A novel view for the scintigraphic assessment of the elbow

Using any imaging modality, the elbow is a complex joint to evaluate. The use of scintigraphy in the evaluation of the effects of acute or chronic trauma has largely been confined to epicondylitis. We developed a skyline view of the elbow that minimized the effect of overlap and assessed its incremental value in the scintigraphic assessment of several pathological conditions. Thirty-four abnormalities were evaluated in 20 patients with a range of pathologies, including epicondylitis, ligamentous avulsion injury, articular injury, fractures and synovitis. The incremental value of addition of the skyline view to the standard views was assessed in addition to the overall accuracy of scintigraphy. Overall, scintigraphy detected 27 of 34 abnormalities, with the standard views of the elbow accurately identifying 15 and the skyline view 23 abnormalities. This gave the skyline view an incremental value of 24% over the standard views. In conclusion, scintigraphy has the potential to identify a greater range of pathologies in the elbow than previously reported, due to the addition of the skyline view to the standard views.     

Rating the appropriateness of coronary angiography, coronary angioplasty and coronary artery bypass grafting: the ACRE study. Appropriateness of Coronary Revascularisation study

BACKGROUND: Previous studies investigating the appropriateness of invasive management of coronary disease had not reported the internal consistency of their ratings and may now be out of date. The aim of this study was to measure the influence of clinical factors on contemporary ratings of the appropriateness of coronary angiography, percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) in the Appropriateness of Coronary Revascularisation (ACRE) study. METHODS: The Delphi-RAND technique was used, in which an expert panel (four cardiologists, three cardiothoracic surgeons, a general physician and a general practitioner), meeting in 1995, rated mutually exclusive indications (n = 2178 for angiography, n = 995 for PTCA and n = 984 for CABG). The main outcome measures were the appropriateness category (inappropriate, uncertain or appropriate) for each of the three procedures and treatment preference. RESULTS: For revascularization, the strongest determinant of inappropriateness was coronary anatomy. The odds ratio (OR) for inappropriate PTCA was 10.6 (95 per cent confidence interval (CI) 4.8-23.5) for the effect of left main stem or three-vessel disease versus single-vessel disease, and for CABG it was 0.06 (95 per cent CI 0.03-0.15). The number of diseased vessels was strongly related to preference for medical, PTCA or CABG treatment (p for linear trend <0.001). Mild versus severe anginal symptoms were associated with inappropriate angiography (OR 2.0 (95 per cent CI 0.9-9.8), although this effect was stronger when only the cardiologists' ratings were considered (OR 10.1 (95 per cent CI 2.4-42.6)). CONCLUSION: These are the first UK ratings of appropriateness covering all three procedures. The associations with clinical factors provide evidence of the internal consistency of these ratings. Prospective validation of these ratings against clinical outcomes is under way in the ACRE study.     

Analytic performance of two automated nonpretreatment digoxin immunoassays

The analytic performance of two automated nonpretreatment digoxin methods, AxSYM Digoxin II and Vitros digoxin immunoassays, was assessed. Both assays had analytic sensitivities of less than 0.2 microg/L, were linear from digoxin concentrations of 0.5 to 4.0 microg/L, and showed acceptable precision, with a maximum total coefficient of variation (CV) of 8.9% and 6.4% for the AxSYM and Vitros, respectively. Comparison of the two methods using samples from patients receiving digoxin gave the following relationship: Vitros = 0.91 x AxSYM + 0.23 (r = 0.97, Sy,x = 0.12). Digoxinlike immunoreactive factor (DLIF) crossreactivity was examined in specimens from patients who had hepatic disease, renal insufficiency, had undergone cardiac surgery, and in neonatal cord blood samples. Minimal crossreactivity was observed for most samples and the average crossreactivity for each group of samples was comparable for the two methods. The recovery of digoxin added to samples from each group of DLIF was similar, except for that from cord blood samples, for which recovery was significantly lower with the AxSYM method. Titration of a digoxin-spiked serum pool with digoxin-immune Fab showed a similar decrease in the measured digoxin concentration for both methods. Overall, the analytic performance characteristics of these two methods were comparable.     

