Sonographic prevalence of acquired cystic renal disease in patients receiving haemodialysis

OBJECTIVE

To determine the sonographic prevalence of Acquired Cystic Renal Disease (ACRD) in patients on maintenance haemodialysis and its relationship to the duration on dialysis.

METHODS

All patients with end stage renal disease (ESRD) who were receiving maintenance haemodialysis in Urology Department of Mayo Hospital Lahore between November 1997 to February 1998 were screened by ultrasound for the prevalence of ACRD.

RESULTS

Forty patients with ESRD on maintenance haemodialysis were evaluated. The mean age of patients was 39.9 years. The male to female ratio was 2.3:1. Four patients (10%) had documented ACRD. The proportion of patients with ACRD increased with increasing duration of dialysis; ACRD was found in 60% of patients who had dialysis for more than 3 years, 20% in those who had been dialyzed for 1-3 years, and no patient developed ACRD who was on dialysis for less than one year. All patients remained asymptomatic except one, who had intermittent macroscopic haematuria. There was no evidence of neoplasm in any of these patients on clinical grounds or on ultrasound.

CONCLUSION

We found a low prevalence of ACRD in the population studied compared to previously published series. This can be explained by the fact that most of our patients were on dialysis for less than one year. A further study is suggested with greater numbers in a center where patient stay on dialysis for longer period and patient turnover is low.

Comparison of fentanyl and nalbuphine in total intravenous anaesthesia (TIVA)

OBJECTIVE

To compare Nalbuphine and fentanyl as total intravenous anaesthesia with propofol infusion in laproscopic cholecystectomy cases.

STUDY DESIGN

Double blind randomised.

METHODS

Changes in haemodynamic variables greater than twenty percent above or below the baseline and recovery profile were observed.

RESULTS

Blood pressure remained within 20% of baseline in either group. Nine patients in fentanyl and fifteen in nalbuphine group required an additional bolus of propofol intraoperatively. Heart rate response after tracheal intubation was significantly higher in the nalbuphine group (25%). No difference was observed in the incidence of nausea and vomiting in the recovery room. Twenty-seven percent patients in the nalbuphine group required analgesia in the recovery in comparison to 87% in the fentanyl group. Patients in the fentanyl group required analgesia earlier (37 minutes vs. 62 minutes).

CONCLUSION

Fentanyl provided better intraoperative haemodynamic stability in comparison to nalbuphine when used as the analgesic component in total intravenous anaesthesia with propofol. The recovery profile with both drugs was similar. Lesser number of patients required analgesia in the recovery in the nalbuphine group.

Effect of age on haemodynamic response to tracheal intubation. A comparison of young, middle-aged and elderly patients

The effect of age on the haemodynamic response to tracheal intubation was studied. Ninety ASA 1 or 2 patients were divided into three groups of 30 each based on age; ie., young (18-25 years), middle-aged (40-50 years) and elderly (65-80 years). The haemodynamic response after tracheal intubation was observed as percentage change in heart rate and blood pressure compared to the baseline. Inter-group comparison was also done at different time points. The greatest percentage change in the systolic arterial pressure after tracheal tube insertion was seen in the elderly group (15%). The increase in systolic arterial pressure was significantly less in theyounggroup compared with the two older groups at one, two, three and four minutes post-intubation. The greatest percentage increase in the diastolic blood pressure compared to the baseline was seen in the middle aged group (24%). The elderly and young patients showed a significant difference in the diastolic blood pressure response only at one minute post-intubation. The heart rate response was greatest in the middle-aged patients (40%) and least in the elderly (16%). These differences may have clinical significance and should be considered in assessing and performing research into the haemodynamic response to intubation.

Calcium-activated K+ channels of mouse beta-cells are controlled by both store and cytoplasmic Ca2+: experimental and theoretical studies

