Severe complications during the management of a child with late presentation of a diaphragmatic hernia.

We report on a 3-year-old boy with late presentation of congenital diaphragmatic hernia who developed cardiac arrest after induction of anaesthesia. The paper discusses the anaesthetic technique, in particular ventilation during and after induction, how these techniques contributed to the complication, and how they might have been avoided.

Lipoblastoma: MRI appearances of a rare paediatric soft tissue tumour.

Lipoblastoma is a rare, benign soft-tissue tumour derived from embryonic fat. Four patients with tumours located in the upper limb are reported, with special reference to imaging techniques and histology. Radical surgical excision is essential to prevent local recurrence and exact imaging techniques are thus crucial. MRI appears to be a reliable preoperative investigation and is the recommended radiological examination. In a child under 3 months of age, images showing a predominantly fatty but inhomogeneous soft-tissue mass are suggestive of lipoblastoma.

[Lipoblastoma. A rare, benign tumor in children]. / Lipoblastom. En sjelden, benign tumor hos barn.

Lipoblastoma is a rare, benign tumour of embryonal fat seen almost exclusively in infancy and early childhood. It occurs mostly in the extremities, but it is also seen in other parts of the body. The tumour may grow rapidly, and the fact that lipoblastomas show immature fat cells could lead to the wrong diagnosis of liposarcoma. Complete surgical excision appears to be the treatment of choice. A correct, preoperative diagnosis is possible in most cases. Two cases of lipoblastoma of the upper limb and one case in the scapular region are reported.

Routine ultrasonography in the diagnosis of acute appendicitis: a valuable tool in daily practice?

Initial clinical examination, laboratory inflammation parameters, and routine ultrasonography (US) were evaluated prospectively in 205 patients admitted for suspected acute appendicitis. The purpose of the study was to compare initial clinical examination and laboratory tests with the accuracy of US obtained in daily practice. All ultrasonographic examinations were performed by residents in radiology and radiologists qualified for routine abdominal US but not specifically trained in the diagnostics of appendicitis. Initial clinical examination had the highest sensitivity, but the specificity was poor. The single laboratory tests were of limited value in predicting appendicitis. The accuracy of US was disappointing, and the reported promising results of previous studies were not confirmed. Sonographers with less experience had a higher sensitivity but a poorer specificity compared with more experienced sonographers, who had a high specificity at the cost of extremely poor sensitivity. Biases, dichotomization problems, and factors influencing the accuracy of US in patients with suspected acute appendicitis are discussed.

Prognosis of radically operated breast carcinoma patients. A retrospective study of 167 consecutive patients with emphasis on histopathological grading, reproducibility and mean nuclear area.

A retrospective study of 167 consecutive radically treated breast cancer patients with histopathologically confirmed ductal carcinoma is presented. The aim was to establish the prognostic significance and reproducibility of histopathological grading done independently by two pathologists. Further-more, the value of measurements of mean nuclear area (MNA) in the primary tumour was assessed. The two pathologists reviewed the same histological sections using a three-point scoring system based on tubular structures, number of mitoses and nuclear pleomorphism. Grading was identical for 70% of the tumours (Kappa value 0.51). With increasing MNA, the fraction of poorly differentiated tumours increased. In the univariate analysis, tumour-related survival was significantly related to histopathological grading when G3 tumours were compared to G1/G2 tumours (p < 0.05). In the multivariate analysis, tumour size (pT category), lymph-node status and grading were the only significant factors influencing patient outcome (p < 0.05). MNA had no significant prognostic value. A combination of tumour size and histopathological grading identifies a group of node-negative patients (pT2 G2/G3) who may have a less favourable prognosis and for whom adjuvant treatment may be beneficial.

[Fluid therapy changes in surgical treatment of abdominal aortic aneurysm]. / Endringer i vaesketerapi ved kirurgisk behandling av abdominale aortaaneurismer.

The use of blood components and blood substitutes was studied in 25 patients undergoing surgical treatment for abdominal aortic aneurysm in 1983, and was compared with the use of such components in 44 patients operated in 1988. The use of blood components had decreased by 49% from 1983 to 1988. In 1988, erythrocytes were administered only when the hemoglobin concentration fell under 9 g/100 ml. The use of plasma postoperatively was reduced to a minimum. Normovolemia was maintained with polygeline, dextran, electrolytes and autotransfusion. The change in transfusion praxis did not lead to any reduction in postoperative hemoglobin values. The stay in hospital and the number of hours spent in a respirator were both reduced, and there was a general improvement in results.

Role of osmosis in biliary NaCl secretion and bile formation.

To challenge the osmotic hypothesis of biliary NaCl secretion and bile formation, experiments were performed in anaesthetized pigs. An increase in plasma osmolality of 7 +/- 1 mosm/kg H2O induced by intravenous sucrose infusion decreased NaCl secretion, NaHCO3 secretion, and bile flow by 36 +/- 3%, 34 +/- 2%, and 34 +/- 3%, respectively. There was no change in the biliary concentration of NaCl and NaHCO3. When bile acids were infused intravenously, the secretion of 1 mmol bile acids caused an osmotic flow of 12.0 ml bile containing 0.92 mmol NaCl and 0.30 mmol NaHCO3 in an isotonic solution. Bile acids are therefore much stronger choleretic substances than NaHCO3. When the plasma sodium concentration was increased to 200 mM, bile flow increased by 31 +/- 5% and the secretion of bile acids, NaHCO3, and NaCl was increased by 63 +/- 3%, 96 +/- 4%, and 93 +/- 4%, respectively. These data are consistent with osmotic transport as the main mode of bile formation, but diffusion could be responsible for a small fraction. A raised plasma sodium concentration stimulates osmotic formation of bile by increasing both the bile acid-dependent and -independent secretion through stimulation of biliary bile acid and NaHCO3 secretion.

Effects of digitoxin and hypokalaemia on pancreatic NaHCO3 secretion and pancreatic Na,K-ATPase activity.

To study the role played by Na,K-ATPase in the pancreatic secretion of NaHCO3, experiments were performed in 20 anaesthetized, secretin-infused pigs (3.0 clinical units X kg b. wt. X h-I). The relationship between pancreatic NaHCO3 secretion and arterial pH was obtained before and during Na,K-ATPase inhibition by digitoxin and hypokalaemia. Na,K-ATPase activity in pancreatic tissue homogenate averaged 5.45 (5.02-6.68) mumol Pi X mg X protein X h-I. Retrograde injection of 0.5 ml 1.4 X 10(-4) mol X l-I digitoxin into pancreatic ducts reduced pancreatic Na,K-ATPase activity by 3I(I8-47)%, while intra-arterial injection of 0.2 mg X kg b. wt-I digitoxin reduced pancreatic Na,K-ATPase activity by 50(45-56)%. Digitoxin and hypokalaemia reduced the rate of pancreatic NaHCO3 and shifted the normal, proportional relationship between NaHCO3 secretion and arterial pH towards higher pH. Hypokalaemia reduced Na,K-ATPase activity and NaHCO3 secretion in proportion. These effects indicate that Na,K-ATPase helps to sustain the requisite electrochemical potential gradients for driving H+ ions, and hence HCO-3 ions, out of secretory cells.