Liver transplantation for neonatal haemochromatosis

Two cases of neonatal haemochromatosis, a rare and often fatal metabolic disorder, presenting with acute liver failure, are reported. Both presented in the first week of life with hypoglycaemia, jaundice, and coagulopathy, with rapid deterioration of liver function. Both received a transplantation using reduced liver grafts. One child was well 18 months later. Few survivors have been reported and despite the difficult perioperative management, liver transplantation is the best treatment for neonatal haemochromatosis.

Intestinal barrier failure and the development of the systemic inflammatory response syndrome

At the present time, terms used to describe the clinical entity of sepsis are used inappropriately and interchangeably. The source and foci of infection are often unidentified, yet it is clear that some form of inflammatory episode is occurring. The following paper seeks to clarify the terminology used to describe 'sepsis' and link this with a non-bacteraemic source of this inflammatory response--the small intestine. The importance of accurately reflecting oxygen extraction and oxygen consumption by cells is addressed and a movement from the current emphasis on haemodynamic measurement to variables which reflect metabolic rate and lactic acidosis is discussed. Issues which are the concern of nurses working in intensive care are examined, in terms of primary prevention and secondary management.

Insulin-like growth factors enhance phagocytosis by human neutrophils in vitro

Polymorphonuclear neutrophils (PMNs) were isolated from human blood, and PMN phagocytosis was assessed by measuring the chemiluminescence (CL) response in the presence of ZAP (opsonized zymosin particles containing luminol). The administration of 6.5 nM of insulin-like growth factor I (IGF-I), des(1-3)-IGF-I, IGF-II or insulin to PMNs for 20 min resulted in significant increases of the CL response for all test preparations. Des(1-3)-IGF-I, a truncated IGF-I with low affinity binding to IGF binding proteins (IGFBPs), was the most potent CL stimulator. The CL production evoked by 6.5 nM of des(1-3)-IGF-I was inhibited significantly by both 0.25 and 1.0 nM of EGTA (Ca2+ chelator), or 10 microM nifedipine (Ca2+ channel inhibitor), pertussis toxin (0.05 and 1.0 micrograms/ml) or cholera toxin (5 micrograms/ml). These results suggest that IGF-I and its homologues are potent stimulators of phagocytosis and that this action is modulated by IGFBP, and may require extracellular Ca2+ and/or IGF-I receptor G-protein coupling.

Education and staffing in the ICU: past, present and future

This article discusses the history of intensive care education in the UK and the impact of recent developments and their effect on the education of nurses in intensive care units.

Simultaneous partial monosomy 10p and trisomy 5q in a case of hypoparathyroidism

We report a case of monosomy for the distal region of the short arm of chromosome 10 (p13----ter) associated with trisomy for the terminal region of the long arm of chromosome 5 (q35.2----ter) that had originated from adjacent 1 segregation of a maternal reciprocal balanced translocation (5;10)(q35.2;p13). We review the clinical findings of previously reported cases of both partial monosomy for 10p and of partial trisomy for 5q, but to our knowledge there are no previous reports of the effects of these two chromosome anomalies together. Clinically our patient showed features typical of partial monosomy for 10p (including hypothyroidism) rather than partial trisomy 5q.

Education and staffing levels in the intensive care unit

The Joint Board of Clinical Nursing Studies (JBCNS), established in 1972, sought to standardize the type of clinical experience and theoretical input required for postregistration nurses in specialist areas. The English National Board (ENB) superseded the JBCNS as a result of the Nurses, Health Visitors and Midwives Act of 1979. Colleges of nursing will become the providers of specialist intensive care education and the clinical areas or individual nurses will become the purchasers. The implementation of Project 2000 may alter the educational needs of nurses wishing to specialize in intensive care. The introduction of the Credit Accumulation Transfer System will lead to diploma or degree level modules being developed in intensive care. Increasing clinical expertise will be engendered through the ENB Higher Award. More flexible use of the workforce is envisaged, promoting the use of part-time and episodic employment, to meet the demands of the NHS as a contract-based organization.

Assay of pyrogens by interleukin-6 release from monocytic cell lines

A novel in-vitro system has been developed for the detection and quantification of pyrogen in pharmaceutical products. The measured variable was evoked secretion of the pyrogenic cytokine interleukin-6 from MONO MAC 6 monocytic cells incubated with the product. The interleukin-6 was detected using a specific and sensitive ELISA developed for this purpose. The test system detected pyrogenic contamination in 3 batches of therapeutic human serum albumin which had caused adverse reactions in recipients. The contamination was not detected in conventional tests: the rabbit pyrogen test and the limulus amoebocyte lysate test.

Endoscopic retrograde cholangiopancreatography in infantile cholestasis

The difficulty of distinguishing surgically correctable causes of conjugated hyperbilirubinaemia in infants from other causes means that some infants may undergo laparotomy and intraoperative cholangiography unnecessarily, and others may be referred for surgery too late. In an attempt to improve the diagnostic accuracy in infants with conjugated hyperbilirubinaemia when standard methods produced equivocal results, we have been using prototype paediatric duodenoscopes (PJF 7.5 and XPJF 8.0; Olympus) to perform endoscopic retrograde cholangiopancreatography (ERCP). From 159 infants with conjugated hyperbilirubinaemia, 11 were referred for ERCP, which was performed in nine. In four in whom bile ducts were definitely visualised laparotomy was avoided. Operative cholangiography confirmed patent bile ducts in one in whom visualisation had been uncertain. Three of four in whom bile ducts were not seen had extrahepatic biliary atresia. Visible bile drainage in the fourth excluded atresia. No major complications ensued but there was radiological evidence of gall bladder perforation in one (common hepatic duct block) and overinflation with air was a problem until finer cannulae (Wilson-Cook) were introduced. In appropriately selected patients with conjugated hyperbilirubinaemia, ERCP with paediatric duodenoscopes in experienced hands may provide useful diagnostic information.