Ascites misdiagnosed as a left pleural effusion during cardiac surgery: case report and suggested echocardiographic features to differentiate these entities.

The spleen and ascitic fluid are rarely imaged by transoesophageal echocardiography. In this case perisplenic ascitic fluid was misdiagnosed as a left pleural effusion and led to unnecessary surgical opening of the left pleural space during aortic valve replacement. On review of the images, three features were found that differentiated perisplenic ascitic fluid from a left pleural effusion. First, the spleen has a uniformly homogeneous, echogenic appearance (unlike atelectatic lung). Second, perisplenic ascitic fluid can be seen to communicate with a lateral space (unlike pleural fluid). Third, perisplenic ascitic fluid lies entirely lateral to the descending aorta (unlike pleural fluid).

Multiple sites of impingement of a tracheal tube as it is advanced over a fibreoptic bronchoscope or tracheal tube introducer in anaesthetized, paralysed patients.

Impingement of the tracheal tube on upper airway structures occurs commonly during advancement over a fibreoptic bronchoscope or introducer. In this descriptive study a fibrescope was used to assess the site and mechanism of tracheal tube impingement during advancement over a variety of fibreoptic bronchoscopes and introducers during orotracheal intubation in anaesthetized adults. The effect of the 90 degree counterclockwise rotation manoeuvre in overcoming impingement was also assessed. We recorded impingement at the right arytenoid, left arytenoid, epiglottis, interarytenoid tissue and the left pyriform fossa. Our study found a wider range of sites at which impingement may occur than in previous studies. We also found that when 90 degree counterclockwise rotation of the tip of the tracheal tube was achieved, the impingement was reliably overcome.

Randomized, controlled trial of the double setup tracheal tube during fibreoptic orotracheal intubation under general anaesthesia.

BACKGROUND: Impingement of the tracheal tube (ETT) on upper airway structures during railroading over the fibreoptic bronchoscope (FOB) occurs commonly. Potential complications of impingement include prolonged intubation time, leading to arterial desaturation, failed intubation and laryngeal trauma. The objective of this randomized, controlled trial was to assess the effect of the double setup ETT (a paediatric ETT is placed inside an adult ETT) on the incidence of impingement during orotracheal fibreoptic intubation. METHOD: Two hundred patients were randomized to have a single ETT or double setup ETT. After induction of anaesthesia, fibreoptic orotracheal intubation was performed. The degree of impingement of the ETT during advancement over the FOB was assessed using a standardized scoring system based on the manoeuvres required to overcome the impingement. RESULTS: The incidence of impingement was lower using the double setup ETT compared with the single ETT (18 vs 93%, P<0.001). The double setup ETT also reduced the incidence of impingement requiring more than a simple 90 degrees counterclockwise rotation to achieve intubation (3 vs 14%, P=0.01) and reduced the median intubation time (31 vs 35 s, P=0.046). CONCLUSIONS: The double setup ETT is effective in reducing ETT impingement and in reducing intubation time. We did not find an association between ETT impingement and arterial desaturation.

Atypical nonketotic hyperglycinemia with normal cerebrospinal fluid to plasma glycine ratio.

The diagnosis of nonketotic hyperglycinemia is considered to depend upon the presence of increased cerebrospinal fluid glycine and an increased cerebrospinal fluid to plasma glycine ratio. We studied two siblings who have the neurologic and peripheral biochemical features of the atypical variant of nonketotic hyperglycinemia but have normal cerebrospinal fluid glycine and cerebrospinal fluid to plasma glycine ratios. The proband had reduced liver glycine cleavage system activity of 17% and 21% of mean normal values, confirmed in two independent laboratories. Her lymphoblast glycine cleavage system activity was normal. Nonketotic hyperglycinemia can be present in the absence of increased cerebrospinal fluid glycine. Measurement of liver glycine cleavage system activity is indicated when nonketotic hyperglycinemia is suggested by clinical features and peripheral glycine levels but cerebrospinal fluid glycine is normal.

Erythrina alkaloids: isolation and characterisation of alkaloids from seven erythrina species.

The alkaloids present in the seeds of seven ERYTHRINA species, E. FUSCA Lour, E. COSTARICENCIS M. Micheli, E. LEPTORHIZA A. DC., E. SPECIOSA Andrews, E. VARIEGATA L., E.MELANACANTHA Taubert ex Harms, and E. BERTEROANA Urban, have been screened by gas chromatography-mass spectrometry (GC/MS). The novel alkaloid erythrartine N-oxide has been isolated from E. BERTEROANA and characterized as an N-oxide of theknown alkaloid, erythrartine.

Unique hereditary sensory and autonomic neuropathy with growth hormone deficiency.

