both types of fistulas. The underlying pathology was cervical cancer (seven cases), colonic cancer (three cases), breast cancer (one case) and ovarian cancer (one case). Vaginal fistulas were unequivocally seen on MRI in eight of 10 cases with fistulas. In the two cases with a difference between the MRI and EUA findings, the MRI was interpreted as showing more than was found at EUA. In the seven women with VVF, MRI detected five of the cases. In the seven women with RVF, MRI detected all seven cases. Magnetic resonance imaging was correct in determining the presence of recurrent disease in the pelvis when an associated mass was seen (seven cases). Computer-assisted tomography was compared in 10 cases and in six cases, the results were comparable and in four cases, more information was obtained from the MRI. Magnetic resonance imaging appears to be accurate in detecting and defining complex gynecologic fistulas and should be considered the investigation of choice to aid the planning of restorative, salvage or palliative surgery.     

Intellectual disability: population‐based estimates of the proportion attributable to maternal alcohol use disorder during pregnancy

Aim The aim of this study was to examine the association between maternal alcohol use disorder and intellectual disability in children. Method All mothers with an International Classification of Diseases (ICD) 9 and/or 10 alcohol‐related diagnosis, a proxy for alcohol use disorder, recorded on the Western Australian health, mental health, and drug and alcohol data sets were identified through the Western Australian Data Linkage Unit (n=5614 non‐Aboriginal; n=2912 Aboriginal). A comparison cohort of mothers without an alcohol‐related diagnosis was frequency matched on maternal age within maternal Aboriginal status and year of birth of their children. Linkage with the Western Australian Midwives Notification System (1983–2001) identified all births to these mothers (n=10 664 and 7907 respectively). Linkage to the Western Australian Intellectual Disability Database and Register of Developmental Anomalies identified cases of intellectual disability with no identified genetic origin (intellectual disability) (n=1487) and fetal alcohol syndrome (n=66). Odds ratios (ORs) and 95% confidence intervals (CIs) for intellectual disability were calculated using logistic regression incorporating generalized estimating equations and used to estimate population‐attributable fractions. Results At least 3.8% (95% CI 2.84–4.89%) of cases of intellectual disability could be avoided by preventing maternal alcohol use disorder: 1.3% (95% CI 0.81–1.86%) in non‐Aboriginal and 15.6% (95% CI 10.85–20.94%) in Aboriginal children. We observed a three‐fold increase in the adjusted odds of intellectual disability in children of mothers with an alcohol‐related diagnosis recorded during pregnancy (non‐Aboriginal OR 2.89, 95% CI 1.62–5.18; Aboriginal OR 3.12, 95% CI 2.13–4.56), with a net excess proportion of 3.7% and 5.5% respectively. One‐third (32%) of children diagnosed with fetal alcohol syndrome had intellectual disability. Interpretation Maternal alcohol use disorder is the leading known risk factor for intellectual disability with no identified genetic origin.     

Maternal angiotensin sensitivity and fetal Doppler umbilical artery flow waveforms

Summary. The angiotensin pressor response was investigated in nor-motensive pregnancies which had umbilical Doppler flow velocity waveforms suggestive of placental vascular disease. Of the 36 pregnancies studied at between 24 and 38 weeks gestation, 18 had a positive response to the angiotensin pressor test, these women were delivered earlier (35.3 vs 38.5 weeks,  P = 0.015  ), had a lower mean birthweight centile (14 vs 36,   P < 0.001  ) and higher frequency of fetal distress in labour (40% vs 7%,  P = 0.06  ) when compared with the 18 women who had a negative response. The Doppler umbilical systolic-diastolic (S-D) ratio decreased with gestation in the negative group, suggesting continuing placental growth and vascular expansion, whereas the S-D ratio increased in the positive group (   P < 0.001  ), indicative of vascular obliteration. We suggest that the positive angiotensin pressor response is primarily associated with the placental vascular pathology. Angiotensin infusion had no acute effect on maternal uteroplacental or fetal umbilical artery flow velocity waveforms.