VBP15, a novel dissociative steroid compound, reduces NFκB-induced expression of inflammatory cytokines in vitro and symptoms of murine trinitrobenzene sulfonic acid-induced colitis

OBJECTIVE AND DESIGN

The goal of this study was to assess the capacity of VBP15, a dissociative steroidal compound, to reduce pro-inflammatory cytokine expression in vitro, to reduce symptoms of colitis in the trinitrobenzene sulfonic acid-induced murine model, and to assess the effect of VBP15 on growth stunting in juvenile mice.

MATERIALS

In vitro studies were performed in primary human intestinal epithelial cells. Colitis was induced in mice by administering trinitrobenzene sulfonic acid. Growth stunting studies were performed in wild type outbred mice.

TREATMENT

Cells were treated with VBP15 or prednisolone (10 μM) for 24 h. Mice were subjected to 3 days of VBP15 (30 mg/kg) or prednisolone (30 mg/kg) in the colitis study. In the growth stunting study, mice were subjected to VBP15 (10, 30, 45 mg/kg) or prednisolone (10 mg/kg) for 5 weeks.

METHODS

Cytokines were measured by PCR and via Luminex. Colitis symptoms were evaluated by assessing weight loss, intestinal blood, and stool consistency. Growth stunting was assessed using an electronic caliper.

RESULTS

VBP15 significantly reduced the in vitro production of CCL5 (p < 0.001) IL-6 (p < 0.001), IL-8 (p < 0.05) and reduced colitis symptoms (p < 0.05). VBP15 caused less growth stunting than prednisolone (p < 0.001) in juvenile mice.

CONCLUSION

VBP15 may reduce symptoms of IBD, while decreasing or avoiding detrimental side effects.

Biodegradable-Polymer-Blend-Based Surgical Sealant with Body-Temperature-Mediated Adhesion

The development of practical and efficient surgical sealants has the propensity to improve operational outcomes. A biodegradable polymer blend is fabricated as a nonwoven fiber mat in situ. After direct deposition onto the tissue of interest, the material transitions from a fiber mat to a film. This transition promotes polymer-substrate interfacial interactions leading to improved adhesion and surgical sealant performance.

Are Immune Modulating Single Nucleotide Polymorphisms Associated with Necrotizing Enterocolitis?

Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency. The purpose of this study is to determine if functional single nucleotide polymorphisms (SNPs) in immune-modulating genes pre-dispose infants to NEC. After Institutional Review Board approval and parental consent, buccal swabs were collected for DNA extraction. TaqMan allelic discrimination assays and BglII endonuclease digestion were used to genotype specific inflammatory cytokines and TRIM21. Statistical analysis was completed using logistic regression. 184 neonates were analyzed in the study. Caucasian neonates with IL-6 (rs1800795) were over 6 times more likely to have NEC (p = 0.013; OR = 6.61, 95% CI 1.48–29.39), and over 7 times more likely to have Stage III disease (p = 0.011; OR = 7.13, (95% CI 1.56–32.52). Neonates with TGFβ-1 (rs2241712) had a decreased incidence of NEC-related perforation (p = 0.044; OR = 0.28, 95% CI: 0.08–0.97) and an increased incidence of mortality (p = 0.049; OR = 2.99, 95% CI: 1.01 – 8.86). TRIM21 (rs660) was associated with NEC-related intestinal perforation (p = 0.038; OR = 4.65, 95% CI 1.09–19.78). In premature Caucasian neonates, the functional SNP IL-6 (rs1800795) is associated with both the development and increased severity of NEC. TRIM21 (rs660) and TGFβ-1 (rs2241712) were associated with NEC- related perforation in all neonates in the cohort. These findings suggest a possible genetic role in the development of NEC.

