[Tests for alcohol consumption during pregnancy: what biomarkers are suitable?]

Alcohol consumption during pregnancy may lead to severe foetal damage, such as foetal alcohol spectrum disorders. It is known that pregnant women under-report to questionnaires about alcohol consumption. It is therefore necessary to determine alcohol consumption during pregnancy objectively. We present 2 pregnant women with negative urine tests for ethyl glucuronide (EtG) and alcohol. However, analysis of two other biomarkers, phosphatidylethanol (PEth) in blood and fatty acid ethyl esters (FAEE) in meconium, revealed alcohol consumption during pregnancy by both women. Analysis of PEth can yield additional information alongside EtG testing. This is due to the much longer half-life of PEth. Meconium testing for FAEE provides relevant information about alcohol consumption during the second and third trimesters. Both PEth and meconium analysis can help identify women who have consumed alcohol during pregnancy. Appropriate counselling and follow-up can be given to these mothers and their children.

[First abdominal access in gynecological laparoscopy: which method to utilize?]

The choice of the technique to enter the peritoneal cavity, during a laparoscopy, depends on a lot of variables which hinder a standardized method and, actually, it appears impossible to show, with certainty, the best method to choose for the first abdominal access in gynecological laparoscopy. The preference for one or another technique depends on the operator experience, school and speciality of the surgeon, laparoscopical upgrading and the work environment; many surgical techniques are not yet used due the limits and fears of some surgeons to change the preference in first access approaching and for the lack of operating versatility by a method or another one. A review of the scientific literature, underlines that the major problems during the first laparoscopical abdominal access are two, vascular and intestinal and their percentage is variable. In this paper we describe the large range of methods for open and closed laparoscopy and for direct access, that permit to perform a first abdominal laparoscopical access, and their major possible problems.

[Pregnant, addicted prostitutes: compulsory admission is sometimes necessary in the interests of the child]

Three drug-addicted prostitutes, who were 37, 27 and 25 weeks pregnant respectively, were admitted to a psychiatric department under court order. After the birth, the children were placed in foster families. The mothers withdrew from further treatment. In Rotterdam, The Netherlands, there is a city network made up of doctors and social workers; in the case of addicted pregnant prostitutes they advise the Child Protection Agency of the Ministry of Justice about the care of the child after its birth. The combination of heavy addiction and prostitution in a pregnancy without any prenatal care can be considered a psychiatric disorder. Consequently, an addicted woman can be compulsorily admitted because of the threat she forms to her unborn child. In these cases the mother's right to self-determination must be limited in the interest of the child.

Effect of the mechanical ventilatory cycle on thermodilution right ventricular volumes and cardiac output

The purpose of this study was to evaluate right ventricular (RV) loading and cardiac output changes, by using the thermodilution technique, during the mechanical ventilatory cycle. Fifteen critically ill patients on mechanical ventilation, with 5 cmH(2)O of positive end-expiratory pressure, mean respiratory frequency of 18 breaths/min, and mean tidal volume of 708 ml, were studied with help of a rapid-response thermistor RV ejection fraction pulmonary artery catheter, allowing 5-ml room-temperature 5% isotonic dextrose thermodilution measurements of cardiac index (CI), stroke volume (SV) index, RV ejection fraction (RVEF), RV end-diastolic volume (RVEDV), and RV end-systolic volume (RVESV) indexes at 10% intervals of the mechanical ventilatory cycle. The ventilatory modulation of CI and RV volumes varied from patient to patient, and the interindividual variability was greater for the latter variables. Within patients also, RV volumes were modulated more by the ventilatory cycle than CI and SV index. Around a mean value of 3.95 +/- 1.18 l. min(-1). m(-2) (= 100%), CI varied from 87.3 +/- 5.2 (minimum) to 114.3 +/- 5.1% (maximum), and RVESV index varied between 61.5 +/- 17.8 and 149.3 +/- 34.1% of mean 55.1 +/- 17.9 ml/m(2) during the ventilatory cycle. The variations in the cycle exceeded the measurement error even though the latter was greater for RVEF and volumes than for CI and SV index. For mean values, there was an inspiratory decrease in RVEF and increase in RVESV, whereas a rise in RVEDV largely prevented a fall in SV index. We conclude that cyclic RV afterloading necessitates multiple thermodilution measurements equally spaced in the ventilatory cycle for reliable assessment of RV performance during mechanical ventilation of patients.

