A homeobox gene, HLXB9, is the major locus for dominantly inherited sacral agenesis

Partial absence of the sacrum is a rare congenital defect which also occurs as an autosomal dominant trait; association with anterior meningocoele, presacral teratoma and anorectal abnormalities constitutes the Currarino triad (MIM 176450). Malformation at the caudal end of the developing notochord at approximately Carnegie stage 7 (16 post-ovulatory days), which results in aberrant secondary neurulation, can explain the observed pattern of anomalies. We previously reported linkage to 7q36 markers in two dominantly inherited sacral agenesis families. We now present data refining the initial subchromosomal localization in several additional hereditary sacral agenesis (HSA) families. We excluded several candidate genes before identifying patient-specific mutations in a homeobox gene, HLXB9, which was previously reported to map to 1q41-q42.1 and to be expressed in lymphoid and pancreatic tissues.

On the 5d 1Pig --> 2 (1)Sigma+<INF POS="STACK">u and 5d 1Pig --> C 1Piu Fluorescence in 7Li2

Following excitation of the 5d 1Pig Rydberg state of 7Li2 by optical-optical double resonance, fluorescence has been observed in the infrared region to the 2 (1)Sigma+<INF POS="STACK">u and C 1Piu states. Analysis of high-resolution Fourier transform spectra yields term energies and rotational constants of the lowest seven vibrational levels of the inner well of the 2 (1)Sigma+<INF POS="STACK">u "double minimum" state. The equilibrium term value and dissociation energy have been determined to be Te = 30101.45 +/- 0.12 cm-1 and De = 5621.3 +/- 0.2 cm-1. The v = 0 and 1 levels of the C 1Piu state have been analyzed, resulting in new values of Te = 30551.0 +/- 0.1 cm-1 and De = 7773.3 +/- 0.2 cm-1. Copyright 1998 Academic Press.

Testicular degeneration in Bclw-deficient mice

To identify genes required for mammalian spermatogenesis, we screened lines of mutant mice created using a retroviral gene-trap system for male infertility. Homozygous ROSA41 male mice exhibit sterility associated with progressive testicular degeneration. Germ-cell defects are first observed at 19 days post-natal (p19). Spermatogenesis is blocked during late spermiogenesis in young adults. Gradual depletion of all stages of germ cells results in a Sertoli-cell-only phenotype by approximately six months of age. Subsequently, almost all Sertoli cells are lost from the seminiferous tubules and the Leydig cell population is reduced. Molecular analysis indicates that the gene mutated is Bclw, a death-protecting member of the Bcl2 family. The mutant allele of Bclw in ROSA41 does not produce a Bclw polypeptide. Expression of Bclw in the testis appears to be restricted to elongating spermatids and Sertoli cells. Potential roles for Bclw in testicular function are discussed.

Problems of reproducibility--does geologically ancient DNA survive in amber-preserved insects?

Apparently ancient DNA has been reported from amber-preserved insects many millions of years old. Rigorous attempts to reproduce these DNA sequences from amber- and copal-preserved bees and flies have failed to detect any authentic ancient insect DNA. Lack of reproducibility suggests that DNA does not survive over millions of years even in amber, the most promising of fossil environments.

Anonymous HIV surveillance with risk-factor elicitation: at Perth (for men) and Cornton Vale (for women) prisons in Scotland

434 male and 145 female prisoners were available to participate in cross-sectional, voluntary anonymous HIV surveillance (using saliva samples) with linked self-completion questionnaire at HMP (Her Majesty's Prison) Perth on 17 May and at HMP Cornton Vale on 18 May 1995. Three hundred and four men (70%) and 136 women (94%) completed a risk-factor questionnaire and 304 and 135 samples were received for HIV antibody testing. Two hundred and eighty-two and 132 questionnaires passed logical checks. Six saliva samples from Perth (all injectors) out of 304 and none from Cornton Vale out of 134 tested were HIV antibody positive. Four were presumptively from known HIV-infected male inmates; the other 2 were local men, under 26 years, who began injecting in 1989-91, and both reported having had a recent HIV test. Overall HIV prevalence was estimated at 2% compared to a known prevalence of 1.4% (6/434), giving a 1.5 ratio of overall: disclosed HIV prevalence at HMP Perth. HIV prevalence was estimated at 7% (6/82) for injector-participants and 14% (5/35) for local injector participants. At Cornton Vale, where both known HIV-infected inmates abstained, overall and disclosed HIV prevalence, were equal at 1.4%. At Perth Prison, 29% of prisoners had injected drugs (82/278); 85% of injector-inmates reported having injected inside (some prison and 31% (25/80) had started to inject while inside, 7 during their present sentence. Of all 21 injector-inmates who first injected after 1991, 10 had started to inject inside, including one of 69 male inmates who had never been inside before. The corresponding figures for Cornton Vale, where 46% of inmates were injectors (58/132), were that 57% of injector-inmates had injected inside (32/56) but only one woman, for whom this was not her first sentence, had started to inject inside. Twenty-eight per cent of male prisoners (78/277) and 57% of male injector-inmates (47/82) had had a personal HIV test since January 1993, as had 35% of female prisoners (43/124) and 57% of female injector-inmates (30/53). A much higher proportion of Glasgow's female prisoners (64%: 38/60) were injectors than of women prisoners from the Edinburgh, Dundee and Fife area (21%: 5/26) or from elsewhere (34%: 15/45). Rape was reported by 23% of women (30/130). Women who had been raped had a more polarized distribution of male sexual partners (none to 2 plus) in the year before sentencing than other women and were more likely to report anal sex (11/30 vs 11/100, P < 0.001). Prostitution had been engaged in by 19% of female injector-inmates (11/57) and was acknowledged by one other woman. However, only 5% of women (6/130) reported ever having been treated for an STD.

Prison rights: mandatory drugs tests and performance indicators for prisons

Mandatory drugs testing of prisoners applies throughout England and Wales. Data from the 1995 pilot study in eight prisons show that the proportion testing positive for opiates or benzodiazepines rose from 4.1% to 7.4% between the first and second phase of random testing and that there was a 20% increase over 1993-4 in the provisional total of assaults for 1995. Interpretation of these data is difficult, but this is no excuse for prevarication over the danger that this policy may induce inmates to switch from cannabis (which has a negligible public health risk) to injectable class A drugs (a serious public health risk) in prison. The performance indicators for misuse of drugs that are based on the random mandatory drugs testing programme lack relevant covariate information about the individuals tested and are not reliable or timely for individual prisons.

