Pneumatic dilatation for childhood achalasia

Treatment of achalasia by pneumatic balloon dilatation (PBD) is well established in adults. Due to limited experience and the rarity of the condition in children, there are relatively few reports in the paediatric literature. Although PBD has been reported as a primary method of treatment, there are no reports of secondary PBD for childhood achalasia. Between 1995 and 1999, five patients underwent treatment for achalasia (age: 9-14 years, M:F = 4:1). The presenting symptoms were dysphagia (5). vomiting episodes (2), aspiration (1), food-bolus obstruction (1), and failure to thrive (1). In all patients a barium swallow and manometry were used to confirm the diagnosis. Three underwent primary PBD. Two who had previously undergone surgical myotomy underwent secondary PBD for recurrence of symptoms. Dilatation was performed using a 35-mm balloon with the child under general anaesthesia. Technical success was defined as demonstration of a waist under screening at lower pressures followed by abolition of the waist at higher pressures. In addition to reviewing our results, a systematic review of the literature was performed (Medline, Cochrane Library, Pubmed, Embase). Three patients (primary dilatation) showed excellent improvement after a single dilatation. In two cases (secondary dilatation) three and five attempts were required. No complications were encountered. The mean follow-up period was 2 years (1-3.5 years) and four patients remained asymptomatic, an overall success rate of 80%. The literature review revealed similar good results in most of the recent reports. Thus, PBD as a primary treatment for childhood achalasia has a success rate of 70%-90% with minimal side effects, short hospital stay, and good patient acceptability over an operation. We have also established the usefulness of this method as a secondary treatment when symptoms recur after surgery.

Ectopic intrathoracic liver

Accessory hepatic tissue, unlike accessory splenic and pancreatic tissue, is rare and has a limited and almost exclusively sub diaphragmatic distribution. Fewer than ten cases of intrathoracic ectopic liver have been reported so far in the literature. This paper reports a case that caused a diagnostic dilemma.

Prenatal sonographic features of congenital lobar emphysema

The prenatal sonographic features of congenital lobar emphysema (CLE) have not been well characterised. Five cases have been reported in the literature and on all these occasions either an echogenic (3) or a cystic (2) lung lesion was detected prenatally and the diagnosis was confirmed after the operation. This is the sixth case of CLE in the literature with prenatal sonographic features documented. The prenatal scans of a 23-year-old lady performed at 22 weeks of gestation revealed cystic lesions and increased echogenicity of the right fetal lung. There were no other anomalies and the karyotype was normal. The lesion decreased in size at 28 weeks and the baby was born by a normal vaginal delivery at 41 weeks. CT scan performed on day 6 confirmed cystic changes on the right lung with compression of the right lower lobe. A repeat CT scan performed at 4 months revealed extensive cystic changes in a hyper-inflated right lung and mediastinal shift to the left. At operation, abnormally inflated right upper and middle lobes were found suggesting a CLE. There were no subsequent complications after removal and histology confirmed CLE. The reported cases are reviewed and the prenatal sonographic features of CLE are discussed.

Congenital segmental dilatation of the duodenum--differential diagnosis for an antenatally-diagnosed intra-abdominal cyst

We report the third case of segmental dilatation of the duodenum and the first to be diagnosed antenatally. The lesion presented as an intra-abdominal cyst on an antenatal scan at 17 weeks and was followed up with more specific investigations after birth. The final diagnosis was obtained only at laparotomy where the dilated segment was resected. The patient is well at eighteen month follow-up. Segmental dilatation of the gastrointestinal tract, although rare, should be considered in the differential diagnosis of antenatally discovered intra-abdominal cysts.

"Cuff-stitch" to prevent inadvertent dislodgement of central venous catheters

The insertion of central venous catheters (CVCs) is an established practice in the management of children who need long-term total parenteral nutrition or chemotherapy. Inadvertent falling out of CVCs before the cuff becomes incorporated in the tissues is a commonly encountered problem. The technique described involves inserting a circular stitch in the subcutaneous plane before the catheter is placed. Once the CVC is pulled into position, the "cuff-stitch" lays around the catheter distal to the cuff, narrows the tunnel, and prevents accidental dislodgement.