[Syphilis in addicted pregnant women: better care through more awareness and contract between organizations involved]

Three women, aged 21, 20 and 30 years, were cocaine users and pregnant. There had been no prenatal monitoring until they reported with uterine contractions. Blood of the first two women was then tested; serology revealed active syphilis infections: their children had died in utero. The blood of the third woman had been tested as part of a street project; it revealed an active syphilitic infection but she could not be found for treatment. After delivery, the child showed withdrawal symptoms. The first and third women and the child of the third woman were treated with benzylpenicillin. The system for screening and treating drug-addicted pregnant women should be intensified.

Three distinct D-amino acid substitutions confer potent antiangiogenic activity on an inactive peptide derived from a thrombospondin-1 type 1 repeat

Mal II, a 19-residue peptide derived from the second type 1 properdin-like repeat of the antiangiogenic protein thrombospondin-1 (TSP-1), was inactive in angiogenesis assays. Yet the substitution of any one of three L-amino acids by their D-enantiomers conferred on this peptide a potent antiangiogenic activity approaching that of the intact 450-kDa TSP-1. Substituted peptides inhibited the migration of capillary endothelial cells with an ED50 of 8.5 nM for the D-Ile-15 substitution, 10 nM for the D-Ser-4 substitution, and 0.75 nM for the D-Ser-5 substitution. A peptide with D-Ile at position 15 could be shortened to its last seven amino acids with little loss in activity. Like whole TSP-1, the Mal II D-Ile derivative inhibited a broad range of angiogenic inducers, was selective for endothelial cells, and required CD36 receptor binding for activity. A variety of end modifications further improved peptide potency. An ethylamide-capped heptapeptide was also active systemically in that when injected i.p. it rendered mice unable to mount a corneal angiogenic response, suggesting the potential usefulness of such peptides as antiangiogenic therapeutics.

"Helper:" A critical events prompter for unexpected emergencies

OBJECTIVE

The medical practitioner is faced with an increasing list of protocols and algorithms related to patient care. These recommendations are often difficult to recall, particularly in stressful emergency situations. Using advanced cardiac life support (ACLS) protocols, we built a computer-based system to exhibit precompiled response plans for medical emergencies. To validate the usefulness of this prompting device, we tested application of two of the nine ACLS algorithms, pulseless ventricular fibrillation/ventricular tachycardia (Vfib/Vtach) and bradycardia, in a simulated operating room (OR) environment.

METHODS

The system utilized the software authoring system IconAuthor (Aimtec Inc., Nashua, NH) and a touch-screen monitor (DiamondScan, Microtouch, Methuen, MA). Prior to testing our system, all 39 subjects were given time to familiarize themselves with its operation. Subsequently, all subjects were videotaped while managing a standard simulated anesthetic. During the anesthetic, the subjects were presented with two emergency scenarios, not viewed during the familiarization period. The electrocardiographic (EKG) signals for normal sinus rhythm, ventricular fibrillation, and second-degree heart block were presented. By random selection, the prompter was available to half of the subjects for help with arrhythmia management (experimental group), while to half it was not (control group).

RESULTS

A total of 39 subjects completed the exercise. Use of the prompter enabled significantly more subjects to administer correct drugs and dosages during ventricular fibrillation. The correct lidocaine dose was chosen more often by the experimental group than by the control (p = 0.015); similarly MgSO4 was appropriately ordered more often in the experimental group (p = 0.003). During second-degree heart block, atropine was correctly followed with a dopamine infusion (p = 0.004), and epinephrine infusion was ordered for refractory bradycardia (p = 0.002) more often in the experimental than the control group.

CONCLUSIONS

These data demonstrate the value of a prompting device at the anesthesia workstation. We foresee the use of such prompters in many areas of medicine.

