The frequency and outcome of biliary atresia in the UK and Ireland

BACKGROUND

Biliary atresia is an obliterative cholangiopathy of infancy that is fatal if untreated. Surgical treatment, the Kasai portoenterostomy, may restore bile flow and clear jaundice, and, if successful, achieve a 10-year survival of 90% with a native liver. The outcome of a 2-year cohort of children with biliary atresia in the UK and Ireland was assessed to find the current frequency, the factors influencing outcome, and the medium-term need for liver transplantation.

METHODS

Cases diagnosed between March, 1993, and February, 1995, were notified by paediatricians to the British Paediatric Surveillance Unit via a monthly reporting system. Confirmed cases were followed up by postal questionnaires to notifying paediatricians.

FINDINGS

93 cases were confirmed, a frequency of 1/16700 livebirths. Primary surgery was done in 91 children in 15 surgical centres with an early success rate for clearing jaundice of 55% overall. Centres were grouped according to caseload; group A had more than 5 cases/year and group B fewer than 5 cases/year. Early success was higher in group-A centres, odds ratio 2.02 (95% CI 0.86-4.73), but this did not reach statistical significance. Of 41 children in whom surgery was unsuccessful in clearing jaundice 9 (22%) died and 30 (73%) underwent liver transplantation. Survival without liver transplantation and overall survival were both significantly greater in group-A centres, rate ratios 0.48 (95% CI 0.27-0.86) and 0.32 (0.11-0.94). Actuarial 5-year survival without transplantation was 61.3% in group-A centres and 13.7% in groupB centres. Actuarial 5-year overall survival was 91.2% in group A and 75% in group B. Once centre size was taken into account, no other factor, including age at surgery, was predictive of survival without transplantation or overall survival.

INTERPRETATION

The outcome of children with biliary atresia is related to the caseload of the surgical centre where they have their primary surgery. Children with biliary atresia should be managed in surgical centres with a caseload of more than five cases annually.

The effect of short stature, portal hypertension, and cholestasis on growth hormone resistance in children with liver disease

Chronic liver disease is associated with GH resistance, which is characterized by high circulating GH and low insulin-like growth factor I (IGF-I) concentrations. Standard GH replacement has no effect on serum IGF-I in pediatric liver disease. The aims were to examine whether GH resistance can be overcome by supraphysiological GH and to determine whether GH resistance worsens with the progression of liver disease. Thirty children, divided into five groups whose liver disease was at clinically different stages, were studied. They were given 0.2 IU/kg x day GH for 4 days and then 0.4 IU/kg x day for the next 4 days. Serum IGF-I and binding proteins (IGFBPs) were measured by immunoassay. IGF-I was lower in all study groups than in normal controls. IGF-I, IGFBP-3, and acid-labile subunit rose in response to GH. The magnitude of the response reflected nutritional status and liver dysfunction; in particular, portal hypertension was associated with a poor IGF-I response. There was no change in IGFBP-2. GH resistance begins early in the natural history of childhood liver disease and develops with the progression of liver disease, particularly with portal hypertension. It may be partially overcome by supraphysiological GH administration, but the effect becomes smaller with worsening liver disease.

Role of slowed Ca(2+) transient decline in slowed relaxation during myocardial ischemia

The goal of this study was to test the hypothesis that during myocardial ischemia, slowing of the Ca(2+) transient decline causes slowed relaxation. Our approach was to monitor pressure and Ca(2+) transients in isovolumic rat hearts during control and low flow ischemia conditions. In addition, we experimentally slowed the decline of the Ca(2+) transient using cyclopiazonic acid (CPA) to inhibit the sarcoplasmic reticulum Ca(2+)-ATPase (SERCA, the most important pump for rapidly transporting Ca(2+) out of the cytosol). Using 9 microm CPA during normoxia, we were able to reproduce the slowed Ca(2+) transient decline and slowed relaxation found during low flow ischemia. The time constants of cytosolic [Ca(2+)] decline and pressure decline (tau(Ca) and tau(P) respectively) with CPA (78+/-5 ms and 64+/-3 ms) were similar to those found with ischemia (89+/-12 ms and 72+/-10 ms, mean+/-SEM, n=7) and were considerably greater than for controls (41+/-3 and 25+/-2 ms, mean+/-SEM, n=14, P<0.01). Furthermore, the relationship of tau(P) v tau(Ca) with CPA was similar to that found with ischemia. These findings are consistent with the hypothesis that the slowed Ca(2+) transient decline with both CPA and ischemia causes slowed relaxation. Consistent with this conclusion, a simple mathematical model to relate cytosolic [Ca(2+)] and pressure also suggests that slowed pressure relaxation can be explained by slowing of the Ca(2+) transient decline. This study suggests that impaired Ca(2+) uptake is a major injury causing slowed relaxation during ischemia.

