Suprasellar lymphoid hyperplasia presenting with diabetes insipidus and hypogonadism

We report a pediatric patient who presented with hypogonadism and diabetes insipidus. Further evaluation revealed hypothyroidism. MRI of the brain revealed a suprasellar mass. Following frontal craniotomy for mass biopsy, histological analysis of the mass revealed benign lymphoid hyperplasia. The patient has had no progression of his mass or symptoms at most recent follow-up (10 months). We review this unusual case and other similar conditions. We believe this to be the first reported case of lymphoid hyperplasia without malignant cells of the suprasellar region.

Ectopic brain tissue in a neonate

We report a 2-week-old male with a large cystic mass in the left cervical and face region. No connection to the brain or spinal cord was discernable either at operation or on imaging. Histological study of this mass revealed central nervous tissue including neuroglia, ependymal cells, non-neuroblastic neurons, pigmented retinal epithelium, and choroid plexus. This case represents the rare ectopic 'brain'. We review this case as well as the literature concerning these unusual masses.

Choristomatous polyps of the aural and pharyngeal regions: first simultaneous case

The first known case of embryological development of a salivary gland choristoma of the middle ear and a hairy teratoid (choristomatous) mass of the pharynx arising in the same patient is reported. On the day after the patient, a female, was born, a posterior pharyngeal mass was discovered, resected, and diagnosed histopathologically as a hairy teratoid (choristomatous) polyp. At 10 months of age, the patient underwent myringotomy and tympanostomy tube placement, and another mass was found in the left middle ear. This mass was diagnosed as a salivary gland choristoma. Our review of the literature showed that, consistent with our case, choristomas are more prevalent in females, and those in the middle ear almost always occur on the left side. Both types of polyps are rare and are thought to be due to errors in development of the second and first branchial arches.

Gastrin-releasing peptide is a growth factor for human neuroblastomas

OBJECTIVE

To evaluate whether gastrin-releasing peptide (GRP) and GRP receptor (GRP-R) expression correlate with tumor behavior and to examine the mitogenic actions of GRP on neuroblastomas.

SUMMARY BACKGROUND DATA

Neuroblastoma is the most common solid tumor of infants and children. Despite recent advances in multimodality treatment regimens, the survival for advanced-stage tumors remains dismal. Neuroblastomas are known to produce GRP; however, the proliferative effects of GRP on neuroblastomas have not been elucidated.

METHODS

Sections of paraffin-embedded neuroblastomas from 33 patients were analyzed for GRP and GRP-R protein expression by immunohistochemistry. Functional binding of GRP-R to the Ca2+ signaling pathway was examined. In addition, the proliferative effect of GRP on neuroblastoma cells (SK-N-SH, IMR-32, SH-SY5Y, LAN-1) was determined.

RESULTS

Immunohistochemical analysis showed GRP and GRP-R protein expression in neuroblastomas; an increased expression of GRP-R was noted in a higher percentage of undifferentiated tumors compared with tumors that were benign. GRP-R mRNA was confirmed in neuroblastoma cell lines. GRP treatment resulted in intracellular calcium [Ca2+]i mobilization in two cell lines (SK-N-SH, LAN-1). GRP treatment stimulated growth of all four neuroblastoma cell lines; this effect was inhibited in SK-N-SH cells by pretreatment with GRP antibody.

CONCLUSIONS

These findings show increased GRP-R expression in the more aggressive and undifferentiated neuroblastomas. The synchronous expression of GRP and its receptor, GRP-R, suggests a role for these proteins in tumor growth. Moreover, these findings show enhanced proliferation of neuroblastoma cells in vitro after GRP treatment, suggesting that GRP may act as an autocrine and/or paracrine growth factor for neuroblastomas. Treatment with specific GRP-R antagonists may provide novel adjuvant therapy for neuroblastomas in children.

Evaluation of a new percutaneous dilatational tracheostomy set apparatus

Percutaneous tracheostomy is a well established technique used primarily to assist weaning from mechanical ventilation on many intensive care units. We report our experiences of a total of 36 procedures performed with the new Blue Rhino Percutaneous Tracheostomy Introducer Set developed by Ciaglia. The technique was successful in all cases and was simpler and quicker to perform than with the earlier Ciaglia percutaneous tracheostomy set. Difficulties were encountered when using Shiley tracheostomy tubes. Significant complications included one posterior wall tear and one tracheal cartilage ring fracture.

Histological appearance of a chronically stimulated vagus nerve in a pediatric patient

Histological analysis of chronically stimulated human vagus nerves is lacking in the literature. In this study, we describe the first microscopic findings in a chronically stimulated left vagus nerve from a pediatric patient. Our results show many histological changes in and around the stimulated nerve with severe demyelination. Further long-term clinical and postmortem examinations of chronically stimulated vagus nerves in both children and adults are needed to ascertain whether prolonged exposure to electrical current can cause clinical dysfunction of this nerve.

