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.

Improvement in intraoperative fresh frozen plasma transfusion practice--impact of medical audits and provider education

OBJECTIVE

To determine the practice of anaesthesiologists in our institution for intraoperative transfusion of Fresh Frozen Plasma (FFP) and to see whether provider education can reduce the incidence of inappropriate FFP transfusion.

MATERIAL AND METHODS

A retrospective audit was done for 6 months in all patients who received intraoperative FFP transfusion. The result were compared with recommendations by the British Committee for Standards in Haematology. These results were presented in the departmental meeting and guidelines were circulated. Another prospective audit was conducted for six months to see whether there was any effect of provider education on the intraoperative transfusion practice.

RESULTS

The first audit showed that 14.6% of the transfusion were definitely indicated, 40.2% were conditionally indicated whereas there was no justification in 45.1%. The subsequent audit showed a significant reduction (23.3%) in the unjustified transfusions of FFP whereas conditional use was significantly increased (69.1%), showing an overall improvement in the intraoperative transfusion practice.

CONCLUSION

Further education and a monitoring system to ensure adherence to the recommended guidelines is required to improve transfusion practice.

Predictors of tobacco and alcohol consumption and their relevance to oral cancer control amongst people from minority ethnic communities in the South Thames health region, England

The purpose of this study was to examine the determinants of the health behaviour of ethnic groups in relation to alcohol and tobacco use. A cross-sectional questionnaire survey was carried out using network sampling amongst community groups in the South Thames region of the United Kingdom. Self-classified ethnic groups were identified: Black-African; Black-Caribbean; Indian; Pakistani; Bangladeshi and Chinese/Vietnamese. A total of 1113 people were recruited in the study. In all of the ethnic groups, men were more likely than women to smoke tobacco. Chewing of pan and tobacco was common in the South Asian communities and alcohol consumption was high among the Black-Caribbean group. Those factors were predicted by education, employment, gender and being born in the UK. It is important to examine the determinants of such risk behaviours in order to aid appropriate targeting of health promotion interventions, particularly those related to cancer control.

Nutritional treatment for acquired immunodeficiency virus-associated wasting using beta-hydroxy beta-methylbutyrate, glutamine, and arginine: a randomized, double-blind, placebo-controlled study

BACKGROUND

The current study was designed to examine whether a combination of three nutrients, consisting of beta-hydroxy-beta-methylbutyrate (HMB), a metabolite of leucine, L-glutamine (Gln) and L-arginine (Arg), each of which has been previously shown to slow muscle proteolysis, could synergistically alter the course of muscle wasting in patients with established acquired immunodeficiency syndrome (AIDS).

METHODS

Sixty-eight human immunodeficiency virus (HIV)-infected patients with a documented weight loss of at least 5% in the previous 3 months were recruited from the HIV clinic at Nassau County Medical Center. The subjects were randomly assigned in a double-blind fashion to receive either placebo containing maltodextrin or the nutrient mixture (HMB/Arg/Gln) containing 3 g HMB, 14 g L-glutamine, and 14 g L-arginine given in two divided doses daily for 8 weeks. Body weights (BW) were recorded weekly and lean body mass (LBM) and fat mass (FM) were measured by air displacement plethysmography and by a single computerized tomography (CT) slice through the thigh at 0, 4, and 8 weeks.

RESULTS

Forty-three subjects completed the 8-week protocol, (placebo, n = 21; HMB/Arg/Gln, n = 22). At 8 weeks, the subjects consuming the HMB/Arg/Gln mixture gained 3.0 +/- 0.5 kg of BW while those supplemented with the placebo gained 0.37 +/- 0.84 kg (p = .009). The BW gain in the HMB/Arg/Gln-treated subjects was predominantly LBM (2.55 +/- 0.75 kg) compared with the placebo-supplemented subjects who lost lean mass (-0.70 +/- 0.69 kg, p = .003). No significant change in FM gain was observed (0.43 +/- 0.83 kg for the group receiving HMB/Arg/Gln and 1.07 +/- 0.64 kg for the group receiving the placebo, p > .20). Similar percentage changes in muscle mass and fat mass were observed with CT scans. Immune status was also improved as evident by an increase in CD3 and CD8 cells and a decrease in the HIV viral load with HMB/Arg/Gln supplementation.

CONCLUSIONS

The data indicate that the HMB/Arg/Gln mixture can markedly alter the course of lean tissue loss in patients with AIDS-associated wasting.

Diaphragmatic rupture: A complication of violent cough

The cough is a complex physiologic response designed to protect airways from unwanted secretions and foreign materials. Violent and paroxysmal coughs are associated with many complications. In this article, we will discuss a patient who sustained diaphragmatic rupture as a result of violent coughing. The possible mechanisms of this rare complication are explained.

Dental caries and treatment experience of adults from minority ethnic communities living in the South Thames Region, UK

OBJECTIVE

To describe the dental caries and treatment experience of groups of adults from minority ethnic communities living in the South Thames Region of England.

DESIGN

Cross-sectional clinical study.

SETTINGS

Community, religious and educational centres for adults from minority ethnic communities.

PARTICIPANTS

Snowball sample of 928 adults from 44 ethnic groups including: Black Caribbean (141), Black African (134); Pakistani (123); Indian (190); Bangladeshi (78); Chinese/Vietnamese (143) and 119 from other groups.

RESULTS

More participants were dentate or had 18 or more sound and untreated teeth than adults living in the same area (Todd and Lader, 1991). Duration of residence in the United Kingdom predicted caries or treatment experience in the sample as a whole and in Chinese/Vietnamese people. Increased DMFT was predicted by age and by history of visiting a UK dentist in the sample as a whole and in the Black African group.