Phylogenetic relationships of the enigmatic hoatzin (Opisthocomus hoazin) resolved using mitochondrial and nuclear gene sequences

The hoatzin (Opisthocomus hoazin) is a bizarre, long-tailed, crested bird that inhabits the riparian lowlands of South America. Among its peculiar attributes are (1) microbial foregut fermentation to convert plant cellulose in consumed foliage into simple sugars, (2) a highly modified skeleton to accommodate its large crop, and (3) in the young of this species, wing claws at the wrist joint which are used to climb among the branches of the nest tree. Consequently, the taxonomic position of this unusual bird has perplexed systematists since its description over 200 years ago. Traditionally classified among the fowl-like birds (Galliformes), recent studies have favored its placement with the cuckoos (Cuculiformes: Cuculidae). To help resolve this systematic uncertainty, we sequenced six mitochondrial genes (cytochrome oxidase I, II, and III, ATPase 8, ATPase 6, and cytochrome b) and one nuclear gene (c-mos), totaling 5,487 base pairs. With this large data set and an appropriate range of outgroup taxa, we demonstrate that the hoatzin should not be classified among the cuckoos or Galliformes. Instead, our analyses indicate that the hoatzin is most closely related to the turacos (Musophagiformes: Musophagidae), a small family of arboreal, frugivorous birds inhabiting sub-Saharan Africa. This phylogenetic relationship is also supported by osteological behavioral, and fossil evidence.

Management of the severely head injured patient

The care of the severely brain injured patient presents important challenges to the anesthesiologist. The patients are often young, there is little time for preparation, there are associated injuries, the airway management may be difficult or risky to the brain or spinal cord, the outcome varies widely and it is not always possible to monitor the desired physiological variables. Furthermore, there is no single intervention or agent that has emerged as being beneficial, but the degree to which care is taken in the domain of the anesthesiologist, will have an important impact on outcome. The central themes in patient care include rapid attention to resuscitation and maintenance of adequate CPP and oxygen delivery. Careful attention to post-operative care will also affect outcome. Recognizing that the outcome may not be determined solely at the time of impact is an important concept for all who take care of these patients.

Colonization history of atlantic island common chaffinches (Fringilla coelebs) revealed by mitochondrial DNA

Common chaffinches (Fringilla coelebs) are thought to have colonized the Atlantic island archipelagoes (the Azores, Madeira, and the Canaries) from neighboring continental populations (Iberia and north Africa) within the last million years. However, colonization may have occurred separately from north Africa to the Canaries and from Iberia to the Azores (as would be predicted geographically) or in one wave from Iberia to the Azores and then to Madeira and the Canaries. These alternatives have different implications for the evolution of morphometric and plumage differentiation in island chaffinches. To determine the most likely colonization route, we estimated the phylogenetic relationships among island and continental subspecies of common chaffinch using sequences from four mtDNA genes (cytochrome b, ATPase 6, NADH 5, and the control region). The most strongly supported mtDNA phylogeny places the continental subspecies together as the sister group to a monophyletic clade containing the island subspecies. This is consistent with a single wave of colonization, and suggests that patterns of similarity among Atlantic island common chaffinches, such as blue pigmentation, short wings, and long tarsi, are due to common colonization history rather than to convergent evolution in a common island environment. However, spectral analysis of phylogenetic splits showed that although monophyly of island haplotypes is favored, there is also substantial support for their polyphyletic origin. We attribute the latter to the confounding effect of homoplasy at multistate sites and to the relatively rapid sequence of colonization events which provided insufficient time for the accumulation of strong phylogenetic signal. These problems are likely to be significant impediments in attempts to test hypotheses of phylogenetic histories of recently evolved populations and taxa.

