Resolution of intractable cholestasis associated with total parenteral nutrition following biliary irrigation

Although the protracted use of total parenteral nutrition (TPN) in infants is known to predispose to cholestasis, which in certain instances may not be reversible, failure to understand the pathogenesis of this condition has hindered the development of an effective medical treatment. That surgical treatment may reverse this process in selected patients is the subject of the present report. Two premature infants and one term infant, with short bowel syndrome acquired in infancy, developed conjugated hyperbilirubinemia following institution of balanced TPN. Infectious and metabolic etiologies for the jaundice were ruled out. No excretion of 99mTc-labeled DISIDA from the biliary tree was demonstrable 24 hours following injection by nuclear scintigraphy, despite the absence of extrahepatic biliary obstruction by abdominal sonography. When all conventional medical methods of managing the problem failed, exploration was performed. Intraoperative cholangiography showed normal intrahepatic and extrahepatic biliary ducts in each instance. Irrigation of the biliary tree with normal saline solution was then performed. In all cases, liver biopsies were obtained that were consistent with TPN-associated cholestasis and in all cases, jaundice resolved promptly following operation. We conclude that intractable cholestasis associated with TPN, regardless of its etiology, is a functional abnormality of biliary excretion that may respond in selected patients to irrigation of the biliary tree with radiographic dye and/or normal saline solution.

A new technique for evaluating cutaneous vascularity in complicated conjoined twins

Ischiopagus tripus conjoined twins were recently encountered. All organ systems were thoroughly evaluated using radiographic, angiographic, radionuclide, and CT imaging techniques. None of these studies were capable of accurately assessing the vascular territories of the skin at the level of the pelvis, the most critical area in terms of separation. Qualitative visual assessment of tissue fluorescein delivery under ultraviolet illumination is subject to subjective errors. Perfusion fluorometry is a recently developed technique whereby tissue fluorescence can be quantitated over time in very small amounts, even with repeated injections. In these conjoined twins, using sequential fluorescein injections in each twin, it was possible to accurately determine which portions of the pelvis and the shared leg belonged to which twin and exactly where the skin incisions should be made. Additionally, during operation it was possible to accurately predict the viability of skin flaps used for closure. Both twins survived. This is the first time it has been possible to accurately assess vascular territories of the skin in a complicated form of conjoined twinning. The technique is also useful in the evaluation of flow patterns in various other parts of the body.

Morbidity and mortality of short-bowel syndrome acquired in infancy: an update

The advent of total parenteral nutrition (TPN) has made survival beyond infancy possible for large numbers of patients who have sustained massive small intestinal loss due to a variety of intraabdominal catastrophes. However, the quantity and quality of life have been limited by the development of late sequelae due both to the protracted use of TPN and the long-term complications of foreshortening of the gut. To determine to what extent the morbidity and mortality of short-bowel syndrome (SBS) may have improved over the last 10 years, we reviewed our experience since 1973 with patients losing more than 50% of total small intestinal mass in infancy. The etiologies of SBS in the 16 study patients were necrotizing enterocolitis (6), midgut volvulus (5), multiple atresias (3), gastroschisis (1), and congenital SBS (1). Overall survival was 81%; total small intestinal length (SIL) at the time of diagnosis was 44.2 +/- 7.9 cm in survivors and 30.3 +/- 7.8 cm in nonsurvivors, probability values not significant. Although no patient survived without an ileocecal valve whose total SIL was greater than 20 cm, the three deaths in this series were not related directly to the SIL, but to end-stage liver disease resulting from TPN-associated cholestasis. Among the survivors, adaptation to enteral feedings required 13.8 +/- 2.5 mo, during which time weaning from TPN occurred; weight at adaptation was 6.87 +/- 1.32 kg.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of carprofen dosage forms and drug substance by high-performance liquid chromatography

A high-performance liquid chromatographic method for the analysis of carprofen in solid dosage forms and as the bulk drug substance was developed. The simple, accurate, reproducible, and stability-indicating method was shown to be applicable to drug substance and dosage form stability studies, as well as the quality control of carprofen dosage forms.

