An unusual case of Erb's palsy in a neonate: a case report

Erb's palsy occurs in neonates following traumatic delivery, where excessive traction on the neck stretches these nerve roots. Nonobstetric causes of Erb's palsy are rare in neonates. The authors report the presentation of a female neonate with Erb's palsy following a postero-lateral thoracotomy. The infant underwent surgery on day 3 of life for esophageal atresia and presented with right upper limb weakness on day 21 of life. She demonstrated features of Erb's palsy with normal higher mental functions. An electromyography and nerve conduction study confirmed Erb's palsy. The surgical procedure in the index case did not involve the brachial plexus. However, her right upper limb was positioned hyperabducted during the intraoperative period, which possibly had led to the palsy. The key message of this report is that prolonged stretching of the brachial plexus roots during surgery of the neck and thorax can be an important nonobstetric cause of Erb's palsy in neonates.

Dorsalis pedis artery pseudoaneurysm: an uncommon cause of soft tissue mass of the dorsal foot in children

Pseudoaneurysm of the dorsalis pedis artery is an extremely rare entity with only 3 pediatric cases previously presented in the English literature. We describe a new case and discuss the clinical presentation and surgical management. A 6-year-old boy was referred to our clinic because of a pulsatile tumor of the right dorsal foot increasing in size. A focused history found a low grade trauma to the dorsal foot one year previously. Magnetic resonance imaging revealed a pseudoaneurysm of the DPA. Resection of the pseudoaneurysm was completed without complications. Pseudoaneurysm of the DPA is a very uncommon cause of soft tissue mass of the dorsal foot. It can appear after low grade trauma. Treatment is surgical.

Mitomycin C as an adjunct in the treatment of localised ocular surface squamous neoplasia

AIM

To report the outcome of topical mitomycin C (MMC) used as adjunctive treatment following primary excision of ocular surface squamous neoplasia (OSSN).

METHOD

Prospective, non-comparative interventional case series of 27 primary OSSN lesions from 26 patients treated in a single ocular oncology centre over a 4 year period.

RESULT

27 cases of OSSN received a treatment regimen of surgical excision, followed by topical MMC. Mean follow up of 27 (SD 12) months (range 12-50, median 25 months) revealed zero recurrences.

CONCLUSION

MMC treatment following surgical excision decreases the recurrence rate of primary ocular surface neoplasia and should be considered as adjunctive therapy in primary treatment.

Analysis of pFQ31, a 8551-bp cryptic plasmid from the symbiotic nitrogen-fixing actinomycete Frankia

The actinomycete Frankia has never been transformed genetically. To favour the development of Frankia cloning vectors, we have fully sequenced the Frankia alni pFQ31 cryptic plasmid and performed analyses to characterise its coding and non-coding regions. This plasmid is 8551 bp-long and contains 72% G+C. Computer-assisted analyses identified 18 open reading frames (ORFs). These ORFs show a synonymous codon usage different from the one of Frankia chromosomal genes, suggesting an evolutionary bias linked to the nature of the replicon or a horizontal transfer. Three ORFs were found to encode genes likely to be involved in plasmid replication and stability: parFA (partition protein), ptrFA (transcriptional repressor of the GntR family) and repFA (initiation of replication). DNA signatures of a replication origin were identified in the ptrFA-repFA intergenic region. These structural motifs are similar to those observed among origins of iteron-containing plasmids replicating via a θ mode.

Bilateral cystic pleuropulmonary blastoma in early infancy

We report 2 cases of multifocal cystic (type 1) pleuropulmonary blastoma, diagnosed during the first 6 months of life. This rare entity must be recognized before evolution into the prognostically unfavorable type 2 or type 3 pleuropulmonary blastoma.

Cataract extraction in a major ophthalmic hospital: day-case or overnight stay?

PURPOSE

Cataract surgery is increasing in Australia and represents a significant burden on limited health resources. This study examines the frequency and outcomes of cataract surgery for patients who were hospitalized overnight compared with those treated as day surgery cases.

