The KBG syndrome

We report on two boys with a combination of short stature, a broad face, macrodontia and developmental delay. These features suggest that they have the KBG syndrome, a rare but distinctive phenotype. The pattern of inheritance remains uncertain and both autosomal dominant and X-linked recessive inheritance should be considered in genetic counselling.

A fluid filtration and clearing technique to assess microleakage associated with three dentine bonding systems

OBJECTIVES

The aims of this in vitro study were to (a) measure fluid flow through teeth restored with one of three dentine bonding systems and a resin composite restoration; (b) measure the distribution of a silver tracer through the same teeth, and make a comparison with fluid flow; and (c) investigate the effect of thermocycling on both measurement types.

METHODS

Coronal segments of 30 premolars, randomly allocated to three equal groups, were assessed by fluid filtration. Each group was restored with a resin composite restoration in conjunction with Fuji Bond LC (FBLC), Scotchbond Multi-Purpose Plus (SMP+) or Prime&Bond 2.1 (P&B2.1). Fluid filtration rates were measured in the intact crown and then after cavity preparation, conditioning, dentine bonding, restoration and at 2 and 24 h, 1 week and 1 month following restoration. Six specimens from each group were thermocycled at 1 week. After final filtration measurements the specimens were perfused with silver nitrate and cleared before scoring tracer penetration.

RESULTS

No significant differences (P > 0.05) in fluid filtration rates were found amongst the different bonding systems or at any restoration stage. Thermocycling was not associated with any significant (P > 0.05) increase in fluid filtration. Final fluid filtration and tracer distribution showed a weak and not statistically significant correlation (P > 0.05). The penetration of silver stain indicated a failure of the restorations to seal the cavity and demonstrated a possible pathway by which in vivo post-operative sensitivity could occur.

CONCLUSIONS

Although not statistically significant, conditioning of the cavity increased the dentinal permeability but this effect was variable. Thermocycling had no statistically significant effect on microleakage.

In vitro dentinal penetration by tracers used in microleakage studies

Many microleakage studies, in their methodology, employ different tracers which may penetrate around restorative materials to varying extents due to their physical or chemical characteristics. The present series of in vitro studies were designed to compare the ability of freshly obtained microleakage tracers to enter cut dentinal tubules. Tracers selected were 5% eosin, 2% methylene blue, 50% silver nitrate and Indian ink all buffered, where necessary, to a range of pH 6.9-7.2. The solution of Indian ink was further investigated by particle size analysis to determine the range of particle sizes within the solution. Particles ranged from < 1 micron to 600 microns. Buffered and unbuffered solutions of the tracers were applied for 1 h to open cavities, devoid of a smear layer, prepared in 42 premolars. Specimens were sectioned longitudinally through the cavities either with or without water coolant. Penetration into dentinal tubules by the tracer resulted in an area of stained dentine and this area was subsequently measured using image analysis. The results demonstrated that there were few statistically significant differences between the areas of dentinal penetration associated with each tracer. Neither the tracer used, its pH nor sectioning technique had a predictably significant effect on dentinal penetration. Indian ink was observed to be capable of entering dentinal tubules.

Peripheral nerve entrapment syndromes: diagnosis and management

Symptoms due to nerve entrapment syndromes are a frequent reason for attendance at GP, rheumatology and orthopaedic clinics. This article outlines the presenting symptoms and signs of some of the more common syndromes and gives guidelines on the clinical diagnosis and subsequent management.

The natural history of chronic demyelinating neuropathy associated with benign IgM paraproteinaemia. A clinical and neurophysiological study

Eighteen patients are described, all of whom had chronic demyelinating peripheral neuropathy and benign IgM paraproteinaemia. All patients had serum antibodies against peripheral nerve myelin or myelin-associated glycoprotein. Seventeen were followed up clinically and electrophysiologically for between 1 and 14 years (mean 7.4 years). The presenting symptoms and signs were almost always those of a distal sensory disturbance in the limbs followed by distal weakness. All patients developed tremor or ataxia in the arms, and gait ataxia. The severity of the neuropathy varied greatly between patients at similar stages. Some had a predominantly sensory deficit and others a predominantly motor deficit. All patients eventually developed both motor and sensory signs. The neuropathy became slowly worse over the first 2-5 years and then appeared to stabilize, although long-term follow-up did reveal a very slow progression in the group as a whole. No patient developed evidence of haematological malignancy but two patients died of malignancy involving other systems. On reviewing 75 patients from the literature, non-haematological malignancy was found to be the commonest cause of death.