Murine gammaherpesvirus-induced splenomegaly: a critical role for CD4 T cells

Murine gammaherpesvirus (MHV-68) causes an acute respiratory infection followed by a latent infection in B lymphocytes. In the first 2-3 weeks after infection mice develop a marked splenomegaly, where the spleen cell number increases by 2-3 fold. Cytofluorimetric analysis during splenomegaly revealed an increase in numbers of B lymphocytes and of both CD4+ and CD8+ T lymphocytes. The largest increase relative to uninfected spleens was in the CD8+ population. The number of latently infected cells in the spleen peaked at day 10 post-intraperitoneal infection, then declined to 1/10(6)-1/10(7) cells per spleen. Depletion of CD4+ T lymphocytes prevented the splenomegaly and greatly reduced the peak infective centre level, while having no effect on the long-term of latently infected cells. Given the similarity between MHV-68-induced splenomegaly and Epstein-Barr virus-induced infectious mononucleosis, these data highlight the usefulness of MHV-68 as a mouse model for the study of gammaherpesvirus immunology and pathobiology.

Anonymous HIV surveillance with risk factor elicitation at Scotland's largest prison, Barlinnie

OBJECTIVE

To determine prevalence of HIV infection and risk behaviours among male inmates of Her Majesty's Prison (HMP) Barlinnie, Glasgow, Scotland on 8-9 September 1994.

DESIGN

Cross-sectional study: voluntary, anonymous HIV surveillance (using saliva samples) of all inmates and linked self-completion risk-factor questionnaire.

SUBJECTS

Of 1073 prisoners available to participate, 985 (92%) completed a risk-factor questionnaire and 982 salivettes were received for testing, of which 978 were tested for HIV antibodies (four were dry samples); 928 questionnaires passed logical checks for consistency.

MAIN OUTCOME MEASURES

HIV prevalence on saliva testing, related risk behaviours and ratio of overall-to-disclosed HIV prevalence. Proportion of all inmates who have ever injected drugs, ever injected inside prison, started injecting inside, ever had acute hepatitis, had a recent personal HIV test (since January 1993).

RESULTS

Nine saliva samples [eight injecting drug users (IDU), one recognized other risk] out of 978 were HIV-antibody-positive (three presumptively from known HIV-infected inmates). Overall HIV prevalence was estimated at 1% compared with a known prevalence of 0.4%, giving an overall-to-disclosed HIV prevalence ratio of 2.6 in HMP Barlinnie in September 1994. A higher proportion of prisoners from Glasgow (48%) than elsewhere (19%) were IDU. Year of first injection was also different by residence with 23% of Glasgow IDU having first injected after 1988 compared with 45% of IDU from elsewhere, mainly West and South Scotland. Half the IDU inmates reported having injected while incarcerated and 6% had started to inject while incarcerated. Ten per cent of all prisoners and 20% of IDU inmates had had a personal HIV test since January 1993. Logistic regression showed that there was a significant deficit of recent HIV test uptake by Glasgow residents (odds ratio, 0.5; 95% confidence interval, 0.27-0.89), that IDU were more likely to have had treatment for a sexually transmitted disease, and that IDU who had injected inside and those whose injecting career began prior to 1989 were more likely to have had acute hepatitis.

CONCLUSION

A consistent harm-reduction policy is needed across prisons in the United Kingdom to avoid transmission of blood-borne viral infections. Drug injecting inside prison is common, a proportion of IDU inmates having first injected drugs while in prison, and much higher rates of hepatitis have been reported in association with injecting while incarcerated compared with that for IDU who only injected outside prison.

Octreotide does not prevent bacterial translocation in an infant piglet model of intestinal ischemia-reperfusion

The process of bacterial translocation (BT) after ischemia/reperfusion (I/R) injury is reported to be mediated by local mucosal factors, the effects of pancreatic enzymes, epithelial disruption, and by dysfunctional intestinal motility. Octreotide (OCT), a somatostatin analog, has been postulated to protect against BT by influencing one or more of these factors. Twenty-two formula-fed piglets (weight, 3.5 +/- 0.5 kg; age, 20 +/- 5 days) were divided into four groups: control (no drug given; no I/R; n = 6), I/R (no drug given; n = 5), I/R plus low-dose OCT (LD OCT, 0.08 microgram/kg; n = 6), and I/R plus high-dose OCT (HD OCT, 8 micrograms/kg; n = 5). All experimental subjects had nonocclusive mesenteric ischemia induced by reversible pericardial tamponade with mesenteric flow decreased to 25 +/- 5% of baseline for 5 hours followed by 15 +/- 5 hours of reperfusion. Mesenteric lymph nodes (MLN), liver, spleen, blood, and peritoneum were harvested for blind microbial analysis. None of the animals in the control group experienced translocation to the tissues tested. All of the animals in the I/R group experienced BT to the MLN. The subjects in the LD OCT and HD OCT groups experienced BT to the MLN 66% and 80% of the time, respectively. Despite the reported clinical evidence that OCT can protect the intestinal mucosa from injury and increase the clearance of bacteria from the gastrointestinal tract, in this study in which variables other than I/R known to promote bacterial translocation were eliminated, OCT failed to modify or prevent the occurrence of translocation to the MLN after I/R injury.

The role of surgery in the management of stage IV neuroblastoma: a single institution study

The role of surgery in the management of Stage IV neuroblastoma is still far from clear. Seventy-nine patients with this diagnosis presented to the Children's Hospital of Philadelphia during the 10-year period, 1977 to 1986. Four-year survival was 23%. A major resection of the primary tumor was undertaken in 54 patients. The timing of the procedure (at presentation or delayed) had no effect on survival. The patients were divided into three groups based on the extent of surgical resection: Group 1, no surgery or biopsy only (25); Group 2, complete gross resection (34); Group 3, incomplete resection with residual gross disease (20). Four-year survival was 16, 15, and 45%, respectively. The patients were then classified as favorable or unfavorable, on the basis of biological prognostic factors at presentation. When this analysis was combined with the extent of surgery it was discovered that Group 3 contained a higher proportion of favorable patients, accounting for the better survival. Within each group survival correlated with the expected prognosis. The outcome for a patient with Stage IV neuroblastoma depends on the biological characteristics of the tumor, and there is currently no evidence that these can be favorably altered by the timing or extent of surgical resection. Defining the appropriate role of surgery in the management of these patients will require a prospective randomized study which takes into account the inherent biological variability of the disease.