Glutamine and glutathione counteract the inhibitory effects of mediators of sepsis in neonatal hepatocytes

BACKGROUND/PURPOSE

Surgical neonates are at risk of sepsis-associated liver dysfunction. Hydrogen peroxide (H(2)O(2)) and nitric oxide (NO) are important mediators of sepsis, which impair neonatal hepatic metabolism. Glutamine has been shown to have beneficial effects on hepatocyte metabolism during neonatal sepsis. However, the molecular basis of these effects are unknown. The aim of this study was to test the hypotheses that (1) glutamine and its dipeptides counteract the inhibitory effect of septic mediators on neonatal hepatocyte oxygen consumption and (2) the effects of glutamine are specific and not shared by other amino acids. In addition, we wished to determine the metabolic pathways and mediators involved in the action of glutamine.

METHODS

Hepatocytes were isolated from suckling rats, and O(2) consumption measured polarographically. Study A: the ability of 10 mmol/L glutamine to reverse the inhibitory effects of 1.5 mmol/L H(2)O(2) and 300 micromol/L S-Nitroso-N-acetylpenicillamine (SNAP; a nitric oxide donor) on O(2) consumption was examined. Study B: the ability of other amino acids and dipeptides of glutamine to reverse the effects of H(2)O(2) was examined. Study C: various concentrations of glutamine were tested for their ability to reverse the H(2)O(2) inhibition of O(2) consumption. Study D: the mechanism of action of glutamine was examined by incubating hepatocytes with either an inhibitor of entry into the Krebs cycle or an inhibitor of glutathione synthesis. Study E: the ability of glutathione to reverse the inhibitory effects of H(2)O(2) was examined.

RESULTS

Study A: glutamine reversed the inhibition of hepatocyte O(2) consumption exerted by either H(2)O(2) or NO. Study B: glutamine dipeptides reversed the inhibition of hepatocyte O(2) consumption by H(2)O(2), but other amino acids did not. Study C: the counteracting effect of glutamine was proportional to the dose administered. Study D: blocking entry of glutamine into the Krebs cycle did not abolish the effects of glutamine, but blocking glutathione synthesis completely abolished the effect of glutamine. Study E: exogenous glutathione reversed the inhibitory effect of H(2)O(2) on hepatocyte O(2) consumption.

CONCLUSIONS

This study found that glutamine and its dipeptides are unique in reversing the effects of septic mediators on neonatal rat liver oxidative metabolism. The effectiveness of glutamine appears to be mediated via glutathione synthesis. Addition of glutamine, glutamine dipeptides, or glutathione to total parenteral nutrition (TPN) may be beneficial in preventing liver damage in neonatal sepsis.

The management of oesophageal atresia in neonates with right-sided aortic arch

BACKGROUND/PURPOSE

The management of oesophageal atresia (OA) in association with a right-sided aortic arch (RAA) is challenging. It is controversial whether right or left thoracotomy is the most appropriate surgical approach. The aim of this study was to determine the prevalence of RAA in patients with OA and the most appropriate surgical approach.

METHODS

The case records of all the neonates with OA treated over an 18-year period (1980 through 1997) were reviewed. Patients with RAA were analysed with particular reference to the preoperative investigations, operative approach and findings, and postoperative complications.

RESULTS

Of the 476 case notes reviewed, 12 (2.5%) had a RAA, and 5 of these infants had major cardiac anomalies. The diagnosis was not suspected on preoperative chest x-ray in any of these infants. In only 1 of the 5 neonates who had a preoperative echocardiogram was RAA suspected. A right thoracic approach was performed in the 11 infants in whom a RAA was not suspected. Immediate conversion to a left thoracotomy with primary anastomosis was carried out in 2 infants. In 2 further infants, fistula ligation alone was performed because of a long gap atresia. Anastomosis via the right thoracotomy was performed in 7 infants. There were 3 anastomotic leaks, 1 intractable stricture, and 1 recurrent fistula. Three patients (25%) had a double aortic arch, and, as a result, a left thoracotomy had to be abandoned in 2. There were 3 deaths, 2 as a result of major cardiac anomalies and 1 related to prematurity and sepsis.