A novel calcium-dependent potassium current (K(slow)) that slowly activates in response to a simulated islet burst was identified recently in mouse pancreatic beta-cells (Göpel, S.O., T. Kanno, S. Barg, L. Eliasson, J. Galvanovskis, E. Renström, and P. Rorsman. 1999. J. Gen. Physiol. 114:759-769). K(slow) activation may help terminate the cyclic bursts of Ca(2+)-dependent action potentials that drive Ca(2+) influx and insulin secretion in beta-cells. Here, we report that when [Ca(2+)](i) handling was disrupted by blocking Ca(2+) uptake into the ER with two separate agents reported to block the sarco/endoplasmic calcium ATPase (SERCA), thapsigargin (1-5 microM) or insulin (200 nM), K(slow) was transiently potentiated and then inhibited. K(slow) amplitude could also be inhibited by increasing extracellular glucose concentration from 5 to 10 mM. The biphasic modulation of K(slow) by SERCA blockers could not be explained by a minimal mathematical model in which [Ca(2+)](i) is divided between two compartments, the cytosol and the ER, and K(slow) activation mirrors changes in cytosolic calcium induced by the burst protocol. However, the experimental findings were reproduced by a model in which K(slow) activation is mediated by a localized pool of [Ca(2+)] in a subspace located between the ER and the plasma membrane. In this model, the subspace [Ca(2+)] follows changes in cytosolic [Ca(2+)] but with a gradient that reflects Ca(2+) efflux from the ER. Slow modulation of this gradient as the ER empties and fills may enhance the role of K(slow) and [Ca(2+)] handling in influencing beta-cell electrical activity and insulin secretion.

Ciliary dyskinesia associated with hydrocephalus and mental retardation in a Jordanian family

OBJECTIVE

To describe the presentation and genetic transmission of ciliary dyskinesia syndrome associated with hydrocephalus and mental retardation in 3 generations of a family.

PATIENTS AND METHODS

A large Jordanian family included 9 individuals in 3 generations with recurrent pulmonary infections; 4 male siblings have been diagnosed as having mental retardation, and a maternal uncle was believed to have been similarly affected. Chromosome analysis of the family showed a normal karyotype.

RESULTS

Electron microscopy of the nasal cilia from 3 affected siblings showed features of primary ciliary dyskinesia. Computed tomographic scans of the brains of all 4 affected siblings showed hydrocephalus.

CONCLUSIONS

The recurrent pulmonary infections and hydrocephalus in this large Jordanian family are likely related to ciliary dyskinesia, which appears to follow an autosomal recessive mode of inheritance. The unusual presentation of ciliary dyskinesia, hydrocephalus, and mental retardation may be due to a new genetic mutation.

Insulin activates ATP-sensitive K(+) channels in pancreatic beta-cells through a phosphatidylinositol 3-kinase-dependent pathway

Insulin is known to regulate pancreatic beta-cell function through the activation of cell surface insulin receptors, phosphorylation of insulin receptor substrate (IRS)-1 and -2, and activation of phosphatidylinositol (PI) 3-kinase. However, an acute effect of insulin in modulating beta-cell electrical activity and its underlying ionic currents has not been reported. Using the perforated patch clamp technique, we found that insulin (1-600 nmol/l) but not IGF-1 (100 nmol/l) reversibly hyperpolarized single mouse beta-cells and inhibited their electrical activity. The dose-response relationship for insulin yielded a maximal change (mean +/- SE) in membrane potential of -13.6 +/- 2.0 mV (P < 0.001) and a 50% effective dose of 25.9 +/- 0.1 nmol/l (n = 63). Exposing patched beta-cells within intact islets to 200 nmol/l insulin produced similar results, hyperpolarizing islets from -47.7 +/- 3.3 to -65.6 +/- 3.7 mV (P < 0.0001, n = 11). In single cells, insulin-induced hyperpolarization was associated with a threefold increase in whole-cell conductance from 0.6 +/- 0.1 to 1.7 +/- 0.2 nS (P < 0.001, n = 10) and a shift in the current reversal potential from -25.7 +/- 2.5 to -63.7 +/- 1.0 mV (P < 0.001 vs. control, n = 9; calculated K(+) equilibrium potential = -90 mV). The effects of insulin were reversed by tolbutamide, which decreased cell conductance to 0.5 +/- 0.1 nS and shifted the current reversal potential to -25.2 +/- 2.3 mV. Insulin-induced beta-cell hyperpolarization was sufficient to abolish intracellular calcium concentration ([Ca(2+)](i)) oscillations measured in pancreatic islets exposed to 10 mmol/l glucose. The application of 100 nmol/l wortmannin to inactivate PI 3-kinase, a key enzyme in insulin signaling, was found to reverse the effects of 100 nmol/l insulin. In cell-attached patches, single ATP-sensitive K(+) (K(ATP)) channels were activated by bath-applied insulin and subsequently inhibited by wortmannin. Our data thus demonstrate that insulin activates the K(ATP) channels of single mouse pancreatic beta-cells and islets, resulting in membrane hyperpolarization, an inhibition of electrical activity, and the abolition of [Ca(2+)](i) oscillations. We thus propose that locally released insulin might serve as a negative feedback signal within the islet under physiological conditions.

