Fetal heart rate monitoring by telephone. I. Development of an integrated system in Cardiff

Summary. We report the development of a practical dedicated system for domiciliary fetal monitoring integrated in a scheme for its rational application. From experience of 1120 domiciliary recordings in 74 women (64 with high-risk pregnancies), we suggest that domiciliary monitoring applied within a structured clinical context should be as safe as monitoring in hospital.     

ACUTE GASTRIC DILATATION IN AN INCARCERATED HIATUS HERNIA

A case is reported of an unusual complication in which acutegastric dilatation occurred in an incarcerated hiatus hernia,resulting in left ventricular failure in the postoperative period.Failure to recognize this gave rise to concern when the patientre-presented for further surgery. ^*Department of Anaesthesia, Royal Liverpool Hospital, PrescotStreet, Liverpool L7 8XP. Walton Hospital, Rice Lane, Liverpool L9 1AE.     

ARE SLOW-ACTING ANTI-RHEUMATIC DRUGS MONITORED TOO OFTEN? AN AUDIT OF CURRENT CLINICAL PRATICE

Rheumatologists usually recommend monthly blood monitoring whenpatients with rheumatoid arthritis (RA) are treated with slow-actinganti-rheumatic drugs (SAARDs). Is monthly monitoring neededor could its frequency be reduced? We audited the opinions ofUK rheumatologists and reviewed clinical experience at threecentres. To ascertain the interval at which patients are monitoredand the determinants of monitoring policy we sent a questionnaireto 193 consultant rheumatologists; 143 (74%) replied. The majorityuse monthly monitoring for most SAARDs except sulphasalazine,chloroquine and hydroxychloroquine. There is extensive variation,which is not related to the type of rheumatology unit or whethera shared scheme with general practitioners is used. Reviewingexperience in 390 patients treated with SAARDs at three adjacentrheumatology units in London showed that haematological adversereactions were infrequent. During 1560 patient-years of treatmentinvolving 18 720 monthly monitoring visits there were 13 haematologicaladverse reactions (1 1 thrombocytopenias and two leucopenias).Five thrombocytopenias occurred in the first 6 months of therapy;two were gradual and three developed more rapidly over 1–2months. Six thrombocytopenias developed after 6 months of treatment;five occurred gradually over 5 months or more and one borderlinelow platelet count was seen once. The two leucopenias were borderlinelow white cell counts occurring gradually over 3–6 months.Such frequent monitoring is expensive. The total cost of monitoring390 patients for 1560 patient-years was $420 000. The cost ofdetecting each adverse reaction was $ 32 000. Three-monthlymonitoring when therapy is established after an initial stabilizingperiod would have identified seven out of eight late adversereactions. Monitoring policies are mainly based on clinicalconsensus with few prospective studies of their value; theyneed re-evaluation. KEY WORDS: Rheumatoid arthritis, Drug toxicity, Slow-acting anti-rheumatic drugs     

IS THE "K-TYPE" CAFFEINE-HALOTHANE RESPONDER SUSCEPTIBLE TO MALIGNANT HYPERTHERMIA ?

The "K-type" designation is used to describe a patient beinginvestigated for malignant hyper-thermia (MH) when concurrentadministration of caffeine and halothane induces muscle contracture(rigidity, spasm) in vitro, but when halothane and caffeinegiven separately produce a normal response. It is accepted insome centres that K-type individuals are susceptible to malignanthyper-thermia (MHS). In this paper, the K-type is shown notto correlate with the MH susceptible (MHS) status as acceptedby the European MH group.     

Prognostic significance of tumor necrosis in ovarian cancer patients treated with neoadjuvant chemotherapy and interval surgical debulking

The objective of this study was to study the significance of tumor necrosis documented at the time of interval surgical debulking after neoadjuvant chemotherapy. Retrospective chart reviews were carried out from 1997 to 2005 to identify ovarian cancer patients treated with neoadjuvant chemotherapy. Patients' demographics together with disease characteristics, treatment-related variables, and outcomes were recorded. Cox proportional hazard models were built to model time to progression using predictor variables such as age, cancer stage, tumor grade, residual disease, percentage change in CA125 level from baseline, and degree of necrosis in resected tumor specimens. One hundred one patients were included in the study. Optimal debulking was achieved in 74% of the patients. Cox regressions revealed three significant predictive variables of time to first progression: younger age (hazard ratio [HR] = 0.95, 95% CI 0.92-0.98, P= 0.004), residual disease (P= 0.048), and the absence/minimal tumor necrosis after three cycles of neoadjuvant chemotherapy (HR = 1.97, 95% CI 1.01-3.87, P= 0.048). The estimated median survival was 50.66 months (95% CI 46.12-55.20). The lack of or minimal tumor necrosis after neoadjuvant chemotherapy is an independent risk factor for recurrent disease.     