METHODS

Medical records of 671 consecutive admissions for cataract surgery at the Royal Victorian Eye and Ear Hospital were reviewed. Data analysed included demographic features, insurance status, length of hospitalization, ophthalmic conditions, medical conditions, social problems and planned surgical technique. Ophthalmic and anaesthetic complications, active ophthalmic and medical interventions were also studied.

RESULTS

Of the 671 patient admissions for cataract during the study period, 226 (33.4%) were hospitalized overnight. Factors significantly associated with overnight hospitalization in univariate analyses include older age, female sex, country residence, Veterans' Affairs insurance, monocular vision status, pre-existing ischaemic heart disease, pre-existing asthma/chronic obstructive lung disease, absence of carer, transportation problems, planned extra-capsular cataract extraction technique, ophthalmic complications and active ophthalmic and/or medical interventions. After adjusting for possible confounding factors using backwards stepwise multivariate logistic regression models all except pre-existing ischaemic heart disease and ophthalmic complications were significantly associated with overnight admission for cataract surgery. In total, 14 cases (2.1%) needed active ophthalmic and/or medical interventions, 13 overnight cases and one day case.

CONCLUSIONS

These data suggest that many patients who are hospitalized overnight for cataract surgery could be safely treated as day cases. Such a shift in the pattern of care for cataract surgery could provide a significant potential for health care savings.

[Pulmonary cystic images as a presentation of a pleuropulmonary blastoma]

A five-month-old infant presented with a sudden choking cough and mild dyspnea. Bilateral cystic pulmonary images were found on a chest X-ray, leading to exploratory surgery. A pleuropulmonary blastoma, a rare malignant embryonic tumor of childhood, was diagnosed on histologic examination. This case illustrates the necessity of performing surgical resection and histologic evaluation of any pulmonary cystic malformations, particularly when bilateral.

Use of a 49-peptide library for a qualitative and quantitative determination of pseudomonal serralysin specificity

The Pseudomonas aeruginosa serralysin (E.C. 3.4.24.40.), which is a zinc-dependent metalloprotease from the metzincin superfamily, has quite a broad specificity, which has not yet been clearly identified. We have studied it with an original approach, using a 49-peptide library of the type Z-AXXA (amide) (X = A, L, V, F, S, R, E). The library was analyzed by LC-MS before and after enzymatic hydrolysis. A great number of hydrolyzed peptides were screened and the preferential hydrolysis was the X-X peptide bond, even if in some cases, A-X and X-A bond could be hydrolyzed. No amino acids with a ionized side chain could be found in the P1' position. The results obtained suggest that the specificity in the P1' position, where an hydrophobic residue was preferentially found, seems more selective that in the Pn position. The P1 position was not very specific, but, on a quantitative point of view, the enzymatic activity was particularly increased when R, F or A were in this position. The results allow us to define the P1' and P1 residues for an optimal substrate of pseudomonal serralysin and usable for the design and the synthesis of a specific inhibitor.

Use of liquid chromatography-mass spectrometry coupling for monitoring the serralysin-catalyzed hydrolysis of a peptide library

The use of a peptide library of limited size, is considered to be more appropriate for studying a protease with a complex specificity, but very sensitive and efficient analytical techniques must be used. We have designed and synthesized a 49-peptide library of the type Z-AlaXXAla(amide) (X=Ala, Leu, Val, Phe, Ser, Arg, Glu) for studying the Pseudomonas aeruginosa serralysin specificity. All compounds of the peptide library could be identified by a LC-MS procedure. After hydrolysis of the library by pseudomonal serralysin, the LC-MS procedure also allowed the identification of the hydrolysis products and the different cleavage sites of the substrates.

Specificity of Pseudomonas aeruginosa serralysin revisited, using biologically active peptides as substrates

The characterization of the specificity of alkaline protease from Pseudomonas aeruginosa has not yet been clearly defined. Some previous results suggested that its specificity was influenced more by amino acids far from the hydrolyzed peptide bond, than by amino acids in P1 or P'1 position. From other data, it was a C-(COOH)-type endoprotease where the preferential amino acid in P1 position was an arginine residue. We have studied the hydrolysis of several biologically active peptides. Many various sites of cleavage have been characterized but no arginine in P1 position was found, despite the presence of arginine in the peptide sequence. In fact P1 and P'1 position could be occupied by various amino acids. It seems unlikely that Pseudomonas alkaline protease may only be considered as a protease specific to arginine in P1 position. On the other hand, we have observed that increase of the peptide chain length led to an important increase of the hydrolysis rate, suggesting an extended number of subsites.