A comparison of OHIP 14 and OIDP as interviews and questionnaires

OBJECTIVE

To assess the completion rates and concurrent validity of the Oral Impacts on Daily Performance (OIDP) and the short form of the Oral Health Impact Profile (OHIP 14) in both questionnaire and interview formats.

BASIC RESEARCH DESIGN

Cross sectional social and clinical study. Clinical setting Dental teaching hospital primary care department in London UK. Participants Two week consecutive sample of 183 patients attending setting.

PARTICIPANTS

came from 19 ethnic groups, 53% were men and 32% had attended for a dental emergency.

MAIN OUTCOME MEASURES

Completion rates and concurrent validity for each instrument and in each format.

RESULTS

Completion rates for OHIP 14 and OIDP were similar in interview format. In questionnaire format usable data were provided on 92.9% of the OHIP 14 but only 86.5% of the OIDP questionnaires. Completion of both questionnaires was related to ethnicity. The number of impacts for both measures and total impact scores for OHIP 14 were related to the age of the participants, the presence of oral disease and the order of administration of the instruments. Analysis of the total score for OIDP was weakened by the severe skewness of these data.

CONCLUSIONS

The psychometric properties of OHIP 14 and OIDP were not related to the method of administration. However, the use of OIDP in this questionnaire format may result in loss of data, particularly from people who are not White English.

Neonatal lead poisoning from maternal pica behavior during pregnancy

Lead toxicity has gained increasing attention in the public media because of its ubiquitous distribution in the environment and the potentially serious medical complications that it can induce, particularly in children. We present a case of an asymptomatic Hispanic woman who exhibited a unique form of pica during her pregnancy. By serendipity, she agreed to enroll into a lead screening study at our medical center when she presented to deliver her child. Her blood lead level was 119.4 microg/dL at delivery, and simultaneous measurement of the neonate's cord blood lead level was 113.6 microg/dL. The infant underwent an exchange transfusion, and the mother was treated with oral 2,3-dimercaptosuccinic acid. Both demonstrated dramatic biochemical improvement.

Patella lead x-ray fluorescence measurements are independent of sample orientation

In vivo x-ray fluorescence bone lead measurements assess long-term lead exposure. Tibia, calcaneus, and patella are the most commonly sampled bones. Patella measurements also include lead signals from the distal femur, proximal tibia, and synovium. It is therefore important to know whether the orientation of the patella relative to the measurement system substantially affects the measured patella lead concentrations and their measurement uncertainties. This study examined whether these parameters exhibited a dependence on the orientation of the patella with respect to the measurement system, a dependence that could arise from varying nonpatella contributions. There was no effect of orientation on measured patella lead concentration, but there was a highly significant effect of orientation on the measurement uncertainty. These data do not conclusively show that there are no nonpatella contributions to a patella lead measurement; rather, that any such contributions are not a function of measurement orientation over the range of orientations considered. Further study is required if the contribution of nonpatella tissues to a patella lead XRF-measured concentration is to be fully addressed. This study also filled a gap in the literature by quantifying the within-patella (29%) and between-patella (71%) variability of measured patella lead concentrations from replicate measures of nine patellae.

Anthelmintic resistance on an organized sheep farm in India

Monitoring anthelmintic resistance in strongyle nematodes by the faecal egg count reduction test and a commercial larval development assay on an organized sheep farm in the semi-arid area of Rajasthan revealed the emergence of resistance to benzimidazoles and rafoxanide and a potential risk of the development of levamisole/tetramisole resistance. A benzimidazole/levamisole combination, avermectins and closantel were each found to be efficacious.

Comparison of spontaneous with controlled mode of ventilation in tonsillectomy

METHODS

This randomized study compares spontaneous versus controlled ventilation in 60 ASA I and II patients undergoing tonsillectomy as regards haemodynamic stability, recovery characteristics, intra- and immediate postoperative complications and surgical impressions.