Combination of Id2 Knockdown Whole Tumor Cells and Checkpoint Blockade: A Potent Vaccine Strategy in a Mouse Neuroblastoma Model

Tumor vaccines have held much promise, but to date have demonstrated little clinical success. This lack of success is conceivably due to poor tumor antigen presentation combined with immuno-suppressive mechanisms exploited by the tumor itself. Knock down of Inhibitor of differentiation protein 2 (Id2-kd) in mouse neuroblastoma whole tumor cells rendered these cells immunogenic. Id2-kd neuroblastoma (Neuro2a) cells (Id2-kd N2a) failed to grow in most immune competent mice and these mice subsequently developed immunity against further wild-type Neuro2a tumor cell challenge. Id2-kd N2a cells grew aggressively in immune-compromised hosts, thereby establishing the immunogenicity of these cells. Therapeutic vaccination with Id2-kd N2a cells alone suppressed tumor growth even in established neuroblastoma tumors and when used in combination with immune checkpoint blockade eradicated large established tumors. Mechanistically, immune cell depletion studies demonstrated that while CD8+ T cells are critical for antitumor immunity, CD4+ T cells are also required to induce a sustained long-lasting helper effect. An increase in number of CD8+ T-cells and enhanced production of interferon gamma (IFNγ) was observed in tumor antigen stimulated splenocytes of vaccinated mice. More importantly, a massive influx of cytotoxic CD8+ T-cells infiltrated the shrinking tumor following combined immunotherapy. These findings show that down regulation of Id2 induced tumor cell immunity and in combination with checkpoint blockade produced a novel, potent, T-cell mediated tumor vaccine strategy.

Culture-independent evaluation of the appendix and rectum microbiomes in children with and without appendicitis

PURPOSE

The function of the appendix is largely unknown, but its microbiota likely contributes to function. Alterations in microbiota may contribute to appendicitis, but conventional culture studies have not yielded conclusive information. We conducted a pilot, culture-independent 16S rRNA-based microbiota study of paired appendix and rectal samples.

METHODS

We collected appendix and rectal swabs from 21 children undergoing appendectomy, six with normal appendices and fifteen with appendicitis (nine perforated). After DNA extraction, we amplified and sequenced 16S rRNA genes and analyzed sequences using CLoVR. We identified organisms differing in relative abundance using ANOVA (p<0.05) by location (appendix vs. rectum), disease (appendicitis vs. normal), and disease severity (perforated vs. non-perforated).

RESULTS

We identified 290 taxa in the study's samples. Three taxa were significantly increased in normal appendices vs. normal rectal samples: Fusibacter (p = 0.009), Selenomonas (p = 0.026), and Peptostreptococcus (p = 0.049). Five taxa were increased in abundance in normal vs. diseased appendices: Paenibacillaceae (p = 0.005), Acidobacteriaceae GP4 (p = 0.019), Pseudonocardinae (p = 0.019), Bergeyella (p = 0.019) and Rhizobium (p = 0.045). Twelve taxa were increased in the appendices of appendicitis patients vs. normal appendix: Peptostreptococcus (p = 0.0003), Bilophila (p = 0.0004), Bulleidia (p = 0.012), Fusobacterium (p = 0.018), Parvimonas (p = 0.003), Mogibacterium (p = 0.012), Aminobacterium (p = 0.019), Proteus (p = 0.028), Actinomycineae (p = 0.028), Anaerovorax (p = 0.041), Anaerofilum (p = 0.045), Porphyromonas (p = 0.010). Five taxa were increased in appendices in patients with perforated vs. nonperforated appendicitis: Bulleidia (p = 0.004), Fusibacter (p = 0.005), Prevotella (p = 0.021), Porphyromonas (p = 0.030), Dialister (p = 0.035). Three taxa were increased in rectum samples of patients with appendicitis compared to the normal patients: Bulleidia (p = 0.034), Dialister (p = 0.003), and Porphyromonas (p = 0.026).

