Identification of accessory bile ducts at cholecystectomy

The presence of accessory channels between the liver and extrahepatic bile ducts has long been recognised by anatomists and the division of such ducts may be a cause of bile leakage following cholecystectomy. However, visualisation of accessory bile ducts at operation is difficult as they are often small and sometimes less than 1 mm in diameter. Cholangiography has been used to help in the identification of accessory ducts in 50 patients included in a prospective trial. X-rays were taken after dissection of the gall bladder from its bed and extravasation of contrast was seen on five occasions (10%) suggesting leakage from divided accessory ducts. The identification of damage to accessory bile ducts in 10% of patients suggests that this may occur more frequently than previously supposed.     

Vitamin K in colostrum and mature human milk over the lactation period--a cross-sectional study

Vitamin K was quantitated in the milk of four groups of 15 mothers from 1 d to 6 mo postpartum in a cross-sectional study. Concentrations were 7.52 +/- 5.90 and 6.36 +/- 5.32 nmol/L (3.39 +/- 2.66 and 2.87 +/- 2.40 micrograms/L) in colostrum and mature milk, respectively. Differences between colostrum and mature milk or among samples of mature milk collected at 1, 3, and 6 mo were not statistically significant. Because of significantly increased volumes of milk over the lactation period, approximately twice as much vitamin K was delivered in mature milk as in colostrum. Within normal ranges, concentrations of vitamin K in milk were not predicted by dietary intake of vegetables or fat. Vitamin K was correlated with fat in colostrum and was localized in the lipid core of the milk fat globule but was not associated with membranes. Vitamin K in human milk is insufficient to meet recommended intakes for infants aged less than 6 mo. Population and clinical studies are needed to assess the vitamin K status of exclusively breast-fed infants and to evaluate current recommendations.     

Elective transplant pneumonectomy in a 38-year-old man.

Transplant pneumonectomy is a rarely performed procedure. It is occasionally carried out in the course of retransplantation. To our knowledge, resection of a transplanted lung without its replacement and with successful outcome in the adult has not been previously reported. We present a case of elective left transplant pneumonectomy in a 38-year-old man 6 years after left single-lung transplant. At 12 months after resection, the patient remains well, with good exercise tolerance.     

Shoulder instability: impact of glenohumeral arthrotomography on treatment

We used arthrotomography to study the glenoid labrum in 114 patients. Sixty-nine of the patients had anatomic instability of the shoulder (including recurrent dislocation and subluxation of the shoulder), and 45 patients had functional instability of the shoulder (denoted by chronic pain, clicking of the joint, and the sensation that an unstable condition exists without the objective signs of it). Labral tears were revealed arthrotomographically in 86% of the patients with anatomic instability, while only 40% of the patients with functional instability had labral abnormalities, and these were primarily of minor severity. Fifty-six patients (44 of whom had anatomic instability; 12, functional instability) required surgery. The surgical findings were correlated with the arthrotomographic findings, and no false-positive results were revealed. However, arthrotomography demonstrated only part of the pathologic condition of two patients. These results confirm that there is a strong correlation between labral pathologic conditions and anatomic instability of the shoulder. Arthrotomographic studies have a great impact on the selection of therapy in cases of both anatomic and functional instability of the shoulder.     

A comparison of acceleromyography and mechanomyography for determination of the dose–response curve of rocuronium in children

In order to compare an acceleromyograph (TOF-Guard^TM) with a mechanomyograph (Grass FT03), the dose–response relationship of rocuronium was simultaneously determined in both arms of 15 children aged 3–11 years during anaesthesia with thiopentone, alfentanil and nitrous oxide. Three subgroups of five children received rocuronium 120, 180 or 240 μg.kg⁻¹ randomly. The effective doses to produce 50% and 95% depression of the first twitch of the train-of-four determined by acceleromyography were 206 and 337 μg.kg⁻¹, respectively, while these values determined by mechanomyography were 151 and 331 μg.kg⁻¹, respectively. The dose–response curve obtained by acceleromyography was steeper and shifted to the right compared with that obtained by mechanomyography (p < 0.0001). The difference between the effective dose producing 50% twitch depression determined by the two devices was highly significant (p < 0.0001). In 13 out of 15 children, the acceleromyograph control train-of-four ratio was significantly greater than unity. Although there was a good correlation ( r  = 0.85) between simultaneous pairs of measurements of neuromuscular block, the acceleromyograph exhibited a bias of −25% relative to the mechanomyograph with wide limits of agreement (−62 to +12%). We conclude that acceleromyographic and mechanomyographic measurements should not be used interchangeably when determining the potency of muscle relaxants.     

THERAPEUTIC PROGRESS IN INTENSIVE CARE SEDATION AND ANALGESIA PART II—DRUG SELECTION

In part I of this review the principles governing the uses of analgesics and sedatives in the ITU were considered. In part II we shall review the drugs available considering first, symptomatic therapy and secondly, regional analgesia.     

Milk production by mothers of premature infants: influence of cigarette smoking.

The volume of milk produced by mothers who smoked cigarettes (n = 11) and control subjects who did not smoke (n = 29) was compared after the delivery of their preterm infants (28 to 32 weeks gestation). Milk production was significantly less among those who smoked, with or without adjusting for age, race, parity, gravidity, weight-for-height, prior nursing experience, customary alcohol and caffeine intake, infant birth weight, and pumping frequency. Each mother maintained her milk production using an electrical breast pump and without the stimulus of her infant suckling at the breast. Daily frequency and duration of breast pump usage were similar in the two groups. At 2 weeks postpartum, 24-hour milk volumes were 406 +/- 262 mL for mothers who smoked and 514 +/- 338 mL for control subjects. Between 2 to 4 weeks postpartum, the mean change in 24-hour milk volume (milliliters per 24 hours) of control subjects increased (+113 +/- 179 mL, P < .005), whereas milk volume of mothers who smoked cigarettes remained unchanged (-47 +/- 122 mL, P = .25). The percentage change in milk volume between 2 and 4 weeks for the combined groups was significantly related to four factors: pumping frequency, change in daily pumping frequency, day of initiation of pumping, and smoking status. Total and protein nitrogen, lactose, calcium, and phosphorous concentrations did not differ in milks from mothers who smoked cigarettes and mothers who did not smoke.(ABSTRACT TRUNCATED AT 250 WORDS)     

Genetic polymorphism in the 3' ntranslated region of human phosphoglucomutase-1

A 317-bp segment of DNA from the 3' region of the human phosphoglucomutase-1 (PGMl) gene has been examined by a non-radioactive technique for the occurrence of single-strand conformation polymorphism (SSCP), Eight phenotypes were detected and attributed to the presence of four alleles. Genetic analysis of 75 unrelated individuals and six CEPH families whose PGMl protein phenotypes were known revealed strong association between the PGMl '+' and '−' isozyme phenotypes and the variation detected in this region, but no association with the PGMl 1 and PGMl 2 isozyme phenotypes. DNA sequence analysis demonstrated the presence of three nucleotide substitutions underlying the alleles, which were located in the untranslated region of the PGMl gene. There was complete correlation between the nucleotide sequence and the phenotype detected by SSCP analysis. This study provides support for the model that the PGMl isozyme polymorphism is determined at two distinct sites in the coding sequence, one coding for the '1' and '2' alleles and the other coding for the '+' and '−' alleles, separated by a region where intragenic recombination occurs.