Localization of Staphylococcus aureus in infected airways of patients with cystic fibrosis and in a cell culture model of S. aureus adherence

Staphylococcus aureus causes chronic respiratory tract infections in patients with cystic fibrosis (CF). Using immunofluorescence and scanning and transmission electron microscopy we located S. aureus in lung specimens of three infected CF patients, in a nasal polyp of one CF patient, and in a suspension cell culture system of primary nasal epithelial cells in vitro. Very little of S. aureus was attached to the lung epithelium, whereas abundant S. aureus was detectable in the mucus of obstructed airways. Similarly, S. aureus adhered to components of secreted mucus on primary nasal epithelial cells of CF patients and healthy control subjects, grown as cell balls in vitro (bacteria/cell +/- SD: CF: 21.9 +/- 1.5; controls: 22. 0 +/- 5.8). Mucus depletion of cell balls prior to incubation with S. aureus resulted in a significantly reduced binding (bacteria/cell +/- SD: CF: 4.2 +/- 0.3; P < 0.001; controls: 5.0 +/- 1.3; P < 0. 007). Binding of S. aureus to cell balls from CF patients or control subjects did not differ significantly. When cell balls were treated with human neutrophil elastase, hypersecretion caused removal of S. aureus from cell-associated mucus. The results suggest that S. aureus adheres primarily to mucus components of the respiratory epithelium and that significant differences do not exist in binding of S. aureus to CF or non-CF cells.

Quantitation and enzymatic activity of the alkaline protease from Pseudomonas aeruginosa in culture supernatants from clinical strains

Alkaline protease from Pseudomonas aeruginosa (E.C. 3.4.24.40), also called pseudomonal serralysin, plays an important role in the infection bacterial process. The alkaline protease concentration and activity in the culture supernatants of 23 Pseudomonas aeruginosa strains from patients suffering from cystic fibrosis were determined by using an ELISA procedure and a specific enzymatic activity test. No correlation was demonstrated between the activity and the concentration of alkaline protease. This could be explained by the presence of an inactive precursor and a partial hydrolysis of the enzyme, confirmed by SDS-PAGE and Western blotting in the supernatants. The activity test is the only one allowing a quantification of the presence of an active form of alkaline protease.

False positive MIBG scan

The fortuitous discovery of a left posterior cervico-mediastinal mass during hospitalization for hemolytic anemia in an 18 month old baby is reported. Metaiodobenzylguanidine (MIBG) uptake suggested a sympathetic tissue origin of the mass despite negative catecholamines excretion, but histopathologic examination revealed a juvenile capillary angioma within a normal sympathic ganglion.

LasA, alkaline protease and elastase in clinical strains of Pseudomonas aeruginosa: quantification by immunochemical methods

Thirty Pseudomonas aeruginosa strains were isolated from the sputa of cystic fibrosis patients. In each culture supernatant, the amount of three exoproteases (LasA, alkaline protease and elastase) was determined using immunochemical procedures. These assays used selected peptide-MAP (multiple antigen peptide) strategy as antigen for animal immunisation. The method appeared to be reproducible, simple, sensitive and specific without cross-reactivity between the antisera. The resulting values differed from one strain to another mostly for elastase production. Despite the fact that four genes (lasA, lasB, lasR and rhlR) were shown to be necessary for full elastolytic activity, it was obvious that if LasA was not secreted in a naturally non-elastase-producing strain, in return in an elastase-producing strain, there were no apparent relationships between LasA and elastase production and between LasA and alkaline protease secretion. Furthermore, in vitro, the secretion of the three exoproteases seemed to be independent of the mucoid or non-mucoid phenotype of the bacteria.

