Similar effects on infants of n-3 and n-6 fatty acids supplementation to pregnant and lactating women.

OBJECTIVE: There have been indications that high intake of n-3 long-chain polyunsaturated fatty acids (PUFAs) during pregnancy may increase birth weight and gestational length. In addition, n-3 long-chain PUFAs may be important for the neurobiological development of the infants. High levels of docosahexaenoic acid (DHA, 22:6 n-3) are found in the gray matter of the cerebral cortex and in the retina, and it seems as if the availability of long-chain PUFAs may be limiting cerebral development. The fetus and the newborn are dependent on a high supply from their mothers, either via the placenta or via breast milk. We supplemented pregnant and lactating women with n-3 or n-6 long-chain PUFAs to evaluate the effect on birth weight, gestational length, and infant development. DESIGN: We performed a double-blind, randomized study recruiting 590 pregnant, healthy, nulli- or primiparous women (19-35 years old) in weeks 17 to 19 of pregnancy. The women were provided 10 mL of either cod liver oil or corn oil daily until 3 months after delivery. MAIN OUTCOME MEASURES: Primary outcomes were gestational length and birth weight. Electroencephalography (EEG) was done on the second day of life and at 3 months of age. Novelty preference (Fagan test) was used as an indicator of cognitive function at 6 and 9 months of age. The fatty acid pattern in umbilical plasma phospholipids and in breast milk was measured, and dietary assessments were performed, both on the mothers during pregnancy and on the infants at 3 months of age. The growth of the infants was followed up to 1 year of age. RESULTS: Three hundred forty-one mothers took part in the study until delivery. There were no significant differences in maternal body mass index before pregnancy and at birth, or parity between the 2 groups. Smoking habits and parental education were also similar in the 2 groups. The mean age of the mothers receiving cod liver oil was, by chance, 1 year higher than the age of the mothers receiving corn oil (28.6 [3.4] vs 27.6 [3.2] years). The maternal dietary intake in the 2 groups receiving cod liver oil or corn oil was similar, except for the supplementation. There were no differences in gestational length or birth weight between the cod liver oil group and the corn oil group (279.6 [9.2] vs 279.2 [9.3] days; 3609 [493] vs 3618 [527] g, respectively). Birth length, head circumference, and placental weight were also similar in the 2 groups. The concentrations of the n-3 fatty acids eicosapentaenoic acid (20:5 n-3), docosapentaenoic acid (22:5 n-3), and DHA in umbilical plasma phospholipids were higher in the cod liver oil group compared with the corn oil group (10.8 [7.6] vs 2.5 [1.8] microg/mL, 5.0 [2.6] vs 2.9 [1.3] microg/mL, 55.8 [20.6] vs 45.3 [12.8] microg/mL, respectively). Neonates with high concentration of DHA in umbilical plasma phospholipids (upper quartile) had longer gestational length than neonates with low concentration (lower quartile; 282.5 [8.5] vs 275.4 [9.3] days). No differences in EEG scores or Fagan scores were found, but neonates with mature EEG (N = 70) had a higher concentration of DHA in umbilical plasma phospholipids than neonates with immature EEG (N = 51) on the second day of life. Dietary information from 251 infants at 3 months of age was collected and 85% of these infants were exclusively breastfed, in addition to 12% who were partly breastfed. The breast milk of mothers supplemented with cod liver oil contained more n-3 long-chain PUFAs and less n-6 long-chain PUFAs than breast milk of mothers supplemented with corn oil. There were no significant differences in infant growth during the first year of life between the 2 groups. CONCLUSIONS: This study shows neither harmful nor beneficial effects of maternal supplementation of long-chain n-3 PUFAs regarding pregnancy outcome, cognitive development, or growth, as compared with supplementation with n-6 fatty acids. However, it confirms that DHA concentration may be related to gestational length and cerebral maturation of the newborn.

[Acute respiratory failure caused by myotonic dystrophy]. / Akutt respirasjonssvikt forårsaket av dystrophia myotonica.