Drug injection and HIV prevalence in inmates of Glenochil prison

OBJECTIVE

To determine prevalence of HIV infection and drug injecting behaviour among inmates of Glenochil Prison on a specified date a year after an outbreak of hepatitis B and HIV infection.

DESIGN

Cross sectional: voluntary, anonymous HIV salivary antibody surveillance and linked self completion questionnaire on risk factors.

SETTING

Glenochil prison, Scotland, a year after an outbreak of hepatitis B and HIV transmission related to drug injection.

SUBJECTS

352 prisoners, of whom 295 (84%) took part; 284 questionnaires (96%) passed logical checks.

MAIN OUTCOME MEASURES

HIV prevalence; proportion of all inmates who had ever injected drugs, had ever injected inside prison, had started injecting drugs while inside prison.

RESULTS

More than half (150/284) the current inmates were also in Glenochil Prison during the critical period of January to June 1993, when hepatitis B and HIV were transmitted. Similar proportions of current inmates and men who were also in Glenochil during the critical period were drug users (27% (75/278) v 30% (44/149)). A quarter of injecting drug users (18/72) had first injected inside prison, irrespective of whether they were in Glenochil in January to June 1993 and regardless of the calendar period when they first injected. Significantly more inmates from Glasgow (41%; 56/138) than from Edinburgh (21%; 7/34) or elsewhere (11%; 12/106) were injecting drug users. On testing for HIV, seven saliva samples out of 293 gave positive results--four were presumed to be from inmates known to be infected with HIV, and the others from injecting drug users from Glasgow, all of whom had been in Glenochil during January to June 1993, when two of the three had injected drugs and had been tested for HIV, with negative results. The ratio of overall (2.4%) to disclosed (1.4%) HIV prevalence was 1.7. For men who had injected drugs in Glenochil during January to June 1993, HIV prevalence was estimated at 29%.

CONCLUSION

Between a quarter and a third of prisoners who injected drugs in Glenochil in January to June 1993 were infected with HIV. There is widespread ongoing risk of bloodborne virus infection within prisons, which is probably long standing but demands urgent attention.

Liquid chromatographic separation of zalcitabine and its stereoisomers

A liquid chromatographic method capable of separating and quantitating the stereoisomers of zalcitabine has been developed and validated. The separation was achieved with an Astec Cyclobond I--RSP column and a mobile phase of 0.25% triethylamine in water adjusted to a pH of 6.5 with glacial acetic acid. All enantiomers were found to exhibit a linear response in the range of 0.1-10% in the presence of 100% zalcitabine. Precision of analysis was found to be less than 1.5% at a level of 1% relative to zalcitabine. The limit of detection for two of the three enantiomeric impurities was determined to be 0.05% relative to zalcitabine. The detection limit for the third was found to be 0.1%. This method was successfully applied to the analysis of reference standards and several production scale batches. All of these materials were found to be stereochemically pure to a level of 99.8% or better.

Deaths, HIV infection, abstinence, and other outcomes in a cohort of injecting drug users followed up for 10 years

OBJECTIVE

To trace, follow up, and interview a group of patients known to be injecting drug users in order to establish current drug taking and other features related to drug use over 10 years.

DESIGN

Descriptive follow up study of a cohort of injecting drug users established between 1982 and 1985.

SETTING

General practice based patient population study initially, with later tracing of subjects throughout the United Kingdom through NHS Central Registries and current general practitioners.

SUBJECTS

203 injecting drug users recruited up to December 1985.

MAIN OUTCOME MEASURES

Survival, cause of death, abstinence, or continued drug use; HIV status; and demographic variables.

RESULTS

Of the 203 injecting drug users recruited into the study, over half were known to be HIV positive and 42 died of various causes (increasingly AIDS). From the start of follow up in 1990, 163 (91%) of the 180 survivors were traced, of whom 116 (71%) were interviewed. Dramatic changes had occurred in drug taking, with a move away from injecting towards oral drug use. A few patients, however, continued to inject. 90 (78%) of those interviewed had been in prison, of whom 37 (41%) had injected drugs while in prison.

CONCLUSIONS

The pattern of deaths had changed from being largely due to overdose in the early 1980s to predominantly AIDS related in later years. The reduction in deaths due to overdose may have been connected with but was not always causally related to a new approach by legal, social, and medical services. Drug use continues in a modified form in a large proportion of patients followed up. As a group, drug users require long term support for a multiplicity of problems.

Prevention of radiation enteritis in children, using a pelvic mesh sling

Between 1986 and 1991, the authors used polyglycolic acid mesh slings (placed at or above the sacral promontory) in eight children with pelvic malignancies to exclude all small bowel from the pelvis during pelvic radiation therapy. The only complications of this treatment were prolonged postoperative ileus (one patient) and temporary, partial small bowel obstruction (one patient). The average amount of radiation administered to the pelvis postoperatively was 5,349 +/- 556 cGy. In one of the eight patients, gastrointestinal symptoms (diarrhea for 24 hours) developed during radiation therapy. Early radiological evaluation confirmed that the small bowel was out of the pelvis in all five of the patients studied. Mesh disruption occurred between 2 and 5 months postoperatively (mean, 3.4 +/- 1.5 months) and was often identified symptomatically by the patient. Seven of the eight survived, with disease remission in six. Pelvic disease was absent at the time of death in the one patient who did not survive. Throughout the follow-up period (mean, 20 months) no survivor has had delayed symptoms of radiation enteritis. In children with pelvic malignancies in whom aggressive application of pelvic irradiation is required, the use of an absorbable pelvic mesh sling appears efficacious in preventing radiation-associated enteritis.

Bacterial translocation in mesenteric ischemia-reperfusion injury: is dysfunctional motility the link?

