Thoracic impedance pneumography in propofol-sedated patients undergoing percutaneous endoscopic gastrostomy (PEG) placement in gastrointestinal endoscopy: A prospective, randomized trial

STUDY OBJECTIVE

To assess the efficacy of an ECG-based method called thoracic impedance pneumography to reduce hypoxic events in endoscopy.

DESIGN

This was a single center, 1:1 randomized controlled trial.

SETTING

The trial was conducted during the placement of percutaneous endoscopic gastrostomy (PEG).

PATIENTS

173 patients who underwent PEG placement were enrolled in the present trial. Indication was oncological in most patients (89%). 58% of patients were ASA class II and 42% of patients ASA class III.

INTERVENTIONS

Patients were randomized in the standard monitoring group (SM) with pulse oximetry and automatic blood pressure measurement or in the intervention group with additional thoracic impedance pneumography (TIM). Sedation was performed with propofol by gastroenterologists or trained nurses.

MEASUREMENTS

Hypoxic episodes defined as SpO2 < 90% for >15 s were the primary endpoint. Secondary endpoints were minimal SpO2, apnea >10s/>30s and incurred costs.

MAIN RESULTS

Additional use of thoracic impedance pneumography reduced hypoxic episodes (TIM: 31% vs SM: 49%; p = 0.016; OR 0.47; NNT 5.6) and elevated minimal SpO2 per procedure (TIM: 90.0% ± 8.9; SM: 84.0% ± 17.6; p = 0.007) significantly. Apnea events >10s and > 30s were significantly more often detected in TIM (43%; 7%) compared to SM (1%; 0%; p < 0.001; p = 0.014) resulting in a time advantage of 17 s before the occurrence of hypoxic events. As a result, adjustments of oxygen flow were significantly more often necessary in SM than in TIM (p = 0.034) and assisted ventilation was less often needed in TIM (2%) compared with SM (9%; p = 0.053). Calculated costs for the additional use of thoracic impedance pneumography were 0.13$ (0.12 €/0.11 £) per procedure.

CONCLUSIONS

Additional thoracic impedance pneumography reduced the quantity and extent of hypoxic events with less need of assisted ventilation. Supplemental costs per procedure were negligible.

KEY WORDS

thoracic impedance pneumography, capnography, sedation, monitoring, gastrointestinal endoscopy, percutaneous endoscopic gastrostomy.

Attitudes of Jordanian Nurses Toward Caring for Dying Patients

Hospital nurses are expected to care for dying patients. Such care provokes many undesired emotions and attitudes that affect the quality of care. This study aims to assess the attitudes of Jordanian nurses toward caring for dying patients in addition to examining the relationship between nurses' attitudes toward caring for dying patients and their selected characteristics. A quantitative descriptive cross-sectional research design was used to recruit a total of 290 Jordanian nurses from two hospitals in Jordan. The findings of this study revealed a significant correlation between nurses' attitudes toward caring for dying patients and receiving educational courses on palliative care (p = .008). Also, the study found a correlation between nurses' attitudes toward caring for dying patients and prior experience attending death cases (p = .004). The attitudes nurses have toward caring for dying patients are affected by educational courses, which make these attitudes adjustable toward the positive.

Final Measurement of the ^{235}U Antineutrino Energy Spectrum with the PROSPECT-I Detector at HFIR

This Letter reports one of the most precise measurements to date of the antineutrino spectrum from a purely ^{235}U-fueled reactor, made with the final dataset from the PROSPECT-I detector at the High Flux Isotope Reactor. By extracting information from previously unused detector segments, this analysis effectively doubles the statistics of the previous PROSPECT measurement. The reconstructed energy spectrum is unfolded into antineutrino energy and compared with both the Huber-Mueller model and a spectrum from a commercial reactor burning multiple fuel isotopes. A local excess over the model is observed in the 5-7 MeV energy region. Comparison of the PROSPECT results with those from commercial reactors provides new constraints on the origin of this excess, disfavoring at 2.0 and 3.7 standard deviations the hypotheses that antineutrinos from ^{235}U are solely responsible and noncontributors to the excess observed at commercial reactors, respectively.