CONCLUSIONS

Effect of duration of UK residence on presence and extent of caries suggests that oral health may be better among adults from these ethnic minority groups than among the general population. However, the differences can also be attributed to sampling bias and old comparison data. Better sampling strategies are required for research of this type.

Comparison of thiopentone sodium and propofol for electro convulsive therapy (ECT)

OBJECTIVE

For safe conduct of electro convulsive therapy (ECT), general anaesthesia is administered to the patients. In this study we compared thiopentone sodium and propofol as induction agents for ECT.

PATIENTS AND METHODS

Twenty five patients each undergoing at least 2 sessions of ECT at the psychiatry department were included in the study. Each patient either received thiopentone or propofol for induction of sleep in a randomized manner. Drugs were evaluated regarding their effects on ECT induced haemodynamic changes (Blood pressure, Heart rate), seizure duration related to the procedure and recovery from sleep. Any side effects during the procedure and recovery were also noted.

RESULTS

Propofol offered a superior haemodynamic stability during the procedure and a quick recovery from sleep.

CONCLUSION

Propofol was found to be a better induction agent for ECT compared to thiopentone sodium.

Effect of cricoid pressure on the incidence of nausea and vomiting in the immediate postoperative period

This study aimed to evaluate whether the application of cricoid pressure at the time of induction of anaesthesia was associated with a lesser incidence of postoperative nausea or vomiting in the immediate postoperative period compared with a group in which no cricoid pressure was applied, in patients undergoing day care gynaecological laparoscopy. One hundred ASA I and II females were randomly allocated to receive cricoid pressure at the time of induction. The peri-operative anaesthetic technique was standardised. The incidence of postoperative nausea and vomiting in the group who received cricoid pressure was 16% in the recovery room compared with 26% in the no cricoid group. When the period was extended to the first 6 h post anaesthesia the incidence was 30% in the cricoid and 44% in the no cricoid group. This difference did not achieve statistical significance in either period (p > 0.05). The results suggest that application of cricoid pressure at the time of induction does not significantly alter the incidence of postoperative nausea and vomiting in the first 6 h of recovery from anaesthesia.

Cultural barriers to successful communication during orthodontic care

OBJECTIVE

To determine to what extent barriers related to culture and language, and how inappropriate expectations might impede orthodontic care, among Pakistani Muslims when compared to white Caucasians from similar socio-economic backgrounds in Bradford, UK.

DESIGN

Semi-structured interviews.

SETTING

Dentists were interviewed in the clinic. Parents and children were interviewed separately in the waiting room or in adjacent rooms depending on availability.

PARTICIPANTS

Four dentists working in the Community and Hospital Dental Services, 30 children and 10 parents of white and Pakistani origin.

RESULTS

Among the white Caucasian groups, three-way communication involving parents, children and dentist enhanced understanding, supported orthodontic treatment and reinforced the need for good home care. Among Pakistani families communication was primarily two-way, involving the dentist and the child. Parents and families had limited understanding of the process and were unable to offer a comparable level of support that would benefit their children most. This can place additional burdens on the Pakistani child patient and requires a very positive approach from the dental team.

CONCLUSIONS

There is a clear need for chairside support, through patient advocates or interpreters, as well as the provision of appropriate educational material to match parents' educational needs on behalf of their children.

Paget's disease of the bone

Full text is available as a scanned copy of the original print version.

Inclusion of entire pancreas in the composite liver and intestinal graft in pediatric intestinal transplantation

An entire pancreatico-duodenal complex was included in the liver and intestinal graft in eight children who received small-size grafts. This method showed several advantages compared to the traditional approach. They included reducing time for graft preparation by eliminating donor pancreas resection, no necessity of biliary reconstruction and leaving natural tissue support for blood vessels. The method was not associated with an increased risk of complications such as pancreatitis or rejection. It should be considered in pediatric liver and intestinal transplant recipients who require small-size grafts.

Genomic organization and promoter activity of glucosidase I gene

Glucosidase I initiates the processing of asparagine (N-) linked glycoproteins by removing the distal alpha1,2-linked glucosyl residue of the tetradecasaccharide Glc(3)Man(9)GlcNAc(2). The gene encoding this enzyme was isolated and its structural organization and promoter activity determined. The major transcript for glucosidase I on northern blot appeared to be 3.1 kb; Southern blotting and DNA sequencing indicated the size of the gene to be 6.8 kb, comprising four exons separated by three introns. The first exon encodes the cytoplasmic tail and transmembrane domain; the fourth encodes the putative catalytic domain of the enzyme. Exon-intron junctions are flanked by consensus splice donor and acceptor sequences. Transcription initiation sites were mapped by primer extension, ribonuclease protection assay and RT-PCR analysis. Primer extension results showed multiple initiation sites at -150, -156, and -272 bp relative to the translation initiation codon ATG. Sequence analysis of 5' flanking region showed no canonical TATA box, a high GC content, Sp1 and ETF binding sites (typical of a housekeeping gene promoter). Also noteworthy, the promoter region contains several generic STAT factor binding sites, one nearly perfect, and two half GR binding elements. Other cis- acting elements recognized by transcription factors such as AP-2, NF-kappaB, estrogen receptor, and progesterone receptor (PR) were also present in the putative promoter region. To determine the promoter activity, a construct encompassing the region between -2114 to -5 bp of the putative promoter was ligated to the chloramphenicol acetyltransferase (CAT) reporter plasmid and transiently transfected into COS 7 cells. CAT assay results clearly show transcriptional activity of the promoter.