A tubeless anaesthetic technique for paediatric laryngeal laser surgery.

Laser surgery on the paediatric larynx requires cooperation between the surgeon and anaesthetist to carry out the procedure in the safest manner possible. Over a period of 3 years, 45 laser procedures have been undertaken on the upper airway of 14 patients at our institution. All procedures were performed with volatile gas anaesthesia supplied via a nasopharyngeal tube in a spontaneously ventilating patient, thus allowing the surgeon an unobstructed view of the larynx. In only one case, was a problem experienced with the technique, that of laryngospasm. The technique provides an unrivalled view of the larynx whilst allowing safe anaesthesia.

Otoplasty: a review of the surgical techniques.

Otoplasty surgery carries a high satisfaction rate for participants (96%). Surgeons are more critical of the results of otoplasty than the participants or parents (92% satisfied). There is no statistical difference in qualitative results with different surgical techniques when comparing the published data. Data on otoplasty surgery is numerous, but quantitative assessment of surgical outcome is rare. The authors propose the measurement of cephaloauricular distance to allow comparison between studies.

Hypercellularity of the mastoid as a cause of spontaneous pneumocephalus.

In this paper two cases are reported in which spontaneous entry of air into the head appears to have occurred through a hypercellular mastoid air cell system. In both these cases forceful sneezing and nose blowing were considered contributory factors. They underwent surgical repair of the bony defects which, combined with less vigorous nose blowing, has affected a successful repair. The aetiology of pneumocephalus is discussed and a review of the pertinent literature is also presented.

A model for the conservative management of mallet finger.

This prospective study assessed the results of a custom-made thermoplastic splint for treatment of mallet finger deformity. From April 1999 to April 2000, 42 patients with mallet finger deformity were recruited. All patients were seen within 1 week and treated with a thermoplastic splint custom-made by the hand therapy department. The splint was simple to make, easy to fit and suitable for all finger shapes and sizes. It improved the deformity in 30 out of 34 cases, and caused no skin irritation.

Immunogenetic analysis reveals that epitope shifting occurs during B-cell affinity maturation in primary biliary cirrhosis.

Primary biliary cirrhosis (PBC) is a liver disease characterized by serum autoantibodies against the pyruvate dehydrogenase complex (PDC) located in the inner mitochondrial membrane. The predominant target in PDC has previously been localized to the inner lipoyl domain (ILD) of the E2 subunit. The etiology of PBC is unknown, although molecular mimicry with bacterial PDC has been proposed. Here, we have investigated the etiology of PBC and nature of the autoimmune response by analyzing the structure of a human monoclonal antibody with ILD specificity. Mutants of the monoclonal antibody, which was originally isolated from a patient with PBC, were expressed as Fab by phage display, and tested for reactivity against recombinant domains of the E2 subunit. Fab in which the V(H)-encoded portions were reverted to germline lost reactivity against the ILD alone, but recognized a different epitope in a didomain construct encompassing the ILD, hinge region and E1/E3 binding domain. The complete V(H) and V(L )germline revertant was unreactive with the human ILD and didomain, the Escherichia coli didomain, and whole PDC. We hypothesize that the IgM on the surface of the naïve B-cell first recognizes an as yet unidentified antigen, and that accumulation of somatic mutations results in an intermolecular epitope shift directed towards an epitope involving the E1/E3 binding domain. Further mutations result in the specificity being redirected to the ILD. These findings also suggest that bacterial molecular mimicry is not involved in initiating disease.

FAD insertion is essential for attaining the assembly competence of the dihydrolipoamide dehydrogenase (E3) monomer from Escherichia coli.

Dihydrolipoamide dehydrogenase (E3) from Escherichia coli, an FAD-linked homodimer, can be fully reconstituted in vitro following denaturation in 6 m guanidinium chloride. Complete restoration of activity occurs within 1-2 h in the presence of FAD, dithiothreitol, and bovine serum albumin. In the absence of FAD, the dihydrolipoamide dehydrogenase monomer forms a stable folding intermediate, which is incapable of dimerization. This intermediate displays a similar tryptic resistance to the native enzyme but is less heat-stable, because its ability to form native E3 is lost after incubation at 65 degrees C for 15 min. The presence of FAD promotes slow, additional conformational rearrangements of the E3 subunit as observed by cofactor-dependent decreases in intrinsic tryptophan fluorescence. However, after 2 h, the tryptophan fluorescence spectrum and far UV CD spectrum of E3, refolded in the absence of FAD, are similar to that of the native enzyme, and full activity can still be recovered on addition of FAD. Cross-linking studies show that FAD insertion is necessary for the monomeric folding intermediate to attain an assembly competent state leading to dimerization. Thus cofactor insertion represents a key step in the assembly of this enzyme, although its initial presence appears not to be required to promote the correct folding pathway.

Neonatal suck reflex pattern does not predict apnea.