Joint Determination of Reactor Antineutrino Spectra from ^{235}U and ^{239}Pu Fission by Daya Bay and PROSPECT

A joint determination of the reactor antineutrino spectra resulting from the fission of ^{235}U and ^{239}Pu has been carried out by the Daya Bay and PROSPECT Collaborations. This Letter reports the level of consistency of ^{235}U spectrum measurements from the two experiments and presents new results from a joint analysis of both data sets. The measurements are found to be consistent. The combined analysis reduces the degeneracy between the dominant ^{235}U and ^{239}Pu isotopes and improves the uncertainty of the ^{235}U spectral shape to about 3%. The ^{235}U and ^{239}Pu antineutrino energy spectra are unfolded from the jointly deconvolved reactor spectra using the Wiener-SVD unfolding method, providing a data-based reference for other reactor antineutrino experiments and other applications. This is the first measurement of the ^{235}U and ^{239}Pu spectra based on the combination of experiments at low- and highly enriched uranium reactors.

Joint Measurement of the ^{235}U Antineutrino Spectrum by PROSPECT and STEREO

The PROSPECT and STEREO collaborations present a combined measurement of the pure ^{235}U antineutrino spectrum, without site specific corrections or detector-dependent effects. The spectral measurements of the two highest precision experiments at research reactors are found to be compatible with χ^{2}/ndf=24.1/21, allowing a joint unfolding of the prompt energy measurements into antineutrino energy. This ν[over ¯]_{e} energy spectrum is provided to the community, and an excess of events relative to the Huber model is found in the 5-6 MeV region. When a Gaussian bump is fitted to the excess, the data-model χ^{2} value is improved, corresponding to a 2.4σ significance.

A prospective evaluation of the American College of Surgeons Surgical Risk Calculator as a predictor of complications for breast surgery

BACKGROUND

The infection rates for operative management of breast cancer are often unpredictable and higher than average for a clean surgical procedure (0.8% and 28%). We aimed to assess the effectiveness of the American College of Surgeons (ACS) Surgical Risk Calculator (SRC), a preoperative scoring system to calculate the risk of surgical site infection (SSI) and serious complications following breast surgery.

METHODS

Prospective risk scoring using the SRC on 213 patients in the preoperative clinic and the incidence of SSI and serious complications within 30 days postoperatively was prospectively collected.

RESULTS

The overall SSI rate in our sample was 5% (n=11/210 patients). For a one-unit increase in SRC score, the odds of having SSI increased by a factor of 1.88 (95% CI 1.33 to 2.74). Odds of developing SSI were higher in patients with high Body Mass Index (OR 1.25; 95% 1.13 to 1.40) and American Society of Anesthesiologists score 3 (OR 11.54; 95% CI 2.98 to 43.65). The odds of developing an SSI were ∼19 times higher if a patient had an SRC score >3.0 versus those with an SRC score <3.0. Only 3% (n=4) of patients who had an SRC score of <3.0 experienced SSI, compared with 33% (n=7) for those with a risk score of >3.0. Out of 210 patients, 9 had serious complications (4.2%).

CONCLUSIONS

ACS SRC Score of more than 3 was associated with a higher likelihood of SSI. SRC was able to predict the risk of SSI and serious complications and can be used preoperatively for identification and risk minimisation.

Nonfuel Antineutrino Contributions in the High Flux Isotope Reactor

Reactor neutrino experiments have seen major improvements in precision in recent years. With the experimental uncertainties becoming lower than those from theory, carefully considering all sources of ν ¯ e is important when making theoretical predictions. One source of ν ¯ e that is often neglected arises from the irradiation of the nonfuel materials in reactors. The ν ¯ e rates and energies from these sources vary widely based on the reactor type, configuration, and sampling stage during the reactor cycle and have to be carefully considered for each experiment independently. In this article, we present a formalism for selecting the possible ν ¯ e sources arising from the neutron captures on reactor and target materials. We apply this formalism to the High Flux Isotope Reactor (HFIR) at Oak Ridge National Laboratory, the ν ¯ e source for the the Precision Reactor Oscillation and Spectrum Measurement (PROSPECT) experiment. Overall, we observe that the nonfuel ν ¯ e contributions from HFIR to PROSPECT amount to 1% above the inverse beta decay threshold with a maximum contribution of 9% in the 1.8-2.0 MeV range. Nonfuel contributions can be particularly high for research reactors like HFIR because of the choice of structural and reflector material in addition to the intentional irradiation of target material for isotope production. We show that typical commercial pressurized water reactors fueled with low-enriched uranium will have significantly smaller nonfuel ν ¯ e contribution.