[Intrathoracic volvulus of the spleen revealing left posterolateral diaphragmatic hernia]

BACKGROUND

Late-recognized congenital left diaphragmatic hernia may have a bad prognosis when it is revealed by perforation or volvulus of the herniated viscera.

CASE REPORT

A 20 month-old boy was admitted for vomiting and abdominal pain. X-rays showed left diaphragmatic hernia and the patient was operated on with the diagnosis of volvulus of the stomach. Surgery showed hernia through the posterolateral segments of the diaphragm with spleen volvulus into the sac, requiring splenectomy before reduction of the hernia and closure of the diaphragmatic defect.

CONCLUSION

This is the fifth report of ectopic intrathoracic spleen with volvulus revealing congenital left diaphragmatic hernia.

[Superior mesenteric artery syndrome]

BACKGROUND

Early diagnosis of superior mesenteric artery syndrome, less frequent in children than in young adults, is improved by the use of ultrasonography and CT scan.

CASE REPORT

An eleven year-old boy was admitted because he suffered from bilious vomiting for 24 hours. A diagnosis of superior mesenteric artery syndrome was made from the results of plain films of the abdomen, ultrasonography and roentgenograms after instillation of dilute barium solution. Diameter of the left renal vein appeared increased. The patient was given fractionated meals and placed in left lateral position. The CT scan performed 5 days later confirmed the diagnosis but did not show dilatation of the left renal vein. The patient is well one year later without treatment. Ultrasonography performed 3 hours after a meal showed similar findings to those seen in the acute phase.

CONCLUSION

Abdominal scanning and ultrasound are valuable tools for diagnosis of such a syndrome. The diagnostic value of dilatation of the left renal vein remains to be determined.

Desmoplastic small round cell tumors of the abdomen

BACKGROUND

Desmoplastic small round cell tumors (DSRCT) have been only recently identified.

METHODS

The authors report DSRCT in two pediatric patients (an 8-year-old boy and 12-year-old boy). In both patients, the initial diagnosis was rhabdomyosarcoma. The resistance to standard chemotherapy and radiation therapy prompted the authors to review the initial biopsy specimens and perform complementary immunophenotypic characterization.

RESULTS

These analyses revealed that the tumor cells were strongly positive for keratin epithelial marker antigen, desmin, vimentin, neurospecific enolase, and S100 protein, corresponding to pleomorphic differentiation, characteristic of DSRCT:

CONCLUSIONS

The authors suggest that extensive immunohistologic characterization be performed in all cases of small round cell tumors of the abdomen so that the diagnosis of DSRCT is not overlooked. These rare tumors are refractory to chemotherapy, and initial aggressive surgery is warranted.

[Role of surgery in pediatric oncology]

In paediatric oncology, the surgeon working in a multidisciplinary team can be called upon to intervene at all stages of the disease. At the time of diagnosis, he performs the biopsy, with or without excision of the tumour. He can also intervene for removal of a residual lesion or to evaluate the response after initial chemotherapy. He occasionally is required for metastatic surgery, or more rarely, for palliative surgery.

[Desmoplastic tumors with multiple differentiation. A new entity. Six cases]

Desmoplastic tumours with divergent differentiation are principally located in the abdomen and develop locally or regionally. They occur in adolescents or young adults and are characterized at histology by a proliferation of undifferentiated small cells surrounded by a dense stroma. Only immuno-histo-chemistry provides the diagnosis. Since their chemosensitivity is rare and often partial the outcome is usually lethal. Six new cases of this recently described entity are presented here. The authors are in favour of a multidisciplinary and aggressive management, combining intensive polychemotherapy, extensive surgical exerisis and total abdominal radiotherapy.

Neuropeptide Y inhibits human and invertebrate immunocyte chemotaxis, chemokinesis, and spontaneous activation

1. In a concentration-dependent manner neuropeptide Y was found to be a potent inhibitor of the spontaneous activation of human granulocytes and macrophages as well as Mytilus edulis immunocytes. 2. Neuropeptide Y also inhibited the chemotaxic response of these immunocytes to the chemoattractant f-MLP. 3. Incubation of both the human and the invertebrate immunocytes in f-MLP (10(-9) M) causes "activation" as noted by random locomotion (chemokinesis). Neuropeptide Y also blocked f-MLP-induced chemokinesis. 4. The results suggest that neuropeptide Y may, in addition to other functions, serve as an endogenous regulator of immunocyte function.