Excessive wastage of blood resources in elective colorectal surgery

A prospective study of perioperative blood transfusion requirements for elective colorectal surgery over a 6-month period has been conducted. A total of 106 procedures was performed, 94 of which were for malignancy. A median of 2 units of packed red cells was cross-matched per patient. Twenty-three patients (21.7%) required a transfusion in the postoperative period. Fourteen of these patients required a second cross-match sample because their transfusion occurred more than 48 h after the original request. The greatest transfusion requirements were for patients undergoing abdominoperineal resection or subtotal colectomy. Routine perioperative cross-matching and reservation of blood for elective colorectal surgery may be an unnecessary expense, resulting in wastage of resources. A selective policy of serum being retained for grouping in these patients is justified.

Small bowel adenocarcinoma complicating Crohn's disease

Crohn's disease of the small intestine is usually managed by medical therapy with surgery being reserved for obstruction or fistula formation. A patient is described who developed small bowel obstruction due to an adenocarcinoma of the ileum after over twenty years of medical therapy for Crohn's disease, originally diagnosed at a laparotomy for acute abdominal pain. The possibility of malignancy in such long-standing disease should be considered.

Relationship of cranial ultrasonography, visual and auditory evoked responses with neurodevelopmental outcome

Sixty-two preterm infants were followed up with flash visual evoked responses (VERs), brainstem auditory evoked responses (BAERs) and neurodevelopmental assessments for 18 months after term. Cranial ultrasonography showed that 18 infants developed intraventricular haemorrhage (IVH) during the newborn period and four of six infants with grade III or IV haemorrhage had absent VERs at term. The mean latency of the VER in the infants with IVH was significantly shorter than that of infants without IVH. There was no correlation between the degree of ventricular dilatation at term and the latency of the VER. Six months after term the four infants with previously absent VERs had normal responses, though there was still a significant difference between the latencies of infants with and without IVH. At 12 and 18 months of age these differences had disappeared. BAERs were not significantly different in the infants with and without IVH, and there was no difference in the VERs or BAERs of infants with neurodevelopmental delay and those developing normally. Neither flash VERs nor BAERs provide a good prognostic indicator of future neurodevelopmental disability or outcome.

Maintenance cimetidine instead of surgery for duodenal ulcer: the first decade

Fifty five patients with severe longstanding dyspepsia originally selected as candidates for elective duodenal ulcer surgery were instead entered into a maintenance cimetidine study. Forty six have been reviewed after 10 years. Twenty patients had required surgery, all in the first three years, but six of them had proven or suspected recurrent ulceration during follow up. Twenty six patients avoided surgery, either with continuous cimetidine 400 mg nocte or intermittent full dose cimetidine. Of the 17 on continuous maintenance cimetidine, six had proven or suspected recurrent ulceration responding to full dose cimetidine. All nine patients on intermittent cimetidine experienced symptomatic relapse within eight to 12 weeks of drug withdrawal. By using cimetidine, 64% of patients selected for surgery have avoided operation over this 10 year period, although none has had drug free remission.

The compatibility of temporary soft materials with immersion denture cleansers

This laboratory study evaluated the effect of five denture cleansers on five temporary soft materials that can be used as interim soft linings or as tissue conditioners. The materials were assessed at 3, 7, 14, and 21 days for evidence of changes in surface quality and softness. It was apparent that the correct combination of lining material and cleanser is essential to ensure the optimum function of the lining material. Since the materials used varied in softness, the appropriate choice should be based on the clinical requirement.

Effect of cimetidine on prognosis after simple closure of perforated duodenal ulcer

A prospective controlled study in 60 patients undergoing simple closure of perforated duodenal ulcer demonstrated a significant (P less than 0.05) benefit following postoperative cimetidine treatment, in terms of avoiding subsequent dyspeptic symptoms and complications of peptic ulcer disease. Thus cimetidine is recommended in the follow-up management of perforated duodenal ulcers.

