Maternal fever at parturition and its effects on the newborn rabbit

The febrile response to administration of endotoxin has been reported to be suppressed in both pregnant animals at term and in their newborn. In a previous study we found that newborn rabbits under appropriate conditions to develop a febrile reaction to injected endotoxin. In this investigation we sought to discover whether pregnant rabbits at term had a febrile response to endotoxin, and if so, its effect on thermoregulation in their newborn. Endotoxin (E. Coli LPS) was injected into 19 pregnant rabbits at term. Six delivered spontaneously within an hour. At one hour, 13 were given oxytocin, and a further 8 delivered within five minutes. The colonic temperature (Tc) of the mothers before endotoxin administration and at delivery, and of their young, was measured. The results were compared with those of 10 pregnant rabbits not given endotoxin, and their young. Within 15 min of delivery newborn rabbits from each litter were placed on a thermal gradient to assess their thermoregulatory responses. Pregnant rabbits at term developed an impressive febrile response to injected endotoxin and their young were born with high colonic temperatures. Newborn rabbits from febrile mothers selected higher thermal environments and maintained a higher colonic temperature than the newborn of non-febrile mothers. We conclude that fever is sustained in the first hours of life in the newborn of mothers injected with endotoxin. The possible mechanisms are of considerable interest. None of the pregnant rabbits died after endotoxin administration, but the stillbirth rate was 50% compared with 10% in non-febrile does.

Liver transplantation for acute fulminant hepatic failure

Orthotopic liver transplantation (OLT) remains the only option for progressive acute fulminant hepatic failure (FHF). The overall one-year survival is approximately 58% versus 75% for all patients undergoing OLT. Nevertheless, this is superior to the results obtained with medical management alone, which carries a mortality of approximately 60-85%. Seven of 32 patients at Hartford Hospital (22%) received liver transplants for acute FHF; the one-year survival was 57%. Four of seven patients are alive with complete neurologic recovery. One case is presented in detail.

Evaluation of techniques for delivery of steroids to lungs of neonates using a rabbit model

Little is known about delivery of aerosolised steroids to neonatal patients undergoing assisted positive pressure ventilation and after extubation. A rabbit model has been established to investigate factors influencing drug delivery. Beclomethasone dipropionate, in a metered dose inhaler, was radiolabelled with technetium 99m. The mass median aerodynamic diameter of the aerosol was 3.3 (2.0) microns and the impactor measurements confirmed that the technetium distribution corresponded with that of the drug particles. The metered dose inhaler was actuated into a collapsible spacer that was used to ventilate and deliver aerosol to anaesthetised rabbits by a tracheostomy. From each actuation of the drug 2.9 (0.4)% of the aerosol deposited in the trachea and main bronchi and 1.2 (0.4)% in the lung. When the drug was delivered by a spacer device, with face-mask attachment, to rabbits breathing freely through a tracheostomy, aerosol deposition increased to 4.4 (2.1)% in the trachea and main bronchi and 1.9 (0.9)% in the lung lobes. The maximum change in systolic blood pressure after administration of aerosol by the collapsible spacer was a decrease of 13%. The methods described may prove useful for the delivery of inhaled steroids to neonatal patients likely to develop bronchopulmonary dysplasia.

Gastroplasty for Morbid Obesity after Cardiac and Renal Transplantation

The success of vertical banded gastroplasty (VBG) in the obese transplanted population is measured by a low operative morbidity and mortality in the context of a good record of permanent weight loss and an enhanced quality of life. Selection of transplanted patients for gastroplasty should be guided by the prevailing standards for the general population. VBG is the procedure of choice because of proven efficacy and has the benefit over gastric bypass of not producing malabsorption. The operation causes early satiety while allowing consistent absorption of immunosuppressive medication from the upper gastrointestinal tract, essential in these patients. This risk of hypertension, diabetes mellitus, hyperlipidemia, and immunosuppressive medication toxicity may be decreased by substantial long-term weight loss afforded morbidly obese transplant patients by gastric restrictive surgery. Cardiac risk factors associated with morbid obesity and immunosuppressive therapy are lessened with sustained weight reduction.