CONCLUSION

Specific taxa are more abundant in normal appendices compared to the rectum, suggesting that a distinctive appendix microbiota exists. Taxa with altered abundance in diseased and severely diseased (perforated) samples may contribute to appendicitis pathogenesis, and may provide microbial signatures in the rectum useful for guiding both treatment and diagnosis of appendicitis.

In Situ Deposition of PLGA Nanofibers via Solution Blow Spinning

Nanofiber mats and scaffolds have been widely investigated for biomedical applications. Commonly fabricated using electrospinning, nanofibers are generated ex situ using an apparatus that requires high voltages and an electrically conductive target. We report the use of solution blow spinning to generate conformal nanofiber mats/meshes on any surface in situ, utilizing only a commercial airbrush and compressed CO₂. Solution and deposition conditions of PLGA nanofibers were optimized and mechanical properties characterized with dynamic mechanical analysis. Nanofiber mat degradation was monitored for morphologic and molecular weight changes in vitro. Biocompatibility of the direct deposition of nanofibers onto two cell lines was demonstrated in vitro and interaction with blood was qualitatively assessed with scanning electron microscopy. A pilot animal study illustrated the wide potential of this technique across multiple surgical applications, including its use as a surgical sealant, hemostatic, and buttress for tissue repair.

A mechanism linking Id2-TGFβ crosstalk to reversible adaptive plasticity in neuroblastoma

The ability of high-risk neuroblastoma to survive unfavorable growth conditions and multimodal therapy has produced an elusive childhood cancer with remarkably poor prognosis. A novel phenomenon enabling neuroblastoma to survive selection pressure is its capacity for reversible adaptive plasticity. This plasticity allows cells to transition between highly proliferative anchorage dependent (AD) and slow growing, anoikis-resistant anchorage independent (AI) phenotypes. Both phenotypes are present in established mouse and human tumors. The differential gene expression profile of the two cellular phenotypes in the mouse Neuro2a cell line delineated pathways of proliferation in AD cells or tyrosine kinase activation/ apoptosis inhibition in AI cells. A 20 fold overexpression of inhibitor of differentiation 2 (Id2) was identified in AD cells while up-regulation of genes involved in anoikis resistance like PI3K/Akt, Erk, Bcl2 and integrins was observed in AI cells. Similarly, differential expression of Id2 and other genes of interest were also observed in the AD and AI phenotypes of human neuroblastoma cell lines, SK-N-SH and IMR-32; as well as in primary human tumor specimens. Forced down-regulation of Id2 in AD cells or overexpression in AI cells induced the cells to gain characteristics of the other phenotype. Id2 binds both TGFβ and Smad2/3 and appears critical for maintaining the proliferative phenotype at least partially through negative regulation of the TGFβ/Smad pathway. Simultaneously targeting the differential molecular pathways governing reversible adaptive plasticity resulted in 50% cure of microscopic disease and delayed tumor growth in established mouse neuroblastoma tumors. We present a mechanism that accounts for reversible adaptive plasticity and a molecular basis for combined targeted therapies in neuroblastoma.

