Pulse oximetry interference in paediatric neurosurgery.
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Biomedical subjects
Publications and source records attributed to J A Short.
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In children with congenital cyanotic heart disease, right-to-left intracardiac shunting causes an obligatory difference between arterial and end-tidal carbon dioxide tension (PaCO2-PE'CO2) as venous blood, rich in carbon dioxide, is added to the arterial circulation. This obligatory PaCO2-PE'CO2 difference, which can be predicted from knowledge of oxygen saturation, haemoglobin concentration and PaCO2, increases as oxygen saturation decreases, most markedly when the haemoglobin concentration is high. A second possible cause of the PaCO2-PE'CO2 difference is the effect of pulmonary hypoperfusion caused by the shunt. We studied 60 children undergoing cardiac surgery and compared the predicted the PaCO2-PE'CO2 difference with measured values to investigate the extent to which additional factors influence the clinically observed PaCO2-PE'CO2. In many children, observed values were much greater than predicted, which is compatible with some degree of pulmonary hypoperfusion. However, this was not felt to represent the complete picture in all patients. Another cause of ventilation-perfusion mismatch was suspected in those children who showed a considerable improvement in oxygen saturation during ventilation with an increased FIO2. We believe that pulmonary congestion caused by large left-to-right shunts may further increase the PaCO2-PE'CO2 difference.
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This study investigated the effect of diclofenac on the lung function of 70 children aged 6-15 years with a diagnosis of asthma, recruited from a hospital respiratory clinic. Peak flow and a forced expiratory flow-volume loop were measured and the patients were then given 1-1.5 mg.kg-1 effervescent diclofenac orally. Spirometry was repeated at 10, 20 and 30 min, a 15% decrease in results being considered a significant reduction in lung function. No patient demonstrated a consistent reduction in lung function of > 15% during the study and there were no reports of wheezing or increased bronchodilator use after completion of the spirometry. In conclusion, we studied a group of genuine asthmatics and found no clinically significant incidence of bronchospasm with the use of a single therapeutic dose of diclofenac.
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A group of 50 children, aged 5 months to 15 years, and who were undergoing routine surgery under general anaesthesia, were studied to investigate the difference in noninvasive blood pressure readings obtained from inflatable cuffs placed on the upper arm and the lower leg. In contrast to adult data, it was found that the blood pressure measured from the leg in children aged 8 years and under, was significantly lower than that measured from the arm. The leg cuff measurements could not, however, be reliably used to predict arm blood pressure.
A 25-yr-old man, subsequently shown to be malignant hyperthermia (MH) susceptible by in vitro contracture testing, developed MH during anaesthesia for tonsillectomy. Prompt treatment, including dantrolene, led to rapid resolution of the metabolic crisis. Eighteen hours later the patient's trachea was extubated in the ICU, when he had been stable and apyrexial overnight. Twenty minutes after extubation, an episode of shivering was followed by the onset of tachycardia, hypertension, tachypnoea and a rapid increase in temperature. Recurrence of MH was suspected and the patient was given another dose of dantrolene with good clinical effect. Shivering in this patient may have been an indicator or a causative factor of recurrence of MH.
Human cytomegalovirus (HCMV) infects a number of organs and cell types in vivo, leading to the hypothesis that HCMV disease and tissue tropism may be related to specific sequence variants. A potential component of HCMV variant strains is the UL144 open reading frame (ORF), which encodes a homologue of the herpesvirus entry mediator, HveA, a member of the tumor necrosis factor receptor superfamily. Sequence analysis of the UL144 ORF in 45 low-passage clinical isolates demonstrated significant strain-specific variability. In individual isolates, nucleotide substitutions occur at up to 21% of the 531 positions, resulting in approximately the same percentage of substitutions in the predicted 176-amino-acid sequence. Phylogenetic analysis indicated that the nucleotide and amino acid sequences diverge into three major groups. For genotypic comparison, the known hypervariable region encompassing the proteolytic cleavage site of the glycoprotein B (gB) gene was also sequenced. All of the isolates could be typed according to the four known gB groups; however, the gB and UL144 sequence groups appeared to be phylogenetically unlinked. The predicted UL144 product homology with tumor necrosis factor receptor family members, along with the unexpectedly high level of sequence variability of the UL144 ORF, suggests that the predicted product may play a role in HCMV infectivity and subsequent host disease.
