The hemodynamic effects of intubation during nitroglycerin infusion in severe preeclampsia

The effectiveness of intravenous nitroglycerin infusion in lowering maternal blood pressure and in blunting the hemodynamic responses to endotracheal intubation was evaluated in six primigravid women with severe preeclampsia. Monitoring consisted of continuous electrocardiogram monitoring, arterial cannulation, and flow-directed pulmonary arterial catheterization in each patient. All patients underwent oxytocin induction of labor and crystalloid and/or colloid expansion to produce a pulmonary capillary wedge pressure of 10 to 15 mm Hg and a colloid osmotic pressure of greater than 17 mm Hg. Intravenous nitroglycerin was administered before induction of general anesthesia. The hemodynamic effects associated with endotracheal intubation revealed a change in the heart rate from 104 +/- 10 to 133 +/- 17 beats/min, an increase in mean arterial pressure from 134 +/- 12 to 164 +/- 32 mm Hg, and an increase in systemic vascular resistance from 1262 +/- 342 to 1351 +/- 259 dynes-sec-cm-5 that was accompanied by a small change in the cardiac index from 4.5 +/- 1.2 to 4.5 +/- 0.9 L.min-1.m-2.     

Update of the Cincinnati experience in pediatric laryngotracheal reconstruction

Surgical endeavors in the field of laryngotracheal reconstruction in children have received much interest in the past 15 years. A unique experience with laryngotracheal reconstruction in 203 children is reviewed. The majority (194) of the cases were classified as acquired; only nine were classified as congenital. Excluded from the study were those cases of stenoses managed endoscopically, all resections and end-to-end anastomoses, all anterior cricoid split procedures, and all cases of anterior glottic stenosis repaired by a laryngeal keel. The degree of stenosis was graded into four categories. Five different methods of laryngotracheal reconstruction were used depending on the pathologic lesion in the larynx and trachea. Of the 203 children, 186 (92%) were decannulated. The results support the use of laryngotracheal reconstruction in children with grades 2, 3, and 4 laryngeal stenosis.     

Severity of disease correlated with fever reduction in febrile infants

A prospective study of the effects of fever reduction on the clinical appearance of infants at risk for occult bacteremia was undertaken to study the hypothesis that infants with bacteremic illness fail to improve clinically following defervescence compared with infants with benign viral illness. A total of 154 children were enrolled in the study, including 19 with bacteremia: 13 with occult Streptococcus pneumoniae bacteremia, two with occult Haemophilus influenzae, type b bacteremia, and four with Haemophilus meningitis and bacteremia. There were no differences in degree of temperature reduction with acetaminophen between the bacteremic and nonbacteremic groups of infants. Among infants with bacteremia but without meningitis, differences from nonbacteremic children were detected in clinical appearance prior to fever reduction but not following defervescence. All patients with meningitis appeared seriously ill before and after defervescence. It was concluded that clinical improvement with defervescence is not a reliable indicator of the presence of occult bacteremia. Lack of clinical improvement with defervescence may be a reliable indicator for the presence of meningitis. Because there were differences in clinical appearance prior to fever reduction, routine administration of acetaminophen may interfere with the clinical evaluation by the physician.     

Use of the chemical cleavage of mismatch method for prenatal diagnosis of alpha-1-antitrypsin deficiency.

The most common mutation in alpha-1-antitrypsin deficiency, conversion of a G to an A at base 9989 (PI-Z), was detected with the chemical cleavage of mismatch method, demonstrating the power of the method for prenatal diagnosis. Exon V of the gene was amplified using the polymerase chain reaction and heteroduplexes were formed to test for the presence of the mutation. The predicted C mismatch was readily detectable with hydroxylamine, and by making the probe from the chorionic villus sample it was possible to determine that the fetus was heterozygous, not homozygous, for the mutation.     

Preventing postoperative complications in the adult cystic fibrosis patient

Herein we report on a 27-year-old cystic fibrosis (CF) patient who developed bronchospasm, secretory plugging of the trachea, and pneumothorax following general endotracheal anesthesia for intranasal polypectomy and bilateral Caldwell-Luc procedures at an adult facility. Intranasal polypectomy and paranasal sinus procedures are the most common surgical procedures performed on cystic fibrosis patients, making the otolaryngologist a frequent member of the cystic fibrosis team [8]. As survival improves, the pediatric otolaryngologist will find himself following CF patients into their 20's and 30's. Adult care facilities may not be as familiar with these patients as the surgeon would like. The otolaryngologist's familiarity with the unique perioperative requirements of the CF patient can prove invaluable in such a setting. Preoperative assessment should identify any acute pulmonary changes, assess nutritional status, assure good control of blood glucose levels, and rule out clotting abnormalities. Good perioperative hydration and meticulous attention to pulmonary toilet are of foremost importance in the surgical care of the cystic fibrosis patient. Chest physiotherapy and suctioning of the tracheobronchial tree should precede arousal from anesthesia and extubation. By insisting on appropriate anesthetic and perioperative care, the knowledgeable otolaryngologist may circumvent potential postoperative complications in the cystic fibrosis patient.     

