Evaluation of young women with congenital adrenal hyperplasia: a pilot study

To evaluate the outcome of medical and surgical treatment of 10 young women with congenital adrenal hyperplasia (CAH), final height, weight, body proportions and body hair growth as well as aspect and functionality of the external genitalia were assessed. The final height was below-2 SD of the target height in 55%, though the body proportions were in the normal range. Only 3 patients were menstruating regularly. Scores for 'hormonal' body hair growth were in a higher range. Gynaecological examination revealed that in 5 out of 9 patients, the genitalia were functionally acceptable. This pilot study stresses that from birth into adulthood of female patients with CAH there is a need for a combined therapeutic approach by a paediatric endocrinologist, a surgeon and a psychologist. This will improve the physical and psychosocial well-being of these patients.

Value of in vivo electrophysiological measurements to evaluate canine small bowel autotransplants

This study aimed to develop a non-invasive method for in vivo measurement of the transepithelial potential difference in the canine small bowel and to evaluate this parameter in small bowel autotransplants. In group 0 (control group, n = 4), two intestinal loops were created without disturbing their vascular, neural, and lymphatic supplies. In group I (successful autotransplants, n = 11), two heterotopic small bowel loops were constructed. Long term functional sequelae of vascular, neural, and lymphatic division were studied. Group II (n = 6) consisted of dogs with unsuccessful autotransplants suffering thrombosis of the vascular anastomosis, which resulted in ischaemic small bowel autografts. In group I, values of spontaneous transepithelial potential difference, an index of base line active electrolyte transport, were significantly lower compared with group 0 (p less than 0.05), probably as a result of denervation of the autotransplants. Both theophylline and glucose stimulated potential difference responses, measuring cyclic adenosine monophosphate mediated chloride secretion and sodium coupled glucose absorption respectively, showed negative luminal values in group I at all time points after transplantation. These transepithelial potential difference responses diminished progressively with time. From day 21 onwards both theophylline and glucose stimulated potential difference responses were significantly less than the corresponding responses at day seven (p less than 0.05). Morphometric analysis showed that the reduction of transepithelial potential difference responses preceded degenerative mucosal changes in the heterotopic small bowel autografts. In group II, potential difference responses to theophylline and glucose showed positive luminal values (p<0.01 v group I), probably as a result of passive potassium effusion from necrotic enterocytes.

Sequential changes in relative liver function assessed by 99mTc-HIDA scintigraphy after auxiliary heterotopic liver transplantation in dogs

Auxiliary heterotopic liver transplantation (HLT) was used to achieve functional repair in a dog model with an inborn error of metabolism. For the interpretation of the results, information on separate liver function is essential when a normal host liver is also present. We developed a radionuclear method to quantitate the relative contribution of each liver to the total uptake of intravenously (IV) injected 99mTc-HIDA. The HLT was performed between 20 mismatched pairs of dogs from two different strains. Four surgical procedures were used. After autopsy the outcome of the premortem HIDA-scan was compared with the wet weight of the graft and the host liver. A good linear correlation was noted between the relative contribution of the uptake and weight of the graft to the total HIDA uptake and total liver weight. Therefore, the relative contribution of an auxiliary heterotopic liver graft to the total liver function can be quantitated with a 99mTc-HIDA scan. With this technique, changes in relative function after an HLT under various flow conditions can be sequentially followed.

Evaluation of mortality in surgical neonates over a 10-year period: nonpreventable, permissible, and preventable death

The mortality pattern and causes of death in surgical neonates were evaluated over the period of 1980 through 1990 in order to assess whether any deaths might have been prevented. In the study period 1,010 neonates were admitted, 104 of whom died (10%). These 104 neonates formed our study population. The Clinical Classification System (CCS) and the Therapeutic Intervention Scoring System (TISS) were used to assess the severity of illness. All 104 nonsurvivors were seriously ill (CCS 3 and 4; TISS greater than 20). The mortality pattern was classified in three groups. Group A (nonpreventable death) included 56 deaths, 48 of which were due to the underlying disease. The other 8 patients died of a nonpreventable complication of treatment. Eleven of the patients in group B (permissible death) had (multiple) congenital anomalies associated with chromosomal anomalies. Three of them were not treated and in the other 8 treatment was initially started but later withdrawn. In most of the other 14 patients further treatment was withdrawn because of serious postoperative complications or inoperable cardiac anomalies. Group C (preventable death) consisted of 23 patients. Six of 10 had irreversible brain damage due to prolonged hypoxemia. In the other 13 patients of group C, death was due to sepsis acquired in the postoperative period and treated inadequately. Staphylococcus epidermidis was the most frequent isolated pathogen (7/13).