Transient increase in interleukin-8 and pulmonary microvascular permeability following aortic surgery

Aortic surgery results in ischemia/reperfusion of the lower body. This may liberate inflammatory mediators that activate neutrophils, and may result in lung microvascular changes with increased permeability and respiratory failure. We studied circulating inflammatory mediators and the pulmonary leak index (PLI) of 67Ga, a measure of transvascular transferrin transport and permeability, in patients scheduled for elective aortic and peripheral vascular surgery, before and after surgery. Aortic surgery patients in Groups 1 (n = 10) and 2 (n = 7) were studied before and at a median of 2.5 and 21.0 h after surgery, respectively. A control Group 3 (n = 6) was studied before and at a median of 2.9 h after peripheral vascular surgery. The PLI (median) increased from a median of 9.1 (range, 6.6 to 14.7) before to a median of 23.4 (range, 18.7 to 86.4) x 10(-3)/min after surgery in Group 1 but not in the other groups (p < 0.001). The postoperative increase in circulating neutrophils and elastase-alpha 1-antitrypsin, a marker of neutrophil activation, was similar among the groups. Plasma levels of activated complement 3a and tumor necrosis factor (TNF-alpha) did not change in any of the groups. In contrast, plasma levels of interleukin-8 (IL-8) increased in Group 1 from < 3 (range, < 3 to 37) before to 324 (range, 36 to 868) pg/ml after surgery, but did not change in the other groups (p < 0.005). The decrease in plasma levels of angiotensin converting enzyme (ACE) was greater in Group 1 than in the other groups (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Acute effect of ibopamine and isosorbide mononitrate on blood volume distribution in congestive heart failure

In order to compare ibopamine (IBO), a dopamine congener, with isosorbide mononitrate (ISMN) and to study their interaction in effects on the capacitance vasculature in congestive heart failure (CHF), a prospective, randomized, placebo-controlled, double-blind clinical trial was performed in 32 patients with New York Heart Association class II-IV CHF, randomly assigned to receive single oral doses of placebo, 200 mg IBO, 20 mg ISMN, or both IBO and ISMN. After labelling of red cells with 99mTc, changes in regional radioactivity, indicative of changes in blood volume, were recorded using a gamma-camera before and at 30, 60 and 120 min after drug administration. At 30 and 60 min, arterial systolic and pulse pressures were higher with IBO than with ISMN and placebo (for pulse pressure by mean 13.7 mmHg, 95% confidence interval 4.5-23.0 mmHg, at 30 min), probably reflecting an IBO-induced rise in stroke volume at unchanged heart rate and mean arterial pressure. IBO did not change regional radioactivity except for a transient increase of 4.4% (0.5-7.6%) in the thorax at 30 min. This was attenuated by concomitant ISMN treatment since, starting at 30 min, the drug increased radioactivity in the legs, compared with patients not receiving the drug, by 8.0% (95% confidence interval 0.2-15.8%), leading to a fall in thoracic and left ventricular radioactivity at 30 min of 3.4% (0.3-7.0%) and 6.4% (0.8-11.9%), respectively, and a fall of 5.5% (0.5-10.5%) in hepatic radioactivity at 60 min.(ABSTRACT TRUNCATED AT 250 WORDS)

Transvascular transport of 67Ga in the lungs after cardiopulmonary bypass surgery

STUDY OBJECTIVE

To examine the effect of cardiac surgery with cardiopulmonary bypass (CPB) on pulmonary vascular permeability.

DESIGN

A prospective, serial study.

SETTING

Department of nuclear medicine and intensive care units of a university hospital.

PATIENTS

Twelve consecutive patients were studied, before and immediately after elective cardiac surgery using CPB (group 1), and 4 consecutive, artificially ventilated patients with acute cardiogenic pulmonary edema (group 2).