Optimum lithium loading of a liquid scintillator for neutron and neutrino detection

Neutral particle detection in high-background environments is greatly aided by the ability to easily load ⁶Li into liquid scintillators. We describe a readily available and inexpensive liquid scintillation cocktail stably loaded with a Li mass fraction up to 1 %. Compositions that give thermodynamically stable microemulsions (reverse-micellar systems) were explored, using a Compton spectrum quenching technique to distinguish these from unstable emulsions. Scintillation light yield and transmittance were characterized. Pulse shape discrimination (PSD) was measured using a ²⁵²Cf source, showing that electron-like and proton-like recoil events are well-resolved even for Li loading up to 1 %, providing a means of background suppression in neutron/neutrino detectors. While samples in this work were prepared with ^nat Li (7.59 % ⁶Li), the neutron capture peak was clearly visible in the PSD spectrum; this implies that while extremely high capture efficiency could be achieved with ⁶Li-enriched material, a very inexpensive neutron-sensitive detector can be prepared with ^nat Li.

Successful embolisation of pelvic fistulating vessels to the prostate arising after TURP - a rare cause of postoperative bleeding

Transurethral resection of the prostate (TURP) is considered the gold-standard operation to treat lower urinary tract symptoms due to benign prostatic enlargement in men. Postoperative bleeding is a recognised complication and managing it is a core skill required by attending urologists. We report a rare case of postoperative bleeding caused by fistulating vessels to the prostate which developed after TURP. These fistulas arose from the right internal iliac vessels and communicated with pre-existing pelvic varices affecting the right paraprostaticand seminal vesicle tissues. The fistulating vessels were successfully embolised with liquid embolic agent. Surgeons should be aware that persisting haemorrhage can occur post-TURP from the rare presence of fistulating vessels communicating with pelvic varices. Early computed tomography angiographic assessment is warranted in cases where bleeding is prolonged and refractory to standard management in view of timely referral for percutaneous embolisation.

Measurement of the Antineutrino Spectrum from ^{235}U Fission at HFIR with PROSPECT

This Letter reports the first measurement of the ^{235}U ν[over ¯]_{e} energy spectrum by PROSPECT, the Precision Reactor Oscillation and Spectrum experiment, operating 7.9 m from the 85  MW_{th} highly enriched uranium (HEU) High Flux Isotope Reactor. With a surface-based, segmented detector, PROSPECT has observed 31678±304(stat) ν[over ¯]_{e}-induced inverse beta decays, the largest sample from HEU fission to date, 99% of which are attributed to ^{235}U. Despite broad agreement, comparison of the Huber ^{235}U model to the measured spectrum produces a χ^{2}/ndf=51.4/31, driven primarily by deviations in two localized energy regions. The measured ^{235}U spectrum shape is consistent with a deviation relative to prediction equal in size to that observed at low-enriched uranium power reactors in the ν[over ¯]_{e} energy region of 5-7 MeV.

First Search for Short-Baseline Neutrino Oscillations at HFIR with PROSPECT

This Letter reports the first scientific results from the observation of antineutrinos emitted by fission products of ^{235}U at the High Flux Isotope Reactor. PROSPECT, the Precision Reactor Oscillation and Spectrum Experiment, consists of a segmented 4 ton ^{6}Li-doped liquid scintillator detector covering a baseline range of 7-9 m from the reactor and operating under less than 1 m water equivalent overburden. Data collected during 33 live days of reactor operation at a nominal power of 85 MW yield a detection of 25 461±283 (stat) inverse beta decays. Observation of reactor antineutrinos can be achieved in PROSPECT at 5σ statistical significance within 2 h of on-surface reactor-on data taking. A reactor model independent analysis of the inverse beta decay prompt energy spectrum as a function of baseline constrains significant portions of the previously allowed sterile neutrino oscillation parameter space at 95% confidence level and disfavors the best fit of the reactor antineutrino anomaly at 2.2σ confidence level.

Regional versus IV analgesics in labor

AIM

The aim of this study was to compare combined spinal epidural (CSE), epidural (E) and IV pethidine analgesia and their effects on the mother, fetus, newborn and the labor course.

