Bilateral sequential lung transplantation for end stage septic lung disease

BACKGROUND

Bilateral sequential lung transplantation (BSLT) has been widely adopted as an alternative to combined heart and lung transplantation for the management of end stage septic lung disease in many transplant centres.

METHODS

A retrospective review was undertaken of the first 32 consecutive patients with septic lung disease to undergo BSLT at the Freeman Hospital.

RESULTS

Between April 1988 and October 1994 32 patients underwent BSLT. Survival at 30 days was 85% and actuarial survival at one year was 70%. Improved pulmonary function was seen in all surviving patients.

CONCLUSION

BSLT for septic lung disease offers comparable survival to heart-lung transplantation, with excellent functional results. Long term results may be superior because the disadvantages of transplanting the heart are avoided.

Evaluation of a rule base for decision making in general practice

BACKGROUND

Decision making in general practice relies heavily on judgmental expertise. It should be possible to codify this expertise into rules and principles.

AIM

A study was undertaken to evaluate the effectiveness, of rules from a rule base designed to improve students' and trainees' management decisions relating to patients seen in general practice.

METHOD

The rule base was developed after studying decisions about and management of thousands of patients seen in one general practice over an eight year period. Vignettes were presented to 93 fourth year medical students and 179 general practitioner trainees. They recorded their perception and management of each case before and after being presented with a selection of relevant rules. Participants also commented on their level of agreement with each of the rules provided with the vignettes. A panel of five independent assessors then rated as good, acceptable or poor, the participants' perception and management of each case before and after seeing the rules.

RESULTS

Exposure to a few selected rules of thumb improved the problem perception and management decisions of both undergraduates and trainees. The degree of improvement was not related to previous experience or to the stated level of agreement with the proposed rules. The assessors identified difficulties students and trainees experienced in changing their perceptions and management decisions when the rules suggested options they had not considered.

CONCLUSION

The rules developed to improve decision making skills in general practice are effective when used with vignettes. The next phase is to transform the rule base into an expert system to train students and doctors to acquire decision making skills. It could also be used to provide decision support when confronted with difficult management decisions in general practice.

Standards for height, weight and head circumference from one month to six years based on Stockholm children born in 1980

Growth data on height, weight and head circumference were collected from Stockholm children from one month to six years of age, born in 1980, and representing all socio-economic groups. The sample consisted of 2471 children (1264 boys and 1207 girls), most of whom were measured on 10-15 occasions. From these measurements centile standards were constructed using a statistical technique which separates between-individual and within-individual variation, since only the former is appropriate to distance standards. Compared to former Swedish standards the present heights and weights were similar up to 2.0 years of age but thereafter considerably greater. Head circumference was larger throughout, perhaps due to a difference in measurement technique.

The use of an abdominal compression belt to reduce stone movement during extracorporeal shock wave lithotripsy

We used an abdominal compression belt in 50 patients undergoing extracorporeal shock wave lithotripsy with the Siemens Lithostar lithotriptor to limit diaphragmatic excursion and, therefore, renal calculus movement. Stone movement was measured on the monitor with and without the compression belt. Abdominal compression was found to decrease the range of stone movement by an average of 32% (-4 to 63%). This technique was less effective in patients with limited chest expansion. Abdominal compression was also found to be useful during treatment of renal and upper ureteral stones in reducing overall patient movement. The decreased stone movement during extracorporeal shock wave lithotripsy with abdominal compression may increase stone fragmentation and may decrease the number of shocks per treatment.

Implication of duodenogastric reflux in the pathogenesis of Barrett's oesophagus

Fasting and postprandial intragastric bile acid concentrations have been estimated and compared in patients with complications of Barrett's oesophagus, patients with Barrett's oesophagus without complications, patients with oesophagitis and a group of normal subjects who acted as controls. There was no significant difference in fasting intragastric bile acid concentrations between the groups. Postprandial bile acid concentrations were significantly greater in the patients with complications of Barrett's than in the remaining groups at 60, 90 and 120 min. Significant concentrations of bile acids were seen in gastric juice of unaltered pH and may be undetected on intra-oesophageal pH monitoring. Duodenogastric reflux may be implicated in the pathogenesis of complications of Barrett's oesophagus.

