Triple-drug immunosuppression for heart transplantation in infants and children

Triple-drug immunosuppression with OKT3 induction is effective rejection prophylaxis in pediatric cardiac allograft recipients. The concerns regarding prevalent lymphoproliferative disease, growth retardation, cytomegalovirus, and other opportunistic infections have not been realized. Since June 1986, 34 pediatric patients, 23 males and 11 females, (age 4 days to 15 years) have undergone orthotopic heart transplantation at our institution. Fifteen patients were less than 6 months old and 13 had type I or II hypoplastic left heart syndrome. There have been four (12%) operative and four (12%) late deaths and a survival rate of 76% after a mean follow-up of 33 months (range, 1 to 82 months). The only deaths attributed to allograft rejection occurred in two newborn recipients (2 and 10 months after surgery) who neither received maintenance steroids nor underwent routine biopsy. The only death from infection (pneumococcus) occurred 6 months after surgery in a 4-year-old patient who was not known to be asplenic. Of the 27 long-term (> 1 year) survivors, 17 (68%) had an average of two rejection episodes during the follow-up period, 10 patients (32%) have been free of graft rejection, and 26 patients (96%) have not experienced a cytomegalovirus infection despite OKT3 induction therapy. Two patients developed lymphoproliferative disease, one of whom was successfully treated by transient reduction of immunosuppression. The other patient died 13 months after transplantation of a lymphoma of the central nervous system. All survivors have demonstrated satisfactory increases in mean height and weight.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost effective EMIT assays, for drugs of abuse in urine, using the Eppendorf EPOS analyser

Laboratories with an increasing work load of drug abuse testing require high turnover techniques at low cost. Syva's EMIT system is suitable for modification onto modern automated instrumentation and, with reagent dilution, costs can be significantly reduced. We describe the modification of these assays onto the Eppendorf EPOS analyser which can process 300 samples an hour at a cost of 13p per test.

Adenocarcinoma of the small intestine in Crohn's disease: a unique finding

Development of adenocarcinoma of the small bowel is rare. We present this report of a patient with a long-standing history of Crohn's disease who was found to have the 95th reported case of adenocarcinoma developed in the presence of Crohn's. The unique feature of this case is the finding of two distinctly separate carcinomas in the same surgical specimen. With report of this case and a review of the literature, certain characteristics are presented in hopes of raising suspicions sufficiently to detect this malady at an earlier stage.

Congenital aneurysm of the left atrial wall in infancy

A 5-month-old male infant with congenital left atrial aneurysm is reported. The youngest patient previously reported was 2 1/2 years old. This case is unusual because the patient was an infant and because of the degree of mitral insufficiency and acute cardiac decompensation observed in the patient.

A capillary column gas-chromatographic method for the identification of drugs of abuse in urine samples

This paper describes the application of capillary column gas liquid chromatography (GLC) to the analysis of urine samples for drugs of abuse. A simple basic extraction into butylacetate is followed by temperature programmed analysis from 90 degrees C to 310 degrees C to provide a comprehensive screen for basic drugs. Retention data are presented for approximately 300 compounds. The use of capillary column GLC is compared with packed column methods used previously in this laboratory. The reproducibility of retention data and sensitivity of this analysis for several commonly encountered drugs are presented.

Management of asymptomatic intracardiac missiles using echocardiography

A child sustained a low-velocity airgun pellet injury to the left ventricle. No cardiovascular compromise was produced. The foreign body was localized by two-dimensional echocardiography to the left ventricular chamber near the mitral valve, and subsequently removed through a left atriotomy incision. In asymptomatic patients, missiles clearly embedded within a chamber wall may be observed; all others should be removed. Two-dimensional echocardiography is recommended for localization.

Surgery for discrete subvalvular aortic stenosis: actuarial survival, hemodynamic results, and acquired aortic regurgitation

Discrete membranous subaortic stenosis (DMSS) accounts for 8 to 30% of congenital left ventricular outflow obstruction. The immediate effectiveness of surgical resection of this discrete obstructing membrane has been well documented, but little has appeared regarding late clinical and hemodynamic follow-up. Fifty-three patients with DMSS underwent operation at our institution from 1957 to 1983. Most (78%) were symptomatic, 79% had left ventricular hypertrophy (LVH) by electrocardiogram, and 92% had roentgenographic evidence of cardiomegaly preoperatively. Catheterization revealed a mean preoperative left ventricular-aortic gradient of 89 mm Hg. Twenty-eight patients had associated aortic insufficiency (AI) on the initial aortogram. Seven patients acquired AI in the interim between the first and second preoperative catheterization. Our patients have been followed for up to 12 years postoperatively. There have been 2 early and 3 late deaths. (Actuarial analysis revealed 5- and 10-year survival of 95% and 83%, respectively.) Seventy-one percent of the previously symptomatic patients noted relief of their preoperative complaints, and 45% of those with LVH had a regression in voltage. Cardiomegaly as determined by chest roentgenogram decreased in 45%. The left ventricular-aortic gradient fell to an average of 35 mm Hg a year postoperatively. Surgical treatment of congenital subvalvular aortic stenosis is effective in reducing the preoperative symptoms and the left ventricular-aortic gradient. It appears that DMSS causes AI.

