Care of women with XY karyotype: a clinical practice guideline

OBJECTIVE

To provide an evidence-based guideline for professionals working with XY women.

DESIGN

Review including patient cases from a Danish fertility clinic.

SETTING

University-associated scientific unit and fertility clinic.

PATIENT(S)

Three selected cases.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Evaluation of etiology, diagnosis, treatment, and associated disorders in XY women.

RESULT(S)

Many gene mutations can cause abnormal fetal development leading to androgen insensitivity syndrome or gonadal dysgenesis disorders. Females with these disorders have an XY karyotype but look like girls. They are mostly diagnosed at puberty, and the condition will often lead to serious psychological problems. Increased risk of malignancies and problems with pregnancy and infertility are other aspects that should be considered. This guideline will aid doctors in caring for XY females.

CONCLUSION(S)

A precise diagnosis is important, because the treatment possibilities (e.g., use of allogenic oocytes) depend on the subgroup to which the XY female belongs.

Intracranial pressure during recovery from nitrous oxide and halothane anaesthesia in neurosurgical patients

Seven patients with intracranial disorders were studied during recovery from anaesthesia with nitrous oxide and halothane. Arterial, intracranial, and central venous pressure, and arterial carbon dioxide tension were measured and compared with the patient's clinical state. No patient had evidence of increased brain volume when the dura was closed. All had been hyperventilated during the surgical procedure. Cessation of hyperventilation and the continued administration of anaesthetics was followed by a moderate increase in intracranial pressure and a reduction in cerebral perfusion pressure, but critically low values were not seen. Spontaneous respiration returned when the PaCO2 was in the range of 33-51 mm Hg. When spontaneous respiration was judged to be normal, anaesthesia was interrupted and the endotracheal tube was removed. In the following minutes, until the patients were awake, the intracranial pressure decreased to normal or near normal values, with minimal change in PaCO2. In these seven patients in whom there were no signs of brain swelling, the skull was closed, the patients were allowed to resume spontaneous respiration, and anaesthesia was terminated without major changes in intracranial pressure or cerebral perfusion pressure. However, hyperventilation is advocated after operation in patients with marked brain swelling.

The neurapraxic lesion: a clinical contribution to the study of trophic mechanisms

Four patients with neurapraxic lesions are described; in spite of the absence of impulse activity in muscle fibers no other signs of denervation could be detected. These observations are interpreted as indirect evidence for the role o f a non-impulsive (axoplasmic flow) system in certain trophic phenomena. The relationship of the present findings to the spectrum of neuropathic lesions is considered.

Relationships between cerebral perfusion pressure and regional cerebral blood flow in patients with severe neurological disorders

Three patients, one with a recurrent brain tumor, one with a severe brain contusion, and one with a brain abscess, are described who had continuous monitoring of the intracranial pressure with epidural and/or ventricular pressure transducers, continuous monitoring of the blood pressure, and periodic regional cerebral blood flow (rCBF) studies by the intra-arterial 133 Xenon method. A fourth patient with a severe brain contusion is described who had only blood pressure monitoring and rCBF studies. By measuring the regional cerebral blood flow and by testing autoregulation through changes in cerebral perfusion pressure and arterial P CO 2 , it is possible to reveal critical levels of cerebral perfusion pressure in the supratentorial compartment. Such measurements allow more rational evaluation of methods for control of increased intracranial pressure. The data point out that monitoring of systemic cardiorespiratory parameters for signs of cerebral compression is generally inadequate. The fact that pressure gradients may exist within the craniospinal enclosure is discussed. For this reason, before valid conclusions can be made regarding brain stem circulatory impairment at the tentorium and in the posterior fossa, the present regional techniques must be applied to these compartments also.