BACKGROUND: Respiratory insufficiency is not always caused by pulmonary diseases or diseases involving the pulmonary vasculature. MATERIAL AND METHOD: We present a case history of a 29-year-old patient with acute respiratory insufficiency following a gynaecological operation. RESULTS: Ventilation/perfusion scintigraphy and spiral-CT of thorax excluded pulmonary embolism. Chest X-ray demonstrated elevated diaphragm and slight right-sided atelectatic changes. Spirometry revealed a restrictive ventilatory capacity, which explained the patient's hypoxaemia. Phrenic nerve conduction studies were normal on both sides. Electromyography showed severe myotonic discharges in all examined muscles including intercostal musculature and the diaphragm. INTERPRETATION: Myotonic dystrophy was the cause of respiratory failure in this patient. The case demonstrates that respiratory failure may be caused by neuromuscular diseases, hence the importance of adequate neurophysiological investigation in such patients.

Childhood autism: the need for physical investigations.

In this paper the results of an extensive medical investigation of 25 children with childhood autism are presented and compared with those found in a group of non-autistic individuals matched for sex, age and intellectual level, all referred for developmental deviancy of unknown etiology. The examination included a psychiatric assessment and a neurological examination in addition to neurophysiological, chromosomal, metabolic and neuroimaging evaluation. In the clinical examination macrocephaly was found only among the autistic individuals, while the frequency of pathological cerebral CT and clinical parameters such as tendon reflexes and mobility problems was significantly greater in the control group. All the other pathological findings were found to occur with the same frequency in the two groups. Except for research purposes this study did not lend support to those who argue for extensive medical examinations for all children with autism. Based on the present findings, ordinary procedures for assessment of developmentally delayed children should be followed. This should include a systematic clinical neuropaediatric examination, an assessment of vision and hearing and a chromosome study, including that for fragile X.

Hypoxemic resuscitation in newborn piglets: recovery of somatosensory evoked potentials, hypoxanthine, and acid-base balance.

We tested the hypothesis that hypoxic newborn piglets can be successfully resuscitated with lower O2 concentrations than 21%. Severely hypoxic, 2-4-d-old, anesthetized piglets were randomly divided into five resuscitation groups: 21% O2 (n = 10), 18% O2 (n = 9), 15% O2 (n = 9), 12% O2 (n = 8), all normoventilated, and a hypoventilated 21% O2 group (PaCO2; 7.0-8.0 kPa, n = 9). Base excess (BE) reached -20 +/- 1 mmol/L at the end of hypoxia. After 3 h of resuscitation, BE had risen to -4 +/- 1 mmol/L in the 21% O2, 18% O2, and hypoventilated groups, but was -10 +/- 2 mmol/L in the 15% O2 group (p < 0.05 versus 21% O2 group) and -22 +/- 2 mmol/L in the 12% O2 group (p < 0.05 versus 21% O2 group). Four animals died during resuscitation, all allocated to the 12% O2 group (p < 0.05 versus 21% O2 group). Somatosensory evoked potentials (SEPs) recovered in 39 of 45 piglets, and remained present during resuscitation in all except the 12% O2 group. SEP recovered initially even in six of eight animals in the 12% O2 group, but disappeared again in all later during resuscitation. The SEP amplitude recovered to levels not significantly different from the 21% O2 group in all groups except the 12% O2 group. Plasma hypoxanthine concentrations and extracellular hypoxanthine concentrations in the striatum decreased during resuscitation to levels not significantly different from the 21% O2 group in all but the 12% O2 group (p < 0.05 versus 21% O2 group). In conclusion, severely hypoxic newborn piglets were resuscitated as efficiently with both hypoventilation and 18% O2 as with 21% O2.

Fibre density in idiopathic ano-rectal incontinence.