The authors previously reported that mesenteric ischemia and reperfusion (I/R) in a chronic newborn piglet model creates dysfunctional intestinal motility. Whether this leads to inadequate bacterial clearance and translocation (BT) through the gastrointestinal tract remains unclear. To test this hypothesis the authors used their chronic piglet model (weight, 3.5 +/- 0.3 kg; age, 18 +/- 4 days; on formula feeding); nonocclusive mesenteric ischemia was induced via reversible pericardial tamponade. Mesenteric flow (SMA Doppler measurement via the retroperitoneal approach) was decreased to 25% +/- 5% of baseline for 300 minutes in the ischemia group (n = 7) and followed by 14 hours of reperfusion in the I/R group (n = 6). Control subjects had a sham operation (n = 7). Mesenteric lymph nodes (MLN), liver (L), spleen (S), ileum, peritoneum, and blood were harvested for blind quantitative microbial analysis. Subjects in the control group had no cultures positive for growth. Eighty-five percent of animals in the ischemia group had positive MLN cultures only (P < .05 v control). All piglets in the I/R group had positive MLN cultures (P < .05 v control), and one third of them manifested bacteremia. Histological examination did not show mucosal disruption in any group. The validity of this model is confirmed by the negative cultures in the control group and by the presence of normal ileal flora in all animals. In the ischemia and I/R groups, MLN cultures were consistently positive with gram-negative bacilli (Escherichia coli and/or Klebsiella pneumoniae). When subjects of the I/R group had more than 1,000 colonies in the MLN, bacteremia with the translocating organisms was also identified.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone marrow transplantation for high risk neuroblastoma at the Children's Hospital of Philadelphia: an update

A bone marrow transplant (BMT) protocol including surgical excision, local and total body irradiation, and high dose multiagent chemotherapy based on melphalan and bone marrow rescue has been in effect for children with high risk or relapsed neuroblastoma at the Children's Hospital of Philadelphia since 1979. The initial results were reported in 1984 [August et al.: J Clin Oncol 2:609-616, 1984]. This report updates the initial results and those that followed changes in the original conditioning regimen. Forty-two patients were treated between may 1979 and November 1987, and included 27 whose disease had relapsed and 15 who received BMT as part of primary treatment. Allogeneic marrow was given to 12 and autologous marrow to 30; in 7 of these 30, the marrow was purged with monoclonal antibodies and magnetic beads. The 4-year actuarial survival rate is 29%. Ten patients died of early treatment-related complications, 18 died of progressive disease, and 2 died of late complications (1 AIDS and 1 acute myelogenous leukemia). Censoring the two late complications the actuarial 4-year relapse-free survival rate becomes 32%. The longest interval after BMT to relapse was 20 months. There was no significant difference in the survival for patients transplanted following relapse or in first remission. The better survival for patients rescued with autologous marrow (30%) is not statistically significantly different from the result with allogeneic marrow (17%).

Analysis of the monoclonal antibodies comprising WC6

The WC6 antibovine monoclonal antibodies (mAbs) CC98, IL-A114 and IL-A53 were investigated for reactivity in sheep by (fluorescence activated cell sorting) FACS analysis, immunoprecipitation and immunohistology. The mAbs behave identically by all criteria although IL-A114 reacts more weakly than the other mAbs. This probably reflects limited cross-species reactivity. The mAbs stain < 30% of lymphocytes from blood, efferent and afferent lymph and the majority of afferent lymph dendritic cells. They also weakly stain granulocytes. They precipitate molecules of apparent molecular weight 220 kD and 180-190 kD. Sequential immunoprecipitation shows that CC98 antigen is not related to CD45. Immunohistology indicates staining of B cell areas and macrophages in Peyer's patch and lamina propria. The data show that these monoclonal antibodies react with a molecule distinct from OvCD45R.

Comparison of workshop CD45R monoclonal antibodies with OvCD45R monoclonal antibodies in sheep

The reactivity of the antibovine monoclonal antibodies (mAbs) comprising temporary cluster TC1 was compared with that of two OvCD45R mAbs on sheep cells. Three of the mAbs--CC31, CC99 and CC103--did not cross-react with sheep cells. All the workshop mAbs precipitated two molecules of apparent molecular weight (MW) 200 kDa and 220 kDa while the antisheep CD45R mAb 20-96 precipitated a single band of 220 kDa. Cell surface expression was examined by single colour FACS (fluorescence activated cell sorting) analysis of efferent and afferent lymph cells and peripheral blood lymphocytes and the distribution of the antigens on CD4+, CD8+ and T19+ (WC1) and B cells was determined by two colour fluorescence staining. By cellular distribution and immunohistology the TC1 mAbs could be divided into four distinct groups which differed from a fifth group comprising the two OvCD45R antibodies.

Ovarian masses in children: a review of 91 cases of malignant and benign masses

Ovarian masses in children are uncommon. We reviewed all cases of ovarian masses presenting to this hospital from 1979 to 1990. Ninety-one patients fulfilled the criteria and had medical records available. All patients were less than 18 years old. Four were diagnosed antenatally. Thirty-four tumors presented prior to 8 years of age and 1 (2.9%) was malignant. Fifty-eight tumors presented after 8 years of age and 18 (33%) were malignant. Seventy-two patients had benign disease and 19 had malignant tumors. Of those with benign disease 22 had simple or epithelial cysts, 25 had teratomas, 13 had torsion with cyst formation, 3 had granulosa cell tumors, and 9 had other less common lesions. Analysis of symptoms could not distinguish between benign and malignant lesions; however, age was less (P < .03) and tumor size smaller (P < .001) in patients with benign lesions. Benign lesions presented at a mean age of 8.8 years. Fifty-four patients had an ultrasound, all were diagnostic: simple mass (14), complex mass (8), or cyst (32). Mean size of the masses was 9.5 x 7.7 cm. Fourteen patients had a contralateral ovarian cyst. The malignant lesions included 14 germ cell tumors (4 endodermal sinus, 4 teratoma, 2 choriocarcinoma, 2 dysgerminoma, 1 embryonal, and 1 mixed), 4 epithelial tumors (1 mucinous cystadenocarcinoma, papillary cystadenocarcinoma, papillary serous cystadenocarcinoma, and endometrioid adenocarcinoma), and one patient with leukemic infiltration (ALL). Germ cell tumors presented at a mean age of 11.8 years. Eight of these patients had an ultrasound and all showed a mass (7) or cyst (1).(ABSTRACT TRUNCATED AT 250 WORDS)

Diaphragmatic hernia in tetrasomy 12p mosaicism

Twelve infants with diaphragmatic hernias plus other anomalies who had mosaicism for tetrasomy isochromosome 12p (Pallister-Killian syndrome) are reviewed. A newborn infant with a diaphragmatic hernia plus dysmorphic features and a normal peripheral blood karyotype should have chromosome analysis performed on fibroblasts or bone marrow.