Molecular mechanisms contributing to necrotizing enterocolitis

OBJECTIVE

To examine the cellular mechanisms involved in the pathogenesis of necrotizing enterocolitis (NEC).

SUMMARY BACKGROUND DATA

Necrotizing enterocolitis is a major cause of death and complications in neonates; the cellular mechanisms responsible for NEC are unknown. The inducible form of cyclooxygenase (i.e., COX-2) is activated by the transcription factor nuclear factor (NF)-kappaB and is thought to play a role in inflammation.

METHODS

Segments of perforated and adjacent uninvolved small intestine from neonates with NEC were analyzed for COX-2 expression by immunohistochemistry. NEC was induced in weanling (18 days old) rats by occlusion of superior mesenteric vessels for 1 hour and intraluminal injection of platelet activating factor (50 micro/kg). Small intestine was harvested for protein extraction. Western immunoblot was performed to determine expression of COX-2. Gel shift assays were performed to assess NF-kappaB binding activity.

RESULTS

Immunohistochemical analysis showed increased COX-2 protein expression in the perforated intestinal sections of all 36 neonates but not in adjacent normal intestine. Increased expression of COX-2 protein and NF-kappaB binding activity was noted in the small intestine of weanling rats at 0 and 3 hours after induction of NEC.

CONCLUSIONS

Increased COX-2 expression was identified in all neonatal intestinal segments resected for perforated NEC. In addition, a coordinate induction of COX-2 expression and NF-kappaB binding was noted in a rodent model of NEC. These findings suggest that the COX-2/NF-kappaB pathway may play a role in the pathogenesis of NEC. Therapeutic agents that target this pathway may prove useful in the treatment or possible prevention of NEC.

Pediatric inflammatory bladder tumors: myofibroblastic and eosinophilic subtypes

PURPOSE

Benign bladder tumors are rare in children. A number of descriptive terms have previously been used to describe inflammatory tumors with myofibroblastic proliferation or eosinophilic infiltration. We present our experience with these tumors and review the literature.

MATERIALS AND METHODS

We retrospectively reviewed the records of all children presenting with a benign focal bladder mass during the last 5 years, including 2 girls and 3 boys 2 to 12 years old (mean age 7).

RESULTS

Presenting symptomatology included irritative voiding symptoms, suprapubic pain and hematuria. All bladder masses were diagnosed by ultrasonography and all patients underwent transurethral resection. Three children who had an inflammatory bladder tumor with myofibroblastic features required open tumor excision with preservation of the bladder. In the 2 remaining children urine culture was positive preoperatively and the diagnosis was an inflammatory bladder tumor with eosinophilic infiltration. Transurethral resection of the mass was performed without partial cystectomy.

CONCLUSIONS

Inflammatory myofibroblastic and eosinophilic tumors represent forms of focal cystitis with a tumefactive component. Differentiation from the malignant bladder neoplasms of childhood has important consequences for therapy. Management of these benign but aggressive inflammatory lesions involves local control by endoscopic or open surgery with bladder preservation. We encourage refined use of the terminology for inflammatory myofibroblastic and eosinophilic tumors.

Urinalysis: current status and prospects for the future

More than 300 million routine clinical analyses are performed annually in the United States. Methods for routine clinical urine examination, including detection of bacteriuria, are briefly reviewed. Prospects of some newer, better techniques to carry out such analyses are introduced. A preliminary report is presented on the use of supravital microscopic fluorescence technique (SMFT), employing acridine orange as a non-specific staining fluorochrome. Results of examining 218 unspun urine specimens by SMFT are compared to traditional bacteriologic culture at a large pediatric hospital reference laboratory.

The development and evaluation of a personal learning log for senior house officers

OBJECT

To develop and evaluate the effect of having a personal learning log on Senior House Officers knowledge and confidence.

METHODS

A multiple choice paper and a confidence checklist for two hospital specialties were developed to assess knowledge and confidence. These were administered to a control group and to an intervention group who had the learning log. Both groups completed an evaluation at the end of the post.

SETTING

The study took place in Accident & Emergency and Obstetric & Gynaecology posts in Greater Glasgow and Lanarkshire.

SUBJECTS

79 Senior House Officers in Accident & Emergency and 78 Senior House Officers in Obstetrics & Gynaecology.

RESULTS

The mean scores in the MCQ and the mode in the confidence checklist increased significantly in both specialties during the post, but there was no significant difference between the control and intervention groups. Forty two learning logs were returned at the end of the study and analysis of these revealed that there was great scope for learning but few documented the specific learning achieved. Evaluation of the posts revealed that some improvements had taken place in teaching and assessment frequency, however, there was scope for further improvement.