Ocular abnormalities in Alagille syndrome

OBJECTIVE

To assess the type and frequency of ocular abnormalities occurring in Alagille syndrome (AS) in a large group of affected patients and their parents and the potential pathogenetic role of fat-soluble vitamin deficiency.

DESIGN

Observational case series.

PARTICIPANTS

Twenty-two children with AS and 23 of their parents participated.

MAIN OUTCOME MEASURES

Participants underwent full ophthalmic examination, including refraction, orthoptic examination, keratometry, slit-lamp examination, and funduscopy. Corneal diameter measurement was performed in a subset of nine and fluorescein angiography in a subset of six. Serum levels of vitamins A and E and cholesterol were measured.

RESULTS

The most common ocular abnormalities in patients with AS were posterior embryotoxon (95%), iris abnormalities (45%), diffuse fundus hypopigmentation (57%, a previously unreported finding), speckling of the retinal pigment epithelium (33%), and optic disc anomalies (76%). Microcornea was not associated with large refractive errors, and visual acuity was not significantly affected by these ocular changes. Vitamin levels were normal. Ocular abnormalities including posterior embryotoxon, iris abnormalities, and optic disc or fundus pigmentary changes were detected in one parent in 36% of cases.

CONCLUSIONS

Alagille syndrome is associated with a characteristic group of ocular findings without apparent serious functional significance and probably unrelated to fat-soluble vitamin deficiency. Simple ophthalmic examination of children with neonatal cholestatic jaundice and their parents should allow early diagnosis of AS, eliminating the need for extensive and invasive investigations.

The Home Instruction Program for Preschool Youngsters (HIPPY)

The Home Instruction Program for Preschool Youngsters (HIPPY) is a two-year home-based early education intervention program designed to help parents with limited formal education prepare their four- and five-year-old children for school. This article begins with a brief overview of the HIPPY program and then presents the findings from a series of interconnected research studies, including a two-site, two-cohort evaluation in New York and Arkansas, a one-site case study, and a three-site qualitative study. With respect to program effectiveness, results varied across the New York and Arkansas sites and across participating cohorts at each site. For Cohort I, children who had been enrolled in HIPPY scored higher than children in the control/comparison groups on measures of cognitive skills (New York), classroom adaptation (New York and Arkansas), and standardized reading (New York); and more children were promoted to first grade (Arkansas). For Cohort II, comparison group children outperformed HIPPY children on school readiness and standardized achievement at posttest (Arkansas). Analyses to account for the differing results between cohorts were inconclusive. Qualitative analyses revealed considerable variation in parent involvement in HIPPY. Program staff identified four patterns of attrition from HIPPY: (1) early attrition within the first month after enrollment, (2) attrition between the program's first and second years, (3) attrition due to changes in the life circumstances of participating families, and (4) attrition due to turnover among the home visitors. Families were more likely to participate in in-home than out-of-home aspects of the program (for example, group meetings), but different family characteristics were associated with participation in the in- and out-of-home aspects of the program. The authors conclude with recommendations for future practice and research.

Gender matching and outcome after pediatric liver transplantation

BACKGROUND

Gender is not a selection criterion for orthotopic liver transplantation (OLT), and reports in adults have shown a less favorable outcome for male recipients of female organs; the only pediatric study did not support this finding. The aim of the present study was to assess the impact of donor and recipient gender on graft and patient survival rates after pediatric OLT.

METHODS

We have reviewed retrospectively 137 children (male=63; median age: 3.4 years; range: 14 days to 15 years) undergoing primary OLT from January 1991 to June 1996. These children were divided into donor-recipient gender match (M; n=64) and nonmatch (NM; n=73) groups and then classified into female to female (FF; n=30), female to male (FM; n=29), male to female (MF; n=44), and male to male (MM; n=34) subgroups.

RESULTS

The M group had better graft and patient survival rates at both 1- and 5-year follow-up compared with the NM group (P<0.01). Graft and patient survival rates were different among gender subgroups (P<0.04). Graft and patient survival rates in the FM group were poorer than in the MM subgroup at both 1 and 5 years (P<0.03, P<0.01). The FM group had a higher incidence of early complications than the MM (P<0.01) group, with 50% and 33% of graft losses, respectively, related to the complications. To minimize the influence of hormonal factors, we have analyzed separately the patients younger than 12 and 10 years who had similar findings.