RESULTS

The patients in the balanced anaesthesia (B) group showed less haemodynamic variability compared to baseline after tracheal intubation, mouth gag application and removal and incision. Two patients had dysrhythmias in the B group compared to six in the spontaneous breathing (S) group. Six patients in the S group had a rise in endtidal carbon dioxide concentration above 7.8 kPa (60 mmHg). Recovery scores were higher in the B group at 10 and 20 min into recovery. The surgical impression of bleeding and jaw relaxation was similar with both groups. The incidence of postoperative nausea and vomiting and agitation was higher in the S group but did not achieve statistical significance.

CONCLUSION

Use of balanced anaesthesia offered more haemodynamic stability and a rapid recovery.

A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country

Critical incident monitoring has the advantage of identifying a potential risk to the patient without it necessarily resulting in morbidity. An added advantage in developing countries is the low cost involved in introducing the programme. This paper analyses the incidents reported from the operating room suite in a teaching hospital in a developing country from August 1997 to 31 December 1999. During the period, 20 819 anaesthetics were administered and 329 incidents were reported (1.58% of the cases). Seventy-three per cent of the incidents were reported in patients of ASA grade 1 or 2. Thirty-nine per cent occurred during induction, 51% during maintenance and 10% during emergence. Human error was the cause in 41%, equipment error in 50% and system error in 8.5%. Twenty-two per cent of the incidents resulted in minor, and 13% in major physiological disturbance. The technique has been found useful in identifying trends and selecting issues to be discussed in departmental quality assurance meetings, but requires persistent motivation of the reporting staff.

The effect of measurement location on tibia lead XRF measurement results and uncertainty

The aims of this study were to determine whether the location on the tibia measured by 109Cd-based K-shell x-ray fluorescence (XRF) affected the measurement result and its uncertainty, and whether higher tibia lead levels at the extremities of the tibia and/or inhomogeneity in the distribution of lead in the tibia could be inferred therefrom. Replicate XRF measurements were performed at multiple locations on ten adult cadaver intact legs and on nine bare tibiae dissected from them. Mean lead levels in the bare tibiae ranged from 16 to 48 microg Pb per g of bone mineral. Bare tibia measurements showed that both the XRF result and its uncertainty increased towards the proximal and distal ends of the tibia. The XRF result decreased away from the medial-lateral mid-point of the tibia, but XRF uncertainty was not significantly affected. Intact leg measurements showed no effect of proximal distal location on XRF result but did show an effect on XRF uncertainty. We conclude that the XRF method used can determine the differences in bone lead level resulting from the more trabecular composition at the ends of the tibia, and we present limited evidence for localized regions of low tibia lead level.

En bloc heterotopic auxiliary liver and bilateral renal transplant in a patient with homozygous protein C deficiency

An 8-year-old girl with homozygous protein C deficiency who had undergone maintenance dialysis since birth because of renal veins with thrombosis was treated with an en bloc heterotopic auxiliary liver and bilateral renal transplantation. The reconstitution of protein C activity by auxiliary liver transplantation facilitated successful renal transplantation.

Provision of dental care for medically compromised children in the UK by General Dental Practitioners

The aim of this study was to investigate the views of General Dental Practitioners (GDPs) regarding their provision of dental treatment for medically compromised children. A questionnaire to assess confidence, experience and willingness to treat eight specific groups of medically compromised children was sent to 524 GDPs. Information is based on 271 completed questionnaires. The median number of children treated by GDPs in each of the eight groups over the previous 5 years was 0-2. Eighty percent of respondents stated that they would value further training in the provision of dental care for medically compromised children. Confidence was highest in providing dental treatment for children with three conditions: congenital heart disease (37% very confident), diabetes (39% very confident) and epilepsy (41% very confident). These were also the conditions that the GDPs reported as presenting most frequently in the dental surgery. GDPs reported least confidence in providing dental care for children with haemophilia (12% very confident) and organ transplants (14% very confident). Only 30% of GDPs wanted to be routinely involved with the provision of dental care for medically compromised children. The results indicate that medically compromised children may have problems accessing dental care and expertise. A system of integrated medical and specialised dental care is suggested.