CONCLUSION

While the problems of hospital training are well documented, an attempt to improve the situation using a learning log did not have a statistically significant impact on SHO knowledge or confidence. A six-month hospital post appears to present many opportunities for learning but these are not exploited. It is suggested that three things are needed. Firstly, active participation by and personalized feedback from a senior member of staff, with training where needed. Secondly, protected time for tutorials with a planned system of formative assessment, and thirdly, a more positive approach to learning by both SHOs and consultants. Once this occurs, a learning log may have a more significant impact on training.

Gastrointestinal autonomic nerve tumors in the pediatric population: a report of four cases and a review of the literature

BACKGROUND

Gastrointestinal autonomic nerve tumors (GANTs) are a subpopulation of gastrointestinal stromal tumors (GISTs) that are characterized by ultrastructural features resembling enteric autonomic nerve cells, without epithelial, Schwannian, or smooth muscle differentiation. Delineation of the clinicopathologic features of GANT in the pediatric population is lacking.

METHODS

The clinicopathologic and outcome data for four pediatric patients with GANT are presented. The data from these patients and four previously reported pediatric patients are summarized and compared with data for GANT in adults.

RESULTS

All four cases occurred in females at a mean age of 12.5 years. The primary tumor site was the stomach in all cases, and the mean tumor size was 6.3 cm. Immunocytochemical and ultrastructural examination were essential in distinguishing GANT from GIST in all cases by identifying features of neural origin (neuron specific enolase in all four cases, NFP in three cases, S-100 in two cases, dense core neurosecretory granules in all four cases, and neuritelike processes in all four cases), while failing to identify features of myogenic origin (no desmin, smooth muscle actin, myofilaments, or dense bodies were found in any of the cases). Primary treatment was surgical, with chemotherapy administered to 1 patient at the time of recurrence. All patients are alive after a mean follow-up of 60 months (range, 8 months to 9 years).

CONCLUSIONS

Similarities of pediatric GANT to GANT in adults include the need for a high index of suspicion for diagnosis; comparable histopathologic, immunohistochemical, and ultrastructural features; and surgery as the primary therapy. Distinguishing features in children may be a prevalence among females in the second decade, a predominance of smaller gastric tumors, and a positive prognostic value of younger age.

Gastrointestinal autonomic nerve tumors in the pediatric population: a report of four cases and a review of the literature

BACKGROUND

Gastrointestinal autonomic nerve tumors (GANTs) are a subpopulation of gastrointestinal stromal tumors (GISTs) that are characterized by ultrastructural features resembling enteric autonomic nerve cells, without epithelial, Schwannian, or smooth muscle differentiation. Delineation of the clinicopathologic features of GANT in the pediatric population is lacking.

METHODS

The clinicopathologic and outcome data for four pediatric patients with GANT are presented. The data from these patients and four previously reported pediatric patients are summarized and compared with data for GANT in adults.

RESULTS

All four cases occurred in females at a mean age of 12.5 years. The primary tumor site was the stomach in all cases, and the mean tumor size was 6.3 cm. Immunocytochemical and ultrastructural examination were essential in distinguishing GANT from GIST in all cases by identifying features of neural origin (neuron specific enolase in all four cases, NFP in three cases, S-100 in two cases, dense core neurosecretory granules in all four cases, and neuritelike processes in all four cases), while failing to identify features of myogenic origin (no desmin, smooth muscle actin, myofilaments, or dense bodies were found in any of the cases). Primary treatment was surgical, with chemotherapy administered to 1 patient at the time of recurrence. All patients are alive after a mean follow-up of 60 months (range, 8 months to 9 years).

CONCLUSIONS

Similarities of pediatric GANT to GANT in adults include the need for a high index of suspicion for diagnosis; comparable histopathologic, immunohistochemical, and ultrastructural features; and surgery as the primary therapy. Distinguishing features in children may be a prevalence among females in the second decade, a predominance of smaller gastric tumors, and a positive prognostic value of younger age.

Isolated epithelial cysts of the uvula in children: a report of three cases

Epidermoid cysts are unusual benign cysts that occur in the oral cavity less than 2% of the time. Epidermoid cysts isolated to the uvula are rare. A review of the literature has revealed only three confirmed cases of isolated uvular epidermoid cysts. We present a series of three such cases, two of which presented with significant symptomatology. The diagnosis and management of these unusual lesions will be discussed, as well as the differential diagnosis.

Extensive tyrosine nitration in human myocardial inflammation: evidence for the presence of peroxynitrite

OBJECTIVES

Production of nitric oxide via the cytokine-mediated activation of myocardial inducible nitric oxide synthase decreases myocardial contractility. Whether myocardial dysfunction is mediated directly by nitric oxide or indirectly through the formation of secondary reaction products, such as peroxynitrite, has not been established. Peroxynitrite, but not nitric oxide, reacts with the phenolic ring of tyrosine to form the stable product 3-nitro-L-tyrosine. Demonstration of tissue nitrotyrosine residues, therefore, infers the presence of peroxynitrite or related nitrogen-centered oxidants.

