Interactions among peripheral perfusion, cardiac activity, oxygen saturation, thermal profile and body position in growing low birth weight infants

Aims: To investigate the correlation between the ‘perfusion index’ (PI) and other commonly used estimates of cutaneous blood flow [heart rate (HR), surface temperatures (ST) and central‐to‐peripheral thermal gradients (C‐P grad)] and to use this new non‐invasive tool to compare differences between prone and supine sleep position in low birth weight (LBW) infants. Methods: Six‐hour continuous recordings of pulse oximetry, cardiac activity and absolute ST from three sites (flank, forearm and leg), along with minute‐to‐minute assessment of behavioural states were performed in 31 LBW infants. Infants were randomly assigned to the prone or supine position for the first 3 h and then reversed for the second 3 h. PI data were correlated with HR and C‐P grad, and compared across sleep positions during quiet sleep (QS) and active sleep (AS). Results: Perfusion index correlated significantly with HR (r² = 0.40) and flank‐to‐forearm thermal gradient (r² = 0.28). In the prone position during QS, infants exhibited higher PI (3.7 ± 0.9 vs. 3.1 ± 0.7), HR (158.4 ± 8.9 vs. 154.1 ± 8.8 bpm), SpO₂ (95.8 ± 2.6 vs. 95.2 ± 2.6%), flank (36.7 ± 0.4 vs. 36.5 ± 0.4°C), forearm (36.1 ± 0.6 vs. 35.5 ± 0.4°C) and leg (35.4 ± 0.7 vs. 34.7 ± 0.7°C) temperatures and narrower flank‐to‐forearm (0.6 ± 0.4 vs. 0.9 ± 0.3°C) and flank‐to‐leg (1.3 ± 0.6 vs. 1.8 ± 0.7°C) gradients, compared to those of the supine position. Similar differences were observed during AS. Conclusion: Perfusion index is a good non‐invasive estimate of tissue perfusion. Prone sleeping position is associated with a higher PI, possibly reflecting thermoregulatory adjustments in cardiovascular control. The effects of these position‐related changes may have important implications for the increased risk for sudden infant death syndrome in prone position.     

Umbilical pyloromyotomy: comparison of vertical linea alba and transverse muscle cutting incisions

Background

Pyloromyotomy is commonly performed through a supraumbilical skinfold incision. Entry into the peritoneal cavity can be achieved via a vertical linea alba incision or a transverse muscle cutting approach. The aim of this study was to compare the morbidity associated with these 2 operative techniques.

Methods

Case records of all babies undergoing umbilical pyloromyotomy between January 2000 and December 2004 were retrospectively compared for postoperative dehiscence, mucosal perforation, and wound infection (defined by the need for antibiotics or wound exploration). Data were analyzed with GraphPad Prism contingency tables and results were compared by Fisher exact test (P < .05).

Results

During the study period, 341 umbilical pyloromyotomies were performed at our institution. The surgeon was permitted choice of either operative approach (219 vertical linea alba, and 122 transverse muscle cutting). There were no significant differences between the 2 groups regarding age at presentation, sex, duration of symptoms, biochemical derangement, and operator seniority. No significant differences in morbidity were encountered with either of these 2 operative strategies.

Conclusions

This study demonstrates that the vertical linea alba and transverse muscle cutting incisions have equivalent postoperative morbidity. These findings indicate that neither technique is demonstrably superior.     

Kidney disease in Bahrain: a biopsy-based epidemiological study

The aim of this study was to establish the incidence of renal diseases in Bahrain during January 2003 through October 2006, based on biopsy results. This study continued a previous biopsy-based survey covering 13 years from January 1990 through December 2002. Comparisons were made with the previous study to ascertain whether the disease pattern continued in the same trend. The current study included 145 biopsies on 130 patients, of whom glomerular diseases constituted 64.8%; transplant biopsies, 23.4%; chronic glomerulosclerosis, 8.9%; and other etiologies, 4.1%. There were comparable numbers of primary and secondary glomerular diseases in the present series. The incidence of renal biopsies per 100,000 population per year did not significantly change over the last 15 years: 5.4/100,000 per year in the present series versus 5.8/100,000 per year in the previous study. The pattern of primary glomerular diseases showed the minimal change disease--focal segmental glomerulosclerosis (MCD-FSGS) complex--remained the most common of all primary glomerular diseases, although decreased in absolute numbers compared with the previous study. A significant increase in the number of patients with immunoglobulin A nephropathy was observed over the years. Secondary glomerular diseases showed an increased incidence with lupus nephritis the number one diagnosis. Also we observed a steady increase in the number of allograft biopsies.     

Respiratory disease in Niemann‐Pick type C2 is caused by pulmonary alveolar proteinosis

Griese M, Brasch F, Aldana VR, Cabrera MM, Goelnitz U, Ikonen E, Karam BJ, Liebisch G, Linder MD, Lohse P, Meyer W, Schmitz G, Pamir A, Ripper J, Rolfs A, Schams A, Lezana FJ. Respiratory disease in Niemann‐Pick type C2 is caused by pulmonary alveolar proteinosis. Niemann‐Pick diseases are hereditary neurovisceral lysosomal lipid storage disorders, of which the rare type C2 almost uniformly presents with respiratory distress in early infancy. In the patient presented here, the NPC2 exon 4 frameshift mutation c.408_409delAA caused reduced NPC2 protein levels in serum and lung lavage fluid and the synthesis of an aberrant, larger sized protein of around 28 kDa. Protein expression was strongly reduced also in alveolar macrophages. The infant developed failure to thrive and tachypnea. Lung lavage, computer tomography, and histology showed typical signs of pulmonary alveolar proteinosis with an abnormal intraalveolar accumulation of surfactant as well as macrophages. An NPC2‐hypomorph animal model also showed pulmonary alveolar proteinosis and accumulation of macrophages in the lung, liver, and spleen long before the mice died. Due to the elevation of cholesterol, the surfactant had an abnormal composition and function. Despite the removal of large amounts of surfactant from the lungs by therapeutic lung lavages, this treatment was only temporarily successful and the infant died of respiratory failure. Our data indicate that respiratory distress in NPC2 disease is associated with a loss of normal NPC2 protein expression in alveolar macrophages and the accumulation of functionally inactive surfactant rich in cholesterol.     

Skin necrosis in a critically ill patient due to a blood pressure cuff

The non-invasive method of blood pressure measurement is regarded as a safe procedure and the reports of any serious complications are rare. We report a unique case of extensive skin necrosis due to an intermittently inflating blood pressure cuff in a 65-year-old critically ill lady following a third time redo mitral valve surgery. A brief review of the literature on complications associated with noninvasive method of measurement of blood pressure is presented along with possible mechanisms of skin injury and ways to avoid it.