Abstract 5042: The mechanism of reversible adaptive plasticity in neuroblastoma

Neuroblastoma (NB) is a pediatric cancer originating from neural crest-derived progenitors. This disease displays considerable clinical diversity, ranging from spontaneous regression to lethal disease. Heterogeneity within cancer cell populations is common and can arise through multiple mechanisms including genetic/epigenetic changes, microenvironmental influences, resistance to anoikis or presence of cancer stem cells. We have recently described a novel form of tumor cell transformation in NB termed reversible adaptive plasticity. Two defined NB phenotypes with anchorage dependent (AD) and anchorage independent (AI) growth patterns were observed in mouse and human cell lines under distinct culture conditions. These phenotypes are capable of reversible transition and identification of specific molecular markers enabled us to observe both phenotypes in established mouse and human NB tumors. In an effort to investigate the mechanism(s) driving this reversible transition in NB, we sought to determine the gene expression profile of the AD and AI phenotypes. In so doing, we were able to elucidate the molecular patterns and pathways associated with each phenotype. Affymetrix gene array analysis of the mouse Neuro2a cells revealed remarkable differences between the two phenotypes in vitro. 1180 genes were differentially expressed and delineated pathways of proliferation in AD cells or tyrosine kinase activation/ apoptosis inhibition in AI cells. In particular, inhibitor of differentiation 2 (Id2) was found to be 20 fold higher in AD while in AI, genes involved in anoikis resistance like PI3K/Akt, Erk, Bcl2 and integrins were upregulated. We hypothesized that Id2 plays a critical role in mediating phenotypic transition of the NB cells. Down-regulation of Id2 expression in the AD phenotype of NB cells with either antisense Id2 oligonucleotide or Id2-siRNA decreased proliferation, increased cell cycle exit, induced apoptosis and resulted in over-activation of Akt and Integrin/Raf/Erk pathways. This altered phenotype was similar to the AI cells in which anoikis resistance is evident. These findings describe the signaling pathways inducing reversible adaptive plasticity in NB. Id2 appears critical for maintaining the proliferative AD phenotype while down-regulating this pathway results in up-regulation of mechanisms governing transition to the anoikis resistant AI phenotype. In a mouse model of NB, targeting both cell phenotypes with the combination of doxorubicin (AD targeting) and Sorafenib (AI targeting) resulted in significant delay in tumor growth compared to either agent alone, highlighting the importance of adaptive plasticity in NB biology.

Citation Format: Lina Chakrabarti, Bi-Dar Wang, Norman H. Lee, Anthony D. Sandler. The mechanism of reversible adaptive plasticity in neuroblastoma. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 5042. doi:10.1158/1538-7445.AM2013-5042

Abstract 2771: Development of a non-thermal plasma model for neuroblastoma treatment

Neuroblastoma is a common extra-cranial solid tumor in children. There are several clinical categories of this disease, ranging from curable to very poor prognosis in which this cancer is treated with multi-modal therapy. We have tested a novel ablative technology, using non-thermal helium generated plasma jets, as a means to selective targeting of neuroblastoma cells. Plasma consists of partially ionized molecules, free radicals and other species. We have investigated the molecular mechanisms involved in non-thermal plasma mediated tumor cell death, as well as the differences in response between tumor and normal cells. Treatment with non-thermal plasma induced apoptosis in cancer cells, while normal cells appear to be less sensitive to the toxic effects. Levels of reactive oxygen species (ROS) such as superoxide anion and hydrogen peroxide are elevated after plasma treatment, suggesting that this may contribute to cell death. Scavengers of ROS were able to abrogate apoptosis in plasma-treated cells. Plasma therapy of tumor cells may be a novel approach to delivery of high levels of ROS, offering the ability to directly target and selectively destroy neoplastic tissue. Methods enhancing the ROS effect and/or technical delivery of the free radicals uniformly to tumor cells within a mass will be needed before this technology could be translated to ablating solid tumors in vivo.

Citation Format: Priya Srinivasan, Jason A. Snyder, Alexey Shashurin, Michael Keidar, Anthony D. Sandler. Development of a non-thermal plasma model for neuroblastoma treatment. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 2771. doi:10.1158/1538-7445.AM2013-2771

Note: This abstract was not presented at the AACR Annual Meeting 2013 because the presenter was unable to attend.

T-cell activation is enhanced by targeting IL-10 cytokine production in toll-like receptor-stimulated macrophages