Mesenteric ischemia in hypoplastic left heart syndrome

Hypoplastic left heart syndrome (HLHS) has been widely viewed as a uniformly fatal form of congenital heart disease. Between January 1984 and December 1990, 387 patients with the diagnosis of HLHS were treated at this institution. Mesenteric ischemia was clinically diagnosed in 31 patients (8% incidence) and confirmed by pathology or surgery in 25 of those patients. The mean age at the time of onset was 17.5 +/- 5.4 weeks and only 13% were premature newborns. In 80% of the patients a low perfusion state and significant hypotension were documented within 48 hours prior to the diagnosis of bowel ischemia. Nine patients (29%) required operative intervention (bowel resection 4, diffuse ischemia 3, and simple drainage 2). Overall, at operation or at autopsy, nine patients (29%) had diffuse gastrointestinal ischemia. Of 31 patients with mesenteric ischemia, 26 children (84%) died shortly after onset of the gastrointestinal symptoms regardless of means of management. Five patients (10%) initially improved with aggressive medical and/or surgical management; however, 4 subsequently died secondary to complications of their primary cardiac disease. Therefore, the overall mortality of patients with mesenteric ischemia was 97%. Previous reports have estimated that up to 7% of full-term newborns with symptomatic congenital heart disease may develop necrotizing enterocolitis (NEC). Our unique group of patients with HLHS is comprised mostly of full-term infants who developed onset of mesenteric ischemia at a mean age of 4 months associated with an underlying low perfusion state. This mesenteric ischemia has been erroneously identified as NEC.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of ischemia and reperfusion on intestinal motility

The interdigestive migrating motor complex (MMC) has been demonstrated to be a reliable indicator of intestinal motility and function. The effects of low perfusion on the MMC have never been studied. Fourteen newborn Yorkshire piglets (5 to 18 days old, weighing 2.9 +/- 0.4 kg) underwent celiotomy under general anesthesia with placement of four jejunal electrodes (50 cm apart) as well as a superior mesenteric artery (SMA) Doppler flow probe and a pericardial catheter. Group 1 (n = 5) had operation alone. Group 2 (n = 9) had nonocclusive mesenteric ischemia induced by reversible cardiac tamponade for 5 hours between postoperative days 6 to 12. All subjects had MMC phase III electrical activity, cycling time, and propagation velocity recorded daily. In group 2 MMCs were recorded prior to and during ischemia, and during reperfusion. Group 2 animals had 75% +/- 4% decrease in SMA flow during the tamponade period. During the ischemic period, the MMC cycling time (CT) increased from 67 +/- 10 (mean +/- SEM) to 98 +/- 12 minutes (P < .05) and MMC propagation velocity (PV) decreased to 4.2 +/- 2.2 from a baseline value of 10.5 +/- 1.5 cm/min (P < .05). During reperfusion CT and PV values were not significantly different from baseline. The validity of this model is confirmed by the comparable baseline recordings in groups 1 and 2, and by the return of MMC to baseline values within 4 to 7 hours of reperfusion, as seen in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Mesenteric, omental, and retroperitoneal cysts in children: a clinical study of 22 cases

Cystic lesions of the mesentery, omentum, and retroperitoneum are rare; from 1956 to 1990, 22 patients had operative treatment for such lesions at our institution. They ranged in age from 1 month to 14 years; 75% were younger than 5 years. All had either an acute abdomen or, more commonly, a silent abdominal mass. In all cases, the histologic diagnosis was lymphangioma. Abdominal ultrasonography was done in all cases after 1977 except for two patients who had an acute abdomen requiring emergency exploration. A cystic abdominal mass was diagnosed in 94% of these cases, but the correct diagnosis of lymphangioma was made prior to surgery in only 24%. Mesenteric cysts are most common in the small bowel mesentery. Omental cysts usually occur singly and are easily resected, but multiple cysts predominate in the mesentery and retroperitoneum. Complete resection was accomplished in 82% of our cases. Two patients required partial bowel resection, and four had partial excision with marsupialization of the cysts. With a mean follow-up of 23 months, we have had three recurrences, but none necessitated reexploration. Extra-abdominal lesions, mainly cutaneous lymphangiomas, developed in two cases. Prognosis is good after surgical excision, but long-term follow-up is advisable because of the possibility of recurrence, even during adulthood.

Systemic and mesenteric vascular effects of platelet-activating factor and cocaine. In vivo effects on a neonatal swine model

Mesenteric hypoperfusion may be responsible for alterations in gut mucosa leading to necrotizing enterocolitis. Platelet-activating factor (PAF) and cocaine have been implicated in the etiology of necrotizing enterocolitis. We have demonstrated direct toxic effects of these compounds in vitro, but the in vivo mechanism of bowel damage is unknown. Newborn piglets (3.0 +/- 0.3 kg) had physiologic parameters (electrocardiogram, blood pressure, pulse, and central venous pressure) continuously monitored as well as Doppler probe recordings of superior mesenteric artery flow (Qsma). Aortic flow with calculation of cardiac index, and systemic and mesenteric vascular resistances (SVR and MVR) were also determined. Group 1 (N = 8) received PAF (0.5 microgram/kg). Groups 2 (N = 8) and 3 (N = 8) received high (17 mg/kg) and low (9 mg/kg) doses of cocaine, respectively. Each subject served as its own control. Histology demonstrated edema or early mucosal hemorrhage in all groups. PAF caused a third-degree atrioventricular block of short duration and a prolonged decrease of the cardiac index, but only a brief elevation of SVR and MVR. The cocaine groups had a sustained increase of SVR and MVR associated with a decrease of cardiac index. The decrease of Qsma paralleled the changes of MVR in each subject. These data show that both PAF and cocaine induce mesenteric ischemia. The effect of PAF is of short duration and mainly related to its cardiotoxic effects resulting in low Qsma. Cocaine causes an increase in MVR with prolonged depression of mesenteric flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Sites of relapse in patients with neuroblastoma following bone marrow transplantation in relation to preparatory "debulking" treatments

