Randomised trial comparing the upright and supine positions for the second stage of labour

Objective To assess the maternal and neonatal effects of upright compared with recumbent positions during delivery, in terms of defined outcome variables.
Design A randomised controlled trial.
Setting St Monica's Nursing Home, a midwife based maternity unit in Cape Town, South Africa.
Participants Five hundred and seventeen women of low obstetrical risk assigned to deliver at the nursing home.
Results The trial showed that women who adopted the upright posture for delivery experienced less pain, perineal trauma and fewer episiotomies than those who delivered in the supine position.
Conclusion The data suggest that in women of low obstetrical risk, choice of posture during delivery may be encouraged.     

Preoperative imaging versus intraoperative localization of tumors in adult surgical patients with hyperinsulinemia: A multicenter study of 338 patients

Three hundred thirty-eight patients with organic hypoglycemia were referred to French-speaking surgeons during an 18-year period (1965–1983). Two hundred sixty-eight (79%) of these patients proved to have benign tumors (12 multiple), 37 (11%) had carcinoma, and 11 (3%) had hyperplasia. Of the remaining 22 patients, 9 (2%) were not operated, 12 (4%) underwent negative pancreatic explorations, and 1 (0.3%) was misdiagnosed. The use of preoperative localization studies (computed tomographic scan, arteriography, ultrasound, and transhepatic portal sampling) were successful in 195 (62%) of 315 patients. Intraoperative diagnostic studies (blood sugar and insulin assays) in peripheral and portal blood, and intraoperative ultrasound were positive in 86% (265/305) of patients.

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Resumen Fuimos comisionados por la Asociación Francesa de Cirugía para resumir la experiencia de los cirujanos de habla francesa que manejaron insulinomas a partir del advenimiento de la arteriografía en 1965. El período cubierto por el estudio fue el de 1965–1983; su enfoque principal fue el análisis de las imágenes diagnósticas pre- e intraoperatorias y la localización de los insulinomas.Trescientos treinta y ocho pacientes con hipoglicemia orgánica fueron referidos a cirujanos de habla francesa durante el período de 18 años del estudio. Doscientos sesenta y ocho (79%) de estos pacientes presentaron tumores benignos (12 fueron múltiples), 37 (11%) presentaron carcinoma, y 11 (3%) presentaron hiperplasia. De los restantes 22 pacientes, 9 (2%) no fueron operados, 12 (4%) tuvieron una exploración pancreática negativa, y 1 (0.3%) tuvo un diagnóstico erróneo. La realización de estudios preoperatorios de localización (tomografía computadorizada, arteriografía, ultrasonografía, y muestreo portal transhepático) fue exitosa en 195 (62%) de 315 pacientes.Los estudios intraoperatorios de diagnóstico (determinación de glicemia y de niveles de insulina) en la sangre periférica y la sangre portal, y la ultrasonografía intraoperatoria fueron positivos en 86% (265/305) de los pacientes.

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Résumé Nous avons étudié les résultats de 338 patients adressés pour hypoglycémie organique entre 1965 et 1983. Deux cent soixante-huit patients (79%) avaient une tumeur bénigne (12 tumeurs multiples), 37 (11%) avaient une lésion maligne, et 11 (3%) avaient une hyperplasie. Des 22 patients restants, 9 (2%) n'avaient pas eu d'opération, 12 (4%) ont eu des explorations pancréatiques négatives, et chez 1 (0.3%) patient, le diagnostic était faux.La localisation préopératoire par tomodensitométrie, artériographie, échographie, et dosages de la veine porte par voie transhépatique était positive chez 195 (62%) des 315 patients.Les études diagnostiques préopératoires (glycémie et dosage d'insuline) dans les prélèvements sanguins périphérique et porte, et l'échographie étaient positives chez 265/305 (86%) des patients.

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Commissioned by the French Association of Surgery.     