MEASUREMENTS AND RESULTS

The kinetics in blood and over both lungs were measured, using two mobile probes at the bedside, of intravenously injected 67Ga, assumed to bind to circulating transferrin, and in vitro 99mTc-labeled red blood cells to account for pulmonary blood volume. From data recorded in time (1 h), a pulmonary leak index (PLI), the time constant of transport of 67Ga from the intravascular to the extravascular space of the lung, was calculated and values for both lungs were averaged. In group 1, the PLI (.10(-3).min-1, mean +/- SD) was 8.2 +/- 3.7 before and 17.0 +/- 13.5 after CPB surgery (p < 0.01) and changes directly related to the duration of CPB. In four patients with a CPB duration > or = 120 min, the PLI, 31.1 +/- 16.3.10(-3).min-1, exceeded 2 SD plus mean preoperative PLI. Changes in PLI tended to relate inversely to changes in arterial WBC, which, in turn, inversely related to CPB duration. The PaO2/FIO2 ratio decreased and tended to relate inversely to PLI after surgery. No patient developed alveolar pulmonary edema on chest radiograph. In group 2, the PLI was 11.1 +/- 3.1.10(-3).min-1 (NS from group 1 preoperative PLI).

CONCLUSIONS

Cardiopulmonary bypass induces a pulmonary vascular leak, as assessed by 67Ga kinetics using a bedside detection technique, in some cardiac surgery patients with prolonged CPB. This leak may reflect pulmonary vascular injury and increased permeability, following activation of leukocytes by CPB and subsequent pulmonary sequestration, rather than increased filtration through pressure factors. It may contribute to impaired gas exchange, even in the absence of manifest alveolar edema of the lungs, after surgery.

Prevalence and prediction of multiple organ system failure and mortality in acute pancreatitis

We studied the prevalence of multiple organ system failure (MOSF), the relations between age, pre-existing chronic conditions, local complications, systemic infection, organ system failure, and mortality in patients with acute pancreatitis. During the study period, 267 consecutive patients were admitted to a tertiary hospital with acute pancreatitis. Multivariate analyses were used to identify factors predictive of MOSF occurrence and mortality. Using a previously developed MOSF scoring system at our center, MOSF (> or = 2 organ systems) was found to occur in 63 (24%) of the patients. Cardiovascular, pulmonary, renal, and hepatic failure predominated. Advanced age (> 55 yr) and chronic disease were related to local complications and systemic infection (both, P < .001). Local complications and systemic infection occurred in 68% and 75% of patients, respectively. In multiple logistic regression, advanced age, chronic disease, local complications, and systemic infection independently contributed to the development of MOSF. Overall mortality was 19%. MOSF accounted for 96% of deaths; mortality increased from 1% to 79% in patients without and with MOSF, respectively. In multiple logistic regression, advanced age, chronic disease, local complications, failure of the cardiovascular, renal, hepatic, gastrointestinal, and neurological systems independently contributed to mortality prediction. Advanced age and prior chronic disease may reflect diminished physiological reserve and predispose to local complications, systemic infection, and MOSF. Although local complications and systemic infection are important predisposing factors for MOSF, a host-dependent response to unknown specific or nonspecific factors may have a role in the pathogenesis of the syndrome in 25% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

TQM and the financial function

The author maintains that financial officers should take a leadership role to improve the processes that provide value to a company's internal and external customers. He suggests several ways that the financial function can participate in and contribute to total quality management.

Total body blood volume redistribution in porcine E. coli septic shock: effect of volume loading, dobutamine, and norepinephrine

The purpose of the present study was to determine the effect of volume loading alone (CONTR) vs. volume loading in combination with dobutamine (DOBU) or norepinephrine (NOR) on total body blood volume distribution in septic shock. After instrumentation, injection of in vitro labelled 99mTc red blood cells, and baseline measurements, anesthetized, ventilated pigs (n = 21) received 3-4.10(8).kg-1 live E. coli bacteria intravenously. Images of thorax, abdomen, and hindlimb were obtained by using a gamma camera simultaneously with hemodynamic measurements. E. coli infusion resulted in a decrease in arterial pressure, ventricular filling pressures, and cardiac output with a concomitant increase in pulmonary arterial pressure. Blood volume was redistributed from the heart, lungs, spleen, abdomen, and leg to the liver. After randomization, the CONTR group (I, n = 5) was subjected to volume loading, and treatment groups (each n = 8) received volume loading in combination with DOBU (group II, 5-10 micrograms/kg/min) or NOR (group III, 0.25-0.50 micrograms/kg/min). As compared to volume loading alone, DOBU and NOR increased cardiac output but only NOR restored arterial pressure. Volume loading increased blood volume in all regions studied; however, it was unequally distributed amongst organs with a preference for the liver. Neither DOBU nor NOR influenced the partitioning of the infused volume between organs. However, NOR prevented pooling of blood in the leg.