Forty-one patients with high-risk neuroblastoma were treated between September 1977 and December 1987 at the Children's Hospital of Philadelphia with supralethal chemotherapy and total-body irradiation rescued by bone marrow transplantation. Twenty-six patients were treated following relapse and 15 were newly diagnosed. At the time of evaluation, January 1991, 11 of 41 patients (26.8%) remained in complete remission. Actuarial survival rates of patients transplanted following relapse were 0.35 and 0.31 at 2 and 5 years, respectively, and actuarial disease-free survival rates were 0.38 at 12 months and 0.27 at 24 months. The 2- and 5-year actuarial survival values for the patients with newly diagnosed disease were 0.53 and 0.25, respectively, and the 12- and 24-month disease-free survival rates were 0.47 and 0.27, respectively. There was no significant difference in survival between these groups. Twenty-nine of the 41 patients reviewed were available for analysis of the effect of local treatment. Thirteen had a combination of surgery and radiation (RT), 2 had surgery alone, 9 had RT alone, and in 5 patients no local treatment was given. The local relapse rate was 17%; it was 15% following surgery plus RT and 22% following RT alone. The failure rate combining local and distant relapse is 62% for surgery plus RT and 44% for RT alone. Although a local relapse rate of 17% is imperfect, it is a relatively small contribution to the overall relapse of 62%.

Postoperative intussusception: increasing frequency or increasing awareness?

Postoperative intussusception in children is a rare but well recognized phenomenon. The diagnosis is often delayed due to the protean manifestations of the disorder (ileus, distention, and nausea and vomiting) which, when encountered shortly after an abdominal operation, usually result in a low index of suspicion because they are common after laparotomy. Experience with two cases of postoperative intussusception within 24 hours heightened our index of suspicion. Review of our records indicated we had diagnosed and treated postoperative intussusception in 14 children during the preceding 4 years. Patient ages ranged from 4 months to 12 years (mean 39 months, median 20 months), and symptoms appeared on postoperative days 3 to 36 (mean 10 days, median 6 days). Initial operations included excision of a retroperitoneal or abdominal tumor (five cases), Nissen fundoplication and gastrostomy (three), ileal resection (two), Ladd procedure (one), Duhamel operation (one), and operative reduction of ileocolic intussusception (the two most recent cases). Eleven patients had appendectomy (five by the inversion technique), and three had placement of a transgastric small bowel feeding tube. Nine children had had either barium enema or upper gastrointestinal studies because of the postoperative suspicion of obstruction; one patient had both. Diagnostic studies were not done in four patients. Operative reduction was successful in all but one child, who required bowel resection.

Maternal cocaine abuse and necrotizing enterocolitis: outcome and survival

Since 1987, multiple complications related to maternal cocaine abuse have been reported. Necrotizing enterocolitis-(NEC) of the newborn has been observed with increasing frequency. We report a comparative analysis of infants with NEC born to cocaine abusing mothers (n = 11) to a standard population of newborns with NEC (n = 50) treated in this institution from January 1987 to July 1989. We also evaluated whether prenatal cocaine abuse predisposes infants to NEC by performing a case-control analysis using 51 of 61 infants and controls matched for race, sex, and birthweight +/- 250g. Significant differences were apparent between the cocaine-affected infants (COC) and the noncocaine-affected infants (Non-COC) with regard to surgical intervention (72.7% v 38%, P less than .05), the presence of massive gangrene (54% v 12%, P less than .01), mortality (54.5% v 18%, P less than .01), and maternal age (28.13 +/- 3.82 years v 24.12 +/- 6.21 years P less than .05). No differences between these groups could be demonstrated for other known NEC risk factors such as gestational age, birthweight, feeding patterns, umbilical artery catheters, or asphyxia. In the matched case-control study, infants born to mothers who were cocaine abusers demonstrated a 2.5-fold increased risk of developing NEC (95% Cl = 1.17 to 5.32, P = .02) when compared with the noncocaine-exposed group. Maternal cocaine abuse appears to play a contributory role in the pathogenesis of NEC, its extent, and its outcome.

Parathyroid surgery in children

Parathyroid surgery in children is uncommon. Spontaneously occurring cases of hyperparathyroidism are almost always due to single-gland disease: however, on exploration all four parathyroid glands should be identified. Most of the other instances in which the surgeon needs to perform a parathyroidectomy on an infant or a child will be situations were multiple-gland disease is the rule rather than the exception. Therefore, the surgeon must have in his mind a well developed logical approach to the management of children with parathyroid disorders on the basis of multiple glandular disease. We believe that the technique of parathyroid autotransplantation very satisfactorily addresses the surgical needs of children with familial hyperparathyroid states, including the multiple endocrine neoplasias. We believe that it is mandatory treatment in patients presenting with neonatal primary hyperparathyroidism and is also the procedure of choice in children with secondary and tertiary hyperparathyroidism. The workup and diagnosis of parathyroid disorders should be familiar to the surgeon who undertakes neck exploration on children, and the entity of familial hypocalciuric hypercalcemia should be looked for, as these patients have a strong likelihood of not benefiting from parathyroidectomy.

A trilaminar skin coverage technique for treatment of severe degloving injuries of the extremities and torso

A 60 percent degloving injury involving the torso and lower extremities of an 8-year-old boy is described. Successful management employed the use of a new trilaminar skin coverage technique. With the avulsed flap still attached to its bed, a 0.14-inch split-thickness graft of epithelium and superficial dermis is raised with a power-driven dermatome. From the same harvest site, one level deeper, a second layer consisting of split-thickness dermis (0.14 inch) is taken. Both the first and second layers are meshed and expanded. The remaining degloved flap is excised and, on a sterile bench, defatted to produce a third layer of deep dermis. In our case, this third layer was ultimately lost, but it functioned well as a temporary biologic dressing. Depending on donor-site morbidity, other potential applications of this method (i.e., major burn injuries) may be feasible.

The role of leukocytes in mediating mucosal injury of intestinal ischemia/reperfusion

The source of oxygen-free radicals in putative intestinal reperfusion injury is unknown. To define the role of the circulating leukocyte in this pathophysiology, we report a rat model of ex vivo intestinal perfusion that permits alteration of the intravascular perfusate. The validity of the model is proven by the degree of intestinal injury produced by reperfusion following occlusive ischemia. Severe damage was noted in the animals reperfused with normal blood; however, reperfusion with a white blood cell-free perfluorochemical significantly ameliorated this damage. The addition of leukocytes to the perfluorochemical negated the previously seen protection of the leukocyte-free perfusate. This study strongly suggests that the intravascular leukocyte is an important mediator of intestinal ischemia/reperfusion injury.