Spinal hemangiomas

Three new cases of spinal cord compression due to vertebral hemangioma are reported. The clinical presentation, with spinal pain, radicular radiation, and paraparesis, is similar to that of primary lymphoma, metastatic tumor, and disc disease. If the characteristic plain film changes of vertical trabeculations and striations are present, the preoperative diagnosis is facilitated, but in the majority of cases these are not seen. In some instances, vertebral body or pedicle erosion is present. A myelographic epidural block will be seen on further study. Spinal arteriography can prove helpful. Surgical decompression results in marked neurological improvement if intervention takes place before the onset of complete paralysis. The authors recommend that the diagnosis of vertebral hemangioma be considered in the differential diagnosis of epidural spinal cord compression whenever considered in the differential diagnosis of epidural spinal cord compression whenever a primary malignant neoplasm cannot be identified.

Latitude of origin influences photoperiodic control of reproduction of deer mice (Peromyscus maniculatus)

Three subspecies of Peromyscus maniculatus originating from different latitudes were maintained from birth in light dark cycles that provided between 10 and 18 h of light per day. At 50 days of age, Chihuahua, Mexico mice (latitude of origin 27 degrees N) and South Dakota, U.S.A. mice (44 degrees N) kept in the 10L:14D photoperiod had reduced gonadal and seminal vesicle weights and a lower spermatogenic index than corresponding mice kept in a 14L:10D photoperiod. Some Chihuahua and South Dakota mice, apparently constituting nonphotoperiodic subpopulations, developed their gonads while kept in the short-day photoperiod. The critical day length for stimulation of sexual maturation was greater for mice from Manitoba, Canada (55 degrees N) than for mice from the lower latitudes. At 70 days of age, testes and seminal vesicle weights, and the spermatogenic index of Manitoba mice in the 14L:10D photoperiod, were lower than those of animals maintained in 16L:8D and 18L:6D photoperiods. Responsiveness to short day lengths was greater among adult South Dakota than adult Chihuahau mice and melatonin treatment significantly reduced testes weights of South Dakota but not of Chihuahua adult mice. Photoperiodic regulation of the reproductive system varies with latitude of origin. Differences in the critical day length necessary for stimulating development of functional reproductive activity and variations in the percent of photoperiodic animals within each subspecies, appear to contribute to latitudinal gradients in reproduction.

Cortical, subcortical, and brainstem dysfunction: a correlation in dyslexic children

A group of dyslexic students was examined by a central auditory test (CAT) battery including competing sentences, binaural fusion, filtered speech, and compressed speech. Auditory evoked brainstem responses (BSER) were measured in conjunction with the CAT data. The auditory tests indicate a high degree of failure in those areas requiring sophisticated integration, coordination, and identification of the modified speech stimuli. The BSER did not identify a significant abnormality. The cortical and subcortical areas of integration are proposed as the multicentric sites of impairment in the hearing function found in dyslexic students.

Clinical and metabolic responses to parenteral nutrition in acute renal failure. A controlled double-blind study