CONCLUSION

Graft and patient survival rates after pediatric OLT are worse in gender mismatch groups, particularly for male recipients of female organs. Early complications play a role in the decreased survival rates.

Ca2+ regulates the kinetics of tension development in intact cardiac muscle

The goal of this study was to determine whether Ca2+ plays a role in regulating tension development kinetics in intact cardiac muscle. In cardiac muscle, this fundamental issue of Ca2+ regulation has been controversial. The approach was to induce steady-state tetanic contractions of intact right ventricular trabeculae from rat hearts at varying external Ca2+ concentrations ([Ca2+]) at 22 degreesC. During tetani, cross bridges were mechanically disrupted and the kinetics of tension redevelopment were assessed from the rate constant of exponential tension redevelopment (ktr). There was a relationship between ktr and external [Ca2+] that was similar in form to the relationship between tension and [Ca2+]. Thus a close relationship also existed between ktr and tension (r = 0.88; P < 0. 001); whereas at maximal tetanic tension (saturating cytosolic [Ca2+]), ktr was 16.4 +/- 2.2 s-1 (mean +/- SE, n = 7), at zero tension (low cytosolic [Ca2+]), ktr extrapolated to 20% of maximum (3.3 +/- 0.7 s-1). Qualitatively similar results were obtained using different mechanical protocols to disrupt cross bridges. These data demonstrate that tension redevelopment kinetics in intact cardiac muscle are influenced by the level of Ca2+ activation. These findings contrast with the findings of one previous study of intact cardiac muscle. Activation dependence of tension development kinetics may play an important role in determining the rate and extent of myocardial tension rise during the cardiac cycle in vivo.

Chronic alcohol-induced changes in cardiac contractility are not due to changes in the cytosolic Ca2+ transient

Long-standing heavy alcohol consumption acts as a chronic stress on the heart. It is thought that alcohol-induced changes of contractility are due to altered Ca2+ handling, but no measurements of cytosolic Ca2+ ([Ca2+]c) after chronic alcohol exposure have been made. Therefore experiments were performed to determine whether alcohol-induced changes in contractility are due to altered Ca2+ handling by measuring [Ca2+]c (indo 1) in hearts from rats drinking 36% ethanol for 7 mo and age-matched controls. Peak left ventricular pressure was depressed (-16%), whereas rates of contraction (12%) and relaxation (14-20%) were faster in alcohol-exposed hearts. Systolic [Ca2+]c (808 +/- 45 vs. 813 +/- 45 nM), diastolic [Ca2+]c (195 +/- 11 vs. 193 +/- 10 nM), and rates of [Ca2+]c rise and decline were the same in alcohol-exposed and control hearts. Protein levels of Ca2+-handling proteins, sarcoplasmic reticulum Ca2+-ATPase and phospholamban, were the same in myocytes isolated from alcohol-exposed and control hearts (SDS-polyacrylamide gel). These data suggest that chronic alcohol-induced contractile changes are not due to altered Ca2+ handling but may be due to changes at the level of the myofilament. As a first step in elucidating the mechanism(s) of alcohol-induced changes at the myofilament, we assessed myosin heavy chain (MHC) isoform content (SDS-polyacrylamide gel). alpha-MHC was decreased relative to beta-MHC (a/a + b = 0.55 +/- 0.03 vs. 0.66 +/- 0.02; P < 0.02) in alcohol-exposed hearts, which cannot account for the observed alcohol-induced contractile changes. In conclusion, changes of myocardial contractility due to chronic alcohol exposure do not result from altered Ca2+ handling but from changes at the level of the myofilament that do not involve MHC isoform shifts.

Effect of aortic cannula characteristics and blood velocity on transcranial doppler-detected microemboli during cardiopulmonary bypass

OBJECTIVES

Cerebral microemboli are responsible to a large extent for the neuropsychiatric deficits after cardiac surgery. Differences in cannula size during cardiopulmonary bypass (CPB) will result in different velocities of blood exiting the aortic cannula. This study determined whether the number of transcranial Doppler (TCD)-detected emboli in the middle cerebral artery (MCA) during CPB correlated with blood speed or the direction of flow as determined by the shape of the aortic cannula.