The design and effectiveness of a graduate survey course in quality assurance and utilization review

This paper reports on the design, presentation, and evaluation of a graduate university course in quality assurance and utilization review. The authors cite the need for expanded course offerings in this field and present descriptions of the course design and student participants, including program location, objectives, learning themes and content, instructor team, students, and course process. Student feedback is reported including comments on course strengths and needs, teaching methods, and learning evaluation. Additional work requirements are cited.

Pressure transducers: an overlooked source of sepsis in the intensive care unit

Between January 1988 and May 1989 twenty cases of bacteremia due to Flavobacterium sp. occurred in 17 patients admitted to a surgical intensive care unit. Epidemiologic studies disclosed that the source of the Flavobacterium bacteremias was contaminated reusable pressure transducers. Despite the use of disposable domes spread of the bacteria from the contaminated transducer heads to the fluids given to the patients occurred. An indirect contamination by hands at the time the equipment was initially assembled must have been the mode of transmission. Reinstitution of routine disinfection of the transducer heads controlled the outbreak. Disposable domes failed to prevent septicemia from contaminated pressure transducers.

The haemodynamics of septic shock

Both peripheral vascular abnormalities and changes in myocardial function are hallmarks of septic shock. Their complex interactions result in inadequate and maldistributed microcirculatory flow and progressive organ dysfunction. Inappropriate vasodilation, microembolization and endothelial cell injury are proposed mechanisms that may induce maldistribution of flow in the microcirculation and inefficient, defective peripheral oxygen extraction. Abnormal myocardial function is manifested by diminished right and left ventricular ejection fractions, ventricular dilatation, altered Frank-Starling curves and diastolic pressure-volume relationships. These changes are already observed in an early stage of septic shock and are entirely reversible in survivors.

Multi-organ damage in exertional heat stroke

Exertion-induced heat stroke is a relatively rare disorder in the moderate maritime climate of The Netherlands. Serious complications of excessive physical activity rarely occur. We describe a marathon runner with multi-organ failure after exertion-induced heat stroke. The patient developed shock, diarrhoea, coma, rhabdomyolysis, acute renal failure, liver cell damage and disseminated intravascular coagulation but recovered completely.

Effect of dopamine vs norepinephrine on hemodynamics in septic shock. Emphasis on right ventricular performance

The effects of continuously infused dopamine and norepinephrine on hemodynamics, oxygen metabolism, and right ventricular (RV) performance were studied by crossover design in ten patients with septic shock who needed treatment with vasoactive drugs after fluid replacement. Standard hemodynamic measurements were obtained and RV performance assessed before and 1 h after the start of the infusion. All but one patient had pulmonary hypertension, and in seven the RV ejection fraction (RVEF) was lower than 50 percent at baseline. Drugs were titrated to a systolic arterial blood pressure of mean 106 +/- 18 mm Hg for dopamine and 116 +/- 20 mm Hg for norepinephrine (NS). Dopamine infusion increased the cardiac index (CI) 16 percent (p less than 0.02), but heart rate and systemic and pulmonary vascular resistances were unchanged. With norepinephrine CI was unchanged, a heart rate decreased 7 percent (p less than 0.05), and systemic and pulmonary vascular resistance increased 35 and 26 percent, respectively (p less than 0.05). With both drugs, RV volumes and RVEF remained unchanged, and systemic oxygen consumption increased equally (by 19 percent for dopamine and 22 percent for norepinephrine, p less than 0.05); systemic oxygen delivery rose by 17 percent during dopamine infusion and was unchanged during norepinephrine infusion. Norepinephrine increased oxygen extraction vs dopamine (p less than 0.05). There were no differences in urinary output. Norepinephrine may improve the RV oxygen supply/demand ratio, but this potentially beneficial effect on RV ejection fraction may be offset by a concomitant increase in pulmonary vascular resistance and RV afterload. Norepinephrine may not adversely affect the peripheral circulation. In short-term treatment of volume-resuscitated, severe septic shock complicated by pulmonary hypertension and impaired RV performance, norepinephrine may be at least as effective as dopamine.

