Diaphragm electromyogram in infants with abdominal wall defects and congenital diaphragmatic hernia.

Measurement of the diaphragm electromyogram (EMGdi) elicited by phrenic nerve stimulation could be useful to assess neonates suffering from respiratory distress due to diaphragm dysfunction, as observed in infants with abdominal wall defects (AWD) or congenital diaphragmatic hernia (CDH). The study aims were to assess the feasibility of recording EMGdi using a multipair oesophageal electrode catheter and examine whether diaphragm muscle and/or phrenic nerve function was compromised in AWD or CDH infants. Diaphragm compound muscle action potentials elicited by magnetic phrenic nerve stimulation were recorded from 18 infants with surgically repaired AWD (n = 13) or CDH (n = 5), median (range) gestational age 36.5 (34-40) weeks. Diaphragm strength was assessed as twitch transdiaphragmatic pressure (TwP(di)). One AWD patient had prolonged phrenic nerve latency (PNL) bilaterally (left 9.31 ms, right 9.49 ms) and two CDH patients had prolonged PNL on the affected side (10.1 ms and 10.08 ms). There was no difference in left and right TwP(di) in either group. PNL correlated significantly with TwP(di) in CDH (r = 0.8; p = 0.009). Oesophageal EMG and magnetic stimulation of the phrenic nerves can be useful to assess phrenic nerve function in infants. Reduced phrenic nerve conduction accompanies the reduced diaphragm force production observed in infants with CDH.

Patient-triggered ventilation.

During patient triggered ventilation, the infant's inspiratory efforts should occur synchronously with ventilator inflations. Such an optimal interaction, however, is dependent on the performance of the triggering device and the ventilator and the infant's lung function. Triggered ventilation (assist control, A/C), synchronous intermittent mandatory ventilation (SIMV), pressure support ventilation (PSV), volume targeted ventilation (VTV) with A/C, SIMV, PSV or proportional assist ventilation (PAV) can be delivered via the endotracheal tube or via nasal prongs. Meta-analysis of randomised trials demonstrated that the only advantage of A/C/SIMV over non-triggered positive pressure ventilation was a shorter duration of ventilation, in particular there was no significant effect on the incidence of chronic lung disease. The reduction in ventilation duration, however, was only seen if triggered ventilation is started in the recovery stage rather than in the acute phase of respiratory distress syndrome. Results from small randomised trials have suggested that A/C rather than SIMV is a better weaning mode, as reduction of the SIMV rate below 20 breaths per minute increases the work of breathing. Other small trials have highlighted triggered ventilation delivered by nasal prongs may reduce extubation failure rate. Physiological studies have demonstrated some advantages of PSV with and without VTV and PAV, whether these translate into improvements in long term clinical outcomes remains to be tested in appropriately designed randomised trials.

Clinics in diagnostic imaging (23). Traumatic rupture of the left iliac vein.

A 3-day-old male baby with neonatal necrotising enterocolitis had a central line (Cavafex No. 18) inserted through the left femoral vein for administration of parenteral nutrition. Forty-eight hours later, he developed progressive abdominal distention with evidence of free abdominal fluid. A contrast injection done through the left femoral vein revealed retroperitoneal leakage of contrast from a traumatic rupture of the left iliac vein. The intravenous catheter was removed and he was treated conservatively with eventual recovery.

Adrenal haemorrhage in a newborn--a case report.

A term female neonate with monolateral adrenal haemorrhage associated with haemorrhagic disease of newborn is described. Diagnosis and follow-up of adrenal haemorrhage was done clinically and sonographically which revealed reduction in the size of adrenal haematoma over a month with no evidence of adrenal insufficiency. She was discharged well and followed up.

Case report--a neonate with nonimmune hydrops fetalis.

A post-dated intra-uterine growth retarded male Malay baby was born to a 30-year-old mother gravida II by Caesarean section. Her previous pregnancy ended in still-birth. The baby was severely asphyxiated at birth. He was intubated and immediately admitted to the neonatal intensive care unit. He had anasarca, anaemia, purpura and firm, massive hepatosplenomegaly. X-rays revealed ascites and bilateral metaphysiitis of the long bones. The haemoglobin level was 5.0 gm/dl and PCV 18.3%. Coombs' test was negative. Prothrombin time (PT) and partial thromboplastin time (PTT) were prolonged. The baby and mother were positive for Venereal Disease Research Laboratory (VDRL) and the treponema pallidum haemagglutination assay (TPHA) tests. The baby was actively resuscitated but expired at three and a half hours of life due to overwhelming sepsis associated with severe anaemia and disseminated intravascular coagulation.

Spontaneous pneumothorax: a review of 29 admissions into Hospital Universiti Sains Malaysia 1984-90.

Twenty-nine patients (16 males, 13 females) with spontaneous pneumothorax admitted into Hospital Universiti Sains Malaysia, Kubang Kerian, from September 1984 to September 1990 were reviewed. Their ages ranged from newborn to 75 years. The commonest chief presenting symptom was dyspnoea (69%), followed by chest pain (35%). Four patients had chronic obstructive airway disease, 7 had pneumonia, 2 had pulmonary tuberculosis, one patient had emphysema while 4 patients had multiple underlying lung disorders. The left and right lungs were involved with equal frequency. Bilateral pneumothorax occurred in one patient. Most patients had a single episode of pneumothorax but recurrent pneumothoraces occurred in 3 patients (10%). Six patients were observed conservatively, 20 patients required chest tube insertion alone and 3 patients also required pleurodesis. Death occurred in 8 patients (28%) mainly due to coexisting infection and respiratory failure.

Primary osteogenic sarcoma of spine in a 12 year old boy--a case report.

A case of primary osteogenic sarcoma of the lumbar spine in child is reported and the difficulties in diagnosis and management are discussed.