An audit of the organisation of neonatal screening for phenylketonuria and congenital hypothyroidism in the Northern Region

BACKGROUND

The objectives of the study were to identify whether all districts in the Northern Region had a system in place to ensure that all resident babies were being screened for phenylketonuria and congenital hypothyroidism and to identify potential delays which could influence whether a result was available on all residents before 28 days of age.

METHODS

Lead professionals involved in the screening programmes were interviewed in 1993 in all 16 districts. Recommendations for improving the service were made to each district. Six months later a follow up telephone interview with the doctor involved in the screening programmes was undertaken to identify the changes that had been made in the service.

RESULTS

In 1993 three districts made no attempt to match neonatal screening results to birth notifications. Of the 13 districts that undertook matching, two districts did no further checks to identify babies without a result and five districts undertook a check on a monthly basis only. Only six districts were, therefore, found to have a timely fail-safe system for checking that results were available for resident babies. In 1994, following recommendations to improve the timeliness and completeness of the screening programmes, all districts except two had improved their fail-safe systems.

CONCLUSION

This multi-disciplinary regional audit resulted in organisational improvements to the neonatal metabolic screening programmes in the Northern Region.

Fine needle aspiration cytology of an ectopic parathyroid adenoma: a case report

BACKGROUND

Surgical exploration in the region of the neck identifies a majority of parathyroid adenomas; however, in individuals in whom surgical exploration has failed, fine needle aspiration (FNA) biopsy can be useful. Ectopic parathyroid adenomas can be rapidly diagnosed by the cytologic appearance of aspirate smears with the identification of stromal and intracellular lipid on oil red O-stained smears.

CASE

A 59-year-old male presented with hyperparathyroidism; surgical exploration of the neck in the region of the thyroid gland failed to identify any parathyroid abnormality. Subsequent imaging with (99m)technetium and (201)thallium showed a mass in the left supraclavicular region that, on FNA biopsy, was confirmed as an ectopic adenoma. Removal of the adenoma resulted in normal serum calcium levels.

CONCLUSION

FNA can be successfully utilized in the localization of ectopic parathyroid tissue.

Perioperative morbidity and mortality in combined vs. staged approaches to carotid and coronary revascularization

Between 1986 and 1994 we identified 57 patients who underwent carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) during the same hospitalization. Simultaneous CABG and CEA was performed in 28 patients (mean age 70.5 years, 58% male). Indications for CABG in these patients were myocardial infarction in two crescendo angina in 19, congestive heart failure in two and left main or triple-vessel coronary artery disease noted during carotid preoperative evaluation in five. Indications for CEA were transient ischemic attack (TIA) in 12, crescendo TIA in six, cerebrovascular accident (CVA) in five, and asymptomatic stenosis in five. There were no postoperative myocardial infarctions or perioperative deaths. Two patients developed atrial fibrillation, and four patients had CVAs (two were ipsilateral to the side of CEA). Twenty-nine patients underwent staged procedures (i.e., not performed concomitantly but during the same hospitalization). Indications for CABG and CEA were comparable to those in the group undergoing simultaneous procedures. In 17 patients CEA was performed before CABG. There was a single CVA, the result of an intracerebral hemorrhage. Five of the 17 patients had a myocardial infarction and two died; one patient had first-degree heart block requiring a pacemaker. Four additional patients developed atrial fibrillation, one of whom required cardioversion. The remaining 12 patients had CABG followed by CEA. There were no CVAs, myocardial infarctions, arrhythmias, or deaths in this subgroup. These data demonstrate that the performance of simultaneous CABG and CEA procedures is associated with increased neurologic morbidity (14.3%), both ipsilateral and contralateral to the side of carotid surgery in contrast to staged CABG and CEA (3.4%). In addition, when staged carotid surgery preceded coronary revascularization in those with severe coronary artery disease, the combined cardiac complication and mortality rate was significantly higher than when coronary revascularization preceded CEA. This evidence suggests that when CABG and CEA must be performed during the same hospitalization, the procedures should be staged with CABG preceding CEA.

An outbreak of group C streptococcal infection in a maternity unit

An outbreak of Group C streptococcal infection (Streptococcus equisimilis serotype T204) occurred in a Maternity Unit in Durham over a 2-week period. The outbreak strain possessed an M-protein antigen identical to that found in a previously reported Maternity Unit outbreak. Seven patients in total were affected, and in two patients infected perineal wounds took several weeks to heal. The source of the outbreak appeared to be a patient who developed a perineal wound infection and who subsequently returned to the ward for reassessment. Environmental contamination is likely to have been the reservoir of infection for the subsequent patients. The outbreak was controlled by applying strict infection control procedures and establishing a high standard of routine cleaning.