Electrophysiologic and histological monitoring of MHC-matched and mismatched canine intestinal allografts

Intestinal transplantation (ITx) has potential applications for the treatment of short-bowel syndrome (SBS). A major obstacle to its clinical use is rejection, which may partly be overcome by major histocompatibility complex (MHC) matching. At present, it is impossible to predict accurately the early onset of rejection. The aim of this study was to assess the value of in vivo measurements of transepithelial potential difference (PD) for the determination of rejection in MHC-matched and -mismatched canine ITx. A heterotopic ITx was performed in MHC tissue-typed Beagle dogs. Two ileostomies were created for PD monitoring and histology. Via one ileostomy, a well-defined segment of the IT, was isolated by a double balloon catheter and the intraluminal PD was measured in reference to a subcutaneous electrode. The PD responses during perfusion of a theophylline solution (crypt cell stimulation, PD theophylline) and during perfusion of a glucose solution (villus cell stimulation, PD glucose) were assessed. The results of in vivo PD measurements were compared with simultaneously obtained histology specimens. Four groups of dogs were studied: group 1 (controls, n = 10) ileal autotransplants; group 2 (n = 6) ileal allotransplants, fully mismatched; group 3 (n = 3) ileal allotransplants, 1 haplotype identical; and group 4 (n = 5), ileal allotransplants, fully matched. No immunosuppression was given. All dogs of group 1 survived indefinitely and both PD and histology showed no abnormalities. In group 2, 3, and 4 the onset of histological changes related to rejection corresponded well with decreased PD responses.(ABSTRACT TRUNCATED AT 250 WORDS)

Sequential renography and renal function in Brown-Norway rats with congenital hydronephrosis

Animal models may be helpful to gain insight into the long-term functional outcome of the hydronephrotic kidney. Inbred Brown-Norway rats frequently have kidneys with a delayed urine outflow. In 26 male rats 99mtechnetium-diethylenetriaminepentaacetic acid (Tc-DTPA) furosemide renography was performed to assess the presence and degree of obstruction, and the contribution of each kidney to the total glomerular filtration rate. The total glomerular filtration rate was measured as the plasma clearance of 51chromium-ethylenediaminetetraacetic acid. The measurements were first done at the age of 3 months, and repeated at ages 6, 10 and 15 months. From the renography curve we derived an obstruction score ranging from 0 (minimum) to 10 (maximum) based on the time to peak, the 99mTc-DTPA accumulation at 15 minutes and the furosemide response. Kidneys were classified as normal, obstructed or equivocal. At the first renography 21 kidneys were normal, 8 were equivocal and 23 were obstructed. The total obstruction score of the next 3 renographies indicated that 29 units were normal, 14 were equivocal and 9 were obstructed. Two groups of rats with unilateral hydronephrosis (hydronephrotic kidney-1 and hydronephrotic kidney-2) were selected based on the total obstruction score of all 4 renographies. These groups were compared with rats with 2 normal kidneys. The hydronephrotic kidney-1 rats had an obstruction score indicating equivocal obstruction, while the obstruction score of the hydronephrotic kidney-2 rats indicated obstruction. During the 15 months of followup the presence of a unilateral hydronephrotic kidney with an obstruction score indicating obstruction did not affect the contribution of the hydronephrotic kidney to the total glomerular filtration rate, or the total glomerular filtration rate. We conclude that the obstruction score of a hydronephrotic kidney in rats may change considerably with time. In cases in which renography suggested the permanent presence of ureteral obstruction the glomerular filtration rate remained stable. Thus, renal functional criteria did not indicate obstruction. In Brown-Norway rats a hydronephrotic kidney is able to maintain a normal glomerular filtration rate during at least 50% of the normal lfie span.