Pharmacologic cardioversion of intrauterine supraventricular tachycardia. A case report

Fetal supraventricular tachycardia was converted successfully with digoxin, and the congestive heart failure resolved. Previous case reports of fetal supraventricular tachycardia have established guidelines for its treatment; digoxin remains the drug of choice.

Acute trazodone poisoning: clinical signs and plasma concentrations

A total of 70 patients presenting with suspected acute trazodone poisoning were notified to the Poisons Unit (National Poisons Information Service for England) from August 1980 until March 1983. Detailed follow-up information was obtained on 41 patients, 22 of whom were thought to have ingested trazodone alone. In these latter patients drowsiness (11), ataxia (5), nausea/vomiting (4) and dry mouth (2) were the manifestations of toxicity reported most frequently, only 2 patients became unconscious (grade 2 or 3 coma), and all recovered uneventfully with no more than minimal supportive therapy. The presence of trazodone was confirmed in 8 out of 9 patients from whom specimens (blood and urine) were received. The highest plasma trazodone concentrations (15 and 19 mg/l, respectively) were both associated with only drowsiness and ataxia. However, in 2 further patients moderate plasma trazodone concentrations (4.2 and 8.2 mg/l, respectively) were associated with deep (grade 3-4) coma, although 1 of these latter patients had also ingested ethanol (plasma concentration 3.0 g/l). Although acute trazodone poisoning does not appear to be associated with cardiac arrhythmias or convulsions, these results emphasise that drowsiness and ataxia are commonly encountered, while coma may occur in severe cases. The possible contribution of metabolites of trazodone to toxicity and the potentiating effect of co-ingested drugs or alcohol must be remembered.

Albumin influences sulfobromophthalein transport by hepatocytes of each acinar zone

To determine whether profiles of decreasing concentration were generated among hepatocytes of the liver acinus during the transport of sulfobromophthalein sodium (BSP), rat livers were perfused with various concentrations of this dye (10 microM to 1 mM) in the presence and absence of albumin. After steady-state conditions for the biliary secretion of BSP had been attained, pieces of liver were rapidly frozen. Following the alkalinization of cryostat-cut sections, the relative concentration of BSP in hepatocytes of each zone and the effect of albumin on this localization were quantitated by microspectrophotometry. The results showed that BSP, perfused in the absence of albumin, was efficiently extracted by the liver (95% on a single pass), generating distinct profiles of decreasing cellular concentration from zone 1 to zone 3 at every concentration of BSP. However, the addition of albumin to the perfusate greatly reduced the extraction of BSP from the sinusoidal compartment and resulted in the abolition of the differences in BSP content between hepatocytes of zone 1 and zone 3. These results represent a direct demonstration that, as predicted by mathematical modeling, binding of BSP to albumin indeed results in a more homogeneous distribution of BSP within the liver acinus. A simple and direct microspectrophotometric method is therefore available to follow the changes in the relative concentration of BSP among the hepatocytes of the various acinar zones.

Toxicological investigations in the detection of drug-induced disease in elderly patients

1 During 1978--1980 general toxicological investigations were performed on specimens from 211 patients (62 male, 149 female) aged 65 years and over. 2 The investigations were an important factor in establishing the diagnosis in 32 of 91 (28 male, 63 female aged 65--92 years, median 73 years) poisoned patients, most (75) of whom had deliberately taken overdoses. 3 Seventy-one patients were severely poisoned (grade 3--4 coma) and 10 died. Benzodiazepines (49%) and barbiturates (43%) were the drugs encountered most frequently, although 54% had ingested more than one pharmaceutical preparation. 4 In the survivors the depth of coma was usually greatest in patients poisoned principally with barbiturates, whilst the duration of coma and the incidence of respiratory complications were greater in those poisoned with benzodiazepines. However, there was considerable variability in the depth and duration of coma associated with a given initial plasma concentration within both groups. 5 Although general toxicological investigations can provide useful diagnostic information when poisoning is suspected in elderly patients, unequivocal interpretation of the results obtained is not always possible.

Spondylocostal dysostosis associated with anal and urogenital anomalies in a Mennonite sibship

Spondylocostal dysostosis, anal atresia, and urogenital anomalies were observed in two male infants of a consanguineous Mennonite couple. A careful review of previously reported syndromes of severe vertebral abnormalities and/or imperforate anus suggests that our patients have a previously undescribed recessive disorder that should be included in the differential diagnosis of rib and vertebral anomaly syndromes.