Toll-like receptor (TLR) agonists represent potentially useful cancer vaccine adjuvants in their ability to stimulate antigen-presenting cells (APCs) and subsequently amplify the cytotoxic T-cell response. The purpose of this study was to characterize APC responses to TLR activation and to determine the subsequent effect on lymphocyte activation. We exposed murine primary bone marrow-derived macrophages to increasing concentrations of agonists to TLRs 2, 3, 4, and 9. This resulted in a dose-dependent increase in production of not only tumor necrosis factor–alpha (TNF-α), a surrogate marker of the proinflammatory response, but also interleukin 10 (IL-10), a well-described inhibitory cytokine. Importantly, IL-10 secretion was not induced by low concentrations of TLR agonists that readily produced TNF-α. We subsequently stimulated lymphocytes with anti-CD3 antibody in the presence of media from macrophages activated with higher doses of TLR agonists and observed suppression of interferon gamma release. Use of both IL-10 knockout macrophages and IL-10 small-interfering RNA (siRNA) ablated this suppressive effect. Finally, IL-10 siRNA was successfully used to suppress CpG-induced IL-10 production in vivo. We conclude that TLR-mediated APC stimulation can induce a paradoxical inhibitory effect on T-cell activation mediated by IL-10.

Management of congenital chest wall deformities

Congenital chest wall deformities are considered to be anomalies in chest wall growth. These can be categorized as either rib cage overgrowth or deformities related to inadequate growth (aplasia or dysplasia). Rib cage overgrowth leads to depression of the sternum (pectus excavatum) or protuberance of the sternum (pectus carinatum) and accounts for greater than 90% of congenital chest wall deformities. The remaining deformities are a result of inadequate growth. Evolution in the management of congenital chest wall deformities has made significant progress over the past 25 years. This article will review chest wall deformities and the current management strategies of these interesting anomalies.

Increased incidence of perforated appendicitis in children with obesity

Based on their clinical impression, the authors hypothesized that children with obesity may more commonly present with perforated appendicitis. Therefore, the authors reviewed their experience from 2008 to 2010 to determine whether obesity affected the clinical presentation of appendicitis. Variables studied were height, weight, use of diagnostic imaging, and clinical findings of appendicitis at presentation. Outcomes assessed were length of stay and complication rate. The study identified 319 patients with appendicitis. Children with obesity were more likely (P = .026) to present with perforation (28/62, 45%) than nonobese patients (78/257, 30%). Neither length of stay nor complication rate was affected by the presence of obesity. The data suggest that children with obesity are more likely to present with perforated appendicitis. This finding suggests that the diagnosis of appendicitis may be more difficult in obese patients or their presentation may be delayed. Practitioners should have heightened awareness in children with obesity and symptoms of abdominal pain.

Reversible adaptive plasticity: a mechanism for neuroblastoma cell heterogeneity and chemo-resistance

We describe a novel form of tumor cell plasticity characterized by reversible adaptive plasticity in murine and human neuroblastoma. Two cellular phenotypes were defined by their ability to exhibit adhered, anchorage dependent (AD) or sphere forming, anchorage independent (AI) growth. The tumor cells could transition back and forth between the two phenotypes and the transition was dependent on the culture conditions. Both cell phenotypes exhibited stem-like features such as expression of nestin, self-renewal capacity, and mesenchymal differentiation potential. The AI tumorspheres were found to be more resistant to chemotherapy and proliferated slower in vitro compared to the AD cells. Identification of specific molecular markers like MAP2, β-catenin, and PDGFRβ enabled us to characterize and observe both phenotypes in established mouse tumors. Irrespective of the phenotype originally implanted in mice, tumors grown in vivo show phenotypic heterogeneity in molecular marker signatures and are indistinguishable in growth or histologic appearance. Similar molecular marker heterogeneity was demonstrated in primary human tumor specimens. Chemotherapy or growth factor receptor inhibition slowed tumor growth in mice and promoted initial loss of AD or AI heterogeneity, respectively. Simultaneous targeting of both phenotypes led to further tumor growth delay with emergence of new unique phenotypes. Our results demonstrate that neuroblastoma cells are plastic, dynamic, and may optimize their ability to survive by changing their phenotype. Phenotypic switching appears to be an adaptive mechanism to unfavorable selection pressure and could explain the phenotypic and functional heterogeneity of neuroblastoma.