Cystic fibrosis and portal hypertension interest of partial splenectomy

Extra pulmonary complications can be major in patients suffering of cystic fibrosis who survive long enough without pulmonary problems. Hepatic cirrhosis is often present and is responsible for portal hypertension with splenomegaly, hypersplenism and esophageal varices. In six patients we have performed a partial splenectomy with conservation of the upper pole of the spleen vascularized by gastrosplenic omentum and its vessels. The post-operative complications (3 scar ruptures but no pulmonary decompensation) are not very important considering the benefits: Normal spleen according to clinical, ultrasonic examination and scintigraphy Correction of hypersplenism Diminution of esophageal varices Stability of hepatic functions. With a post-operative follow-up between 2.5 and 7 years, none of the patients had an increased risk of infection. This technique allows a good survival for those patients waiting for pulmonary transplantation.

Double megatherapy and autologous bone marrow transplantation for advanced neuroblastoma: the LMCE2 study

In the LMCE1 study using a single course of megatherapy most of the relapses occurred during the first 2 years after autologous bone marrow transplantation. A second pilot study (LMCE2) was therefore set up using a double harvest/double graft approach with two different megatherapy regimens. Objectives were to test the role of increased dose intensity on response status, relapse pattern and overall survival. Thirty-three patients (20 boys, 13 girls) with a median age of 53 months at first megatherapy (range, 17-202 months) entered this study. They were cases either with refractory disease in partial response after second line treatment for stage 4 neuroblastoma (n = 25) or after relapse from stage 4 (n = 5) or stage 3 disease (n = 3). All patients received Etoposid and/or Cisplatinum (or Carboplatin) containing treatments before megatherapy. The first megatherapy regimen was a combination of Tenoposid, Carmustine and Cisplatinum (or Carboplatin), the second applied Vincristin, Melphalan and Total Body Irradiation. The first harvest was scheduled 4 weeks after the last chemotherapy, the second 60 to 90 days after megatherapy. All marrows were purged in vitro by an immunomagnetic technique. Median follow up time since first megatherapy is 56 months. Response rates for evaluable patients were 65% (complete response rate: 16%) for megatherapy 1 and 60% (complete response rate: 25%) for megatherapy 2. Considering that only patients with delayed response or relapse were eligible for this pilot study the overall survival was encouraging with 36% at 2 years and still 32% at 5 years. The costs for these survival rates were high in terms of morbidity (four early and four late toxic deaths; toxic death rate: 24%). Double harvesting may have the disadvantage of delayed engraftments related in part to a disturbance of marrow microenvironment by megatherapy 1. This double megatherapy approach achieved a prolonged relapse free interval (median 11 months, range 2-31 months) in patients reaching megatherapy 2 and justifies further evaluation of concepts with consecutive dose-escalation.

Heart-lung transplantation in a 16-month-old infant

A 16-month-old boy who had a heart-lung transplantation is doing well 16 months postoperatively. The HLT can be a successful treatment for very young patients. Most of the postoperative management can be assessed with noninvasive techniques. Normally, the allograph grows with the recipient.

Ultrasound diagnosis of midgut volvulus: the "whirlpool" sign

The authors present their US findings in 24 patients with proved complicated midgut malrotation: volvulus in 18 and occlusive Ladd's bands in 6. All the 24 patients have had US examination prior to surgery. Contrast examinations were performed in only 9 patients, always after US and before surgery. The sonographic "whirlpool" pattern of the superior mesenteric vein and mesentery around the superior mesenteric artery was detected in 15 of the 18 patients with midgut volvulus, and was best seen using Doppler color. Embryological signification of midgut malrotation is discussed.