DESIGN

Patients were studied prospectively for evidence of TCD-detected emboli. If patients met the inclusion criteria, the choice of cannula was determined by surgical preference.

SETTING

All studies were conducted at a single tertiary care academic cardiac surgery hospital by a single observer.

PARTICIPANTS

Thirty-two patients undergoing first-time elective aortocoronary bypass surgery who were free of neurologic dysfunction or peripheral vascular disease and weighed 60 to 85 kg were studied. Patients who had other concurrent cardiac operations or who were in cardiogenic shock were excluded.

INTERVENTIONS

Three aortic cannula types for elective aortocoronary bypass surgery were used: 24F curved (n = 19), 24F straight (n = 6), and 22F straight (n = 7), with internal diameters (IDs) of 7.2, 6.6, and 5.9 mm, respectively. TCD-detected emboli were identified in the MCA.

MEASUREMENTS AND MAIN RESULTS

The rate of TCD-detected emboli (0.02 to 11.4 emboli per minute) was not related to the velocity of blood (46 to 77 cm/s) and was not affected by the choice of either a straight or curved aortic cannula.

CONCLUSIONS

The choice of a straight or curved aortic cannula or of a 24F versus 22F cannula may not be important with respect to the number of cerebral microemboli.

Rates and patterns of mitochondrial DNA sequence evolution in fringilline finches (fringilla spp.) and the greenfinch (Carduelis chloris)

Rates and patterns of evolution in partial sequences of five mitochondrial genes (cytochrome b, ATPase 6, NADH dehydrogenase subunit 5, tRNA(Glu), and the control region) were compared among taxa in the passerine bird genera Fringilla and Carduelis. Rates of divergence do not vary significantly among genes, even in comparisons with the control region. Rate variation among lineages is significant only for the control region and NADH dehydrogenase subunit 5, and patterns of variation are consistent with the expectations of neutral theory. Base composition is biased in all genes but is stationary among lineages, and there is evidence for directional mutation pressure only in the control region. Despite these similarities, patterns of substitution differ among genes, consistent with alternative regimes of selective constraint. Rates of nonsynonymous substitution are higher in NADH dehydrogenase subunit 5 than in other protein-coding genes, and transitions exist in elevated proportions relative to transversions. Transitions appear to accumulate linearly with time in tRNA(Glu), and despite exhibiting the highest overall rate of divergence among species, there are no transversional changes in this gene. Finally, for resolving phylogenetic relationships among Fringilla taxa, the combined protein-coding data are broadly similar to those of the control region in terms of phylogenetic informativeness and statistical support.

Cerebral oxidative metabolism and evoked potential deterioration after severe brain injury: new evidence of early posttraumatic ischemia

BACKGROUND

We commonly observe progressive deterioration in somatosensory evoked potentials (SSEPs) after severe head injury. We had previously been unable to relate this deterioration to raised intracranial pressure but had noted a relationship with decreasing transcranial oxygen extraction (arteriovenous oxygen difference [AVDO2]). The purpose of this study was twofold: to prove the hypothesis that deterioration in SSEP values is associated with decreasing AVDO2 and to test the subsidiary hypotheses that deteriorating SSEPs were the result of either ischemia/reperfusion injury or failure of oxygen extraction/utilization.

METHODS

Monitoring of 97 patients with severe traumatic brain injury (Glasgow Coma Scale scores of < or = 8 after resuscitation) included twice daily AVDO2 measurement and hourly SSEP recording for an average of 5 days. The last 51 patients also underwent 12-hourly measurement of cerebral blood flow (CBF), with calculation of the cerebral metabolic rate of oxygen. Cluster analysis was used to classify patients based on initial AVDO2 values and subsequent SSEP trends. The time courses of CBF, SSEPs, AVDO2, and cerebral metabolic rate of oxygen were examined in the groups defined by the cluster analysis. The clinical outcomes considered were survival or nonsurvival and the Glasgow Outcome Scale scores obtained at 3 months or more after injury.

RESULTS

Cluster analysis confirmed the association between high initial AVDO2 values and subsequent SSEP deterioration. Patients in this category initially had significantly higher AVDO2, lower CBF, and higher cerebral metabolic rates of oxygen but recovered to adequate levels within 24 to 36 hours after injury. SSEP values were initially identical in the patients with normal AVDO2 values and those with elevated AVDO2 but differed significantly at 60 hours after injury and beyond.