Cologastric fistula as a complication of percutaneous endoscopic gastrostomy

Percutaneous endoscopic gastrostomy (PEG) is frequently used for long-term enteral nutrition or gastrointestinal decompression in both adults and children. The rare complication of a cologastric fistula following PEG has been seen recently in two pediatric patients. One fistula did not close after removal of the gastrostomy tube. A mechanism for the occurrence of this complication in these two children is proposed and technical points are emphasized to prevent this complication.

Partial splenectomy: the preferred alternative for the treatment of splenic cysts

We report six pediatric patients who had a partial splenectomy for splenic cysts and a seventh patient who had a total splenectomy. There were six epidermoid cysts and one traumatic cyst. All patients had benign postoperative courses. All patients who underwent partial splenectomy had a significant postoperative rise in platelet count that subsequently returned toward baseline. This rise implies a loss of splenic function, although the exact meaning of this is unclear. All patients had late postoperative liver-spleen scans that showed mean spleen size and function to be normal. We have described several methods of partial splenectomy used at Children's Hospital of Philadelphia. Recommendations for patients undergoing partial splenectomy include preoperative pneumococcus and Hemophilus influenzae vaccinations and prophylactic antibiotics postoperatively. The antibiotics are terminated if a liver-spleen scan and platelet count at the end of 3 months' time are normal.

Pediatric neck masses: guidelines for evaluation

Neck masses are frequent findings in the pediatric population. Unlike the adult, there are few established guidelines for evaluation of these children. The etiology of cervical masses includes many conditions. Knowledge of these conditions and their clinical presentations is essential. To elucidate the clinical characteristics which may help in establishing a correct diagnosis, the charts of 445 patients with biopsies of neck masses performed at the Children's Hospital of Philadelphia were analyzed. There were 244 (55%) congenital lesions, 118 (27%) inflammatory lesions, 23 (5%) non-inflammatory benign masses, 12 (3%) benign neoplasms, and 48 (11%) malignancies. The preoperative diagnosis was correct in 270 (61%) patients. Guidelines are established for the evaluation of the child presenting with a neck mass.

Surgical experience with thirteen conjoined twins

Conjoined twins occur in approximately one in 50,000 or so births, and most do not survive. The authors report herein their experience with 13 conjoined twins over the last 30 years, involving those of the following forms: thoracopagus (4 cases), omphalopagus (1 case), ischiopagus (4 cases), pygopagus (1 case), craniopagus (1 case), and incomplete or parasitic varieties (2 cases). The various diagnostic and imaging studies used are described in detail for each form of twinning. Separation is best delayed until such infants are relatively mature (i.e., 6-12 months of age). Operative survival was 50% in those operated on in the neonatal period, but 90% in those over 4 months of age. Ten separations were attempted in 13 sets of twins, with 16 operative survivors. Significantly, up to 10 years after surgery, there were six late deaths due to serious associated congenital anomalies, predominantly cardiac. Improved recent survival is probably the result of the availability of more accurate imaging studies and better anesthetic and operative techniques, with great emphasis on performing immediate reconstruction whenever possible. Use of skin expanders and prosthetic mesh has facilitated wound closure. In the future, ex vivo cardiac reconstruction and autotransplantation may permit separation of twins with complicated conjoined hearts.

The usefulness of open-lung biopsy in the pediatric bone marrow transplant population

From October 1976 to October 1986, 126 children had bone marrow transplants at the Children's Hospital of Philadelphia. The indications were acute lymphocytic leukemia (ALL) (30), nonlymphocytic leukemia (24), aplastic anemia (15), solid tumors (47), and miscellaneous conditions (10). Of these, 21 (17%) underwent 22 open-lung biopsies. Fourteen of these patients showed no causative microorganism. When a cause was found it was viral (usually cytomegalovirus [CMV]) in three, fungal in one, Pneumocystis carinii alone in two, both viral and pneumocystis in one, and a combination of viral, bacterial, and pneumocystis in one. Thirteen patients died due to continued deterioration after the biopsy. In only two patients was there a significant change in antimicrobial therapy as a result of the biopsy. Both had Pneumocystis (one in combination with virus and bacteria). One patient with chronic infiltrates showed a lymphocytic interstitial pneumonia, which responded well to steroids. Open-lung biopsy is currently of limited value in this patient population. Survival is dismal unless the patient has Pneumocystis. We believe that prospective studies should be set up to compare open-lung biopsy with empiric antimicrobial therapy. A major emphasis must be on prevention.

Resection with primary anastomosis for necrotizing enterocolitis: a contrasting view

Resection with primary anastomosis is currently being advocated for treatment of infants with necrotizing enterocolitis. To determine whether our own data would support such an approach, we reviewed retrospectively our experience with this disease since 1974. Since that time, 173 infants have been admitted for treatment of advanced (surgical) disease in its acute phase, of whom 143 underwent resection for cure; the remainder either underwent laparotomy with decompression (3), laparotomy with drainage (3), laparotomy alone (14), died at operation (1), or could not be resuscitated sufficiently to withstand operation (9). Excluded were patients who underwent operative repair of late stricture (6), all of whom survived with no morbidity. Among those resected for cure, 27 infants were carefully selected by the operating surgeon for treatment by means of resection with primary anastomosis, based on the limited and apparently discrete nature of their disease; in three the procedure was combined with a decompressing enterostomy. In the majority of cases (14), the disease was found to involve multiple areas of intestine, but was limited to a particular anatomic region, usually distal ileum and/or ascending colon; in the remainder, it was due to discrete ileal or jejunal perforation or ulcer. Overall survival among those resected for cure was 65% (96/143). It was 48% (13/27) among those treated by means of resection with primary anastomosis but 72% (83/116) among those who underwent resection with enterostomy. However, if the early years of the series (1974 to 1976) are excluded, a time when resection with enterostomy had not yet become established as standard therapy, overall survival was 77% (77/100), 64% (9/14) among those anastomosed primarily.