METHODS

This is a prospective parallel single blind study, where 60 women in active labor were recruited and were allocated to five subgroups to receive analgesia by different routes. The mother and the fetus were assessed. The results were recorded and compared using Visual Analogue Scale (VAS) and modified Bromage scale for motor block, in addition to other clinical findings.

RESULT

The duration of first stage of labor was significantly longer in the E group, compared with the CSE and IV pethidine groups. When the pain control achieved by CSE bupivacaine and lidocaine was compared with the corresponding epidural, it was found that the first technique achieved better pain control. Women who received pethidine had higher incidence of nausea and vomiting compared to those received CSE or E analgesia. There was no significant difference between the five groups with respect to other side effects.

CONCLUSION

Regional analgesia especially CSE using bupivacaine or lidocaine is a safe effective method for analgesia in labor with relative better efficacy of bupivacaine.

Acute scrotum: is scrotal exploration the best management?

AIM

Selective scrotal exploration of only those boys believed to have testicular torsion (TT), relying on history and clinical examination for diagnosis, can result in a missed or delayed diagnosis of TT. To minimise testicular loss we propose early scrotal exploration in all boys with acute scrotum (AS). To validate our approach we investigated the accuracy of clinical diagnoses of all boys with AS admitted to our unit. Clinical features and diagnoses were correlated with operative findings.

METHODS

A retrospective review of the records of all boys (1-16 years of age) presenting with AS between 2003 and 2007 was done. Overall, 138 boys were seen during this period. Three boys were treated conservatively. The 135 boys who underwent scrotal exploration were divided into three groups: Group A (47 boys) with a history and clinical features considered preoperatively to be consistent with torsion of appendix of testis (TAT); Group B (46 boys) whose characteristics were thought to be more consistent with TT; and finally Group C (42 boys) in whom a preoperative definitive diagnosis could not be made. The preoperative clinical features and diagnoses of the 135 boys were correlated with the operative findings.

RESULTS

In Group A, exploration confirmed TAT in 37 (78%) boys, but in 7 (15%) boys it revealed TT. In Group B, exploration confirmed torsion in 31 (68%) boys, but 13 (28%) had TAT. In Group C, exploration revealed 39 (93%) cases of TAT and 3 (7%) cases of TT.

CONCLUSION

Surgical exploration in all cases of paediatric AS offers an accurate diagnosis and treatment, thus minimising the risk of testicular loss.

A new primary standardization of 229Th

The National Institute of Standards and Technology (NIST) has certified a high-purity (229)Th Standard Reference Material as SRM 4328C, based on live-timed 4pialphabeta-gamma anticoincidence counting (LTAC) of the equilibrium solution. The LTAC system was optimized to minimize the uncertainty in the result due to the two short-lived ground-states present in the decay chain. Confirmatory measurements were carried out by four other methods. Furthermore, the present absolute activity and measured gamma-ray emission rates were combined to obtain gamma-ray emission probabilities.

Delayed diagnosis for undescended testes

Delayed diagnosis of undescended testes is a major problem. A retrospective review of 298 testes units was performed to assess the age at referral, age at operation, complications and final outcome. The mean age at referral was 57 months. Only 24% of cases were operated below 2 years. A similar pattern of delayed orchidopexy has been reported by many other centres. As orchidopexy is recommended soon after 6-7 months of age, there is an urgent need for increased awareness of undescended testes and its consequences at all levels of child health care.

Modified prognostic criteria for oesophageal atresia and tracheo-oesophageal fistula

AIM

With the advances in technology, the outcome of oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) has significantly changed. The aim of this study was to review the outcome of OA and TOF with respect to the various known prognostic criteria and to find out if there is a need for a further modification of the prevailing prognostic classification.

METHODS

The case notes of 57 newborns with OA/TOF treated between 1996 and 2004 were reviewed retrospectively. Patient demographics, associated anomalies and management were studied. The outcome was analysed with respect to different published prognostic criteria (Spitz, Waterston, Bremen and Montreal).