CONCLUSION

The findings of increased oxygen utilization and lowered CBF in the patients with deteriorating SSEPs strongly imply that early ischemia rather than failure of O2 extraction or utilization is responsible for the associated SSEP deterioration. This issue of defining thresholds for ischemia based on AVDO2 is confounded by the dependency of CBF and AVDO2 values on the time after injury.

Serum leptin and insulin in paediatric end-stage liver disease and following successful orthotopic liver transplantation

OBJECTIVE

Leptin, the product of the ob gene, is a postulated feedback regulator of adiposity with appetite suppressant and catabolic effects. Catabolic states are associated with decreased body fat mass as a result of both nutritional and metabolic perturbation. Low serum leptin has been described previously in a number of catabolic states. It has been unclear whether the observed changes in leptin are a cause or consequence of changes in adiposity. Paediatric end-stage liver disease (ESLD) is characterized by decreased body fat mass and poor linear growth. Successful treatment by orthotopic liver transplantation (OLT) is accompanied by increase in fat mass. We investigated the hypothesis that serum leptin would be low in paediatric ESLD and that increase in body fat mass post-OLT would result in increased serum leptin.

DESIGN

Serum leptin and insulin were measured by radioimmunoassay in children with ESLD before and after successful OLT and in age-matched controls.

PATIENTS

Twenty-four children with ESLD attending the outpatient department of King's College Hospital, London and 10 age-matched controls.

MEASUREMENTS

Anthropometric measurements were performed according to standard techniques and standard deviation (SDS) derived from population standards. Serum leptin and insulin were measured by radioimmunoassay.

RESULTS

Serum leptin pre-OLT, leptin (4.06 micrograms/l, [3.45, 5.68] median, with 25th and 75th interquartile ranges) was significantly lower than controls (6.62 micrograms/l, [4.33, 8.05], P = 0.02). Following OLT, serum leptin fell to levels which were significantly lower than pre-OLT values (3.32 micrograms/l, [2.30, 3.99], P = 0.01). There was no significant difference between boys and girls either pre-OLT (boys; 3.64 micrograms/l, [2.45, 5.57], girls; 4.14 micrograms/l, [3.18, 5.65]) or post-OLT (boys; 3.32 micrograms/l, [2.93, 3.62], girls; 3.69 micrograms/l, [2.23, 4.63]. Neither the age at OLT nor the age at the time of blood sampling was correlated with serum leptin pre-OLT or post-OLT. Pre-OLT the children were significantly malnourished with low measures of body fat mass (mid-arm circumference (MAC) SDS -1.90 [-4.67, -1.07]; triceps skinfold thickness (TSF) SDS -1.53, [-2.23, -0.23]; body mass index (BMI) 16.2, [15.5, 16.9]). Three months post-OLT, there were significant improvements in MAC SDS (-0.77, [-1.08, -0.20], P = 0.02) and TSF SDS (-0.41, [-1.95, -0.38], P = 0.003), but no significant change in BMI (15.9 [15.3, 16.7], P = 0.41. Pre-OLT, log serum leptin did not correlate with BMI, MAC SDS or TSF SDS. In contrast, post-OLT, there was a positive correlation between log serum leptin and BMI (r = 0.59, P = 0.003), MAC SDS (r = 0.49, P = 0.01) and TSF SDS (r = 0.41, P = 0.05). BMI also correlated with log serum leptin in the control children (r = 0.64, P = 0.04).

CONCLUSIONS

Serum leptin is low in children with end-stage liver disease but does not show the expected correlation with measures of body fat mass. Surprisingly, following orthotopic liver transplantation serum leptin falls significantly despite significant increases in measures of body fat mass (triceps skinfold thickness standard deviation scores, mid-arm circumference standard deviation scores). Orthotopic liver transplantation restores the expected correlation of serum leptin with measures of body fat mass within the treatment group. The elevation of serum leptin above predicted levels in paediatric end-stage liver disease offers a mechanism for the anorexia and cachexia characteristic of this disease.