CONCLUSIONS

RAA occurs in 2.5% of infants with OA. Preoperative chest x-ray and echocardiogram are unreliable as diagnostic modalities. Anastomosis via a right thoracotomy is associated with a 42% leak rate. The presence of a double aortic arch can make the oesophageal anastomosis via a left thoracotomy as difficult as via a right thoracotomy.

International, collaborative assessment of 146,000 prenatal karyotypes: expected limitations if only chromosome-specific probes and fluorescent in-situ hybridization are used

The development of chromosome-specific probes (CSP) and fluorescent in-situ hybridization (FISH) has allowed for very rapid identification of selected numerical abnormalities. We attempt here to determine, in principle, what percentage of abnormalities would be detectable if only CSP-FISH were performed without karyotype for prenatal diagnosis. A total of 146 128 consecutive karyotypes for prenatal diagnosis from eight centres in four countries for 5 years were compared with predicted detection if probes for chromosomes 13, 18, 21, X and Y were used, and assuming 100% detection efficiency. A total of 4163 abnormalities (2.85%) were found including 2889 (69. 4%) (trisomy 21, trisomy 18, trisomy 13, numerical sex chromosome abnormalities, and triploidies) which were considered detectable by FISH. Of these, 1274 were mosaics, translocations, deletions, inversions, rings, and markers which would not be considered detectable. CSP-FISH is a useful adjunct to karyotype for high risk situations, and may be appropriate in low risk screening, but should not be seen as a replacement for karyotype as too many structural chromosome abnormalities will be missed.

Comparison of balloon angioplasty versus debulking devices versus stenting in right coronary ostial lesions

Angioplasty of aorto-ostial stenosis is associated with lower procedural success and a higher complication rate. The aim of the present study was to compare the acute and long-term results of balloon and new device angioplasty in 110 consecutive patients with right coronary ostial lesions. Patients were divided into 3 groups according to the angioplasty device used: group I (balloon only, n = 26), group II (debulking devices including excimer laser, directional and rotational atherectomy, n = 26), group III (stent, n = 58). Procedural success was highest in group III (96%) followed by group I (88%), and group II (77%). In-hospital complications were similar among the groups (p = NS). Patients in group III achieved the highest acute gain (2.61 mm) followed by groups II (1.92 mm), and I (1.39 mm, p <0.05). During follow up, target lesion revascularization and/or bypass surgery was required in 24% of patients in group III compared with 47% and 40% in groups I and II, respectively (p <0.05). Cardiac-event free survival was highest in the stent group (74%, p <0.005) and was similar between the balloon (39%) and debulking device groups (45%). Thus, among the currently available technologies, stenting of right coronary ostial lesions appears to provide excellent angiographic and long-term results.

Mitrofanoff principle for continent urinary diversion

In 1980 Mitrofanoff described a method to achieve continent urinary diversion by surgically closing the bladder neck and creating a continent catheterizable stoma from the appendix which had been implanted in a nonrefluxing manner into the bladder or from a nonrefluxing distal ureter. The Mitrofanoff principle (MP) serves well as a continence mechanism for either the native bladder or intestinal reservoirs. We review 17 patients, including 10 children, who were treated with the MP and received a continent catheterizable channel. For the MP, appendix was used in 16 patients and ureter in 1. The continuity between the urinary reservoir and urethra was maintained wherever possible. Bladder neck suspension was preferred to bladder neck closure in incontinent females and boys. Complications and their management have been discussed at length. Stable renal functions, ease of catheterization and urinary continence were achieved in 93.8% of the patients.

Synthetic peptides related to laminin pentapeptide (YIGSR) fragment

The synthetic laminin pentapeptide amide fragment (LF), Tyr-Ile-Gly-Ser-Arg-NH2 corresponding to a part of B1 chain of the glycoprotein, laminin, and six of its analogues having structural modifications at positions 1, 3 and 4 were synthesized by solid phase method employing mainly 9-fluorenylmethoxycarbonyl-amino acid trichlorophenyl esters as coupling agents and Merrifield resin as the solid support. Their biological activities were studied in vivo by lung tumor colonization assay and in vitro by cell adhesion assay. The activity of synthetic LF was found to correlate with the earlier reported results in both in vivo and in vitro assays. Among the analogues made, [Tyr4] LF and [Thr4]LF were found to inhibit the lung tumor colonies more efficiently than LF itself in the in vivo assay whereas [D- Ser4]LF exhibited almost the same inhibition as LF.