D-Lactate associated encephalopathy in short bowel syndrome: management with long-term non-absorbable oral antimicrobials

We describe a child with short bowel syndrome consequent upon jejunal atresia who developed recurrent episodes of D-Lactate associated encephalopathy. Three species of lactobacillus were isolated from the stool, each sensitive to neomycin. Oral neomycin administration resulted in rapid relief of all symptoms. Cessation of the neomycin on two occasions led to recurrent encephalopathic episodes which quickly resolved with recommencement of treatment. We discuss the possible aetiologies of this encephalopathy syndrome and the therapeutic options.

A dose ranging study of ibuprofen suspension as an antipyretic

A double blind trial was conducted to determine the dose of ibuprofen suspension, which is effective in reducing the body temperature. The principal measure of efficacy was a reduction in axillary temperature of 1 degree C or more three hours after dosing. A second objective of the trial was to compare the incidence and severity of side effects and the palatability of a range of ibuprofen doses. Ninety three children were included in the analysis. All four doses of ibuprofen studied (0.625 mg/kg-5 mg/kg) were associated with temperature reduction and only the lowest dose failed to satisfy the principal measure of efficacy. The influence of dose on the magnitude of the body temperature reduction was significant and the 5 mg/kg dose achieved the largest mean reduction in body temperature (2 degrees C). The tolerability and palatability of all doses studied were excellent. These findings suggest that ibuprofen is a good alternative to paracetamol as an antipyretic.

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Effects of altering umbilical flow and umbilical free fatty acid concentration on transfer of free fatty acids across the rabbit placenta

The transfer of free fatty acids across the placenta perfused in situ was studied in anaesthetized rabbits in late gestation. In the first series of experiments, umbilical flow rate was varied between 0.6 and 4.0 ml/min in nine rabbits. Although increasing umbilical flow rate significantly decreased the free fatty acid concentration in the umbilical venous effluent (P = 0.0001), placental clearance of free fatty acids from the maternal circulation was not significantly changed by alterations in umbilical flow rate. In the second series of experiments, the materno-fetal free fatty acid concentration gradient was varied between + 1.58 mmol/l and -2.81 mmol/l in eight rabbits. There was a significant relationship between increasing materno-fetal gradient and increasing transfer of free fatty acids across the placenta (P less than 0.001). Moreover, net transfer of free fatty acids into the umbilical circulation was observed even with zero concentration gradient. Net transfer of free fatty acids from fetus to mother occurred when umbilical arterial free fatty acid concentration exceeded maternal arterial concentration by 1.3 mmol/l.

Maternal and umbilical venous plasma lipid concentrations at delivery in the mare

The concentrations and fatty acid composition of the plasma free fatty acid, triacylglycerol and phospholipid fractions were determined in maternal and umbilical cord vein blood samples taken at delivery from 17 mares. Maternal and umbilical vein plasma free fatty acid concentrations were of a similar order and a positive correlation was found between the two levels suggesting that the equine placenta is permeable to fatty acid. Substantial amounts of the essential fatty acids and their longer chain derivatives were seen in both umbilical vein plasma free fatty acid and phospholipid fractions supporting this view. Certain long chain polyunsaturated derivatives of the essential fatty acids found in the umbilical venous plasma phospholipid fraction were not seen in the maternal circulating lipids. The precursor fatty acids were readily available to both foetal and placental tissues and therefore must have been elongated and incorporated into phospholipid by either or both. Very small amounts of the essential fatty acids were found in adipose stores in the newborn foal and virtually no fat stores at all in the newborn foal liver.

A randomised single blind trial of a combined mumps measles rubella vaccine to evaluate serological response and reactions in the UK population

Four hundred and twenty children were randomly assigned to receive either mumps measles rubella (MMR) vaccine (207) or measles vaccine (213) in a single blind study, to investigate the reactogenicity and serology of the MMR vaccine. There was no significant difference between the number of children developing symptoms after MMR vaccination to those developing symptoms after measles vaccination. Both vaccines are associated with a rash, temperature and restlessness five to thirteen days after vaccination. The serological response to measles vaccine was similar in both groups with 92-6% seroconverting with MMR, and 96-8% with measles. Seroconvertion against mumps and rubella with the MMR vaccine was 88% and 96% respectively. This study confirms the safety and efficacy of the MMR vaccine in a UK population.