An out-patient nutritional supplementation programme in COPD patients

Studies that have assessed the role of nutritional supplementation in patients with emphysematous chronic obstructive pulmonary disease (COPD) have shown conflicting results. Improved respiratory muscle strength and exercise capacity have been demonstrated following intensive and costly nutritional support programmes under controlled conditions. We have evaluated a simple programme of out-patient nutritional support in a clinical setting. Twelve malnourished COPD patients (9 male and 3 female; mean age 66 yrs; < 90% ideal body weight) were studied. Forced vital capacity (FVC), forced expiratory volume in one second (FEV1), estimation of maximal oxygen uptake (VO2max) during exercise, respiratory muscle strength (PImax and PEmax), and measurement of body weight, height, triceps skinfold thickness, and mid-arm muscle circumference were performed before and after a 4 month period of out-patient nutritional support. Patients were advised by a dietician on increasing their daily caloric intake by a minimum of 50% above estimated daily energy expenditure. Three patients withdrew from the study. The mean increase in body weight in the nine remaining patients after 4 months of supplementation was 0.3 kg. There was no significant improvement in the anthropometric measures, lung function, respiratory muscle strength or VO2max for the group as a whole. Three patients who gained more than 1 kg weight were from a higher socioeconomic background compared with those who failed to do so. We conclude that achieving weight gain and improving lung function by means of simple out-patient nutritional programmes in a clinical setting is difficult.

Cell-mediated and humoral immune responses induced by scarification vaccination of human volunteers with a new lot of the live vaccine strain of Francisella tularensis

Tularemia is a disease caused by the facultative intracellular bacterium Francisella tularensis. We evaluated a new lot of live F. tularensis vaccine for its immunogenicity in human volunteers. Scarification vaccination induced humoral and cell-mediated immune responses. Indications of a positive immune response after vaccination included an increase in specific antibody levels, which were measured by enzyme-linked immunosorbent and immunoblot assays, and the ability of peripheral blood lymphocytes to respond to whole F. tularensis bacteria as recall antigens. Vaccination caused a significant rise (P less than 0.05) in immunoglobulin A (IgA), IgG, and IgM titers. Lymphocyte stimulation indices were significantly increased (P less than 0.01) in vaccinees 14 days after vaccination. These data verify that this new lot of live F. tularensis vaccine is immunogenic.

Penicillin-resistant pneumococci in a Merseyside hospital

Strains of Streptococcus pneumoniae (N = 915) from clinical specimens were examined for penicillin resistance over a 2-year period. The prevalence of resistance [minimum inhibitory concentration (MIC) greater than 0.1 mg l-1] increased from 1.4 to 2.5% per year during this time. In addition, 83% of penicillin-resistant pneumococci (PRP) showed resistance to chloramphenicol. Most PRP were isolated from uninfected children colonized with the organism, but two out of the three adult cases were clinically infected, one by cross-infection between in-patients. In only two cases was there an association with foreign travel. Three children showed prolonged carriage providing a potential reservoir of infection for other members of the community. The percentage of strains showing high level resistance (MIC greater than 1 mg l-1) increased from 0.7% to 1.9% of all isolates during the 2-year study period. This high prevalence of high level resistance has not been reported previously in the UK and if the trend continues, it will have serious implications for the management of invasive pneumococcal infection, particularly meningitis.

Stature loss among an older United States population and its relation to bone mineral status

Age-related statural loss has been recorded but incompletely assessed in modern populations. In this study, data collected on stature during annual bone mineral assessments are analyzed for 1,024 Caucasian individuals from southern Arizona. Continued stabilization in reported maximum heights is seen in this population. With advancing age there is a gradual decrease in height apparently beginning in the mid-40s. Thereafter, there is a relatively rapid decrease in measured height. This contrasts to the much slower rates predicted from earlier populations (Trotter and Gleser: American Journal of Physical Anthropology 9:311-324, 1951). The rate of stature loss is associated with diminution of bone mineral density as well as with maximum height. Since there are suggestions of a secular trend toward greater reductions in bone mineral density, this study suggests there may be a secular trend toward an increase in statural loss with age.

Antibody coated bacteria in urine of patients with recent spinal injury

Twenty patients with an acute spinal injury were prospectively studied to assess the clinical importance of antibody coated bacteria (ACB) in the urine and the association among the different bacterial species with a positive antibody coated bacteria test. Clinical urinary tract infection was associated with a positive ACB test on 45% of occasions. Three hundred and ninety nine urine samples containing 541 bacterial isolates were assessed for the presence of ACB; 13% were found to be positive and 87% negative for ACB; 67% of urines contained a single bacterial isolate. Pseudomonas aeruginosa was most commonly associated with clinical urinary tract infection, found in 25% of episodes, followed by Proteus mirabilis (17.5%), Klebsiella sp (12.5%), and Proteus morganii (10%). Providencia stuartii, however, was most commonly associated with a positive ACB test (found in 17%). Other bacteria associated with a positive ACB test included Klebsiella sp (14%), Acinetobacter sp (12.5%), Pseudomonas aeruginosa (12%), Citrobacter sp (11.5%). A positive ACB test is not to be expected from a patient with spinal injury who has a catheter in place, and the test may provide a useful guide to identify those patients with an invasive infection. It is doubtful that a decision to treat or not treat bacteriuria could rest on the identification of the bacterial species alone.