Resection of olfactory groove meningiomas: technical note revisited

BACKGROUND

Although large olfactory groove meningiomas present in the midline, tumor volume is often unequally distributed to one side. Most surgeons favor a bifrontal craniotomy with retraction or partial resection of the frontal lobes to resect these tumors. However, frontal lobe retraction is not without complications.

METHODS

We present a technical note regarding the resection of these large olfactory groove meningiomas. We describe the advantages of a unilateral frontal craniotomy complemented with orbital osteotomy.

RESULTS

The orbital osteotomy has considerably reduced the need for frontal lobe retraction and avoids partial resection of the frontal lobe to uncap the tumor. Utilizing this approach we have been able to remove the tumor from one side, followed by an incision to the falx cerebri in order to remove the tumor from the other side. With this approach, we have gained excellent visualization of the tumor in its entirety. Moreover, this approach permits the surgeon to intercept the arteries emerging from the skull base during the initial stages of the procedure.

CONCLUSIONS

Unilateral frontal craniotomy and orbital osteotomy has obviated the need to retract or resect the frontal lobe when resecting large olfactory groove meningiomas, which extend to either side of the falx. Because surgery is performed from one side, olfaction may also be preserved on the contralateral side.

Esthesioneuroblastomas with intracranial extension. Proliferative potential and management

A total of 15 patients with esthesioneuroblastomas were treated between 1978 and 1992 at the Neurosurgery Department, Nordstadt Hospital, Hannover. In 9 cases, the tumors invaded the anterior cranial fossa. One patient died before any surgical intervention. Eight tumors were operated by a combined paranasal and subfrontal approach. Gross total tumor removal was achieved in all cases. Apart from anosmia, the only postoperative complication was transient mental changes in one case. Immunohistochemical analyses with MIB 1 monoclonal antibodies, directed against recombinant parts of Ki-67 antigen, were performed to estimate the proliferative potential of the esthesioneuroblastomas. Most of the tumors showed high proliferating cell indexes, which ranged from 3 to 42% (mean, 16%). The proliferating cell index with MIB 1 showed a correlation with postoperative outcome, although this was not statistically significant. Esthesioneuroblastomas can be totally removed surgically. The proliferating cell index may reflect histologically the biological behavior of tumor. Long-term follow-up is mandatory, and immunohistochemical studies may be of help in predicting outcome.

Impact of cytogenetic abnormalities on outcome of bone marrow transplants in acute myelogenous leukemia in first remission

This study analyzed the impact of cytogenetic abnormalities on outcome of 1516 HLA-identical sibling bone marrow transplants for acute myelogenous leukemia (AML) in first remission reported to the International Bone Marrow Transplant Registry by 188 centers. 708 patients (47%) had cytogenetic studies performed. Transplant outcome in these subjects was similar to the 808 in whom cytogenetic studies were not performed. One or more cytogenetic abnormalities were detected in 284 (40%) of subjects studied. Relapse rates were higher and leukemia-free survival lower in patients with poor prognosis abnormalities vs those with no abnormality or with good or intermediate prognosis abnormalities (relative risk of relapse 2.40, P < 0.01; relative risk of treatment failure 1.68, P < 0.03). We conclude that cytogenetic abnormalities correlated with increased relapse in patients treated with chemotherapy. HLA-identical sibling transplants are similar.

Synthetic peptides related to the delta-receptor agonist, dermorphin gene associated peptide

The delta-receptor selective dermorphin gen associated peptide (DGAP) and five of its analogues having structural modifications at positions 2, 4 and 5 were synthesized by the solid phase method using 9-fluorenylmethoxycarbonyl amino acid trichlorophenyl esters as coupling agents and rho-benzyloxybenzyl alcohol resin as the solid support. The delta-receptor selectivity of these peptides was determined by guinea pig ileum and mouse vas deferens assays. The latter assay was carried out using modified Kreb's solution aerated with pure oxygen instead of carbogen. All the synthetic peptides were found to be delta-receptor selective.