Variability in XRF-measured tibia lead levels

A few studies have examined the variability in 109Cd-based K-shell x-ray fluorescence (KXRF) bone lead measurements from replicate measurements made either at the same time or over a period of time, and one of these studies has shown that the uncertainty in an individual measurement is an underestimate of the standard deviation of replicate measurements. Variability in KXRF tibia lead measurements was assessed from ten cadaver intact legs, from the bare tibiae dissected from nine of these legs, and from four in vivo volunteers. Cadaver legs underwent replicate measurements on multiple occasions. In vivo volunteers underwent single measurements of the left tibia monthly for one year. Average tibia lead levels in the cadaver legs and in vivo volunteers ranged from 6 to 50 and from 6 to 13 microg Pb per g of bone mineral respectively. The factors influencing the standard deviation of replicate measurements were investigated. Both cadaver and in vivo measurements confirmed that the uncertainty in an individual measurement is an underestimate of the standard deviation of replicate measurements, suggesting a methodological deficiency probably shared by most current 109Cd-based K-shell XRF lead measurement systems.

Self-assessed oral health status of ethnic minority residents of South London

OBJECTIVE

To determine the self-assessed oral health status of individuals from minority ethnic communities living in South London.

METHOD

A sample of 1,057 individuals from minority ethnic communities (as defined by Office of Censuses and Surveys categories) resident in South London were asked to complete measures of their oral and facial symptoms, the impact of their oral health on their daily functioning and of their satisfaction with the appearance of their teeth and gums.

MEASURES

Self-assessed oral health status was determined by means of two short scales addressing oral symptoms and the impact of oral health on activities of daily living. Satisfaction with the appearance of the teeth and gums was also assessed.

FINDINGS

No significant differences were found between minority ethnic communities in the number of symptoms reported, in the level of impact which such symptoms cause, or in their dissatisfaction with the appearance of their teeth and gums. Reporting of symptoms and impact were mildly though significantly correlated with dissatisfaction.

CONCLUSIONS

There appears to be little difference between ethnic communities in their reporting of oral and facial symptoms, though these groups report higher levels of dissatisfaction with the appearance of their teeth and gums. Social and demographic factors play an important role in determining perceptions of oral health. The findings should be interpreted with caution given the difficulty of sampling minority ethnic communities and the subsequent limited representativeness of the sample.

A comparative study of positive pressure ventilation via laryngeal mask airway and endotracheal tube

OBJECTIVE

To investigate the use of Laryngeal Mask Airway (LMA) and its comparison with the endotracheal tube for positive pressure ventilation.

SETTING

A tertiary care teaching hospital.

METHODS

Fifty adult ASA I and II patients undergoing peripheral limb surgery were randomly allocated to 2 groups for LMA or endotracheal tube insertion. A standardized anaesthetic technique was used. The groups were then compared regarding haemodynamic changes on insertion as well as removal of LMA and ETT and any complications that occurred were noted.

RESULTS

The haemodynamic response to insertion was significantly attenuated (p < 0.05) in LMA group as compared to ETT group. The cardiovascular response to extubation was not significantly different between the groups. A higher incidence of coughing and mild hypoxaemia at extubation was noted in ETT group as compared to LMA group (p < 0.05) and blood was detected in 4 cases after LMA removal.

CONCLUSION

It is concluded that the use of LMA during positive pressure ventilation is safe in selected cases. There is an attenuated haemodynamic response to insertion of LMA as compared to endotracheal tube which will be beneficial in certain patients e.g., those with ischaemic heart disease, vascular disease and hypertensives.

Graft failure secondary to necrotizing enterocolitis in multi-visceral transplantation recipients: two case reports

We report on two recipients of multi-visceral grafts who exhibited sudden onset of acute abdomen discomfort 2 weeks post-transplantation after a fairly uneventful immediate post-operative course. Both patients were shown to have pneumatosis intestinalis and one had air in the portal vein. Both patients underwent exploration, which showed non-viable intestine (terminal ileum and colon in the first patient and the entire small intestine distal to the ligament of Treitz in the second patient). There was no vascular thrombosis. The necrotic intestine was resected in both cases. The first patient developed sepsis and died 15 days later despite the rescue efforts. The second patient was re-transplanted twice and is doing well. The histopathology of the segments involved revealed cryptitis, vasculitis, and features of transmural necrosis. Accordingly, both clinical and pathologic features are diagnostic of necrotizing enterocolitis. To our knowledge this is the first report of this complication following intestinal or multi-visceral transplantation.