Magnesium deficiency in patients on home enteral nutrition

Home enteral nutrition (HEN) is an established method of long term nutritional support. Many patients receiving HEN have Crohn's disease complicated by intestinal failure and malnutrition, including magnesium deficiency. It is unknown if HEN can correct magnesium deficiency or if patients on HEN can become magnesium deficient. We measured total magnesium intake in nine patients receiving HEN, and assessed their magnesium status. Two patients had magnesium intakes below the recommended dietary allowance of 15 mmol/day. Four patients (44%) had biochemical evidence of magnesium deficiency, although no patient had clinical signs of magnesium deficiency. Several magnesium deficient patients used a liquid feed which had a low magnesium content. Patients on HEN should have their magnesium status checked regularly and may require magnesium supplements.

The effect of ventilation on aortic blood gases during left ventricular ejection before separation from cardiopulmonary bypass

The time to begin ventilating a cardiac surgical patient recovering from hyperkalemic arrest is controversial. Those who advocate ventilating as soon as the left ventricle begins to eject believe that blood ejected from the left ventricle is likely to be hypoxic since it perfuses collapsed, nonventilated alveoli and that this may be the major blood supply perfusing the coronary arteries. The present study attempts to answer this question by sampling blood gases from the aorta in proximity to the coronary ostia in patients both before and after ventilation. Ten patients undergoing coronary artery bypass grafting using the left internal mammary artery were studied. Each patient served as his own control. Distal anastomoses were placed under hyperkalemic, hypothermic cardiac arrest. The aorta was unclamped, and an intrinsic or paced heart rate of 70 beats per minute was achieved. The heart was allowed to eject to a pulse pressure of 20 to 40 mmHg. Rectal temperatures were between 32 degrees C and 34 degrees C. Blood gases were drawn simultaneously from the proximal aortic root, radial artery, pulmonary artery, and the venous circuit of the cardiopulmonary bypass (CPB) machine. The lungs were then twice inflated with a sustained positive pressure of 30 cm H2O, and the patient was ventilated (10 mL/kg tidal volume, FIO2 1.0, 10 breaths per minute) for two minutes. Another set of blood gases was then obtained. Filling pressures, aortic systolic and diastolic pressures, and CPB flows were kept constant for both sets of samples. There was no significant difference in aortic root PaO2 attributable to ventilation. PCO2 was significantly lower, and pH was significantly higher in the ventilated group.(ABSTRACT TRUNCATED AT 250 WORDS)

Decay rates of human remains in an arid environment

The environment of southern Arizona with mild winters and hot, dry summers produces great variability in decay rates of human remains. Summer temperatures, which range well over 38 degrees C (100 degrees F), induce rapid bloating as a result of the accumulation of decompositional gases. However, in certain circumstances, the aridity can lead to extensive mummification, allowing preservation of remains for hundreds of years. A retrospective study of 189 cases, concentrating on remains found on the desert floor or in the surrounding mountains and on remains found within closed structures, outlines the time frame and sequences of the decay process. Remains can retain a fresh appearance for a considerable time in the winter, but the onset of marked decomposition is rapid in the summer months. Bloating of the body usually is present two to seven days following death. Following this, within structures, there is frequently rapid decomposition and skeletonization. With outdoor exposure, remains are more likely to pass through a long period of dehydration of outer tissues, mummification, and reduction of desiccated tissue. Exposure of large portions of the skeleton usually does not occur until four to six months after death. Bleaching and exfoliation of bone--the beginning stages of destruction of the skeletal elements--begins at about nine months' exposure. Insect activity, including that of maggot and beetle varieties, may accelerate decomposition, but this process is greatly affected by location of the body, seasonal weather, and accessibility of the soft tissues. Carnivores and other scavengers also are contributing factors, as are clothing or covering of the body, substrate, elevation, and latitude.

Estimating actual height in the older individual

The widely used formulas for estimating adult stature require modification of the estimated height to account for the effects of age. The recording of measured and reported height in a living older population from southern Arizona, in conjunction with bone mineralization monitoring, provides an opportunity to test the currently used correction factor. Loss of height appears to commence around the age of 45, and the average rate of loss is relatively rapid at 0.16 cm per year. The correction factor suggested by this study is 0.16(age--45), subtracted from the maximum height. The loss is also affected by the maximum height of the individual. In cases of low bone mineralization, the increased incidence of vertebral crush fractures may cause further reductions in standing height. The low rate of recognition of height changes among the older community lowers the usefulness of the age adjusted height estimate. It is recommended that both the maximum and age adjusted heights be provided in forensic science reports to aid in matching with missing person reports.