Ciliated cutaneous cyst of the foot

We report a 36-year-old woman with a cutaneous cyst of the dorsal aspect of the left foot. Because of the symptoms of pain and paresthesias attributed to the lesion, it was clinically felt to be a ganglion. After excision, these symptoms abated. Yet histologic examination showed this lesion to be a rare tumor, the ciliated cutaneous cyst. This is the third patient with this distinctive lesion on the foot or ankle.

Signal statistics in objective auditory evoked potential (AEP) detection by the phase spectral method

This paper reports on statistical aspects relevant to the use of the phase spectrum of post-stimulus EEG, in objective detection of the auditory evoked potential. The sampling statistics of two statistical estimators are discussed: the mean phase vector magnitude, and the standard deviation of an ensemble of post-stimulus EEG phases. These two estimators are circular statistics, and subject to strong sample size bias. Their confidence intervals have been derived empirically for sample sizes routinely used in clinical audiometry. A trial example illustrates the use of the objective phase statistics developed here; it is noted that the method may also be more efficient than the visual scoring of averaged responses.

Effects of calcium and cyclic nucleotides on rat calcitonin and parathyroid hormone secretion

Recently we developed a system for studying concurrent secretion of calcitonin (CT)and parathyroid hormone(PTH)in vitro from single rat thyroparathyroid gland complexes. In the present study, mechanisms involved in secretion of CT and PTH were explored by altering the medium [Ca ] and by using the Ca antagonist, verapamil. We also re-examined the idea that cyclic nucleotides may help regulate secretion of these hormones and attempted to determine if effects of cyclic nucleotides might be altered by changes in medium [Ca]. Thyroparathyroid glands from 8-day-old rats were incubated in serum-free medium for 8h, and CT and PTH levels in the medium were measured by radioimmunoassays. We show for the first time that: (1) although low [Ca] is well known to promote PTH release, some extracellular Ca is needed for PTH secretion to occur at a maximal rate; (2) inhibition of Ca entry into cells with verapamil mimics the effects of low medium Ca on both CT and PTH release; and (3) cyclic nucleotides may exert their effects on secretion of CT and PTH at least in part via effects on Ca entry into cells.

Differential pulse polarographic determination of 2,3-dimercaptosuccinic acid and tin (II) in radiopharmaceuticals

A differential pulse polarographic procedure was developed for the assay of dimercaptosuccinic acid and tin(II), components of a commercially available pharmaceutical kit for kidney scintigraphy. The method is quantitative and qualitative for both the chelated and unchelated forms of dimercaptosuccinic acid and tin(II) in a mixture of the two.

Parathyroid transplantation: fate of a long-term allograft in man

Previously our group reported clinical, histological, and biochemical evidence of parathyroid allograft survival in a patient transplanted sequentially with renal and parathyroid tissues from the same donor. After 30 months of function, both grafts were concomitantly rrjected. The prolonged parathyroid allograft survival described in certain experimental animals has been attributed to the tissue's being "immunologically privileged." Our current clinical observations do not support this hypothesis.

Fully objective ERA by phase spectral analysis

A method of ERA using the Vertex potential is presented which is entirely objective. The result is given by means of a statistical evaluation which is derived automatically. The method is based on pattern analysis of the V-potential, the technique relying essentially on analysis of the phase spectrum of the appropriate Fourier components.

Description of a bacterium associated with redmouth disease of rainbow trout (Salmo gairdneri)

A description was given of a gram-negative, peritrichously flagellated, fermentative bacterium that was isolated on numerous occasions from kidney tissues of rainbow trout (Salmo gairdneri) afflicted with redmouth disease. Although the bacteria apparently were members of the family Enterobacteriaceae, it was impossible to determine their taxonomic position within the family with certainty. Hence it was recommended that their taxonomic position remain sub judice for the present. As a temporary designation RM bacterium was used.Redmouth disease was transmitted from infected to normal fish through the medium of water.