Relationship between the cardiovascular effects and both plasma and myocardial levels of clentiazem, a new benzothiazepine calcium antagonist, in anesthetized dogs

We evaluated the relationship between the cardiovascular effects of clentiazem (TA-3090), a new 1,5-benzothiazepine calcium antagonist with high lipophilicity, and both its plasma and myocardial concentrations. Anesthetized, open-chest dogs, instrumented for hemodynamic data recording and blood sampling, were divided into three groups treated with 15, 50, or 200 micrograms/kg of clentiazem, respectively, as an intravenous bolus. At the end of the protocol (240 minutes), myocardial samples were tested for clentiazem. The results indicated that the peripheral and coronary vasodilatory effects of clentiazem were dose dependent and closely related to its plasma concentrations. It was also observed that the minimal effective plasma concentration was in the range of 15-20 ng/ml. Sustained negative chronotropic effects were recorded at the highest dose only and were best related to the amount of clentiazem detectable in the myocardium, suggesting that myocardial clentiazem retention is a major factor governing its depressant cardiac impact.

TP53 gene mutations and 17p deletions in human astrocytomas

Astrocytomas, including the most malignant form, glioblastoma multiforme, are the most frequent and deadly primary tumors of the human nervous system. Recent molecular genetic analyses of astrocytomas have demonstrated frequent chromosome 17 deletions involving the telomeric region of the short arm (17p12-pter). This region contains a candidate tumor suppressor gene, TP53, which has recently been implicated in the etiology of a broad array of human cancers. To study the possible role of TP53 in astrocytoma development, 24 randomly chosen human astrocytic tumors were examined for genomic TP53 sequence aberrations using primer-directed DNA amplification in conjunction with direct sequencing. Five of the 11 grade III astrocytomas (glioblastoma multiforme), but only one of seven grade II astrocytomas (anaplastic astrocytoma) and none of either the grade I astrocytomas or oligodendrogliomas demonstrated distinct point mutations involving the TP53 gene. These data suggest that TP53 mutations may play a role in astrocytoma development and are predominantly associated with higher grade tumors.

Management of pediatric non-Hodgkin's lymphoma

Over the past 15 years, significant progress has been made in the understanding of the molecular mechanism involved in malignant transformation of lymphocytes as well as in the management and treatment of non-Hodgkin's lymphoma (NHL) in childhood. Cyto-histological classifications and immunophenotyping of different types of NHL have contributed to the characterisation of three major subtypes of NHL in children i.e. Burkitt's lymphoma (BL), lymphoblastic lymphoma (LL) and large cell lymphoma (LCL). Precise staging of the disease at diagnosis is necessary before the onset of the treatment and should be performed as quickly as possible. Presence of bone marrow and central nervous system (CNS) involvement are major prognosis criteria. In most cases, surgery has no therapeutic role and is required only for diagnostic procedures. Similarly, several studies have demonstrated that irradiation of various sites including the CNS does not improve survival. Thus, NHL patients are usually treated with chemotherapy alone. BL and LL have distinct clinical presentations and require completely different chemotherapy protocols. After comparable induction phases with intensive chemotherapy regimens, the former is usually treated with a short consolidation phase while the latter receives a long lasting consolidation consisting of intermittent chemotherapy for at least one year. The prognosis of stage I-II, and III-IV bone marrow negative NHL of children is excellent with respectively 95% and 75% long term survival. However, patients with concomittent CNS and bone marrow involvement in both histological subtypes have a considerably worse prognosis with only 30% long term survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Preservation of infralevator structures in imperforate anus repair

In this report, we describe the most recent refinements to the anterior perineal approach originally described by Mollard for the repair of high and intermediate forms of imperforate anus. A skin tube is constructed from perineal skin, passed through the center of the external sphincter, and anastomosed to the fully preserved rectum with or without tapering. The anastomosis lies within the puborectalis sling and is anchored to the striated muscle complex. Sixteen patients have been operated on by this technique with excellent anatomic results in 15 patients and excellent early functional results in patients who are 2 years of age or older.