Immunostimulatory sutures that treat local disease recurrence following primary tumor resection

Neuroblastoma is a common childhood cancer that often results in progressive minimal residual disease after primary tumor resection. Cytosine-phosphorothioate-guanine oligonucleotides (CpG ODN) have been reported to induce potent anti-tumor immune responses. In this communication, we report on the development of a CpG ODN-loaded suture that can close up the wound following tumor excision and provide sustained localized delivery of CpG ODN to treat local disease recurrence. The suture was prepared by melt extruding a mixture of polylactic acid-co-glycolic acid (PLGA 75:25 0.47 dL g⁻¹) pellets and CpG ODN 1826. Scanning electron microscopy images showed that the sutures were free of defects and cracks. UV spectrophotometry measurements at 260 nm showed that sutures provide sustained release of CpG ODN over 35 days. Syngeneic female A/J mice were inoculated subcutaneously with 1 × 10⁶ Neuro-2a murine neuroblastoma wild-type cells and tumors were grown between 5 to 10 mm before the tumors were excised. Wounds from the tumor resection were closed using CpG ODN-loaded sutures and/or polyglycolic acid Vicryl suture. Suppression of neuroblastoma recurrence and mouse survival were significantly higher in mice where wounds were closed using the CpG ODN-loaded sutures relative to all other groups.

Effective adoptive therapy of tap-deficient lymphoma using diverse high avidity alloreactive T cells

High avidity for antigen and diversity of T cell receptor (TCR) repertoire are essential for effective immunity against cancer. We have previously created a transgenic mouse strain with increased TCR avidity in a diverse T cell population. In this report, we show that strong alloreactive responses of transgenic T cells against targets with low MHC class I expression can be used for effective adoptive transfer of tumor immunity in vivo. Alloreactive transgenic T cells could be an effective therapeutic approach counteracting tumor evasion of the immune system.

Immune stimulatory antigen loaded particles combined with depletion of regulatory T-cells induce potent tumor specific immunity in a mouse model of melanoma

Anti-tumor vaccines capable of activating both CD4 and CD8 T cells are preferred for long lasting T cell responses. Induction of a tumor-specific T-cell response can be induced by tumor vaccines that target innate immunity. The ensuing T-cell response depends on efficient antigen presentation from phagocytosed cargo in the antigen presenting cell and is augmented by the presence of Toll-like receptor (TLR) ligands within the cargo. Biodegradable polymers are useful for vaccine delivery in that they are phagocytosed by antigen presenting cells (APCs) and could potentially be loaded with both the antigen and immune stimulatory TLR agents. This study was undertaken to evaluate the effect of poly lactic-co-glycolic acid (PLGA) polymer particles loaded with antigenic tumor lysate and immune stimulatory CpG oligonucleotides on induction of tumor specific immunity in a mouse model of melanoma. We found that after delivery, these immune stimulatory antigen loaded particles (ISAPs) efficiently activated APCs and were incorporated into lysosomal compartments of macrophages and dendritic cells. ISAP vaccination resulted in remarkable T cell proliferation, but only modestly suppressed tumor growth of established melanoma. Due to this discordant effect on tumor immunity we evaluated the role of regulatory T cells (Treg) and found that ISAP vaccination or tumor growth alone induced prolific expansion of tumor specific Treg. When the Treg compartment was suppressed with anti-CD25 antibody, ISAP vaccination induced complete antigen-specific immunity in a prophylactic model. ISAP vaccination is a novel tumor vaccine strategy that is designed to co-load the antigen with a TLR agonist enabling efficient Ag presentation. Targeting of T-reg expansion during vaccination may be necessary for inducing effective tumor-specific immunity.

Robotic resection of mediastinal masses in children

PURPOSE

Robotic surgery may be particularly well suited for solid chest masses. In this paper, we present our initial experience by using robotic surgery to resect mediastinal masses in children.