Fibre density (FD) was measured in the external anal sphincter (EAS) in 54 patients with idiopathic anal incontinence and compared to normative data from a control group of 18 patients. The aim of the study was primarily to establish a diagnostic tool which could give an objective analysis of the anal sphincter muscles. Secondly, to examine whether or not FD was correlated to clinical symptoms of incontinence and manometric measurements from the anal canal. Our data show that the FD was increased in patients with anal incontinence and further that FD was correlated to clinical symptoms of incontinence as well as to manometric parameters of the function of the anal canal. In conclusion, we suggest that FD measurement should be used as a routine in patients with idiopathic anal incontinence. FD values will give an objective estimate of the state of denervation/reinnervation present in the EAS. This is particularly valuable in patients being considered for operative treatment since severe denervation of the EAS generally is correlated to a poor result of surgery.

[Treatment of paracetamol poisoning. An indication for liver transplantation?]. / Behandling av paracetamolforgiftning. Indikasjon for levertransplantasjon?

Development of metabolic acidosis (pH < 7.30) or the combination of encephalopathy grade III-IV, coagulopathy (PT > 100s) and oliguric renal failure are associated with a poor prognosis in paracetamol-induced fulminant liver failure. It is important to administer N-acetylcysteine as soon as possible after the overdose, but N-acetyl-cysteine also seems to improve survival when given 36-80h following ingestion. Liver transplantation has been performed in some patients with paracetamol-induced fulminant liver failure, but convincing evidence that transplantation improves survival in this group of patients is still lacking. We discuss the difficulties met in deciding if and when to perform liver transplantation. Renal failure may develop some days after paracetamol poisoning, even in the absence of severe liver damage, and haemofiltration and haemodialysis may be necessary.

Cerebral blood flow and evoked potentials during reoxygenation with 21 or 100% O2 in newborn pigs.

The effects of resuscitation with 21 or 100% O2 on cerebral blood flow (CBF) and somatosensory evoked potentials (SEPs) were studied in 19 newborn pigs anesthetized with pentobarbital sodium. They were ventilated with 8% O2 until base excess reached -20 mmol/l and then were randomly reoxygenated with 21% O2 (n = 10) or 100% O2 (n = 9) for 25 min followed by 21% O2. Mean duration of hypoxemia in the two groups was 57 +/- 6 (SE) and 59 +/- 6 min, respectively. CBF determined by radioactive microspheres was significantly increased in all areas in both groups after 5 and 20 min of reoxygenation. At 5 min of reoxygenation forebrain O2 uptake (CMRo2) had increased significantly compared with baseline values in the 21% O2 group (2.5 +/- 0.1 to 3.2 +/- 0.2 ml.100 g-1.min-1) but not in the 100% O2 group. There were, however, no significant differences between the two groups in CBF or CMRo2 at any time, and by 60 min of reoxygenation both had returned to baseline levels. SEPs were not significantly different in the two groups. We conclude that, as judged by CBF, CMRo2, and SEP, 21% O2 is not inferior to 100% O2 when hypoxemic newborn pigs are reoxygenated.

[Botulinum toxin. A new therapeutic alternative in spastic dysphonia (laryngeal abductor dystonia)]. / Botulinumtoksin. Et nytt behandlingsalternativ ved spastisk dysfoni (laryngeal adduktordystoni).

Laryngeal dystonia is a condition characterized by involuntary spasms of the laryngeal muscles. In most patients this involves the adductor laryngeal muscles (adductor laryngeal dystonia). Treatment with a variety of therapies, including speech therapy and pharmacotherapy, have led to minimal improvement. Injections of botulinum-toxin (Botox) bilaterally into the vocalis muscles is a new treatment for adductor laryngeal dystonia. Since May 1991 we have treated 23 patients with adductor laryngeal dystonia with botulinum-toxin. In 74% of the patients the voice improved within 24-72 hours, and effect lasted for 2-14 months (average four months). Most of the patients got a breathy voice and a mild sensation of dysphagia during the first week after the injection.

Complete ulnar innervation of the thenar muscles combined with normal sensory fibres in a subject with no peripheral nerve lesion.

A complete ulnar innervation of all thenar muscles, including the opponens, have to our knowledge been described only in patients with severe traumatic lesions of the median nerve. The present study reports a subject with exclusive ulnar innervation of the thenar muscles in the right hand. The patient had no anamnestic or objective signs of peripheral nerve lesions. While his sensory and motor ulnar nerve fibres were normal, electrophysiological examination of the right median nerve showed normal course of the sensory fibres but apparently no motor fibres to the thenar muscles.