Biventricular performance during volume loading in patients with early septic shock, with emphasis on the right ventricle: a combined hemodynamic and radionuclide study

The cardiac response to a rapid volume infusion was studied in 18 patients with septic shock accompanied by pulmonary hypertension. Right and left ventricular ejection fractions were measured, and right and left ventricular volume indices were calculated from ejection fractions and stroke volumes before and 30 minutes after the start of the infusion. Responders (13 patients) showed an increase in stroke volume index (SVI) as a result of a mean 30% increase in right ventricular end-diastolic volume index (RVEDVI) and a mean 17% increase in left ventricular end-diastolic volume index (LVEDVI) during volume loading. In the nonresponders (five patients) fluid loading resulted in a decreased or unchanged SVI; this was accompanied by a 7% increase in RVEDVI but no change in LVEDVI, although both the central venous pressure and pulmonary capillary wedge pressure increased. At baseline, nonresponders differed from responders as evidenced by a high central venous pressure and RVEDVI but a lower mean arterial pressure: thus, right ventricular coronary perfusion pressure was lower and right ventricular wall stress may have been higher. Mean pulmonary artery pressure did not differ between the groups. Our data suggest that in some patients with septic shock volume loading does not result in increased forward flow because of right ventricular failure associated with pulmonary hypertension and coronary hypotension.

The influence of catecholamines on right ventricular function in septic shock

Catecholamines play an important role in the treatment of septic shock. Not much is known about their effects on right ventricular function. In this paper the available data on the effects of different catecholamines on right ventricular dysfunction complicating septic shock are reviewed.

The immediate effect of nitroglycerin on total body blood volume distribution in patients with congestive heart failure: a non-invasive study

The effect of sublingually administered nitroglycerin (0.5 mg) on distribution of blood volume in 16 patients with congestive heart failure (NYHA class II and III), randomly assigned to placebo (N = 8) or nitroglycerin (N = 8) was studied 20 minutes after in vivo labelling of red blood cells with 99m-Tc pertechnetate. Count rates over thorax, abdomen and legs were collected with a large field gamma camera and expressed as percentage changes of baseline value. Changes in count rates, averaged for 5, 10 and 15 minutes after drug administration showed a significant decrease in the nitroglycerin group as compared to the placebo group over the thorax (mean 5%, P less than 0.01) and over the liver (mean 5%, P less than 0.05) and a significant increase over the abdomen (mean 4%, P less than 0.01) and the legs (mean 9%, P less than 0.01). After nitroglycerin, the changes in pulmonary activity were variable and did not differ from the placebo group. These results indicate that nitroglycerin causes a redistribution of blood volume in patients with congestive heart failure. An increase in the vascular capacitance in the abdomen and legs may be responsible for a decrease of blood volume of the thorax and the liver in these patients.

Necrotizing enterocolitis: intraluminal biochemistry in human neonates and a rabbit model

The intestinal contents of 17 neonates with necrotizing enterocolitis were analyzed for pH, carbohydrate, protein, and bacteria. The intraluminal pH was less than 5.0 (16/17). Sufficient carbohydrate and bacteria capable of fermenting the carbohydrate to organic acids were found. The intraluminal protein content was greater than 5 g/dl. The variables of acid and protein were then examined in a rabbit intestinal loop model. The hemorrhagic response in individual loops was measured using Cr51 tagged red blood cells such that the microliters of blood per centimeter intestine could be determined. Loops with organic acid and protein had significantly (p less than 0.01) more intramural blood than control loops. Organic acid (possibly generated by bacterial mixed acid fermentation of carbohydrate) in the presence of protein promotes intramural hemorrhage similar to that seen in neonates with necrotizing enterocolitis.