Liver transplant for metastatic neuroendocrine tumor

Generally, the results of liver transplantation for metastatic liver disease have not been favorable. One exception has been the unique group of neuroendocrine tumors, the slow growth of which allows liver transplantation to effectively palliate and control symptoms. We report two cases: (a) A 51-year-old man who underwent orthotopic liver transplantation and resection of the pancreatic primary tumor for a nonfunctioning malignant neuroendocrine tumor with features of both carcinoid and islet-cell glucagonoma remains symptom-free and without evidence of tumor recurrence at 13 months follow-up. (b) A 47-year-old man who underwent orthotopic liver transplantation and Whipple resection for a metastatic islet-cell tumor in the head of the pancreas is fully recovered at 5 months follow-up.

D(+)-glyceric aciduria: etiology and clinical consequences

A family comprising mother, father, and five children is described. Four of the children were found to excrete massive amounts of D(+)-glyceric acid in their urine. This was verified by gas chromatography-mass spectrometry and the configuration determined by capillary gas chromatography of O-acetylated menthyl esters. The excretion ranged from 10.8 to 19.9 mmol/24 h. The remaining child and the parents showed no evidence of this unusual metabolite. The virtual absence of clinical manifestations in this family was particularly interesting. Only two of the children showed any clinical abnormality and this was limited to mild microcephaly and speech delay; the other two children found to excrete large amounts of D(+)-glycerate were healthy and developmentally normal at 7 y and 9 y of age. There was a marked increase in the excretion rate of D(+)-glycerate in response to both oral fructose and serine loading. These results are consistent with a deficiency of D(+)-glycerate kinase and indicate the potentially benign nature of this disorder.

Maternal to fetal transfer of free fatty acids in the in situ perfused rabbit placenta

The transfer of free fatty acids (FFA) across the placenta perfused in situ was studied in anaesthetised rabbits in late gestation. [14C]Palmitic acid and antipyrine were infused into 11 pregnant rabbits and samples collected for up to 90 min from the mother and the umbilical vessels. Levels of total FFA, radioactivity and antipyrine, a marker of placental integrity, were measured. Net FFA flux across the placenta increased with maternal FFA concentrations, confirming observations made using different methods. The specific activity of [14C]palmitic acid in perfusate also related to maternal levels and indicated that almost half of the FFA crossing the rabbit placenta must be derived from sources other than circulating maternal FFA. The composition of the perfusate FFA had a profile similar to that of circulating maternal FFA, except for an increase in a number of long chain, polyunsaturated fatty acids. These findings are consistent with maternal triacylglycerol as the other fatty acid source, with the placenta adding the longer chain, polyunsaturated fatty acids.

Noncompliance in organ transplant recipients

Noncompliance with medication and follow-up care was evaluated in 538 renal, 50 heart, and 13 liver transplant recipients. In a retrospective review of 260 kidney transplant recipients followed from three months posttransplant, the incidence of medication noncompliance was 18%. It was 15% in a prospective study of 196 kidney recipients from 1984 to 1987. Patients most likely to become noncompliant were young and in a lower socioeconomic group. There was no significant difference in the incidence of noncompliance with respect to cadaveric vs. living-related donor kidney source, or in male vs. female patients. There was a higher incidence of noncompliance in blacks and Hispanics, but that may have been due to a higher incidence of lower socioeconomic status in those groups. Noncompliance can occur many years posttransplant and was seen in heart and liver transplant recipients. In the retrospective study, 91% of kidney transplant recipients who were noncompliant with medications and follow-up care either lost their grafts or died. Noncompliant behavior was usually not predictable and was often without an identifiable reason. Efforts to increase compliance, such as better patient selection, more education, and simplified medical regimens may have reduced the incidence of noncompliance in recent patients.