The proband, a French-Canadian white boy, presented with congenital sensory polyneuropathy, moderate to severe sensorineural hearing loss, infantile cataracts, nystagmus, esotropia, unusual facies, hypotonia, bilateral congenital hip dysplasia, delayed ossification of the femoral heads, scoliosis, short stature secondary to growth hormone deficiency, and developmental delay. His parents are consanguineous. His maternal first cousin, a 16-year-old girl, has congenital sensory polyneuropathy, infantile cataracts, unusual facies, scoliosis, short stature secondary to growth hormone deficiency, late-childhood-onset arthritis, and hypoglycemia. Reportedly, she has no hearing difficulties and has normal intelligence. Her parents are third cousins. These children appear to have a distinct variant of hereditary sensory and autonomic neuropathy with infantile cataracts, unusual facies, skeletal dysplasia, short stature secondary to growth hormone deficiency, and other features, with probable autosomal recessive inheritance.

The isolation and identification of indigoid pigments from urine.

A purple pigment, phyriaviolin, and a blue pigment, phyriaazulin, have been found in relatively large amounts in the urine of patients suffering from two diverse pathological conditions, porphyria cutanea tarda and Crohn's disease. The two pigments have been characterised by chemical, spectroscopic, and chromatographic studies and identified to be indirubin and indigo (indigotin). Possible reasons for their formation are discussed.

The synthesis of stereoselectively labelled porphobilinogen and its incorporation into protoporphyrin-IX.

11-(R)-2H porphobilinogen, stereospecifically labelled with deuterium in the aminomethylene group has been incorporated into protoporphyrin-IX by haemolysates of chicken erythrocytes. High field NMR spectroscopy confirms that the overall biochemical process is stereospecific, deuterium being retained at the alpha-, gamma- and delta-meso positions and lost from the beta-meso position.

H.p.l.c. analysis of di- and tri-carboxylic porphyrins in porphyric patients.

New h.p.l.c. methods have been developed for the quantitative determination of di- and tri-carboxylic porphyrin methyl esters, and applied to the analysis of faecal extracts from patients with four different types of porphyria.

Apnea documentation for determination of brain death in children.

Discontinuing ventilatory support for determination of respiratory drive is a recognized means of assessing clinical brain death. Methodology must include a means for assuring adequate oxygenation during the test as well as providing sufficient duration for appropriate hypercarbia. Nine patients with other findings of clinical brain death were prospectively assessed with a standardized apnea test protocol. None demonstrated spontaneous respirations. Whereas adequate oxygenation was maintained in each case, wide variability was evident in degree of hypercarbia and acidosis.

Sputum sol-phase proteins and elastase activity in patients with cystic fibrosis.

Sputum and serum samples were obtained from 38 patients with cystic fibrosis seen as out-patients at routine follow-up, or from patients admitted with acute pulmonary exacerbations of their disease. Elastolytic activity was measurable in the sputum of 13 of 16 out-patient samples and detectable in 21 of 22 patients admitted with pulmonary exacerbation. The enzyme activity was inhibited by soy bean trypsin inhibitor and alpha 1 antitrypsin, but not by ethylenediamine tetracetic acid, suggesting that it was predominantly a serine proteinase, probably leucocyte elastase. The mean sputum/serum albumin ratio was 2.53 X 10(-2) (SD +/- 2.4) for the out-patients and this was not significantly different from those of patients admitted with pulmonary exacerbation. However, those patients admitted with fever had increased sputum/serum albumin ratios (mean = 4.66 X 10(-2); SD +/- 3.19) compared with those admitted with a normal temperature (mean = 1.52 X 10(-2); SD +/- 0.41. 2p less than 0.01). The albumin ratios of the pyrexial group fell with antibiotic therapy. The sputum/serum alpha 1 antitrypsin ratios were generally greater than expected (by comparison with albumin) and evidence is presented suggesting that this is due to immunological over-estimation.

Brain death in the pediatric intensive care unit. A clinical definition.

The establishment of criteria for brain death is important for decision making in the treatment of critically ill patients. Our experience involving 15 children with coma, apnea, and absent brain-stem reflexes for a period of greater than three days supports previous reports in adults that the diagnosis of brain death can be made by clinical criteria alone. None of these patients survived, and each of the 11 autopsies performed revealed marked liquefactive necrosis in the brain.

Reproducibility of saliva and plasma theophylline levels following single dose administration of two sustained release preparations.

1 Concomitant saliva and plasma theophylline concentrations were measured in six healthy male volunteers following single dose administration of two sustained release preparations (Nuelin SA and Phyllocontin Continus). 2 Using mean values, a good correlation was obtained between saliva and plasma drug concentrations. Prediction of plasma values using individual saliva was poor and varied widely. The ratio of saliva to plasma concentrations in the same individual, assessed under standardised conditions, was not always reproducible.