Familial extrahepatic biliary atresia

Only a small number of cases with familial extrahepatic biliary atresia, suggesting a recessive autosomal inheritance, have been reported. However, the cases reported in twins are consistent with an acquired disease. Here the case of two brothers with familial atresia of the extrahepatic biliary system is studied. Diagnosis was confirmed by laparotomy and histologic study of biliary fibrous remnants. In the present cases parental consanguinity might suggest a recessive autosomal inheritance. However, clustering of cases in a family might also suggest a common exposure to responsible factors not so far identified.

[Terminal constipation caused by abdominopelvic asynchrony: analysis of etiological, clinical, manometric data and therapeutic results after rehabilitation by biofeedback]

The aim of this study was to describe the etiological, clinical, rectoanal manometric findings as well as the results of biofeedback therapy in a series of 65 patients (34 males, 31 females, aged between 5 and 77 years) presenting with severe primary constipation due to pelvic abdominal asynchronism. Pelvic abdominal asynchronism was statistically more frequent in males during childhood and in female patients during adult life (p less than 0.005). This study disclosed a high frequency of psychogenic factors in the onset of pelvic abdominal asynchronism (26 p. 100) as well as a high frequency of soiling (46.2 p. 100) in constipated patients. In 36.2 p. 100 of cases, pelvic abdominal asynchronism was the only abnormality. In contrast, in most of the patients, asynchronism was associated with miscellaneous rectoanal disorders: increased anal closure pressure (43.3 p. 100), decreased anal closure pressure (11.8 p. 100), impaired rectal conscious sensitivity (11.7 p. 100), and increased rectal compliance (31 p. 100). This study demonstrated that when high-fiber diet and laxatives fail, biofeedback therapy is a very interesting alternative, providing 80 p. 100 of good results in selected cases. However, we were unable to find any clinical or manometric parameters predictive of results of treatment. Follow-up studies are needed to determine long-term results of biofeedback training.

Current surgical treatment of post-operative eventrations

A series of 247 post-operative eventrations (POE) is reported with a study of general features, such as: patients' sex and age, size, location and etiology of POE (serial laparotomies, parietal sepsis), classic predisposing factors. Pre-operative preparation involved the use of Goni-Moreno progressive pneumo-peritoneum in 18.5% of patients. The procedures used were: parietal suturing (25%), the same plus a dacron buttress (6%), or a large reinforcing Dacron Mesh prosthesis (67%). Early sepsis was slightly more frequent after Dacron use. The incidence of predisposing factors in this field is reported. Other complications of the use of Dacron Mesh are studied (hematomas, skin necrosis). The post-operative uncomplicated course rate is 91%. Follow-up of 77% of operated patients showed satisfactory overall results in 81% of patients treated with Dacron prosthesis and in less than 50% after parietal suturing. Aseptic recurrence factors and late sepsis factors are also studied. Finally the efficiency of POE prosthetic repair is stressed and mandatory rules for the safe of Dacron Mesh are underlined.

[Neonatal bilateral interstitial emphysema. Surgical treatment. Apropos of 1 case]

The authors report a case of respiratory distress secondary to inhalation of meconial amniotic fluid treated by mechanical ventilation, which was complicated by severe interstitial emphysema. Treatment by pleurotomy allowed a favorable evolution. The various therapies of interstitial emphysema of the neonate, in particular surgical technics are described.

Vascular connective tissue changes in experimental portacaval anastomosis

Hepatic vascular changes are generally associated to fibrotic lesions of the liver but their role in the development and extension of fibrosis is not well known. By performing a portacaval anastomosis in rats, a proliferation of hepatic vessels was attained progressively, comparable to proliferations seen in cirrhosis and schistosomiasis. Such a modification of the hepatic vasculature was accompanied by changes in the connective matrix of the liver, mainly related to the vascular walls. Moreover, sinusoidal capillarization was detected at the electron microscopical level whereas no alterations could be seen neither in the distribution nor in the quality of the connective matrix proteins with immunofluorescence technique. The only modification detected by light microscopy, at this zone, was the shrinked aspect of reticulin fibers which could be related to the important liver atrophy provoked by the anastomosis. It can be assumed that in liver pathology, selective changes occur in the connective matrix components depending on the type of injury. Necrotic and inflammatory processes lead mainly to the deposition of interstitial collagens and associated proteins, related to a diffuse stroma reaction resultant from activation of specific cell populations whereas in portacaval anastomosis, a selective increase of vascular connective matrix (mainly basement membrane components) occurs as a direct consequence of vessel proliferation.