[Neurointensive monitoring. Experiences with neurophysiological examinations]. / Neurointensiv overvåking. Erfaring med bruk av neurofysiologiske undersøkelser.

Multimodal-evoked responses and EEG are used as a routine in many intensive care units and have proved their diagnostic and prognostic significance in a series of studies on comatose patients and patients with severe head injuries. The article includes a brief description of the methods, and of their use and interpretation in neurointensive medical care.

Long-term metabolic control in recipients of combined pancreas and kidney transplants.

Metabolic glucose control was followed in 36 patients at 12-month intervals for up to 5 years after a successful combined kidney and segmental duct-occluded pancreas transplantation. All recipients had normal blood glucose levels at each examination. HbA1 values, intravenous glucose tolerance test, C-peptide levels and C-peptide responses to glucagon stimulation were also, on average, within the normal range. Several individual patients had, however, abnormal values for these parameters. At most 46% had abnormal values for HbA1 and intravenous glucose tolerance test, up to 13% showed low C-peptide values and up to 46% of the stimulated C-peptide responses were inadequate at the different intervals. These parameters did not deteriorate with time. This was true both for the whole group of patients as well as for the 6 patients with a 5-year observation time evaluated separately. Despite these abnormalities in glucose metabolism, all patients remained normoglycaemic without need for exogenous insulin up to 5 years after transplantation. The long-term ability of duct-occluded segmental pancreatic grafts to preserve euglycaemia therefore seems to remain intact at least for 5 years.

[Liver transplantation in fulminant hepatic failure]. / Levertransplantasjon ved fulminant leversvikt.

The prognosis for patients suffering from fulminant hepatic failure is still poor. The possibility of performing liver transplantation has improved the outcome for the patient. The article presents three cases illustrating some of the difficulties in selecting patients for transplantation, and discusses clinical and laboratory monitoring of patients with fulminant hepatic failure and criteria for selecting patients for liver transplantation.

Iopentol compared with iohexol in carotid angiography. A double blind crossover test of a new non-ionic contrast medium.

A randomized double blind crossover test with iohexol and the new non-ionic contrast medium iopentol in 12 patients undergoing carotid angiography showed no difference in tolerability, EEG, ECG, neurologic status or image quality. Iopentol seems to be well suited for cerebral angiography.

Failed ileoanal anastomosis: correlations between clinical function and anal canal neurophysiologic and histologic examinations.

Ten patients with an ileoanal anastomosis had conversion to permanent ileostomy 13 (range, 6-29) months after the primary procedure. Causes for reoperation were incontinence in seven patients, unacceptable stool frequency without incontinence in two patients, and atypia in the mucosal remnant with perfect continence in one patient. Stool frequency, continence function, anal canal resting pressure, external anal sphincter (EAS) EMG/pressure relationship (in terms of slope, m), EAS fiber density (FD), and pressure in the distal ileum were registered, and the mucosa and the anal sphincter muscles were examined histologically. There were significant correlations between continence function and EAS changes in terms of both neurophysiologic tests (m and FD) and the histologic picture. The abnormalities in six incontinent patients were consistent with denervation of the EAS. The main reason for fecal leakage in one patient was the high amplitude of pressure waves in the distal ileum. Preservation of mucosal epithelium proximal to the dentate line per se did not seem essential to maintain continence.

Clinical and electrophysiological abnormalities in the visual system in myotonic dystrophy.

The investigation comprised 16 patients with verified myotonic dystrophy. The patients were examined ophthalmologically, by electroretinography (ERG) and pattern visual-evoked potentials (VEPs). The results were compared to those of a normal control group. More than 50% of the patients had changes in their lenses or retinas, and the ERGs and VEPs were frequently abnormal. No statistical relation was found between the clinical and electrophysiological findings, and the pattern of abnormalities seemed to vary at random. The number of abnormal clinical and electrophysiological findings increased slightly with the age of the patients, but no statistically significant relation was found either to the patients' age or the duration of the disease.