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The purpose of this study was to compare three engine driven (nickel-titanium) NiTi instrument systems with hand files for their effect on canal transportation. Mesial roots of mature lower first molars with separate canals were paired on the basis of curvature and morphology. Canal lengths were standardized to 11 mm from orifice to apical foramen. Profile, Lightspeed, McXIM, and Flex-R hand filing techniques respectively were randomly assigned to one of the four canals of each tooth pair. The roots were mounted and sectioned at 1 mm, 3 mm, and 5 mm from working length using a modified Bramante technique. All sections were video imaged preoperatively after instrumentation to size #30 and after final instrumentation to size #40. The images were computer analyzed for changes in canal area and centering at each stage of instrumentation. Preparation time was also recorded. Data were analyzed using ANOVA. The NiTi systems remained better centered in the canal than stainless steel hand files. There were no significant differences among the NiTi systems at any level. The difference between hand filing and the NiTi techniques was more pronounced at size #40 than at size #30. The NiTi systems were all significantly faster than hand filing. No significant differences in preparation were found between the NiTi systems when canals were instrumented to the size nearest #40.
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In this study we investigate the molecular genetic basis for VHa- Ig. Knowing that the expression of VHa allotype Ig is suppressed by neonatal injection of rabbits with anti-VHa allotype antibody, and that the decreased level of VHa allotype Ig, VHa+, in the suppressed rabbits is compensated for by an increase in VHa- Ig, we determined the nucleotide sequences of 41 VDJ genes from a2/a2 rabbits neonatally suppressed for the expression of a2 Ig. We compared these nucleotide sequences to each other and identified two groups of VH sequences. We predict that the molecules of each group are encoded by one germline VH gene. Inasmuch as VHa+ Ig is encoded predominantly by one germline VH gene, VH1, it appears that more than 95% of the VDJ repertoire of rabbits may be encoded by as few as three germline VH genes. A genomic VDJ gene whose VH sequence was similar to those of group I molecules was expressed in vitro and was shown by ELISA to encode molecules of the VHa- allotype, y33. Analysis of the D regions in the VDJ gene indicated that germline D2b and D3 gene segments were preferentially used in the VDJ gene rearrangement. A comparison of sequences of D regions of the 41 VDJ gene rearrangements in 3-, 6-, and 9-wk-old rabbits to sequences of germline D gene segments showed an accumulation of mutations in the D region. Inasmuch as we have previously shown that V regions of rabbit VDJ genes are diversified, in part, by somatic gene conversion, it appears now that rabbit VDJ genes diversify by a combination of somatic mutation and somatic gene conversion.
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A unique feature of rabbit Ig is the presence of VH region allotypic specificities. In normal rabbits, more than 80% of circulating immunoglobulin molecules bear the VHa allotypic specificities, al, a2 or a3; the remaining 10% to 20% of immunoglobulin molecules lack VHa allotypic specificities and are designated VHa-. A mutant rabbit designated Alicia, in contrast, has predominantly serum immunoglobulin molecules that lack the VHa allotypic specificities (Kelus and Weiss, Proc. Natl. Acad. Sci. USA 1986. 83: 4883). To study the nature and molecular complexity of VHa- molecules, we cloned and determined the nucleotide sequence of seven cDNA prepared from splenic RNA of an Alicia rabbit. Six of the clones appeared to encode VHa- molecules; the framework regions encoded by these clones were remarkably similar to each other, each having an unusual insertion of four amino acids at position 10. This insertion of four amino acids has been seen in only 2 of 54 sequenced rabbit VH genes. The similarity of the sequences of the six VHa- clones to each other and their dissimilarity to most other VH genes leads us to suggest that the VHa- molecules in Alicia rabbits are derived predominantly from one or a small number of very similar VH genes. Such preferential utilization of a small number of VH genes may explain the allelic inheritance of VH allotypes.
Preparations of IgG 3 isolated by absorption of IgG 1, IgG 2, and IgG 4 from a human iv immunoglobulin with protein A-Sepharose were evaluated for their opsonic activities against type III group B streptococcal (GBS) strains. The resulting preparations were free of IgG 1 and IgG 2 and contained only trace amounts of IgG 4 (less than 2% of total IgG). These IgG 3 preparations exhibited excellent opsonic activities against type III GBS strains, similar to those of the unfractionated iv immunoglobulin (based on total IgG concentrations in the opsonic assays). In contrast, preparations of IgG 1, 2, and 4 eluted from protein A-Sepharose with 2 M acetic acid and 7 M urea were significantly less effective in enhancing phagocytosis and killing of type III GBS than IgG 3 preparations or iv immunoglobulin. The reasons for excellent opsonic activity of IgG 3 preparations as well as for decreased opsonic activity of IgG 1, 2, and 4 preparations are not clear. Perhaps alteration of IgG by lower pH and high concentrations of urea may have impaired the functional activity of IgG 1, 2, and 4 preparations. The significant finding of this study is the first demonstration of the excellent opsonic activity of IgG 3, emphasizing the importance of having intact IgG 3 in commercial immunoglobulin preparations used in prophylaxis or treatment of GBS infections.