Surgical treatment of trigeminal schwannomas

A total of 27 patients with trigeminal schwannoma were treated between 1982 and 1992 at the Neurosurgery Department of Nordstadt Hospital. Twelve cases of solitary schwannoma without any family history or physical stigmata of neurofibromatosis were included and form the basis of this study. There were four women and eight men (mean age 44 years) in this series. Duration of symptoms ranged from 2 months to 6 years. The most frequent symptoms were either pain or numbness of the ipsilateral hemiface. The surgical approach was chosen depending on the tumor type. Tumors that belonged to Type A (five cases), which were predominantly in the middle fossa, were approached using a transsylvian method; Type B (one case), which presented predominantly in the cerebellopontine angle, was operated on via a retrosigmoid suboccipital craniectomy; Type C (five cases), which were dumbbell-shaped extending into both the middle and posterior fossa, were removed via a combined temporal craniotomy-presigmoidal method; and in Type D (one case), in which tumor was primarily extracranial with intracranial extension, an infratemporal extradural approach was undertaken. There was no operative mortality or long-term disability in this series. The follow-up period ranged from 12 to 60 months; during that time magnetic resonance imaging revealed tumor recurrence in two cases after 12 and 48 months, respectively, and these were excised again. An additional 178 cases collected from the world literature are also reviewed and analyzed.

Detection of BCR-ABL fusion genes in adult acute lymphoblastic leukemia by the polymerase chain reaction

The sensitivity and clinical utility of the polymerase chain reaction (PCR) assay for the detection of BCR-ABL gene rearrangement was compared to conventional cytogenetics for the Philadelphia chromosome (Ph1) in adult acute lymphoblastic leukemia (ALL) patients entered onto a single clinical trial. Ninety-three patients had evaluable PCR assays for both the p190bcr-abl and p210bcr-abl type of BCR-ABL gene rearrangements. Twenty-one of 93 patients (23%) were positive for the BCR-ABL rearrangement by the PCR assay. Fourteen of these patients had the p210brc-abl BCR-ABL rearrangement characteristically seen in CML patients, while seven had the p190bcr-abl rearrangement seen in ALL alone. Of 61 patients analyzed, both with conventional cytogenetics and PCR, eight (13%) were positive for the Ph1, while 14 (23%) were positive for the BCR-ABL rearrangement by the PCR assay. Discordance between the PCR assay and cytogenetics occurred in eight cases where the PCR assay was positive and the cytogenetics negative, and two cases where the PCR assay was negative and cytogenetics positive. PCR positivity did not correlate with treatment response, survival, or relapse-free survival, but there was a higher percentage of L2 FAB morphology in the PCR+ cases compared to the PCR-cases (67 vs. 28%, p = 0.003). In addition, the data suggested that patients with a p190bcr-abl rearrangement have a better response to induction therapy, but a worse relapse-free survival compared to patients with a p210bcr-abl breakpoint, but these differences were not statistically significant. These data suggest that PCR and conventional cytogenetics may provide complementary information, since there appear to be a subset of patients who are Ph1-negative yet BCR-ABL positive by PCR. Further studies will be required to determine the prognostic significance of the detailed information about BCR-ABL breakpoints that is available from the PCR assay.

Cavernous angiomas of the internal auditory canal. A case report and review of literature

Cavernous angiomas of the internal auditory canal (IAC) are rare. They are angiographically occult; and because the clinical symptoms are similar both in intracanalicular cavernous angiomas and acoustic tumors it had been difficult to differentiate pre-operatively both of these pathologies until the advent of magnetic resonance imaging (MRI). Even nowadays the correct diagnosis may be missed if the patient is imaged only with gadolinium enhanced MRI without prior obtaining a non-contrast MRI. These diagnostic difficulties are illustrated by the report of a related case. The importance of thorough neuroradiological investigations stressed and MRI features, surgical management and relevant literature concerning the cavernous angiomas of the internal auditory canal are discussed.

Late radiation necrosis of the brain: case report

We report a case of radiation necrosis occurring 47 years after resection and radiotherapy for a juvenile pilocystic cerebellar astrocytoma, the longest yet reported. The patient presented with progressive lower cranial nerve dysfunction, and eventually died from cardiopulmonary arrest secondary to aspiration. The presentation, diagnosis, pathological features, and management of radiation necrosis are discussed.