Clinical significance of CSF glutamate concentrations following severe traumatic brain injury in humans

Glutamate excitotoxicity is a putative mechanism of secondary damage after traumatic brain injury (TBI). No relationship between glutamate release and clinical status has been shown in humans, however. We hypothesize a dose-response relationship between CSF glutamate concentrations and severity of injury, electrophysiological deterioration as measured by somatosensory evoked potential amplitudes, and clinical outcome. From August 1991 to March 1996, intensive monitoring of 55 patients with severe TBI (GCS < or = 8 after resuscitation) included twice daily CSF glutamate levels and hourly somatosensory evoked potentials (SSEPs) for an average of 5 days. Clinical outcomes were survival/nonsurvival and Glasgow outcome score (GOS) at 3 months or more post-injury. Glutamate levels were not associated with severity of injury, electrophysiological deterioration, or clinical outcome. Neither peak nor mean glutamate levels significantly improved a simple logistic regression model which used only age and presence of bilaterally unreactive pupils to predict survival. Using this methodology CSF glutamate concentrations did not display a dose-response relationship to severity of injury, electrophysiological deterioration, or predict clinical outcomes following TBI in a group of 55 patients. An early effect of glutamate, an effect dependent on time of exposure to glutamate or other modulating effects cannot be ruled out.

The insulin-like growth factor and binding protein axis in children with end-stage liver disease before and after orthotopic liver transplantation

Over 50% of children with established cirrhosis have evidence of growth failure and malnutrition. Orthotopic liver transplantation (OLT) is a successful treatment for many children and leads to improved growth and nutrition. Most of the anabolic actions of GH are mediated through the generation of the mitogenic polypeptide insulin-like growth factor-I (IGF-I). Although this is synthesised ubiquitously, the bulk of circulating IGF-I is derived from the liver. The actions of IGF-I are modulated by a family of at least six high-affinity binding proteins (IGFBPs). Growth failure in end-stage liver disease, both before and after OLT, may result from abnormalities in the IGF-IGFBP axis. Children who had undergone successful OLT were studied before and after OLT. Anthropometry was measured by standard techniques. Serum IGFs, IGFBPs and acid labile subunit (ALS) were measured by RIA, IRMA, ELISA, Western ligand and immunoblotting. The most severely affected anthropometric parameters were skin fold thickness and mid-arm circumference. After OLT there was a marked improvement in these parameters. Chronic liver disease was characterised by low serum IGF-I, IGF-II, IGFBP-3 and ALS levels with raised IGFBP-1 and -2 levels. Serum IGFBP-1 and -2 were negatively correlated with pre-OLT anthropometric parameters. After OLT, there was a rapid normalisation of serum IGF-I, while IGF-II and IGFBP-3 overshot to supranormal levels. ALS levels post-OLT remained below control levels. By 3 years post-OLT, IGFBP-3 had fallen to levels which were insignificantly different from controls. IGFBP-1 fell but remained above normal, while there was no significant change in IGFBP-2. Growth post-OLT correlated positively with serum IGF-I and negatively with IGFBP-1. In conclusion, chronic liver disease is associated with marked changes in body composition. These changes are associated with and may be caused by an impaired generation of IGF-I and altered production of IGFBPs. After OLT there is a marked improvement in growth associated with partial normalisation of the IGF-IGFBP axis. However, there are persistent abnormalities in this axis which may explain growth failure post-OLT.

An assessment of the radiation dose to patients and staff from a Lunar Expert-XL fan beam densitometer

Dual-energy x-ray absorptiometry (DXA) is a widely used technique for measuring bone mineral density for the identification and management of osteoporotic subjects. The original DXA pencil beam systems expose patients to an effective dose of ionizing radiation of around 2 muSv and require no additional protective shielding for staff. The new fan beam densitometers incorporate solid state detectors and have a higher photon flux, enabling faster acquisition times and giving improved resolution. However, this may be at the expense of higher radiation dose. This study was conducted to assess the radiation dose to patients and staff from the standard scan modes using a Lunar Expert-XL fan beam densitometer. This is, we believe, the first dose assessment of the Expert-XL. The results indicate that the scatter dose at 1 m from the scan table, assuming four AP spine and femoral neck examinations per hour, is about 4 muSv h-1. This is well below the limit of 7.5 muSv h-1 set by the UK's Ionising Radiation Regulations for defining a Controlled Area but above the lesser limit of 2.5 muSv h-1 for a Supervised Area. Typical effective doses to patients are 59 muSv for an AP lumbar spine scan, up to 56 muSv for AP femoral neck, 71 muSv for lateral spine morphometry and 75 muSv for whole body. Although exceeding those of pencil beam DXA machines, these doses are less than for standard radiographic procedures, particularly of the lumbar spine. Where reduced scan time, improved image resolution or morphometric analysis of the spine are required, the patient doses from the Lunar Expert-XL are not prohibitive.