Respiration and suck are gestational age-dependent reflexes modulated in the brain stem. To determine if the suck reflex pattern could be used to predict apnea, the relationship between the two was examined in 28 neonates. The suck reflex was quantified with respect to burst-pause rhythm, amplitude of negative suck pressure, and synchrony of the negative-positive pressure. Apneas were counted 5 days prior to and following measurement of the suck reflex pattern. Increasing gestational age correlated with a lower frequency of apnea (P < .01) and higher suck scores (P < .01). A mature suck reflex pattern, however, failed to predict the occurrence of apnea.

Tumor necrosis factor locus polymorphisms in rheumatoid arthritis.

We examined six polymorphic elements in the tumor necrosis factor (TNF) locus and determined their allelic distribution in 98 Caucasian rheumatoid arthritis patients in comparison with 91 ethnically-matched controls. Polymorphic elements at four biallelic sites were distributed similarly between patients and controls, irrespective of the presence or absence of DR4. Differences were observed between the two groups at the TNFa and TNFe loci, but these were consistent with extended MHC haplotypes known to be present in rheumatoid arthritis patients. Therefore, this study suggests that there is little, if any, independent contribution of the TNF locus to the genetic background for rheumatoid arthritis susceptibility.

Oral mucosal melanomas: the WESTOP Banff workshop proceedings. Western Society of Teachers of Oral Pathology.

A workshop to discuss primary oral melanomas was convened at the annual Western Society of Teachers of Oral Pathology meeting in Bannf, Alberta, Canada. Fifty oral melanomas, identified from the files of the participants, were reviewed in order to better understand the clinical features, histologic spectrum, and natural history of these perplexing lesions. Results confirmed that oral melanomas occur in adults almost three times more frequently in men than women and have a decided predilection for the palate and gingiva. Some lesions exhibit a clinically detectable and prolonged in situ growth phase, whereas others seem to lack this property and exhibit only or predominantly invasive characteristics. Recurrences, metastases, and death from tumor were characteristic of the follow-up of a limited number of patients. Until definitive prospective data are collected that elucidate natural history, oral mucosal melanomas should be tracked separately from cutaneous lesions. All oral pigmented lesions that are not clinically diagnostic should be biopsied. Lesions with equivocal histopathologic features might be referred to as "atypical melanocytic proliferation" and should be excised. Recognition of lesions in an early in situ phase and aggressive treatment should have a favorable effect on prognosis. To enhance future or prospective study of these rare neoplasms, guidelines for reporting oral melanomas are suggested.

Polymorphisms in the TNF gene cluster and MHC serotypes in the West of Scotland.

We examined the distribution of polymorphic elements within the tumor necrosis factor (TNF) gene cluster in 105 unrelated individuals and determined their relationship to class I and class II major histocompatibility complex (MHC) antigens, and to the highly polymorphic microsatellites TNFa and TNFb. The data demonstrate the contribution of elements within the TNF cluster to two extended haplotypes which are recognized to straddle the MHC. The A1.B8.DR3 haplotype appears to contain the TNF alleles TNFa2, TNFb3, LT.Nco-1.B*1, and TNF-308.2, while the A3.B7.DR2 haplotype is associated with the TNF alleles TNFa11, TNFb6, TNFc1, LT.Nco-1.B*2, LT.AspH1.1, TNF-308.1, and TNFe1. The presence of other extended associations which covered smaller parts of the MHC was also suggested. In most cases, the associations described here were in keeping with previously described extended haplotypes which dominate the structure of the MHC, but these did not always match completely. Taken together, these data suggest that the structure of the TNF locus is well integrated into the rest of the MHC but that important ethnic differences may exist.

Right ventricular infarction. Aids to recognition.

Right ventricular infarction is often associated with myocardial infarction located in the inferior or posterior left ventricular wall. It should be suspected if a patient has distended neck veins with Kussmaul's sign, ST-segment elevation in the V4R precordial lead, possible heart block, and extreme sensitivity to preload reducers such as nitroglycerin and diuretics (administration of which may lead to hypotension). Measures such as administration of fluid (with Swan-Ganz monitoring), inotropic support with dobutamine (Dobutrex), and atrioventricular sequential pacing may be of benefit in hypotensive patients. Mortality can be significant, especially when there is hemodynamic compromise; however, reperfusion as a result of thrombolytic therapy or angioplasty may have a salutary effect. Early investigations imply that long-lasting benefit is obtained from opening an infarct-related artery.

Atypical chest pain. Differentiation from coronary artery disease.

Atypical pain in the chest accounts for many visits to physicians. Possible sources of the pain include the pericardium, the pulmonary system, the aorta, the gastrointestinal tract, the chest wall, the mitral apparatus, and psychogenic factors. Identifying the source primarily involves taking an accurate history and understanding the prevalence of coronary artery disease in various patient populations. Electrocardiography chest films, and stress testing may help identify the source of pain. Cardiac catheterization should be reserved for patients with abnormal findings on non-invasive tests, those with unclear test results, and, rarely, as reassurance for patients with frequent episodes of atypical chest pain or their caregivers.