SULPHASALAZINE IN THE MANAGEMENT OF PSORIATIC ARTHRITIS

There are few ‘second-line’ drugs available forthe treatment of PSA and their use is often limited by toxicity.Thirty-nine patients with active PSA recruited from two rheumatologyunits were randomly allocated to either enteric-coated sulphasalazine(SASP) or placebo and followed for 24 wk. Six patients in theSASP group and 11 on placebo discontinued therapy before 24wk. Evaluation of effect of treatment revealed significant improvementsin articular index in both groups at 12 wk. By 24 wk the articularindex in placebo group was still showing benefit. In additionto articular index the SASP group improved significantly interms of visual analogue scale, duration of morning stiffnessand ESR. SASP is effective in PSA but the partial clinical response toplacebo indicates the importance of placebo-controlled studiesin this variable disease. KEY WORDS: Skin, Arthritis, Treatment     

OSTEOARTHRITIS IN WEIGHT-BEARING WRISTS?

To test the suggestion [1] that turning the wrist into a weight-bearingjoint by using a stick is likely to cause OA in that joint,50 consecutive patients (excluding those with RA) who had useda stick for more than 1 year were studied clinically and radiographically.The data did not support this hypothesis. The changes in theoriginal paper, as in one of these patients. were likely tobe due to avascular necrosis.     

Advanced interventional pulmonology procedures: Training guidelines from the Thoracic Society of Australia and New Zealand

Training in interventional pulmonology procedures is increasing in popularity. However, the nature of training is difficult to define, particularly with respect to an adequate number of cases. These guidelines approach training not just from a modest number of supervised cases, but also from a range of educational and outcome targets which give a rounded approach to the issue. These include prerequisite skills from basic procedures, the place of simulated training, formal simulation testing, modest procedural outcome and side effect targets, audit presentations, ongoing reading, and hands‐on training expectations. All of this would still be under the supervision of an experienced trainer.     

A SUGGESTED CURRICULUM FOR THE PROFOUNDLY HANDICAPPED CHILD. 3: Integrating the special care class

The first two parts of this series outlined a basic teaching programme suitable for use with profoundly handicapped children, and appropriate classroom organisation and routine. This part concentrates on the integration of the children within the main school.     

Synthesis and immunological characterization of a 134-mer synthetic peptide corresponding to the N-terminal half of the HIV-1 nucleoprotein,p24

A 134-mer peptide corresponding to the N-terminal sequence of p24 (residues 146–279 of the gag gene product of the LAV strain) was chemically synthesized using highly optimised protocols on an ABI 430A synthesizer. The crude peptide was obtained by treating the peptide-resin with HF, then purified by a combination of size exclusion and RP-HPLC. One hundred milligram of 90% pure 134-mer can be obtained within a month. Both mice and rabbit polyclonal antisera raised against a commercial preparation of recombinant p24, and a pooled sera from HIV-1 infected individuals reacted strongly with the 134-mer peptide in ELISA. Both mice and rabbits immunized with the free peptide emulsified in Freund's complete adjuvant generated strong anti-peptide and anti-p24 antibody responses as judged by immunoblots and ELISAs. Immunodominant epitopes were mapped to residues 201–227 (LKETINEEAAEWDRVHPVHAGPIAPG). These B-cell epitopes had previously been identified by mouse monoclonal antibodies raised against HIV-1 virus or gag gene products. Furthermore, murine T-cell lines generated against the 134-mer peptide were found to respond to two short peptides, P24B (residues 195–215) and P24D1 (residues 268–279). These two T-cell epitopes were previously reported as human helper T-cell and CTL epitopes, respectively. These results clearly indicate that the synthetic 134-mer peptide could elicit both T- and B-cell responses to HIV-1 similar to those obtained with the natural viral gag protein, and could be useful for the development of a synthetic HIV vaccine