Anti-thymocyte globulin, cyclosporin A and granulocyte colony-stimulating factor for severe aplastic anaemia complicating paediatric liver transplantation

We describe a sustained trilineage haematopoietic response to intensified immunosuppressive therapy with anti-thymocyte globulin, cyclosporin A and recombinant human granulocyte colony-stimulating factor in a 4-year-old girl, who developed severe aplastic anaemia after orthotopic liver transplantation for fulminant liver failure induced by non A-E hepatitis. The outcome was successful and allows the following.

CONCLUSION

Intense immunosuppression in combination with haemopoetic growth factors and antimicrobial prophylaxis should be considered as first line therapy in severe aplastic anaemia after orthotopic liver trans-plantation.

Hepatic growth hormone receptor, insulin-like growth factor I, and insulin-like growth factor-binding protein messenger RNA expression in pediatric liver disease

Major changes in serum levels of insulin-like growth factor I (IGF-I) and IGF-binding proteins (IGFBPs) occur in children with end-stage liver disease in association with changes in body composition. We hypothesized that these changes would be associated with changes in hepatic messenger RNA (mRNA) expression. Eleven children with end-stage extrahepatic biliary atresia and 11 controls (liver donors) were studied. Serum samples were obtained from the children with biliary atresia immediately before orthotopic liver transplantation. Serum IGF-I, IGFBP-1, and IGFBP-2 levels were measured by radioimmunoassay, and IGFBP-3 by immunoradiometric assay. In both groups, growth hormone receptor mRNA expression was examined by quantitative reverse transcription-polymerase chain reaction, IGF-I mRNA expression by ribonuclease protection assay, and IGFBP-1 to -4 mRNA expression by Northern analysis. Growth hormone receptor and IGF-I mRNA levels were reduced 1.7-fold (P = .003) and 9.6-fold (P = .0001) in biliary atresia compared with levels in controls. Despite increased serum IGFBP-1 levels and reduced IGFBP-3 levels in biliary atresia, there was no change in either IGFBP-1 or IGFBP-3 mRNA expression. In contrast, serum levels and mRNA expression of IGFBP-2 were increased 1.6-fold (P = .003) and twofold (P = .0001), respectively, compared with controls. Gene expression did not correlate with liver dysfunction or body composition. Changes in growth hormone receptor and IGF-I mRNA expression may account for the reduction in serum IGF-I found in pediatric liver disease. In contrast, the marked alteration in circulating IGFBP levels was not accompanied by changes in hepatic IGFBP gene expression, suggesting that posttranslational mechanisms may be important.

Hepatitis GB virus-C/hepatitis G virus infection in liver disease

Hepatitis GB virus-C (HGBV-C)/hepatitis G virus (HGV) infection was investigated in 106 children with liver disease (54 boys and 52 girls, mean age 7.3 years); 12 with chronic hepatitis C virus infection, 29 with positive hepatitis B surface antigen, nine with idiopathic fulminant hepatic failure, seven with graft dysfunction after liver transplantation associated with autoimmune features, 20 with cryptogenic liver disease, and 29 with autoimmune liver disease. HGV RNA detected by reverse transcription polymerase chain reaction was found to be positive in 4/106 patients (3.8%). Risk factors were identified in three patients, including blood transfusion and/or medical treatment in Eastern Europe. The prevalence was higher than that of blood donors but lower than that of 2 adult patients with liver disease. HGV is not associated with any specific disease group and does not seem to be a major aetiological agent of liver disease in childhood in the UK.

Liver transplant for giant cell hepatitis with autoimmune haemolytic anaemia

Giant cell hepatitis (CGH) with autoimmune haemolytic anaemia (AHA) is a distinct entity with an aggressive course. Immunosuppression may help early disease. A case is reported of a child with GCH and AHA with early disease recurrence after liver transplantation for end stage liver disease.