RESULTS

The results in this series show identical results for Waterston class A and B as well as for the Bremen "without complications" groups. Furthermore, there was no statistically significant difference between Spitz type I (survival 100 %) and type II (survival 92.8 %) (Fisher's exact test [p = 0.259], Pearson's chi-square [p = 0.088] and Mann-Whitney test [p = 0.091]). There was, however, a significant variation (Fisher's exact test) after combining the results for Spitz type I & II and comparing them to type III (p = 0.006). On the basis of these results, a further modified prognostic criteria for infants with OA/TOF is proposed. Group A would include infants with either a single poor prognostic risk factor (i.e., weight below 1.5 kg or a major cardiac anomaly) or isolated TOF/OA. According to this study, the prognosis for such infants should be excellent (survival = 98 %). The alternate group (B) would include infants affected by both negative risk factors and TOF/OA; such infants have a poor prognosis (survival = 33 %).

CONCLUSIONS

Survival for children with TOF/OA is not dependent on factors including birth weight, gestational age, pre/postoperative ventilation and a major cardiac anomaly taken independently. In the modified prognostic classification for OA/TOF, a low birth weight combined with cardiac malformations is associated with a poor prognosis. This alternate prognosticator offers benefits for appropriately advising parents of babies with such anomalies taking the current standards of care into consideration. It should also serve as a foundation stone for further prospective studies.

Pyloric stenosis: unusual presentations and rare assoclations

Pyloric stenosis is a common paediatric surgical condition with a well-recognised pattern of clinical features. Diagnosis is usually straightforward and a Ramstedt pyloromyotomy is curative. We present three patients who developed pyloric stenosis incidentally during the management of other primary surgical conditions. Issues of diagnostic difficulty following presentation of pyloric stenosis in the post-operative period (all three patients), its rare syndromic associations (one patient) and its management in this unusual situation are discussed. An awareness of the unusual presentations of pyloric stenosis during treatment for other primary surgical conditions can help in earlier diagnosis and treatment.

Radium-228 determination of natural waters via concentration on manganese dioxide and separation using Diphonix ion exchange resin

The objective of this work was to establish a new procedure for 228Ra determination of natural waters via preconcentration of radium on MnO2 and separation of its daughter, 228Ac, using Diphonix ion exchange resin. Following removal of potential interferences via passage through an initial Diphonix Resin column, the first daughter of 228Ra, 228Ac, is isolated by chromatographic separation via a second Diphonix column. A holding time of > 30 h for 228Ac ingrowth in between the two column separations ensures secular equilibrium. Barium-133 is used as a yield tracer. Actinium-228 is eluted from the second Diphonix Resin with 5 ml 1M 1-Hydroxyethane-1,1-diphosphonic acid (HEDPA) and quantified by addition of scintillation cocktail and LSC counting. Radium (and 133Ba) from the load and rinse solutions from the 2nd Diphonix column may be prepared for alpha spectrometry (for determination of 223Ra, 224Ra, and 226Ra) by BaSO4 microprecipitation and filtration. Decontamination tests indicate that U, Th, and Ra series nuclides do not interfere with these measurements, although high contents of 90Sr (90Y) require additional treatment for accurate measurement of 228Ra. Addition of stable Sr as a "hold back" carrier during the initial MnO2 preconcentration step was shown to remove most 90Sr interference.

Preconcentration of radium isotopes from natural waters using MnO2 Resin

We have characterized "MnO2 Resin," a new resin developed by the PG Research Foundation, for radium adsorption over wide ranges of pH, reaction times and salt concentrations. We show that the sorption of 133Ba (used as a proxy for Ra) is highly dependent on pH with the most useful range from pH 4 to 8. The surface layers of the Mn oxides apparently become more positively charged under acidic conditions (below pH 4), which prevents diffusion of positively charged alkaline earth species (e.g. Ba2+, Ra2+) into the sorption sites. Adsorption at higher pH is thought to be inhibited because of carbonate complexation. We found that the sorption characteristics for radium onto MnO2 Resin are especially favorable for low-salinity waters but the sorption is still very satisfactory for highly salted solutions (KD=2.8x10(4) in both cases) but with slower kinetics. For analytical purposes, both column and pump experiments showed high recoveries with no measurable discrimination between Ra and Ba regardless of flow rates in fresh water. Seawater tests showed that recoveries of Ra and Ba are lower than fresh water at elevated flow rates with Ra adsorption higher than Ba at flow rates above 10 ml/min.

Management of superficial neck abscesses

OBJECTIVE

To evaluate clinical features, management options and outcomes in children with neck abscesses, with a view to correlating this data with the different causative micro-organisms, specifically mycobacteria.