DESIGN

Retrospective analysis of human autopsy specimens.

SETTING

University pathology and basic science laboratories.

PATIENTS

Formalin-fixed, paraffin-embedded myocardial tissue samples were obtained from 11 patients with a diagnosis of sepsis, seven patients with a diagnosis of viral myocarditis, and five control patients without clinical or pathologic cardiac disease.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Specific antibodies to nitrotyrosine were utilized to detect nitrotyrosine residues in human autopsy specimens. Cardiac tissue obtained from patients with myocarditis or sepsis demonstrated intense nitrotyrosine immunoreactivity in the endocardium, myocardium, and coronary vascular endothelium and smooth muscle. In contrast, connective tissue elements were without appreciable immunohistochemical staining. Nitrotyrosine antibody binding was blocked by coincubation with nitrotyrosine or nitrated bovine serum albumin, but not by aminotyrosine, phosphotyrosine, or bovine serum albumin. In situ reduction of tissue nitrotyrosine to aminotyrosine by sodium hydrosulfite also blocked antibody binding. Densitometric analysis of nitrotyrosine immunoreactivity demonstrated significantly higher values for specimens from myocarditis and sepsis patients when compared with control tissue specimens.

CONCLUSION

These results demonstrate the formation of peroxynitrite within the myocardium during inflammatory disease states, suggesting a role for peroxynitrite in inflammation-associated myocardial dysfunction.

Vitronectin expression in differentiating neuroblastic tumors: integrin alpha v beta 5 mediates vitronectin-dependent adhesion of retinoic-acid-differentiated neuroblastoma cells

The metastatic potential of undifferentiated neuroblastomas is typically lost when differentiation into ganglioneuroblastomas occurs spontaneously or is induced. Cell adhesion may play a role in metastasis, and we have shown recently that expression of integrin alpha v beta 5 protein and mRNA is up-regulated in ganglioneuroblastomas in vivo. To investigate whether interactions of alpha v beta 5 with matrix components play a role in the loss of metastatic potential, we used immunohistochemical and in situ hybridization to analyze neuroblastic tumors at various stages of differentiation for expression of the alpha v beta 5 ligands, vitronectin and osteopontin, and determined the ability of vitronectin to promote attachment and neurite outgrowth in vitro in a retinoic-acid-differentiated neuroblastoma cell model. We found that vitronectin, but not osteopontin, was expressed in 5 of 5 ganglioneuroblastomas but was absent or weakly expressed in 6 of 6 undifferentiated neuroblastomas. Neuronal cell vitronectin was detected in 7 of 9 ganglioneuromas, 5 of 8 peripheral ganglia, and 14 of 21 adrenal gland medullae, confirming expression of vitronectin in mature peripheral neurons. In vitro, vitronectin promoted attachment of both undifferentiated and retinoic-acid-differentiated neuroblastoma cells, which was inhibited 20 and 60%, respectively, by monoclonal antibody anti-integrin alpha v beta 5. Vitronectin-promoted neurite outgrowth of retinoic-acid-differentiated neuroblastoma cells was not inhibited by monoclonal antibody anti-alpha v beta 5. These data suggest that the synthesis of vitronectin and the ability of integrin alpha v beta 5 to mediate vitronectin adhesion on retinoic-acid-differentiated neuroblastoma cells may promote differentiation of neuroblastoma cells in vivo.

Training for minor surgery in general practice: is it adequate?

To assess training and operative practice in minor surgery a postal questionnaire was sent to all general practitioners practising in the Scottish Highlands and Western Isles in 1992. Information was requested regarding the type and adequacy of surgical training, operations performed, the desire for surgical skills training and possible methods of assessment. Seventy per cent (144/205) of general practitioners (GPs) replied to the questionnaire. Teaching in minor surgery had been received by 74% of GPs (107/144), yet 43% (62) considered their training inadequate. Although confident to suture simple wounds or excise skin lesions from the trunk, significantly fewer were confident to excise such lesions from the face (P < 0.001, 1 df, Chi square test). From 86% of GPs (124/144) who wished to attend a training course on minor surgery, 62% (77) would prefer to be taught on patients and 36% (45) on a realistic skin simulator. Assessment of technical competence by a hospital consultant was considered desirable by 56% (80/144) either on patients 40% (57), or using a skin simulator 38% (54). While most GPs receive some training in minor surgery, there is a perceived need for improved training. The use of a skin simulator may allow both the teaching and assessment of surgical competence for GPs who undertake minor surgery.