Multimodal evoked potentials, EEG and electroretinography in patients with dystrophia myotonica.

EEG, somatosensory (SEP) and visual evoked potentials (VEP) and electroretinography (ERG) were recorded from 16 patients with clinical and electromyographically verified dystrophia myotonica. The results were compared to an age- and sex- matched control group and revealed statistically significant differences between the group mean values for almost all records. Furthermore, abnormal individual electrophysiological tests were relatively frequent in the patient group. No correlation was found between abnormalities in one test compared to abnormalities in the other tests. Furthermore, no correlation was found between the number of electrophysiological abnormalities and the frequency of the disease in the nearest family. The number of abnormal electrophysiological tests increased, however, with age of the patients and duration of the disease.

Visual evoked responses in hereditary motor and sensory neuropathies.

The P2 latency of the pattern reversal visual evoked response was measured in 11 patients with hereditary motor and sensory neuropathy (HMSN). The P2 latency was inversely related to the peripheral nerve conduction velocity, but no significant relation was found between the P2 latency and the age of the patients or the duration of their symptoms. When the whole group was considered the mean P2 latency was longer but not significantly different from a control group. When the 11 patients were differentiated into HMSN I (5 males) and HMSN II (2 females, 4 males) the P2 latencies of the patients with HMSN I were significantly longer than those with HMSN II. The data support earlier findings that subclinical involvement of the optic nerve may occur in HMSN and suggest that measurement of P2 latency may be of value in the differentiation of HMSN. More than two subtypes, however, may exist.

EEG and evoked potentials in comatose patients with severe brain damage.

EEGs and evoked potentials were recorded in 76 deeply comatose and unresponsive patients with traumatic or non-traumatic cerebral damage. Spontaneous EEG activity was absent in 37 of the patients on the initial examination. The cortical somatosensory evoked potentials were invariably absent in these patients as were the visual evoked potentials. Brain-stem evoked potentials were abnormal, either lacking all waves or with only wave I or II present. Cerebral angiography performed in 33 of the patients within minutes to a few hours after the neurophysiological examination verified an established brain death, showing full intracerebral circulatory arrest in all. Spontaneous EEG activity was initially present in 32 patients on the first examination, 20 of whom had bilaterally abolished cortical somatosensory potentials. Ten of the patients died a few hours after the initial examination, another 10 were followed for 2-3 days and subsequently developed electrocortical silence (ECS). Twelve of the patients with spontaneous EEG activity had preserved cortical somatosensory potentials, either uni- or bilaterally. The only two who survived were found in this group. In the patients followed with multiple recordings over a few days, the first parameter to indicate a grave prognosis was always disappearance of the cortical somatosensory potentials bilaterally, which generally occurred hours, and sometimes a day or two, before cessation of the spontaneous EEG activity. EEG records from 7 patients did not meet the technical criteria of ECS; all, however, had abolished cortical somatosensory potentials bilaterally, and none in this group survived.

Effect of near normoglycaemia for two years on progression of early diabetic retinopathy, nephropathy, and neuropathy: the Oslo study.

Forty five insulin dependent diabetics were randomised to treatment with continuous subcutaneous insulin infusion (CSII), multiple insulin injections (five or six daily), or conventional twice daily insulin injections. Near normoglycaemia was obtained with CSII and multiple injections but not with conventional treatment (p less than 0.01). Hypoglycaemic coma was observed less frequently with CSII than with multiple injections and conventional treatment (p less than 0.001), but blood glucose concentrations below 2.5 mmol/l (45 mg/100 ml) were more common. After two years fewer retinal microaneurysms and haemorrhages had developed in the patients given CSII and multiple injections compared with those given conventional treatment, in whom the number had increased significantly (p less than 0.01). Motor nerve conduction velocity deteriorated in the patients given conventional treatment; in those given CSII it was unchanged during the first year but had improved after two years (p less than 0.01). Glomerular hyperfiltration was reduced with CSII, but no change occurred in urine albumin excretion rates. Long term near normoglycaemia may prevent the progression of early stages of late diabetic complications.