Massive gastrointestinal hemorrhage in children with posterior fossa tumors

Over a 12-month period (September 1984 to September 1985), 64 children with newly diagnosed brain tumors were admitted to the Neurosurgical Service at The Children's Hospital of Philadelphia. Of these children, 29 had posterior fossa tumors. Of this population of children with posterior fossa tumors, three patients aged 4 months, 22 months, and 4 years old developed massive exsanguinating upper gastrointestinal hemorrhage within seven days of their primary neurosurgical procedure. In each instance, large posterior duodenal ulcers were encountered and were treated with oversewing of the duodenal ulcer and vagotomy-pyloroplasty. Follow-up currently ranges from 18 to 26 months. All three children have survived and none have had any gastrointestinal bleeding since then. Massive exsanguinating hemorrhage was not seen in children with brain tumors in locations other than the posterior fossa. In this population of patients, we advocate the use of prophylactic cimetidine and titration of gastric acidity with antacids.

Microdiverticulitis: a rare but distinct cause of small bowel obstruction in early infancy

During a 20-year period, eight term infants admitted to a large children's hospital for treatment of dehydration associated with diarrhea (6) and vomiting (2), and who ranged in age from 10 to 60 days at onset of symptoms and 18 to 75 days at presentation, developed distal small bowel obstruction following apparently successful rehydration. With the exception of a single infant who was dead on arrival, and another whose obstruction went unrecognized, all infants came to operation shortly after obstruction was confirmed. In each case, a severely inflamed area of distal ileum (7) or proximal colon (1) was found at autopsy (2) or operation (6) to be the cause; perforation was present in four of the cases. Resection of the diseased segments of intestine, and primary anastomosis, were performed in all six operated cases; reoperation was required in four of the six for leaks (3) and adhesions (1). All but two survived. Pathologically, the resected intestinal segments showed a unique pattern of injury: numerous punctate ulcers were apparent, which undermined the muscularis mucosae, without evidence of necrosis. Regenerating epithelium extended through these defects, resulting in the presence of glandular invaginations, which were surrounded by a brisk inflammatory response: hence the term "microdiverticulitis." We believe this lesion represents a beginning or furtive attempt at repair of severely inflamed, but viable intestine, and that it is a rare but true cause of small bowel obstruction in early infancy, separate and distinct from necrotizing enterocolitis.

Recent experience with choledochal cyst

This report details an 11-year experience with 17 patients ranging from newborn to 17 years with choledochal cyst. Two distinct groups were noted: an infantile group (mean age: 3 months) with obstructive jaundice identical to biliary atresia and a late onset group (mean age: 9 years) with various combinations of pain, mass, and jaundice. Two patients had cystoduodenostomy performed and both required revision. One of six patients who had Roux-Y cystojejunostomy required revision. All seven patients who had primary cyst excision and two patients who had secondary cyst excision with Roux-Y hepaticojejunostomy have been followed prospectively and have done well. The follow-up period ranges from 1-11 years with an average of 5.8 years. Cyst excision should be performed as a primary or secondary procedure whenever feasible. The rare patients with intrahepatic ductal dilatation (Caroli's disease) are best approached by hepatic lobectomy when possible, and those with choledochocele should be treated by unroofing the cyst as indicated by the anatomy encountered.

Kinetics and mechanism of the hydrolysis of a 2-substituted imidazoline, cibenzoline (cifenline)

The results of a kinetic and mechanistic study of the hydrolysis of a new antiarrhythmic agent, cibenzoline, are reported. The reaction is subject to specific base catalysis which proceeds via the protonated cibenzolinium ion. No evidence for the existence of a "pseudobase"-type intermediate could be found. The results support only one of two different mechanisms which have been proposed previously for the hydrolysis of this class of compounds.

Total intestinal aganglionosis: a new technique for prolonged survival

Total small bowel aganglionosis is uniformly fatal; and prolonged nutritional treatment for the resulting severe short bowel syndrome in the absence of a therapy designed to achieve a functional bowel length has not been warranted. We report an operative technique, long segment small bowel myectomymyotomy, which has produced a functioning length of intestine capable of supporting ever increasing amounts of enteral nutrition. A term female was noted to have neonatal intestinal obstruction, and two laparotomies proved total colonic and near-total small bowel aganglionosis. At 2 months of age reoperation was done and the aganglionosis was proved to extend to 7 cm below the ligament of Treitz. From this transition zone to 10 cm distally, a myectomy was done removing a 1 cm wide length of seromuscular tissue to the level of the submucosa. From the distal end of the myectomy, another 40 cm of bowel received an antimesenteric border myotomy cutting to the submucosal level followed by spreading of the cut surface to a width of 1 cm. This left the patient with 55 to 60 cm of small bowel from the ligament of Treitz to the end of the myotomy at which point an end ostomy was created. The remainder of the small bowel was excised and the colon exteriorized as a mucous fistula. The patient was continued on total parenteral nutrition alone for ten days at which time small volume enteral feeds were introduced. By 5 months of age, 25% of calories were enteral; by 6 months, 33% of calories were enteral; and by 8 months, 45% of intake was enteral.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary hyperparathyroidism in infancy

Primary hyperparathyroidism in the neonate is a rare and often fatal disorder. These infants typically display severe hypercalcemia, respiratory distress, muscular hypotonia, and skeletal demineralization. They are usually diagnosed within the first three months of life and have hyperplasia of the four parathyroid glands. Twenty-nine infants with primary hyperparathyroidism are reported in the literature. Mortality is 87.5% in medically managed patients and 24% in surgically managed patients. Surgical management has not been satisfactory, in that recurrent hypercalcemia has been encountered in most patients undergoing subtotal parathyroidectomy, and total parathyroidectomy has resulted in the need for lifelong calcium and vitamin D supplementation. We have recently cared for a term newborn female in whom the diagnosis of primary hyperparathyroidism was made clinically on the second day of life, and later was confirmed biochemically. The baby underwent neck exploration on the 11th day of life and was successfully treated with total parathyroidectomy and parathyroid autotransplantation. Although initially rendered eucalcemic, the infant subsequently developed recurrent hypercalcemia requiring the removal of some of the autograft. Currently, the child is more than 2 years following surgery, growing well, and off all medication. The world literature is reviewed in this report of one of the first and the youngest infants, to our knowledge, to undergo parathyroid autotransplantation. In view of its success in avoiding the complication of repeated neck exploration for recurrent hyperparathyroidism or the creation of permanent hypoparathyroidism, we recommend this surgical approach for the rare neonate with primary hyperparathyroidism.