PATIENTS AND METHODS

A retrospective chart review of fifty-one consecutive children who were admitted with suspected superficial neck abscesses to the Unit between January 1994 and June 1999 was performed.

RESULTS

The causative organisms were identified in 21 cases--bacteria in 13 patients, atypical mycobacteria in 6 cases, and mycobacterium tuberculosis in 2 instances. Children with atypical mycobacterial infection had a significantly longer duration of symptoms at the time of admission (mean = 87 days) versus those with bacterial infection (mean = 6 days). Ultrasonography was performed in 20 patients in this series, and was seen to be of value in demonstrating a collection in situations where there was doubt on clinical basis alone. The outcome was seen to be complicated in all children with mycobacterial infections--either atypical or tuberculous.

CONCLUSIONS

Neck abscesses are commonly encountered in paediatric practice. In most instances the diagnosis and treatment is straightforward, with an uncomplicated outcome. However, it is important to bear in mind that there exists a subset of abscesses caused by atypical mycobacteria, with greater risk of complications and recurrence, that needs special attention at the time of diagnosis, intervention and follow-up.

Quantitation of regional cerebral blood flow corrected for partial volume effect using O-15 water and PET: II. Normal values and gray matter blood flow response to visual activation

One of the most limiting factors for the accurate quantification of physiologic parameters with positron emission tomography (PET) is the partial volume effect (PVE). To assess the magnitude of this contribution to the measurement of regional cerebral blood flow (rCBF), the authors have formulated four kinetic models each including a parameter defining the perfusable tissue fraction (PTF). The four kinetic models used were 2 one-tissue compartment models with (Model A) and without (Model B) a vascular term and 2 two-tissue compartment models with fixed (Model C) or variable (Model D) white matter flow. Furthermore, rCBF based on the autoradiographic method was measured. The goals of the study were to determine the following in normal humans: (1) the optimal model, (2) the optimal length of fit, (3) the model parameters and their reproducibility, and (4) the effects of data acquisition (2D or 3D). Furthermore, the authors wanted to measure the activation response in the occipital gray matter compartment, and in doing so test the stability of the PTF, during perturbations of rCBF induced by visual stimulation. Eight dynamic PET scans were acquired per subject (n = 8), each for a duration of 6 minutes after IV bolus injection of H2(15)O. Four of these scans were performed using 2D and four using 3D acquisition. Visual stimulation was presented in four scans, and four scans were during rest. Model C was found optimal based on Akaike's Information Criteria (AIC) and had the smallest coefficient of variance after a 6-minute length of fit. Using this model the average PVE corrected rCBF during rest in gray matter was 1.07 mL x min(-1) x g(-1) (0.11 SD), with an average coefficient of variance of 6%. Acquisition mode did not affect the estimated parameters, with the exception of a significant increase in the white matter rCBF using the autoradiographic method (2D: 0.17 mL x min(-1) x g(-1) (0.02 SD); 3D: 0.21 mL x min(-1) x g(-1) (0.02 SD)). At a 6-minute fit the average gray matter CBF using Models C and D were increased by 100% to 150% compared with Models A and B and the autoradiographic method. There were no significant changes in the perfusable tissue fraction by the activation induced rCBF increases. The largest activation response was found using Model C (median = 39.1%). The current study clearly demonstrates the importance of PVE correction in the quantitation of rCBF in normal humans. The potential use of this method is to cost-effectively deliver PVE corrected measures of rCBF and tissue volumes without reference to imaging modalities other than PET.