The use of the iSTAT portable analyzer in patients undergoing cardiopulmonary bypass

Objective. To evaluate the utility of the iSTAT blood analyzer, a bedside device for hematocrit, sodium, potassium, and glucose measurement during cardiopulmonary bypass (CPB).Methods. Forty patients scheduled for elective CPB were evaluated prospectively. In addition to using the iSTAT analyzer, blood samples were analyzed at four time points: following induction of anesthetic, 10 min. after initiation of CPB, 60 min. after initiation of CPB, and following heparin neutralization by protamine. Blood glucose concentration was measured by the hospital laboratory using a Kodak Analyzer and by a glucose meter, electrolytes were evaluated by the Kodak Analyzer and BGE (a device which is commonly used for satellite laboratory determinations of electrolyte and blood gas results), and hematocrit samples were measured by the hospital laboratory using an NE 8,000 and a centrifuge. The means and standard deviations of the differences between the methods were calculated.Results. The hematocrit values determined by the iSTAT machine, when adjusted for the level of total protein (according to manufacturer's directions), differed from the laboratory values by 0.53 = 1.46 percentage points. An alternative to measuring total protein and making the adjustment is simply adding 1 % to the hematocrit in the pre-CPB period and 3% on-CPB or post-CPB, which we found to yield values that differed from the laboratory by 0.52 ± 1.42 percentage points. For all four tests (hematocrit, sodium, potassium, and glucose) the iSTAT had a similar relationship to the laboratory values as did the other commonly used means (centrifuge, BGE, and glucose meter) of clinical evaluation.Conclusion. In summary, we found that in patients undergoing CPB, the iSTAT values agreed sufficiently well with standard laboratory values and that the iSTAT instrument can be relied upon for bedside measurements.Presented in part at the Annual Meeting of the Society of Cardiovascular Anesthesiologists, Philadelphia, PA, May 1995, and at the 70th meeting of the IARS, Washington DC, March 1996. Supported in part by a grant by iSTAT Corporation.     

Erythropoiesis and renal transplant pregnancy

OBJECTIVE: To examine erythropoiesis in renal transplant pregnancies. METHODS: Retrospective cohort study of 30 renal transplant cases and 30 age, smoking and parity-matched healthy controls with normal index pregnancy. Retrospective chart review and assay of frozen antenatal serum (for serum erythropoietin concentration [serum EPO]), transferrin receptor protein [TfR], ferritin, folate and B12) were performed. The linear regression equation for normal pregnancy controls was used to calculate predicted [serum EPO] and the observed/predicted (O/P) log [serum EPO] was plotted. The relationship between [serum EPO] and haemoglobin (Hb) among transplant cases was considered to be different from that among controls if the slope of the O/P log [serum EPO] versus Hb regression was significantly different from zero. RESULTS: The transplant (14 cadaveric) to conception interval was (median [range]) 33.5 [4, 189] months. Immunosuppressants were azathioprine (n = 25), cyclosporine (n = 22) and/or prednisone (n = 25). Cases were more often primiparous (20 vs. 7 [controls]; p = 0.01), had pre-existent hypertension (20 vs. 0 [controls]; p < 0.001), developed new/increased hypertension or pre-eclampsia (28 vs. 0 [controls]; p < 0.001) and an antenatal rise in creatinine (14 vs. 2 [controls]; p < 0.001). In early pregnancy, cases had similar EPO (15.2 [2.6, 84.6] vs. 15.7 [6.4, 41.0] [controls] U/L) but lower Hb (101 [65, 129] vs. 116 [106, 150] g/L; p < 0.001). Twenty-two (73%) cases had Hb < 100 g/L (vs. 4 [controls]; p < 0.0001); Hb was comparable at 6 wk postpartum. With advancing gestational age (GA), Hb remained stable and serum EPO increased in both groups. The slope of the O/P log [serum EPO] versus Hb for transplant cases was significantly different from zero within both the 17-28 wk (slope +/- SEM: 0.010 +/- 0.002; p < 0.0001) and the 29-42 wk GA categories (0.006 +/- 0.003; p = 0.02). Cases showed smaller rises in serum TfR (change 481 [- 1471, 2780]) vs. 1119 [- 698, 4195] [controls] ng/mL; p = 0.005). CONCLUSIONS: Anaemia frequently complicates renal transplant pregnancies, in which serum EPO is inappropriately low and the rate of erythropoiesis blunted.     