1. Thirty patients with acute renal failure who were unable to eat adequately were evaluated while they received parenteral nutrition with glucose alone (n = 7), glucose and 21 g/day essential amino acids (EAA, n = 11) or glucose, 21 g/day essential and 21 g/day nonessential amino acids (ENAA, n = 12). Energy intake did not differ with the three treatments. Patients were studied in a prospective double blind fashion. 2. Thirteen patients recovered renal function and 11 survived to leave the hospital. Those in whom renal failure was attributed to hypotension and/or sepsis had a poorer recovery of renal function (17%) and survival (17%). Recovery of renal function and survival was greater in patients on the medical service as compared to the surgical service and in those who received more energy. Recovery of renal function was worse in those treated with dialysis. There were no differences in recovery of renal function of survival among the three treatment groups. 3. Many patients were markedly catabolic as indicated by nitrogen balances, urea in nitrogen appearance rates (UNA), serum protein concentrations, and plasma amino acid levels. There was no correlation between the degree of catabolism and recovery of renal function or survival. Mean UNA in individual patients also correlated with body weight. Among the three groups, however, UNA was significantly less with the group receiving EAA as compared to ENAA. 4. Serum protein concentrations were lower than normal in all treatment groups. Serum albumin fell significantly during the treatment in the more catabolic patients. Plasma amino acid levels tended to fall in all three groups and concentrations at the end of the treatment were frequently lower than normal. 5. These data suggest that acute renal failure patients who are unable to eat adequately are often hypercatabolic and have a high mortality, particularly if hypotension or sepsis is the cause of renal failure. The improved survival in those with higher energy intakes, the high rate of net protein breakdown, the low serum protein levels and the reduced plasma concentrations of both essential and nonessential amino acids suggest that greater quantities of energy and both essential and nonessential amino acids may be beneficial to such patients.

Effect of an oral dose of 25-hydroxyvitamin D3 on its blood levels in patients with the nephrotic syndrome

Patients with the nephrotic syndrome have low blood levels of 25-hydroxyvitamin D3 (25OHD3) due to urinary losses of the sterol. It is not known whether supplementation of this metabolite could raise its blood levels in these patients. The changes in the plasma levels of 25OHD3 and its kinetic behavior were studied after an oral dose of the sterol (200 microgram) in patients with the nephrotic syndrome in an effort to evaluate the usefulness of oral therapy to achieve and maintain normal blood levels of 25OHD3. Normal subjects served as controls. The results showed that intestinal absorption of 25OHD3 is significantly delayed and its elimination rate is significantly enhanced in patients with the nephrotic syndrome compared to control subjects. Despite these abnormalities, the plasma levels of 25OHD3 were within normal values even 48 h after the ingestion of the sterol. These data indicate that oral therapy with 25OHD3 given in proper doses is adequate to maintain normal blood levels of the sterol in patients with the nephrotic syndrome. Therefore, a therapeutic approach could be designed to manage the target organ disease due to 25OHD3 deficiency seen in these patients.

The formation, isolation and importance of isopeptides in heated proteins

The separation and resolution of the isopeptides Nepsilon (gamma-L-glutamyl)-L-lysine and Nepsilon (beta-aspertyl)-L-lysine, formed in heated proteins, has been successfully achieved. The method demands a well characterised ion-exchange column and the use of pH 3.40 lithium citrate buffer (O.2N Li+). Due to variations in particle size and percentage crosslinkages in the ion-exchange resin a computer assisted buffer gradient system has been developed. This system affects resolution of both isopeptides in 7h. The use of leucyl-glycine as an internal standard facilitates quantitative estimation of the isopeptides. This separative method has been used to analyse a series of heated protein samples and to estimate the quantities of isopeptides formed. The ability of a protein to form isopeptides links is discussed as well as the implication of such links on the reactivity and digestibility of proteins.

Further experience with discriminant functions in differential diagnosis of hypercalcaemia

Further experience has been obtained in the use of discriminant functions in the differential diagnosis of hypercalcaemia from the study of 140 new patients. The discriminant functions described in an earlier paper were derived from the results for plasma inorganic phosphate, alkaline phosphatase, chloride, bicarbonate and urea obtained from hypercalcaemic patients on admission to hospital. They indicated the correct diagnosis in ninety-two of 103 new hypercalcaemic patients (89·3%) admitted to University College Hospital and in thirty-one of thirty-seven hypercalcaemic patients at two other hospitals.

Revised discriminant functions have been calculated including the erythrocyte sedimentation rate as a sixth variable. These revised functions have led to some improvement in diagnostic accuracy. The correct diagnosis was indicated in ninety-three of ninety-eight patients (94·9%) at University College Hospital and in thirty-three of the thirty-seven patients at the two other hospitals.