Neutrophil surface-bound immunoglobulin–a feature of Felty's syndrome?

Summary In a study of eight patients with Felty's syndrome, surface-bound immunoglobulin (IgG ± IgM and complement) was demonstrated in all cases by a fluorescein-labelled antihuman globulin technique using paraformaldehyde-fixed neutrophils to prevent non-specific surface adsorption of immunoglobulin. The test was negative in control patients with rheumatoid arthritis alone. The neutrophil binding of immunoglobulin occurred in vivo and could not be reproduced with the patient's serum and normal neutrophils. The presence of alloantibodies due to previous pregnancy or transfusion can obscure this picture. A neutrophil autoantibody or cell-bound immune complexes may be the cause of this phenomenon, which may be a useful marker of Felty's syndrome in patients with rheumatoid arthritis.     

THE EFFECT OF YTTRIUM-90 IMPLANTATION ON ENDOCRINE FUNCTION AND VISUAL FIELDS IN PATIENTS WITH ''FUNCTIONLESS'' PITUITARY TUMOURS, WITH BIOPSY AND RADIOLOGICAL FINDINGS

Thirty patients with symptoms from "functionless" pituitary tumours were treated by yttrium-90 implants, and we report here the effects on symptoms, pituitary function and visual fields. On biopsy, about a third of the tumours showed some hormone granules. In the sixteen fully assessed at 1 year, pituitary function was improved in 25%, unchanged in 62-5%, and reduced in 12-5%. Improvement was confined to those in whom gonadotrophin secretion was the only function impaired pre-implant. Visual field defects were present pre-implant in ten patients (twenty eyes); at 1 year post-implant these defects had lessened in 80% and deteriorated in only 5% of eyes. Subsequently, within 5 years of the implant the field defects had worsened or recurred in four patients, all with initially extensive suprasellar projection; further treatment was then given. Remineralization of the sella was seen after implantation in seven cases, with reduction in fossa size in five. Thus pituitary implantation appears to be a practicable and reasonably simple procedure suitable for the treatment of most cases of "functionless" pituitary tumour. The "supressive" doses of irradiation used are adequate to shrink most tumours without loss of pituitary function.     

The Radiological Features of Henoch-Schonlein Purpura in the Gastro Intestinal Tract

Involvement of the G.I. tract is a common feature of Henoch-Schonlein Purpura. The diagnosis is likely when abdominal pain and G.I. bleeding occurs in a patient with haematuria, rash and joint pains. The principal radiological features in the cases described were found in the duodenum, jejunum, ileum and colon, and consisted of submucosal haemorrhage and subsequent ulceration.     

OUTPATIENT TERMINATION OF PREGNANCY: HALOTHANE OR ALFENTANIL-SUPPLEMENTED ANAESTHESIA

Inhalation anaesthesia with halothane was compared with i. v.alfentanil in 66 unpremeditated patients undergoing suctiontermination of pregnancy as outpatients. Blood loss was significantlygreater in the halothane group with a mean loss of 213 ml, comparedwith a mean loss of 89.8 ml in the alfentanil group. There wasa greater frequency of nausea and vomiting in the alfentanilgroup, but no reduction in abdominal pain or need for analgesiaafter operation. Positive relationships were found between bloodloss and duration of anaesthesia and between blood loss andgestational age in the halothane group, but not in the alfentanilgroup. We conclude that a/fentan/l-supplemented anaesthesiais satisfactory for suction termination of pregnancy when rapidrecovery is required or the duration of the procedure is likelyto be long, but that halothane anaesthesia cannot be recommended,especially if the procedure is long.     

COMPARISON OF PATIENT-CONTROLLED ANALGESIA WITH AND WITHOUT A BACKGROUND INFUSION AFTER LOWER ABDOMINAL SURGERY IN CHILDREN

Forty children aged 6–12 yr undergoing appendicectomywere allocated randomly to receive postoperative i.v. morphineby a patient-controlled analgesia (PCA) system (bolus dose 20µg kg^–1 with a lockout interval of 5 min) or thesame PCA with a background infusion of morphine 20 µgkg^–1 h^–1 Patients breathed air and oxygen saturationwas monitored by continuous pulse oximetry. Scores for pain,sedation and nausea were recorded hourly. Patients with PCA+ background infusion received significantly more morphine thanthose with PCA only. Both groups selfadministered similar amountsof morphine using the PCA machine. There were no significantdifferences in the pain scores of the two groups. Patients withPCA + background infusion suffered more nausea (P < 0.01),more sedation (P < 0.05) and hypoxaemia (P < 0.001) thanthose with PCA only. They also had a better sleep pattern thanthose with PCA only. (Br. J. Anaesth. 1993; 71: 670–673).     