Human extrahepatic biliary atresia: portal connective tissue activation related to ductular proliferation

Surgical bile flow restoration in extrahepatic biliary atresia (EHBA) does not prevent the development of ongoing hepatic fibrosis and cirrhosis. Portal connective matrix was studied on liver biopsies obtained from seven children submitted to portoenterostomy. Electron microscopy and immunohistochemical techniques (using specific antibodies directed against collagen isotypes and associated glycoproteins) were performed. The study of extracellular and cellular components of connective matrix demonstrated the existence of two distinct areas according to their situation with regard to ductular proliferation: loose connective matrix--mainly composed of fibronectin, type III collagen, type IV collagen and laminin--associated with microvessels and myofibroblasts proliferation characterized periportal zones adjacent to bile ductules; in areas distant from ductular proliferation, connective matrix appeared dense, composed of type I and type III collagen associated with fibroblasts. The connective matrix pattern observed in periductular areas can be compared to that described in cicatricial and hypertrophic processes where the myofibroblastic cell population is known to play an important role in fibrosis development. Although the connective matrix activation process remains unclear in EHBA, it may be suggested that activation of a connective tissue cellular clone might be responsible for this portal fibromatosis.

[Portacaval anastomosis in 2 cases of homozygote familial hypercholesterolemia]

We report the cases of two siblings, both suffering from familial hypercholesterolemia in homozygotic form, followed up before and after portacaval shunt. A total parenteral nutrition failed to decrease plasma cholesterol levels. However, on the basis of clinical data, a portacaval shunt was performed at the age of seven and five and a half. The two patients showed great effectiveness of the shunt with dramatic regression of clinical signs, reduction of plasma cholesterol, without serious complications over a five to six years period after the shunt.

[Postoperative eventrations. Apropos of 247 surgically treated cases]

The 247 eventrations operated upon concerned 230 patients (60% women and 40% men) mean age 54.5 years. Eventrations were large (collar greater than 10 cm) in 18, 5% and were in the median line in 81%. Serial laparotomies by the same approach had been performed in 21%, the principal causes of eventration being biliary and gynecologic surgery. Parietal sepsis developed in 31,5% of cases after operation for the original affection. Classical favoring factors found included obesity (51%), multiparity (42% of women) and chronic lung disease (14%). Preoperative preparation involved the use of Goni Moreno's progressive pneumoperitoneum in 18,5% of patients. Procedures used were parietal repair by raphe (22%), the same but with the addition of a dacron prosthesis (6%) or the large dacron tulle prosthesis for wide reinforcement of the visceral sac (67% of cases). Early sepsis was a slightly more frequent occurrence after dacron tulle, predisposing factors being the prosthesis itself, a previous history of parietal sepsis, swabs and the number of Redon tubes. After use of dacron tulle complications were mainly also hematoma (3.2%) and skin necrosis (2,6%). Postoperative course in general was uncomplicated in 91% of the 247 operations. Follow up of 67% of operated patients for a mean of 5 1/2 years showed recurrence in 50% of raphe procedures and 18.5% of prosthesis implantations; factors of aseptic recurrence (16,5%) were multiparity and chronic lung disease. Delayed sepsis after dacron tulle use affected 8% of patients and were related to chronicity of early sepsis, nonresorbable sutures and sepsis complicating the primary laparotomy. Doming of the parietal wall was noted in 4% of cases repaired by prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Massive hemoperitoneum caused by rupture of the spleen, a complication of congenital afibrinogenemia. Conservative treatment]

An hemorrhagic shock caused by spontaneous spleen rupture in a 14 year old child with a congenital afibrinogenemia is reported. A conservative treatment was carried out with perfusions of whole blood and fibrinogen and with regular echographic examinations and a splenectomy was avoided.