Monitoring of central venous oxygen saturation versus mixed venous oxygen saturation in critically ill patients

Continous monitoring of mixed venous (SvO₂) and central venous (ScO₂) oxygen saturation was compared in 7 critically-ill patients (Apache II score: 19±2.1) to determine whether or not information derived from ScO₂ were reliable in clinical practice. Patients were catheterized with both a pulmonary artery (PA) and a central venous (CV) catheter, each of them mounted with fiberoptic sensors (Opticath PA Catheter P7110 and Opticath CV Catheter U440, Abbott). A total of 580 comparative measurements were obtained during periods without and with therapeutic interventions (drug-titration, bronchial suction, use of PEEP, changes in FiO₂...). The systematic error between the 2 measurement techniques was 0.6% and 0.3% in periods with and without therapeutic interventions, respectively. The variability between the 2 techniques was 10% for both periods. Differences between the values were 5% in 49% of values during periods of stability and in 50% of values during periods with therapeutic interventions. There were poor correlations between the values during periods without (r=0.48) and with therapeutic interventions (r=0.62). Better, but still less than ideal, correlations were obtained with changes in SvO₂ and ScO₂ during periods without (r=0.70) and with therapeutic interventions (r=0.77). Although there is a need to develop a simple technique to monitor mixed venous oxygen saturation, the present study indicates that ScO₂ monitoring was not reliable in the study patients.     

The use of quinacrine (Atabrine) in rheumatic diseases: A reexamination

Atabrine has been available for nearly 60 years. It has a variety of actions and has been administered to millions of individuals. Its antirheumatic properties have been well documented but have not been exploited optimally for a variety of reasons. The drug is generally quite safe and could be used in low doses in lupus and rheumatoid arthritis patients as a steroid-sparing agent or synergistically with hydroxychloroquine. Its bothersome side effects should not deter the clinician from using it, because they are easy to deal with or prevent (Table 5). Future studies should attempt to better characterize the immunosuppressive actions of this powerful drug, particularly in the treatment of lupus erythematosus and rheumatoid arthritis. Studies of the role of combination or single-agent antimalarial therapy in combination with other "remittive" drugs could be of great potential benefit.     

New image-processing system for analysis,display and measurement of static and dynamic foot pressures

A new image-processing system, using a video digitiser with an IBM-compatible PC/AT, is developed for acquisition and processing of low-contrast, lowintensity barographic images of both feet for assessment of pressure distribution during standing and walking. Data displays, in the form of centres of pressures, isopressures contours, perspective views of pressures, grey scale image and walking pressure patterns, combined image of walking pressures, paths of centres of pressures and pressure variations with time, are developed. These have provided very useful and early information regarding the internal structural changes in the bones of the foot and sites at risk of ulcer development in leprosy subjects and enable suitable corrective orthopaedic procedures to be adopted. unitl the end of November 1990, and will then return to the Indian Institute of Technology.     

Regional Administration of Recombinant Tumour Necrosis Factor-α in Cancer, with Special Reference to Melanoma

Recombinant tumour necrosis factor-alpha (rTNFalpha) possesses the unique property of activating and selectively destroying the tumour-associated microvasculature. Systemic application of rTNFalpha has shown that the maximum tolerated dose (MTD) is 10 times lower than the efficient dose in animals. The main toxicity corresponds to the systemic inflammatory response syndrome (SIRS), with a decrease of vascular resistance and hypotension. We found that it is possible to administer rTNFalpha at 10 times the MTD in an isolated limb perfusion system, using a heart-lung machine, for advanced melanoma and sarcoma of the limbs. Our results, using the combination of high dose rTNFalpha, interferon-gamma and melphalan (TIM), produced an overall objective response rate of 100% in 2 successive studies on melanoma, with 90% and 78% complete response, respectively. In sarcoma, there was an overall response rate of 64%, with 36% complete response. Angiographic and immunohistological studies demonstrated selective and early damage of the tumour-associated microvasculature, preceded by upregulation of adhesion molecules and intratumoural leak of von Willebrand factor. Tumour invasion by platelets and, in some cases, by polymorphonuclear cells, appeared within hours after the application of rTNFalpha, long before the lysis of the tumour. Systemic changes after rTNFalpha treatment included the production of soluble TNFalpha receptors and of interleukin-6. A typical acute phase reaction was observed within 3 days, with increase of C-reactive protein parallelled by an increase of tenascin-C. A selective effect on intratumoural endothelial cells seems to be involved in the mechanism of the impressive antitumour effect of rTNFalpha, but the role of acute phase protein production is not fully understood. In selected cases of melanoma, specific cytotoxic T lymphocytes were increased after perfusion.