[Experiences with congenital duodenal obstruction in the Sophia Kinderziekenhuis]

In the department of Paediatric Surgery, Sophia Children's Hospital, University Hospital, Rotterdam, we investigated whether the presence of Down's syndrome influenced the chances of survival of patients with a congenital duodenal obstruction. The retrospective study comprised all 109 patients admitted to the Sophia Children's Hospital with a congenital duodenal obstruction in the period 1971-1989. The additional presence of Down's syndrome itself did not influence the prognosis. The presence of other additional anomalies (especially cardiac anomalies) did influence the mortality rate. In the past these anomalies--which are present more frequently in association with Down's syndrome--were responsible for the higher mortality in children with both a congenital duodenal obstruction and Down's syndrome. We conclude that with the availability of the current medical (especially cardio-surgical) techniques, it may be expected that the mortality rate of duodenal obstruction will be the same in patients with and without Down's syndrome (10%). Only non-medical, non-technical arguments can be of overriding importance in the decision whether a newborn child suffering from both a duodenal obstruction and Down's syndrome will or will not be operated on.

Continence after posterior sagittal anorectoplasty

Posterior sagittal anorectoplasty (PSARP) was introduced in 1982 by Peña and De Vries as a new operation for patients with a high anorectal malformation. The degree of postoperative continence is reported to be high. During the past decade, too, new insights have been gained into the embryology of anorectal malformations. Evaluation of PSARP in relation to current understanding of the development and anatomy of the anorectum and the pelvic floor has led us to conclude that optimal continence cannot be expected. Fifty patients with a high anorectal malformation underwent PSARP between June 1983 and May 1990. Postoperative follow-up consisted of anamnesis (subjective) and electrostimulation, defecography, and anorectal manometry (objective). All patients are alive, and all but one are being evaluated regularly. Subjectively, the majority of patients were more or less incontinent, with soiling of pants at least once a day. On the basis of objective criteria, virtually all patients appeared to be incontinent, and in only one patient was the mechanism of defecation almost unimpaired after PSARP. From this study, we conclude that although PSARP provides a good aesthetic result, patients will never acquire normal continence.

Detection of canine intestinal allograft rejection by in vivo electrophysiologic monitoring

The aim of this study was to evaluate the significance of in vivo measurements of electrophysiologic parameters for the detection of canine small bowel (SB) allograft rejection. In dogs of group I (n = 17) a heterotopic SB autotransplantation was performed. Dogs of group II (n = 8) received a heterotopic SB allograft in a fully mismatched donor-recipient combination. No immunosuppression was given. All grafts were monitored regularly by in vivo measurements of transepithelial potential differences (PDs) and by biopsies of the grafts. The overall technical failure rate was 36% caused by thrombosis at the vascular anastomosis in most cases. All successful autografts survived the experimental period and showed physiologic PD responses after stimulation by both a theophylline solution and a glucose solution. The successful allografts survived 5.5 +/- 0.2 days (mean +/- SEM); the transepithelial PDs showed normal responses at postoperative day 3, but showed decreased responses at day 5 (P less than 0.05) and reversed responses at day 6 (P less than 0.05). The diminished PD responses correlated well with the onset of histologic alterations characteristic of rejection. This study demonstrates that serial monitoring of transepithelial PD responses is a noninvasive method to detect acute SB allograft rejection.

[Parents' reactions to the birth of a child with a congenital anatomical abnormality: an exploratory study]

In an exploratory study of 12 couples the emotional reactions to the birth of a child with extensive anatomical malformation were investigated retrospectively, using semistructured interviews (on average 18 months after the birth). The couples were selected from the group of parents of children admitted between January 1986 and August 1988 to the Paediatric Intensive Care Unit of the Sophia Hospital, Rotterdam. The couples were divided into three groups: those who had had no ultrasonography during the pregnancy (n = 4), those in whom ultrasonography during pregnancy had revealed a foetal abnormality (n = 4) and those in whose children no such diagnoses had been made at ultrasonography during pregnancy (n = 4). After the birth of a child with congenital abnormalities, most parental couples displayed a shock reaction, denial, anger and hurt. In general there was no difference in emotional reaction between the three groups. In all couples the mourning process appeared to have begun only after the birth. Parents of a child with clearly visible abnormalities appeared to have more problems. Two-thirds of the couples had accepted the child's anomaly after some time. Persistent anger, feelings of guilt and anxiety are probably due to uncertainty regarding complications in the child or another pregnancy. Teams treating a child with a congenital anomaly should be aware of the consequences for the parents and should regard support of the parents as an essential part of their task.