Improved results in newborns undergoing coarctation repair

Among 172 children who underwent repair of coarctation of the thoracic aorta from June 1, 1967, to June 1, 1979, there were 50 who were less than 6 weeks old. A review was undertaken to assess mortality and postoperative residual hypertension in this newborn age group. Forty-five (90%) had one or more associated congenital cardiac lesions, which were repaired or paliated at the time of coarctation repair. The three most common associated lesions were patent ductus arteriosus (74%), atrial septal defect (74%), and ventricular septal defect (62%). Thirty-one newborns underwent resection with parimary end-to-end repair with 8 deaths (26%), and 18 underwent Dacron patch angioplasty and 1 underwent subclavian angioplasty with 4 deaths (21%). Of the 38 survivors, 36 (95%) had good pedal pulses on postoperative clinical examination 3 months to eleven years postoperatively. Seventeen (45%) had upper and lower extremity blood pressure measured; 2 (5%) showed residual upper extremity hypertension (greater than 2 standard deviations above the mean and a gradient less than 20 mm Hg). One of these 2 patients has undergone repeat repair. Based on this low mortality and infrequent need for repeat repair, we advocate aggressive early operation and judicious use of palliative procedures in newborns, when indicated, for associated defects.

Divalent cation stimulation of in vitro fibre assembly from epidermal keratin protein

Keratin was extracted from purified cornified cells of newborn rats in Tris-HCl-buffered 8 M urea containing beta-mercaptoethanol. Microfilaments were assembled in vitro by reducing the ionic strength of buffer and the urea concentration. One millimolar concentration of KCl and NaCl did not affect filament formation, but the same concentration of divalent cations greatly altered this process. CaCl2 and MgCl2 induced gelation of keratin by formation of bundles of birefringent macrofilaments. ZnCl2, CuSO4 and HgCl2 formed greater numbers of macrofilaments and the protein aggregated.

Activity of alpha-1, 4-glucosidase in furazolidone-induced glycogenosis

Furazolidone (FZ) at 700 and 800 p.p.m. was added to feed mixtures fed turkey poults two and three weeks posthatching, respectively, to induce acute experimental cardiomyopathy. Poults in the control pen received the same ration but without FZ. From EKG data obtained at 2, 4, and 5 weeks of age, control unaffected and experimental affected poults were selected for sacrifice. Poults were sacrificed by cervical dislocation and appropriate samples of hepatic tissue were removed for assays of activity of alpha-1, 4-glucosidase. Results indicate that enzyme activity in affected FZ-treated poults is similar to that in unaffected control poults. Lack of significant differences in activity of this lysosomal enzyme suggests that FZ-induced glycogenosis may be related to the adult form of idiopathic generalized glucogenosis, the etiology of which remains unidentified.

Ochratoxin A toxicosis in swine

Ochratoxicosis was induced in young female swine by a diet contaminated with a rice culture of Aspergillus ostianus that contained ochratoxin A and by daily oral doses of 2.0 or 1.0 mg/kg body weight pure ochratoxin A. Mycotoxicosis was characterized early by depression and reduction in feed intake and loss of body weight, followed by diarrhea, polyuria, polydipsia and dehydration. The pigs given pure ochratoxin A were dead or moribund in 5 to 6 days. Packed cell volume, hemoglobin, total plasma protein, and blood urea nitrogen were increased. Progressive leukocytosis, neutrophitia and moderate left shift in the differential count occurred. Concentrations of lactic dehydrogenase, isocitric dehydrogenase and glutamic-oxalacetic transaminase in the serum and urine were increased by the fourth to sixth day, but only the increase in urinary concentrations was significant. Gross findings included dehydration, enteritis, pale tan discoloration of the liver, and edema and hyperemia of the mesenteric and other lymph nodes. Microscopic lesions were most frequent and severe in the kidney and gastrointestinal tract. Necrosis of renal tubular epithelium was most frequent in the convoluted tubules. Many renal tubules were dilated. The intestinal lesions were focal and necrotizing and occurred in mostanat omic regions. Fatty change was demonstrated in most of the livers. In lymphoid tissues the changes were edema, hyperemia and focal necrosis of lymphocytes within germinal centers and around follicles.

Effects of promethazine-hydrochloride on human polymorphonuclear leukocytes

Promethazine hydrochloride at a concentration of 0.033 mg/ml has pronounced effects on leukocyte metabolism and function. The drug inhibits the phagocytosis-induced increases in O(2) consumption and hexose monophosphate shunt activity. Associated with these effects is an inhibition of the iodination of zymosan particles and an inhibition of bacterial killing by the cell. At least two mechanisms appear to be involved. Many of the effects can be explained by an inhibition of phagocytosis, but promethazine also inhibits the decarboxylation of amino acids and iodide fixation in a cell-free system, indicating a specific effect on metabolism. These results may partially account for the action of the drug in ameliorating the effects of erythroblastosis.