Managed Care Network for the assessment of cardiac problems in children in a district general hospital: a working model.

AIM: To assess a model for cardiology assessments in children with suspected heart disease by a general paediatrician with special expertise in paediatric cardiology (PsePC) in a district general hospital. METHODS: A new monthly "screening" clinic was established in May 2004 by the PsePC to reduce the burden of new referrals on outreach tertiary paediatric cardiology services. All patients were to have echocardiograms as part of their referral for cardiac assessment. Over a one year period (May 2004-April 2005), through audit, details of referrers, indications for referral, echocardiography assessments, and subsequent management were recorded. This was compared with the pattern of patients seen in the joint paediatric cardiology outreach clinics over a two year period (May 2003-April 2005). RESULTS: In the "screening" clinic, there were 75 appointments for 65 patients seen in 12 months. Fifty five of these patients had normal echocardiographic studies. Of the 47 referrals with heart murmurs in asymptomatic children, four had structurally abnormal hearts on echocardiographic assessment. Between May-October 2003 and November 2003-April 2004, the number of new patients with normal echocardiographic studies seen in the paediatric cardiology outreach clinic was 33/106 (31%) and 28/110 (25.4%) respectively. Following the introduction of the "screening" clinic, the number decreased to 21/99 (21%) during May-October 2004, and 10/102 (9.8%) during November 2004-April 2005. CONCLUSION: This model can work effectively in order to identify pathology requiring input of a paediatric cardiologist more appropriately. Paediatricians with specific training in paediatric cardiology are potentially well equipped to provide this basic screening service.

Ultrasound examination of neonate's hip joints.

In a mass screening project, 872 neonates were examined clinically and by ultrasound. Hip joint stability was assessed in the ultrasound stress test showing a normal or physiologic instability, in the range of 0 to 2 mm. Along with the dynamic examination, a modified Graf's method was used. All obtained sonograms were submitted to careful assessment by one of authors, including regular measurement of alpha and beta angles. This relatively small group in the low-risk population served as a model of normality. White newborns compared with an black Caribbean group did not show the presence of apparent primary acetabular dysplasia. Both methods--dynamic ultrasound test and Graf's scanning--seemed to us to be valuable.

A new method of intestinal salvage for severe small bowel ischemia.

The morbidity and mortality in short bowel syndrome are directly related to the length of the remaining small bowel and to the duration of total parenteral nutrition. We describe the successful salvage of an infant with extensive small bowel infarction for whom a new technique was used to preserve all viable mucosal surfaces. The infant, with gastroschisis, was found to have a tight volvulus of the extruded bowel and extensive small bowel ischemia at the time of delivery. Forty-eight hours after reduction of the volvulus and abdominal decompression, a second-look laparotomy was performed. Although only the terminal 13 cm of ileum was completely viable, 25% of the circumference of a further 23 cm of proximal jejunum/ileum was considered salvageable. After debridement of the dead tissue, the remaining gutter of jejunum was divided at its midpoint, and the two halves were anastomosed longitudinally to provide a "neojejunum" of 12 cm in length, which was anastomosed between the duodenum and terminal ileum. Full enteral feeding was tolerated from day 47. Although the neojejunum was excised on day 149, after becoming dilated and atonic, by that time the remaining small bowel had elongated to 30 cm. Because of the early institution of full enteral feeding, there were no long-term complications related to total parenteral nutrition.

Accuracy of prenatal diagnosis of congenital cystic adenomatoid malformation.

A series of 13 consecutive patients with a prenatal diagnosis of congenital cystic adenomatoid malformation (CCAM) were reviewed with respect to prenatal ultrasound findings, clinical features at birth, and postnatal outcome. In two cases (15%) the abnormality regressed in utero. Only three infants (23%) showed any respiratory distress at birth. After a mean of 25 months postnatal follow up, 11 patients (85%) were found to have a definite pulmonary abnormality. In seven patients (54%) the specific prenatal diagnosis of CCAM has been confirmed (five histologically, two radiologically). Four infants (31%) were found to have other types of pulmonary abnormality and in two (15%) the lungs remain apparently normal. Prenatal ultrasound appears reliable in the detection of pulmonary abnormalities but the variety of conditions identified postnatally suggests that specific prenatal diagnoses and prognoses should be avoided; prenatal counselling and perinatal management should be adapted accordingly.

Maternal and cord blood plasma. Comparative analyses by 1H NMR spectroscopy.

Normal and 'Hahn' spin-echo 500 MHz 1H NMR spectra of 21 pairs of plasma from mother and cord taken at the time of delivery are reported. The concentrations of 'NMR-visible' lactate, alanine, and valine in the cord plasma significantly exceed those in the maternal plasma. In both maternal and cord plasma, measured lactate levels appear to increase with the length of the second stage of labour. Ethanol was unexpectedly detected in five samples of cord plasma. Lipoprotein--CH3 and--(CH2)n--resonances are more intense in the spectra of maternal plasma compared to cord plasma, and are unusual in composition. The intensities of N-acetyl signals from 'acute-phase' plasma glycoproteins are greater in spin-echo spectra of maternal plasma compared to those of cord plasma (mean ratio 2.1 (SD 0.8]. These results suggest that high resolution NMR spectroscopy may provide a useful new insight into the comparative biochemistry of maternal and cord plasma.