Infants born to narcotic dependent mothers: Physical growth patterns in the first 12 months of life

Objectives: To describe the physical growth patterns of infants born to narcotic dependent mothers (INDM) over a 12 months period and, if possible, to relate the growth to drug taking patterns during pregnancy.
Methodology: The growth of a cohort of 43 INDM was measured during the first 12 months of life. Weight and length measurements were compared with percentile charts and converted to Z scores. Questionnaire data about drug taking practices, demographic variables and the neonatal period (including withdrawal scores) were obtained.
Results: Twenty-four (55.8%) of INDM had evidence of neonatal drug withdrawal requiring treatment with phenobarbitone. At birth, Z scores for weight and length indicated relative intrauterine growth retardation. By 12 months, there had been some catch up growth, but Z scores for weight and length were still below zero. Persistent weight retardation at 12 months was correlated with methadone dosage during pregnancy, but not the need for phenobarbitone therapy.
Conclusions: The growth patterns of INDM in the first 12 months of life indicated that at birth there was evidence of intrauterine growth retardation, but by 12 months the growth was little different from the rest of the community. There appears to be some influence of narcotic agents taken while pregnant on subsequent growth of INDM.     

Are boys better than girls at building a tower or a bridge at 2 years of age?

This study was designed to look at the differences in visuospatial abilities between boys and girls before they can speak fluently. At the mandatory two year follow up visit, children were given the opportunity to build a tower and a bridge. In children whose birth weight was > or = 2500 g, the capacity for erecting a tower was the same in both sexes, but for building a bridge striking differences were noted according to their sex. Among the 376 children of this category, 41 out of 199 boys (21%) were able to build a bridge in comparison with 15 out of 177 girls (8%). This difference is highly significant. In children whose birth weight was < or = 2500 g, no differences were noted either for building a tower or a bridge. By showing that boys outnumber girls among the most skilled toddlers in spatial abilities, this work confirmed the action of a male related factor on cerebral lateralisation.     

Hypoglycémie hyperinsulinémique persistante du nouveau-né et du nourrisson

Persistent hyperinsulinemic hypoglycaemia of infancy (PHHI) is the most frequent cause of hypoglycaemia in infancy. Clinical presentation is heterogeneous, with variable onset of hypoglycaemia and response to diazoxide, and presence of sporadic or familial forms. Underlying histopathological lesions can be focal or diffuse. Focal lesions are characterised by focal hyperplasia of pancreatic islet-like cells, whereas diffuse lesions implicate the whole pancreas. The distinction between the two forms is important because surgical treatment and genetic counselling are radically different. Focal lesions correspond to somatic defects which are totally cured by limited pancreatic resection, whereas diffuse lesions require a subtotal pancreatectomy exposing to high risk of diabetes mellitus. Diffuse lesions are due to functional abnormalities involving several genes and different transmission forms. Recessively inherited PHHI have been attributed to homozygote mutations for the beta-cell sulfonylurea receptor (SUR1) or the inward-rectifying potassium-channel (Kir6.2) genes. Dominantly inherited PHHI can implicate the glucokinase gene, particularly when PHHI is associated with diabetes, the glutamate dehydrogenase gene when hyperammonaemia is associated, or another locus.