Interaction between bovine casein and V. cholerae enterotoxin in the rabbit ileal loop

Secretory IgA from human breast milk neutralizes cholera enterotoxin in the rabbit ileal loop system. No similar protection by purified bovine milk proteins could be demonstrated; however, one bovine milk protein, casein, had a deleterious effect on intestine exposed to very small quantities of enterotoxin. Highly purified cholera toxin (10 or 100 ng) was incubated with bovine protein solutions for 60 min at 37 degrees C. One-milliliter aliquots were then injected into prepared rabbit intestine loops. The animals were sacrificed at 18 h and the intestinal loop contents were aspirated, and a volume to length of loop ratio (V/L) was determined. The activity of 100 ng of toxin was not enhanced by the majority of bovine milk proteins, but bovine casein caused a 14-40% increase in the fluid production (V/L of casein + toxin versus toxin, 1.05 versus 0.92 and 1.82 versus 1.30). All of the bovine proteins but casein inhibited the action of low dose enterotoxin. Bovine casein caused a 78-90% increase in fluid production by loops exposed to a suboptimal toxin dose (10 ng) (V/L of casein + toxin versus toxin, 1.12 versus 0.63 and 0.95 versus 0.50). Virtually all of this enhancement of enterotoxin fluid response resided in the purified alpha-casein fraction.

Assessment of risk factors and surgical outcome

Patients with known cardiac disease who face operative procedures are usually more concerned than other patients because they perceive themselves to be at greater risk. By reviewing several studies of preoperative risk factors, the author attempts to find which factors imply significant risk of mortality in surgical patients with cardiac disease.

Spontaneous rupture of the spleen complicating portal hypertension

A 54-year-old male with alcoholic liver cirrhosis and hepatic coma grade IV is described, who succumbed as a result of spontaneous rupture of the spleen. A relationship to portal hypertension is suggested, although haemorrhagic diathesis and sepsis may have been contributing factors.

Starting insulin therapy in children with newly diagnosed diabetes

Eight years ago, a decision was made to eliminate unnecessary hospitalization of children with newly diagnosed diabetes mellitus. This decision required changes in the basic approach to starting insulin therapy and education of the parents. Since then, 52 children aged 11 months to 16 years have been treated. Forty-four of these children were sent home after one to four hours of instruction. Five children received intravenous therapy for two to five hours and then went home. The remaining three children were admitted to the hospital for 18 to 40 hours. Subsequent establishment, at home, of diabetes control was accomplished without incident. The first injection of subcutaneous insulin was generally a combination of regular and slowly absorbed insulin. This approach has been well received by patients, parents, and referring physicians.

Newborn phenylalanine/tyrosine metabolism. Implications for screening for phenylketonuria

Controversy over the sensitivity of newborn screening for phenylketonuria (PKU) has recently led to the specific recommendation that infants discharged within the first 24 hours of life be routinely retested at 1 to 2 weeks of age. To address this controversy, data from cord blood samples, phenylalanine (Phe) tolerance tests at 3 days of age, and sequential plasma Phe determinations in six siblings of known cases of PKU or hyperphenylalaninemia were analyzed, along with data from the literature. These analyses showed that normal and probably heterozygous infants decrease their Phe concentrations with age, while infants with PKU or PKU variants increase their Phe concentrations with age but at varying rates. Predictive equations showed that the sensitivity of the screening test rapidly increases with age, so that the usual critical value of 4 mg/dL is satisfactory for suspecting PKU after 18 hours of age. A critical value of 3 mg/dL would be equally satisfactory at any age, if the Guthrie test were appropriately modified to include a 3-mg/dL standard.

Transfusion nomogram: an application of physiology to clinical decisions regarding the use of blood

A nomogram has been prepared that depicts relationships between cardiac output (Q), oxygen consumption (Vo2), hemoglobin concentration (Hb), the position of the oxygen-hemoglobin dissociation curve, the oxygen saturation of arterial blood (SaO2), and the partial pressure of oxygen in the mixed venous blood (PVO2). Examples are provided to illustrate how this nomogram may be employed to facilitate decisions regarding the need for blood transfusions in patients in whom oxygen delivery may be impaired.