Demonstration of Intrabiliary Rupture of Hepatic Hydatid Cysts by Retrograde Cholangiography

Intrabiliary rupture of hepatic hydatid cysts was demonstrated by retrograde cholangio-graphy in five cases of hydatidosis complicated by abdominal pain, jaundice or cholangitis. The bile duct contained typical laminated membrane in two cases, daughter cysts in two cases and membrane fragments in one case. In three of five cases there was marked displacement of the left and right hepatic ducts due to the location of the cyst close to the Mum of the liver. Endoscopic sphincterotomy resulted in spontaneous passage of biliary hydatid material in two cases in whom rupture was accompanied by jaundice and cholangitis.     

Assisted ventilation and survival of extremely low birthweight infants

Objective : To determine the incremental consumption of ventilator resources associated with the improving survival rate of extremely low birthweight (ELBW, birthweight 500–999 g) infants, from the time assisted ventilation was introduced. Methodology : Cohort study of ELBW infants born in one tertiary perinatal centre (The Royal Women's Hospital, Melbourne). All ELBW infants born from 1971 to 1993 were included in the study. Inhospital survival rates and patient-days of assisted ventilation were the main outcome measures. Discrete eras of relatively stable survival rate and consumption of ventilator resources were identified. These comprised the years 1971–74, 1977–83, 1985–90, and 1992–93. Cost-effectiveness ratios (the incremental consumption of ventilator resources per additional survivor) were calculated between adjacent eras by dividing the increment in the consumption of ventilator resources by the increment in the survival rate. Results : The survival rates rose progressively between eras (6.2, 33.9, 49.1, 68.8%, respectively, as did the consumption of ventilator resources (0.1, 6.6, 16.2, 24.7 patient-days of assisted ventilation per livebirth, respectively). The cost-effectiveness ratio deteriorated initially, increasing from 23.2 to 63.5 additional patient-days of assisted ventilation per additional survivor, but then improved, falling to 43.1 additional patient-days of assisted ventilation per additional survivor in the last era. These changes were even more marked for those of birthweight 750-999 g (20.0, 63.2 to 35.9 additional patient-days of assisted ventilation per additional survivor, respectively). In contrast, the cost-effectiveness ratio was initially worse for those of birthweight 500-749 g, being three-fold higher than for the larger infants, and only improved substantially in the last era (59.8, 58.3 to 44.1 additional patient-days of assisted ventilation per additional survivor, respectively). Conclusions : The initial deterioration in cost-effectiveness ratios between successive eras probably reflected the increased availability of resources for assisted ventilation, without any other major advances in perinatal care. The improvement in cost-effectiveness in the last era reflected, in part, the increased use of antenatal steroid therapy and the introduction of exogenous surfactant to neonatal intensive care.     

Herpes simplex virus type 1 infections presenting at birth

Two cases of intra-uterine acquired neonatal herpes simplex type I presented with atypical skin lesions apparent at or shortly after birth; the timing and appearance of the lesions meant that herpes virus infections were not considered to be the most likely diagnosis. Once herpes simplex was diagnosed, both infants were treated with acyclovir. Prompt diagnosis and institution of acyclovir are imperative for a favourable outcome from neonatal herpes infections.     

Biologically active conformations of thymopentin Studies with conformationally restricted analogs

Four cyclic analogs of thymopentin were synthesized and evaluated for biological activity on the human T cell line CEM. Three of these conformationally restricted analogs were biologically active. The one analog which most closely mimicked the conformation predicted from NMR and theoretical energy minimization calculations proved to be inactive. These studies establish that the biologically active conformations of thymopentin differ from the most probable conformation predicted from solution NMR and theoretical energy minimization studies.