[Results of prenatal echographic studies in the diagnosis of pediatric surgical abnormalities]

In 180 newborns with congenital anatomical anomalies, admitted to the Department of Paediatric Surgery, Sophia Children's Hospital, Rotterdam, we retrospectively determined whether ultrasound studies had been performed during the second and third trimesters of pregnancy. The correlation between prenatal and postnatal diagnoses was investigated as well. Ultrasound study had been performed in 86 if the 180 pregnant mothers (48%). In 41 cases the anomaly of the newborn had not been diagnosed prenatally. In 45 cases anomaly had been diagnosed prenatally. The ultimate diagnosis was the same as the prenatal diagnosis in 35 patients and was different in 10. We conclude that routine prenatal ultrasound study in the second or third trimester of pregnancy, aimed at detecting congenital anatomical anomalies to be treated by the (general) paediatric surgeon, provided little certainty about the health of the baby. Permanent education of obstetricians, and at the slightest doubt referral to one of the University Hospital Centres for specific ultrasound study, are mandatory in order to be able to correctly inform an increasing number of parents about the prospects of their unborn child.

Long-term survival of a patient with congenital short bowel and malrotation

Since 1969, reports of 16 patients presenting with the congenital short bowel and malrotation syndrome have been published. The prognosis of this malformation is poor; only two patients survived. We present the history of a third patient, successfully treated with long-term survival.

Stenting of the ureterovesical anastomosis in pediatric renal transplantation

From January 1985 to July 1989, 36 children received a renal transplant at our hospital. Their ages ranged from 2 to 18 years. All patients had a standard neoureterocystostomy according to Lich-Grégoir. In the first 18 patients, no transanastomotic stent was placed. In the latter 18, a transanastomotic stent with or without suprapubic bladder drainage was performed. In the nonstented group, six severe urological complications occurred, two of which eventually resulted in loss of the transplant. In the stented group, only one severe urological complication occurred. No kidneys in this group were lost due to urological complications. The number of urinary tract infections in the nonstented group was the same as in the stented group.

[Children and accidents: decreasing mortality, different care]

In order to explore the demand for trauma care facilities for children with severe injuries in the University Hospital of Rotterdam, the departments of Paediatric Surgery and Epidemiology initiated a study of mortality, morbidity and patterns of trauma care. The standardized mortality rate in the region declined by 40% between 1979 and 1986, as did the clinical prevalence of trauma injuries, expressed by the number of days spent in hospital per 100,000 children. This was in agreement with the national epidemiological data. The number of hospital admissions for childhood injuries in the University Hospital of Rotterdam stabilized in recent years, which may be considered a relative increase. Moreover the number of children with severe injuries admitted to Intensive Care Units increased by 46%, which was mainly due to Intensive Care admissions of children living outside Rotterdam. Obviously, another pattern of referral of these patients has developed in the south-west of The Netherlands. The decrease of the number of severe injuries in childhood together with the complexity of trauma care and the increasing number of physicians raises questions on the maintenance of skills. This is an argument for centralization of trauma care for severely injured children, which to some extent has already been implemented in this region.

Congenital diaphragmatic hernia: impact of prostanoids in the perioperative period

A prospective study of 10 neonates with congenital diaphragmatic hernia and five controls to determine the importance of prostanoid concentrations perioperatively and the relation with persistent pulmonary hypertension (PPH) is reported. In neonates with congenital diaphragmatic hernia postoperative concentrations of the vasoconstrictor thromboxane B2 rose significantly and were higher during episodes of PPH; this rise may provoke PPH and subsequent right to left shunting.