Schwannoma of the fourth ventricle presenting with hemifacial spasm. A report of two cases

Two cases of cystic brainstem schwannomas protruding into the fourth ventricle are described. Both patients presented with hemifacial spasm. While there is only one previous case report of an intraventricular brainstem schwannoma, there has been no prior description in the literature of hemifacial spasm associated with such a tumor. The clinical, radiographic, surgical, and histopathological features of these tumors are elaborated. The relationship of hemifacial spasm to the various putative theories of origin proposed for intraparenchymal schwannomas is discussed.

Meningeal melanocytoma of the C8 nerve root: case report

A case of a meningeal melanocytoma involving the C8 nerve root is presented. The clinical symptoms and the radiological investigations resembled a neurinoma of the spinal nerve root. Intraoperatively the tumor was seen to be firmly attached to the dural covering of the dorsal nerve root. By using microsurgical technique, complete removal of the tumor with preservation of the ventral nerve root was accomplished. Histological examination revealed a typical meningeal melanocytoma as described by Limas and Tio in 1972. Ten additional cases of previously reported spinal meningeal melanocytomas are reviewed. The importance of differentiating this benign lesion from meningeal malignant pigmented tumors is stressed.

Intramedullary abscess associated with a spinal cord ependymoma: case report

Intramedullary spinal cord abscesses are relatively uncommon. We report the first case of an intramedullary spinal cord abscess in a preexisting spinal cord ependymoma. The clinical features and pathogenesis are discussed. Salient features of the management of intramedullary spinal cord abscesses are outlined.

Arachnoid cyst of the cerebellopontine angle manifesting as contralateral trigeminal neuralgia: case report

A case of an arachnoid cyst in the cerebellopontine angle manifesting as contralateral trigeminal neuralgia is presented. Decompression and excision of the lesion resulted in total relief of symptoms. The possible causes of contralateral trigeminal neuralgia are briefly reviewed, and the surgical treatment of this entity is discussed.

Elevated level of hyaluronic acid binding protein in diabetic rats

Hyaluronic acid binding protein (HABP), an extracellular matrix glycoprotein which interacts specifically with hyaluronic acid (HA) has been purified to homogeneity by HA affinity chromatography. Antibody was raised against it and the specificity of antibody towards HABP was confirmed by western blot analysis. A specific and sensitive assay method has been developed adopting solid phase non-competitive double sandwich method of ELISA. This new assay method enabled us to determine the levels of HABP in different tissue extracts of normal, diabetic and reverse diabetic rats. A significant increase in the levels of HABP was observed in diabetic animals, which however attained normal levels with insulin treatment.

Effect of intravesical instillation of varying doses of verapamil (20 mg, 40 mg, 80 mg) upon urinary bladder function in chronic traumatic paraplegics with overactive detrusor function

The effect of intravesical instillation of verapamil was studied in eight chronic, traumatic paraplegics. Cystometry was performed before and 2 h after intravesical instillation of 20 mg of verapamil. After a gap of 10 days, the study was performed with 40 mg of verapamil and after an interval of another 10 days, the effect of intravesical instillation of 80 mg of verapamil was studied. No side-effects were observed after the intravesical administration of 20 mg, 40 mg or 80 mg of verapamil. The intravesical volume at detrusor reflex activity or at first uninhibited detrusor contraction (IV-DR) showed no significant change after intravesical instillation of 20 mg; but IV-DR increased from 90 +/- 22 ml to 131 +/- 21 ml (p less than 0.001) after intravesical instillation of 40 mg of verapamil. There was a significant increase in IV-DR from 96 +/- 23 ml to 242 +/- 35 ml after intravesical instillation of 80 mg of verapamil (p less than 0.001). There was no significant change in detrusor pressure at detrusor reflex activity or at first uninhibited detrusor contraction after intravesical instillation of 20 mg, 40 mg or 80 mg of verapamil. The frequency of voiding recorded before and one day after intravesical instillation of either 20 mg or 40 mg of verapamil showed no significant change. But the frequency of voiding recorded before and one day after intravesical instillation of 80 mg of verapamil showed a significant decrease from 19 +/- 2 to 8 +/- 1 (p less than 0.001).