Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021.

OBJECTIVE: To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021. DESIGN: Descriptive multi-country secondary data analysis. SETTING: Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021. POPULATION: Liveborn infants. METHODS: Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study. RESULTS: Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%). CONCLUSIONS: Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Orthostatic tremor: report of a case and review of the literature.

Orthostatic tremor is a rare movement disorder characterized by tremulousness of the lower limbs on standing that disappears on walking, sitting or on lying down and a distinctive electromyographic burst of 14 to 16 Hz. On inspection, fine ripples can sometimes be seen over the quadriceps on standing. The tremor has a tendency to reappear even in the supine posture if the lower limb muscles are put to an isometric contraction state, indicating thereby that in spite of the fact that the tremor occurs on standing, it is essentially 'orthostasis independent' and the central factor is the contraction of the muscles. As a matter of fact, the tremor is abolished if the subject is suspended by harness, thus relieving him of muscle contraction. Doubts are being cast whether it is a variant of essential tremor since a number of families are being reported to be suffering from this disease as well. Positron emission tomography reveals hyperactivity of cerebellum in orthostatic tremor as it shows in essential tremor, therefore lending credence to such a hypothesis. However, lack of response to alcohol, propranolol and primidone in orthostatic tremor stands out as a serious challenge to such a view. Lack of positive family history, synchrony of contracting group of muscles and negative 'resetting' of the tremor by increasing peripheral load-phenomena consistently observed in orthostatic tremor and not in essential tremor, are other features that often help to distinguish between the two conditions. We report a case of orthostatic tremor that presented with the classical clinical and electromyographic features. Relevant literature in this regard is also being reviewed.

The prognostic significance of marrow micrometastases in women with early breast cancer.

Twenty-five patients with early breast cancer (T0-T2, N0-N1, M0) have been studied prospectively to determine the relationship between marrow micrometastases, disease-free interval and survival. Marrow specimens were aspirated from three sites immediately prior to breast surgery. An immunocytochemical technique using monoclonal antibody LICR.LON.M8.4 was employed to detect micrometastases. The minimum follow-up was 38 months. Twelve of the 25 patients (48%) had micrometastatic lesions in their marrow at presentation. Four of these patients developed distal recurrence during follow-up, causing death in two of them. Five of the 13 patients with no evidence of micrometastases developed distant recurrence and four of them have died. There was no correlation between the state of the marrow and the development of metastatic disease, although axillary lymph node status, disease stage and tumour volume correlated significantly with outcome (all P less than 0.025). Micrometastatic lesions appear to be common in the marrow of patients with early breast cancer. We have been unable to demonstrate that they have prognostic significance.

Wound sepsis in 10,000 surgical patients.

A twelve year prospective wound audit was undertaken in an academic surgical unit. Data from 10,000 operations were analysed. Overall, wound infection rates decreased during this time. Infection rates in contaminated wounds in particular fell from 19.2% to 4.7%. This decrease in wound infection may be related in part to a change in the antibiotic prophylactic regimen and in part to the institution of the wound sepsis audit which provided regular information on the unit infection rates. This audit permitted early detection of adverse trends, and may have had a direct influence on surgical techniques.

High colloidal uptake in axillary nodes with metastatic disease.

Axillary lymphoscintigraphy using 99Tcm antimony sulphide colloid has been carried out in 29 patients with suspected breast cancer and was correlated with histology. Of the 23 with proved tumour, axillary node metastases were found in 19 and, although 10 did have diminished uptake on the side of the lesion, 5 had an equal uptake in both sides and 4 had an increased uptake on the side of the lesion. Further, some of the nodes in which the high uptake had occurred were those heavily infiltrated by tumour. It is concluded that: a, lymphoscintigraphy with antimony sulphide colloid is not a reliable technique for the detection of metastatic disease in the regional nodes; b, any lymphoscintigraphy with this or any other agent requires more meticulous histological correlation than hitherto before it can be assumed to have any proved clinical value.

Idiopathic intestinal pseudo-obstruction: a familial visceral neuropathy.

Four individuals with idiopathic intestinal pseudo-obstruction (IIP), a familial visceral neuropathy with autosomal dominant inheritance, are presented. The disorder is characterised by abdominal colic, abdominal distension and diarrhoea, and is of a progressive nature with relapses and remissions. The main feature is a disturbance of motility in the affected intestine, with histological evidence of a neuronal disorder, characterised by hyperplasia and eventual atrophy. Management of the condition is difficult; initially, treatment should be conservative by nasogastric suction with intravenous nutrition. When laparotomy is undertaken to exclude mechanical obstruction, resection of the intestine is inadvisable, and ileo-colic anastomosis may be beneficial.

Faecal bile acid concentration of patients with carcinoma or increased risk of carcinoma in the large bowel.

Faecal 3-hydroxy bile acids were assayed enzymatically in patients with carcinoma, or at increased risk of developing carcinoma of the large bowel. No rise in bile acid concentration was demonstrated in patients with ulcerative colitis, previously resected adenoma, or resected carcinoma. Patients with carcinoma, before treatment, had faecal bile acid concentrations similar to control values, and surgery did not affect the mean level. These findings cast doubt on the importance of the 3-hydroxy bile acid concentration in the faeces in the pathogenesis of large bowel cancer.

Surgical care in the village.

The care of people suffering from surgical disease or injury is unique in requiring, even at its simplest level, a certain degree of psychomotor skill and technological support. This cannot be achieved and maintained in isolation with any consistency. Villages must therefore be interdependent and related to supervision from the district hospital. The responsibility for village care rests with the district physician. He must be adequately trained for this purpose and provided with the simple facilities that are required. He extends his reach into the villages through the auxiliary health workers, who must be taught the skills necessary for simple surgical procedures and be trained to stabilize those patients that they cannot treat for transport to the district hospital. Although the skills and facilities required must be determined locally, there is a need to define the broad principles of training and to develop simple and adequate technology at village and district levels.

The problems of massive small bowel resection and difficulties encountered in management.

Massive small bowel resection is imperative in the management of several pathological conditions and is accompanied by high operative mortality. In those that survive, serious nutritional disturbances are inevitable. Intestinal adaptation is said to occur but cannot be relied upon. Long-term parenteral nutrition is problematical and often unsuccessful. Many surgical procedures have been adopted in an effort to improve prognosis and have been found wanting. Controlled experimental studies in the use of reversed segments and a limited number of reported clinical cases using the method after massive resection suggest that this technique may improve the function of the residual intestine to such an extent that other supportive measures are unnecessary.