Cerebral activation during micturition in normal men

Specific cerebral lesions have shown the crucial role of the brain in the control of micturition. The precise identification of the anatomical cerebral structures involved in micturition can contribute to a better understanding of the control of micturition and the development of therapeutic models. Various neuropathological and animal studies have referred to the medulla oblongata, pons, limbic system, superior frontal lobe and premotor cortical regions as areas implicated in micturition control. The aim of this study was to investigate whether the activity of these areas during micturition can be confirmed by PET in normal men. The distribution of the regional cerebral blood flow after bolus injection of (15)O water was used as an indirect measure of cerebral activation. PET scans were performed during the following three conditions: (i) at rest with the bladder empty; (ii) during simulated micturition after instillation of isotonic saline into the urinary bladder; and (iii) the withholding of urine (saline). Normal micturition using this model was achieved in eight out of 12 right-handed normal subjects. The changes in bladder contraction, bladder pressure and intra-abdominal pressure were monitored on-line during the whole scanning session by a cystometry device. The images were analysed using statistical parametric mapping at a significance threshold of P < 0.05 with correction for multiple independent comparisons. Micturition versus rest was associated with bilateral activation of areas close to the postcentral gyrus, inferior frontal gyrus, globus pallidus, cortex cerebelli, vermis and midbrain. On the left side, activation of the middle frontal gyrus, superior frontal gyrus, superior precentral gyrus, thalamus and the caudal part of the anterior cingulate gyrus was seen, while on the right side we found activation in the supramarginal gyrus, mesencephalon and insula. When the threshold value was lowered to P < 0.001 (Z > 3.09) without correction for multiple comparisons, we found additional activation in the medial pontine tegmentum, mesencephalon, right thalamus, right middle frontal gyrus and left insula. When urine- withholding was compared with rest, the left insula showed a tendency to activate. We conclude from this study, in which urinary bladder contraction was verified cystometrically, that the onset and maintenance of micturition in normal men is associated with a vast network of cortical and subcortical regions, confirming observations from clinical and animal studies.

Gastrostomy complications in infants and children

Thirty children have had percutaneous endoscopic gastrostomy (PEG) inserted for feeding purposes. During a follow-up period of 5-45 months (mean 24 months), complications were recorded in 13 patients. Some patients had more than one complication. Complications included colocutaneous fistula, gastro-oesophageal reflux, wound infection, granulation tissue formation, tube leakage, tube blockage and bleeding. The authors present a retrospective review of the results and discuss the management of these complications.

Colostomy complications in infants and children

This study analyses the morbidity and mortality of colostomy formation and closure over a 17-year period during which 138 consecutive infants and children had a colostomy formed as the initial management of Hirschsprung's disease or anorectal malformation. Complications after colostomy formation were encountered in 38 (27.5%) patients and included colostomy prolapse, stenosis, retraction, dysfunction, skin excoriation and parastomal hernia. The complication rate with transverse colostomies was higher than with other types. Colostomy closure was associated with complications in nine patients (6.5%), the most serious of which was adhesive small bowel obstruction (5). The mortality was less than 1%, but significant morbidity still exists. Refinements in surgical technique may help reduce the incidence of complications, but stoma prolapse, particularly with transverse colostomies, remains a major challenge.

Antibiotic prophylaxis for infantile pyloromyotomy

A retrospective study of 50 patients with infantile hypertrophic pyloric stenosis (IHPS) showed wound infection in six patients. In an attempt to assess the value of antibiotic prophylaxis in infantile pyloromyotomy 150 patients with infantile hypertrophic pyloric stenosis were entered in a prospective randomized controlled study. The infants were allocated to receive a dose of Cefuroxime (30 mg/kg) at induction of anaesthesia or no antibiotic. Eight infants developed wound infection, five in the control group and three in the antibiotic prophylaxis group. Although the difference between the two groups was not statistically significant there was an overall reduction of wound infection (6.5%) compared with pre-trial figures (12%). In order to study the bacterial flora in the umbilicus in these infants, culture swabs were taken from the umbilicus on admission, immediately prior to surgery and from the wound prior to skin closure. It was shown that the umbilicus was not the source of infection.

Mitrofanoff stoma--an iceberg of problems?

The advent of a self-catheterisable continent abdominal wall urinary stoma has provided an enormous improvement in the quality of life for many patients. Successful results of surgery have been presented from many centres. However, these reports concentrate on the technical aspect of patient care. In this paper we review the work of the outreach nursing sister in supporting thirty patients operated upon during a four-year period, and their families.

A gene for autosomal dominant sacral agenesis maps to the holoprosencephaly region at 7q36

Sacral agenesis is a rare disorder of uncertain incidence that has been reported in diverse populations. Although usually sporadic and most commonly associated with maternal diabetes, there is a hereditary form which may occur in isolation or with a presacral mass (anterior meningocele and/or presacral teratoma) and anorectal abnormalities, which constitute the Currarino triad (MIM 176450). The radiological hallmark of hereditary sacral agenesis is a hemi-sacrum (sickle-shaped sacrum) with intact first sacral vertebra. Bowel obstruction is the usual neonatal presentation, but, unlike other neural tube defects, adult presentation is not uncommon. The major pathology is confined to the pelvic cavity and may present as a space-occupying lesion or meningitis due to ascending infection. All recurrences in families have been compatible with autosomal dominant inheritance except for those associated with the isomerism gene at Xq24-q27.1 (ref. 3). Several associated cytogenetic defects have been reported, including 7q deletions. Previous studies failed to detect linkage to HLA markers, but we now present evidence for a location on 7q36. The same region also contains a gene for holoprosencephaly, an early malformation of the extreme rostral end of the neural tube.