Isoflurane: effect on the encephalogram during carotid endarterectomy

The effect of isoflurane on the electroencephalogram was studied in patients monitored during carotid endarterectomy. Increasing concentrations of this agent cause changes, but did not affect the ability to detect the onset of cerebral ischaemia consequent upon temporary occlusion of the internal carotid artery. At 1.0% and 1.5% concentration isoflurane caused significant decreases in mean arterial pressure which is undesirable in patients undergoing vascular surgery.

Chronic demyelinating neuropathy associated with benign IgM paraproteinaemia

Twelve cases of chronic sensorimotor neuropathy associated with benign IgM paraproteinaemia are described. The onset was in the sixth or seventh decades and 9 cases were male. Tremor and ataxia were common features. The ESR was raised in 6 cases and the CSF protein content elevated in 10. There was severe reduction of motor nerve conduction velocity. Sera from all cases contained monoclonal IgM antibodies strongly reactive with human peripheral myelin, made up by the paraprotein. Histological studies on nerve biopsies taken from 8 cases all demonstrated a demyelinating neuropathy. Eight biopsies were examined by immunofluorescence. Monoclonal IgM was present on the myelin sheaths of surviving myelinated nerve fibres. The findings suggested that the neuropathy was of autoimmune origin and caused directly by the antimyelin antibody.

Colonic rupture after blunt trauma

A case report of an unusual colonic injury from closed abdominal trauma is described. Diagnosis was made late by an air enema but prompt staged surgical intervention resulted in successful recovery.

Neurological involvement in hereditary transcobalamin II deficiency

A case of hereditary transcobalamin II deficiency with neurological involvement is described. The patient presented in early infancy with megaloblastic anaemia and was treated with folinic acid from 6 weeks of age. The diagnosis of transcobalamin II deficiency was not made until he was 2 years old when he showed severely retarded intellectual development, ataxia and pyramidal deficit in the limbs. Following treatment with hydroxocobalamin, his condition has slowly improved but he has remained with a severe neurological deficit. The consequences of vitamin B12 deficiency on neurological development in infancy are discussed.

Spinal somatosensory evoked potentials in hereditary spastic paraplegia

Cervical somatosensory evoked potentials elicited by median nerve stimulation were recorded from 18 cases of hereditary spastic paraplegia. Motor and sensory nerve conduction in the median nerve was normal in each. In one third of the patients no spinal evoked potential was detectable. In the remainder the amplitude of the evoked potential was reduced in comparison with a control series; the latency was not significantly different. These changes suggest that a selective degeneration of the centrally directed axons derived from the dorsal root ganglion cells occurs in this disorder. The findings are discussed in relation to previous reports on the pathological appearances.

Long term cimetidine in the management of severe duodenal ulcer dyspepsia

Sixty patients who had been referred for elective ulcer surgery, and in whom a remission had been induced, entered a prospective double blind controlled trial of a single daily dose of 400 mg of cimetidine given at bedtime, or placebo. Eighty per cent of patients receiving placebo suffered symptomatic relapse and recurrence of duodenal ulceration at endoscopy within 6 months. The mean interval to relapse was 10 weeks. On the other hand, only 27 percent of patients had a recurrence during the 6-month period on low dose cimetidine therapy. No significant toxic or other side effects which could be attributed to the drug were observed.

Oral cimetidine in severe duodenal ulceration. A double-blind controlled trial

40 adult outpatients with active endoscopically proven duodenal ulceration, who would otherwise have merited elective ulcer surgery, entered a double-blind trial of either cimetidine (1g/day) or placebo. After twenty-eight days, 17 of 20 (85%) patients receiving cimetidine showed ulcer healing, compared with 5 of 20 patients receiving placebo (p less than 0.0005). Patients receiving cimetidine had significantly more pain-free days and pain-free nights than those receiving placebo. There was good correlation between ulcer healing and symptomatic relief (p less than 0.0005).

A three-phase clinical evaluation of prazosin

A preliminary study of cardiac hemodynamics with measurement in both supine and tilt positions showed that the antihypertensive effect of prazosin given intravenously is associated with a fall in total peripheral resistance, with minor effects on cardiac output and heart rate, and with no consistent orthostatic hypotension. The postural reflexes appear to remain intact. The results are entirely similar to those reported by Lund-Johansen. In a second, short-term study of ambulatory patients, prazosin alone exerted an antihypertensive effect somewhat less than that of methyldopa, but the difference in blood pressure reduction between supine and standing positions was less with prazosin than with methyldopa. Both drugs were well tolerated. In a third, long-term study, prazosin alone gave satisfactory antihypertensive results, and prazosin used in combination with polythiazide produced a satisfactory response in 80% of the patients.