Atypical (mild) forms of dihydropteridine reductase deficiency: neurochemical evaluation and mutation detection.

We investigated two patients with an atypical (mild) form of dihydropteridine reductase (DHPR) deficiency. Both responded to the loading test with tetrahydrobiopterin; their plasma phenylalanine levels were lowered from 278 mumol/L to 85 and 48 mumol/L and from 460 mumol/L to 97 and 36 mumol/L after 4 and 8 h, respectively. In one of the patients, a combined loading test with phenylalanine followed by tetrahydrobiopterin was also carried out and showed a profile typical for DHPR deficiency. The phenylalanine hydroxylation rate was calculated to be 43 and 87%, 4 and 8 h after cofactor administration, respectively. Diagnosis was confirmed by the absence of DHPR activity in the patient's erythrocytes. In cultured fibroblasts, residual activity of 4 and 10%, respectively, was found. Excretion of urinary pterins was essentially normal, and the biopterin to neopterin ratio in cerebrospinal fluid was increased. Although in both patients cerebrospinal fluid homovanillic acid was found to be normal, and 5-hydroxyindoleacetic acid was substantially reduced, there was no sign of neurologic alterations until the age of 2 y. However, one of the patients recently developed deceleration of head growth, whereas psychomotor development continued to be normal for age. Using the chemical cleavage method on the amplified cDNA, mismatches of T to G at nucleotide 659 and of G to A at nucleotide 475, respectively, were identified. These results also demonstrate that screening for tetrahydrobiopterin deficiency by urinary pterin analysis alone can miss some newborns with mild DHPR deficiency and that all children with tetrahydrobiopterin defects need full neurochemical evaluation together with analysis of the enzyme activity.     

Phonation and swallowing considerations in pediatric laryngotracheal reconstruction.

Experience with laryngotracheal reconstruction (LTR) has resulted in and continues to yield modifications and refinements in approach and technique with the goal to restore and maintain total laryngeal function. In addition to airway obstruction, the laryngeal functions of phonation and swallowing also may be affected by the underlying injury as well as by procedures designed to enlarge the airway. This paper discusses various problems encountered with phonation and swallowing in pediatric patients who underwent LTR and postoperative patients who were seen during the year July 1, 1990, through June 30, 1991. Phonation problems became apparent as long-term difficulties that persisted after tracheotomy decannulation. Swallowing was frequently a short-term perioperative problem while a stent was in place following LTR. The approaches and techniques that have been employed to treat, minimize, and prevent these problems are discussed.     

Four-quadrant cricoid cartilage division in laryngotracheal reconstruction.

Four-quadrant division of the cricoid cartilage is a relatively new technique of laryngotracheal reconstruction. Division of the lateral walls of the cricoid cartilage, with or without placement of autogenous cartilage grafts, allows for increased expansion of the subglottic lumen. Between October 1, 1986, and January 1, 1990, 185 laryngotracheal reconstructions were performed at our institution. During that time, 31 four-quadrant division laryngotracheal reconstruction procedures were performed in 29 patients (mean age at surgery, 5 years 5 months). Grade 3 or 4 laryngeal stenosis existed preoperatively in 72% (22/31) of cases. The initial decannulation rate after four-quadrant division laryngotracheal reconstruction was 58% (18/31). Of 11 patients requiring revision surgery after four-quadrant division laryngotracheal reconstruction, four were eventually decannulated, for an overall decannulation rate of 76% (22/29). The indications, technique, results, and potential complications of four-quadrant division of the cricoid cartilage in laryngotracheal reconstruction are discussed.     

CLINICAL REPORT ON THE TREATMENT OF 806 CASES OF STIFF NECK WITH TUINA (CHINESE MASSAGE)

The author treated 806 cases of acute stiff neck with Tuina. Among all the treated pa-tients,804 were cured with one session, the cure rate was 99. 75 %; and the other 2 were improved,the improvement rate was 0. 25%. So the total effective rate was 100%.