Intra-abdominal extravasation complicating parenteral nutrition in infants

Two infants receiving total parenteral nutrition via a central venous catheter positioned in the inferior vena cava developed an acute abdomen secondary to extravasation of the infusate. The presence of an associated abdominal mass necessitated a laparotomy in one patient. Both infants recovered completely after the catheter had been removed.

Applied potential tomography in the measurement of gastric emptying in infants

The aim of this study was to investigate the feasibility of using applied potential tomography (APT), a noninvasive and nonradioactive method, to measure the rate of gastric emptying in preterm babies and infants < 3 months old. APT, a form of electrical impedance tomography, creates tomographic images of tissue resistivity to a small electrical current and has been used to study gastric emptying in adults. The rate of gastric emptying of 53 preterm infants and 29 term infants was measured. The test feed was either milk (formula milk or expressed breast milk) or Dioralyte (a commercial rehydration solution). When a nasogastric tube was present, the results obtained by APT were validated by comparing the volume of feed estimated to be present with the volume that could be aspirated. All infants completed the investigation without any problems. APT demonstrated a slower rate of emptying of milk feeds than Dioralyte and showed that milk and Dioralyte feeds in preterm babies emptied at a similar rate to feeds in term infants. In validation studies, gastric emptying has been observed in 44 of 47 studies, and this finding was confirmed by aspiration of the nasogastric tube. Applied potential tomography is a safe, noninvasive method for measuring gastric emptying in small infants.

Experience with surgery for continence in children with a neuropathic bladder

We report our experience of surgery for continence in a series of 23 children with a neuropathic bladder. Overall good results were obtained (85.7% continent). The complications and their management are discussed.

Long-Term Faecal Continence in Infants Born with Anorectal Malformations

In a retrospective study of 92 patients admitted between 1975 and 1986 with anorectal malformations, we reviewed the faecal continence according to the level of their anomaly using a scoring system taken from Pescatori et al. The results of the different operative procedures were compared. Forty-seven of the 50 patients in the low anomaly group had complete faecal continence. Two died from associated anomalies and one infant had incomplete continence. This child had an associated neural tube defect. Of eight patients in the intermediate group, three had good results while two were incontinent: three patients died from associated anomalies. There were 34 patients with high anomalies, 27 of whom showed a wide range of faecal control from complete continence to different degrees of incontinence. Seven infants died from septicaemia and/or associated anomalies. The anatomical level of the lesion and the presence or absence of any associated neurological defect were the main determinants of outcome. The sex of the child and the operative procedure employed to correct the anomaly appeared to be less important.

Measurement of gastric emptying in infants with pyloric stenosis using applied potential tomography

Gastric emptying in a group of 49 vomiting infants with infantile hypertrophic pyloric stenosis (IHPS) was investigated using applied potential tomography. Fourteen asymptomatic infants were also studied as a control group. A Dioralyte test feed (25 ml/kg/feed) was used for all the studies. The infants with IHPS were investigated before and at two, four, and seven days after an operation; the other infants were investigated once. The results show that the infants with IHPS have no or little gastric emptying before the operation and gradually return to normal emptying by the seventh day after the operation. A significant difference in gastric emptying was noted between the control infants and the infants with IHPS before and at two and four days after the operation. The applied potential tomography method is suitable for studying gastric emptying in infants, with no morbidity nor complications. It also allows multiple studies to be performed without upset or discomfort.

Ovarian cysts and tumours in childhood

The clinical features of 39 children with ovarian cysts and tumours are presented. Over two-thirds presented as an emergency with abdominal pain. Thirty-four patients had benign ovarian disease. Only two of the five malignant tumours were of primary ovarian origin. Ultrasonography and computed tomographic scanning can be of valuable assistance in diagnosis and planning surgery. The diagnosis of ovarian cysts and tumours should be considered among the less common causes of acute abdominal pain in children.