Results of surgery for Crohn's disease in the Glasgow region, 1961-70

During the period 1961-70, 283 patients in the Glasgow region have been studied with regard to the outcome of 418 surgical procedures performed for Crohn's disease. Resection was followed by an overall recurrence rate of 33 per cent, but in disease confined to the large bowel the rate was 18 per cent. Exploratory operations and bypass procedures were followed by a recurrence rate of 70 per cent. Evidence is provided that recurrence following bypass procedures for small bowel disease and ileocolitis occurs at a later stage than after exploratory operations alone. By the end of the study 77 per cent of patients in this series had required one or more resections.

Prazosin in the treatment of hypertension

1. Prazosin decreases blood pressure in normotensive, renal hypertensive and spontaneous hypertensive rats. The effect is greatest in the last-named. 2. In spontaneously hypertensive rats the decrease in pressure is associated with a decrease in heart rate. 3. In hypertensive patients prazosin decreases blood pressure by decreasing total peripheral resistance with minor effects on cardiac output. 4. Prazosin is effective in the long-term therapy of hypertensive patients, alone and in combination with a diuretic. The effect on blood pressure is the same in the supine and standing position.

Gastric-acid output, pepsin output, and lean body mass in normal and duodenal-ulcer subjects

Gastric-acid output bears a significant relationship to parietal cell mass and to lean body mass. The relationships of pepsin output to gastric-acid output and to lean body mass have been investigated in 13 normal subjects and 40 duodenal-ulcer patients. Peak pepsin output (P.P.O[I]) was stimulated by insulin-induced hypoglycaemia and the enzyme was assayed by Piper's method. Peak acid output to pentagastrin (P.A.O.[Pg] was obtained at a separate test. P.P.O.(I) correlated significantly with P.A.O.(Pg) in normal subjects (r equals 0-889, P less than 0-0001). P.P.O.(I) also showed good correlation with lean body mass (L.B.M.) (r equals 0-714, P less than 0-01), suggesting that P.P.O.(I) reflects peptic cell mass in normal subjects. In 40 duodenal-ulcer subjects there was no significant overall correlation of P.P.O.(I) with P.A.O(Pg) or with L.B.M. However, expressing the results as output of pepsin per milliequivalent of acid per kilogramme of lean body mass allowed separation of the ulcer patients into two groups whose ratios appeared to correlate with their symptomatic state at the time of testing: thus mean P.P.O(I) per meq. acid per kg. L.B.M. for duodenal-ulcer patients in relapse was significantly greater than the ratios for the patients in remission and for the normal group (P less than 0-001), suggesting either the presence of an increased sensitivity to insulin stimulation or a lack of pepsin inhibitor substance during a relapse of ulcer symptoms.

Epidemiological aspects of Crohn's disease in Clydesdale 1961-1970

A retrospective study of Crohn's disease has been carried out in Clydesdale covering the decade 1961-1970. Three hundred and fifty-seven patients had acceptable evidence of either acute ileitis or of chronic granulomatous bowel disease. Of those fulfilling the criteria for inclusion in the study of chronic disease, 95% had accurate pathological and/or operative documentation of the lesions. Overall, females outnumbered males by 1-6:1 but colonic disease alone tended to affect females, particularly those over the age of 50. The annual incidence of all forms of the chronic disease in both sexes has increased during the decade, but diagnosis of colonic disease alone increased two-fold in the latter half of the study.

Pasture management and cultural methods for the control of annual ryegrass (Lolium rigidum) in wheat

The effects of four pasture management treatments-haycutting, heavy grazing, burning and a control-and two cultural treatments,-mouldboard or disc ploughing-on the densities of annual ryegrass (Lolium rigidum) under subsequent wheat crops, was measured in 16 experiments conducted from 1961 to 1968. Pasture management treatments before cropping significantly reduced subsequent ryegrass populations in first, second, third and fourth year crops, compared with the untreated control and increased grain yields in the first and second year crops. Subsequent ryegrass populations were reduced more by mouldboard ploughing than by disc ploughing and this was reflected in higher yield for all crops. The results indicate that these management and cultural methods may obviate the need for chemical control in first and second year crops.