METHODS

Five pediatric patients with an average age of 9.8 years (range, 2-17) and an average weight of 41.5 kg (range, 13.9-70.5) underwent a robotic resection of a mediastinal chest mass using the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA).

RESULTS

Operative time ranged from 44 to 156 minutes, with an average of 113 minutes. The pathology varied considerably and included a ganglioneuroma, ganglioneuroblastoma, teratoma, germ cell tumor, and a large inflammatory mass of unclear etiology. No complications or conversions occurred. Average length of hospitalization was 1.4 days. Follow-up averaged 2 years, with no evidence of recurrence in any patient.

CONCLUSIONS

Robotic surgery is safe and effective for resecting solid mediastinal chest masses. The articulating instruments are particularly helpful for dissecting around a solid mass within the rigid thoracic cavity.

Open-label use of placebos in the treatment of ADHD: a pilot study

BACKGROUND

This study examined short-term efficacy, side effects and acceptability of a placebo treatment procedure designed to maintain children with attention deficit hyperactivity disorder (ADHD) on 50% of their usual stimulant dose.

METHODS

An open-label prospective crossover trial was conducted in 26 children with ADHD, ages 7-15 years, stable on stimulant therapy, followed at a community-based developmental paediatrics ADHD clinic. Subjects were randomly assigned to one of two orders of experimental conditions: (1) baseline (100%) dose (1 week), then 50% dose (1 week), then 50% dose + placebo (1 week), or (2) baseline (100%), then 50% dose + placebo, then 50% dose. The inert nature of the placebo was fully disclosed to parent and child. Treatment was open-label for child, parents and physician, but single blind for teachers. Main outcome measures included weekly IOWA Conners parent and teacher rating scales, the Pittsburgh side effects rating scale (PSERS) and the Clinical Global Impressions (CGI) scale.

RESULTS

Parent IOWA showed ADHD behaviour tended to remain the same when the dose of stimulant medication was reduced with placebo but to deteriorate when the dose was reduced without placebo. There were no significant differences between conditions on the Teacher IOWA. PSERS scores were higher at baseline than on 50% dose. On the CGI, there was a significant difference (P = 0.004) between the 50% dose and the 50% + placebo conditions. Individual subject analysis showed that eight subjects met criteria for responder.

CONCLUSIONS

Results indicate that the open-label placebo treatment was acceptable and efficacious in the short term for some children.

H-type congenital tracheoesophageal fistula: University Of Iowa experience 1985 to 2005

OBJECTIVES

We review the diagnostic workup, associated disorders, surgical technique, and postoperative course of patients who underwent repair of H-type tracheoesophageal fistulas.

METHODS

We performed a retrospective chart review of patients who received a diagnosis of tracheoesophageal fistula at the University of Iowa.

RESULTS

Seven patients with an H-type tracheoesophageal fistula and a single patient with a missed proximal fistula associated with esophageal atresia were identified. Their symptoms included coughing with feeding, recurrent pneumonia, and episodic cyanosis. A delay in diagnosis was seen in 4 patients and ranged from 2.5 months to 5.9 years. In all patients, the diagnosis was made with an esophagogram. The level of the fistulas was between C5 and T3, and all were successfully repaired via a right cervical approach.

CONCLUSIONS

A high index of suspicion for an H-type tracheoesophageal fistula should be maintained in the presence of neonatal respiratory symptoms, as the condition can be associated with a delay in diagnosis. Repeat esophagograms and bronchoscopy may be required for diagnosis. In the postoperative period, airway obstruction is a potential risk; however, long-term difficulty with swallowing, respiration, and phonation was not observed.

Experience with alternate sources of venous inflow in the meso-Rex bypass operation: the coronary and splenic veins

The meso-Rex bypass procedure has been used to treat patients with portal hypertension from extrahepatic portal vein obstruction. This report describes modifications of this procedure in 5 patients. Either the splenic or coronary vein was used as the venous inflow point, and the bypass was performed either directly through transposition of the vein or with the use of a venous conduit.