The A1 pulley in rheumatoid flexor tenosynovectomy. To retain or divide?

We report a detailed comparative evaluation of flexor tenosynovectomy in 55 fingers in which the A1 pulley was divided and 45 fingers in which the A1 pulley was retained. The metacarpophalangeal joint subluxed volarly in 49% when the A1 pulley was divided, compared to 11% when the pulley was preserved. Bowstringing occurred in 7% and only when the A1 pulley was divided. Ulnar deviation was 7 degrees worse when the pulley was divided. Active range of movement was limited in both groups. It was 11 degrees less when the A1 pulley was divided.

Detection of cytomegalovirus in formalin-fixed paraffin-embedded donor, native and allograft liver tissue using a multiplex polymerase chain reaction-liquid hybridization assay

A multiplex polymerase chain reaction (PCR)-liquid hybridization assay detecting a minimum 10 fg of cytomegaloviral (CMV) DNA has been developed. This assay successfully detected viral nucleic acids in 25/26 (96.2%) routinely embedded allograft liver biopsies with CMV hepatitis. No CMV DNA was detected in 15 native and 12 donor liver tissues sampled at the time of liver transplantation. These results indicate that archived formalin-fixed, paraffin-embedded liver tissues obtained from patients with significant liver disease can be successfully analyzed for CMV by PCR, retrospectively. Failure to detect CMV in native and donor livers implies that any latent virus present within these tissues is very focally distributed, or is below the threshold of detection applicable to PCR.

Prenatal sonographic assessment of early, rapidly growing fetal cervical teratoma

Although malignant transformation of fetal cervical teratoma is extremely rare, perinatal morbidity is high and usually related to the size of the tumour, which may compromise fetal swallowing and subsequently lead to upper airway obstruction. We present a case in which mid-trimester serial sonography demonstrated markedly rapid early growth of a lesion of this type between 17 and 19 weeks' gestation indicating the aggressive nature of this tumour, assisting parental decision to terminate the pregnancy. Histopathology confirmed grade 3 immaturity of the lesion.

Review of human dendritic cells: isolation and culture from precursors

There is no single characteristic or marker that identifies a dendritic cell. This review of the methods used for dendritic cell identification stresses that changes occur over the lifetime and changing functional status of the cell. Human dendritic cell populations have been obtained from adult peripheral blood, umbilical cord blood, bone marrow, thymus, and monocytes as starting substrates. Most recently dendritic cell populations have been grown from separated hematopoietic precursors, suggesting that there is a common granulocyte-monocyte-dendritic cell progenitor. Whether monocytes and dendritic cells can be modulated back and forth remains an open question. Granulocyte-monocyte colony stimulating factor (GM-CSF) appears to be critical to the development and function of these enriched and cultured cells. The characteristics of the cells produced by these various methods are tabulated. Important to the understanding of Langerhans cell biology is the variation in CD1 expression under different circumstances.

Complications of intercarpal arthrodesis

Fifty patients who underwent intercarpal arthrodesis were retrospectively reviewed at an average follow-up period of 34 months. Eighteen patients had a good result, 16 results were fair, and 13 were poor. Thirty-six patients experienced some complication, and 25 patients underwent further surgical therapy: The most common indication for secondary surgery was nonunion (16 patients). Good results were significantly decreased among patients who experienced nonunion, required secondary surgery, or experienced any complication. Patients with static carpal instability treated by scaphoid trapezoid trapezium arthrodesis had a significantly greater proportion of good results.

Investigation of abnormal first-trimester gestations by color Doppler imaging

Color Doppler imaging was employed to assess the uteroplacental circulation in abnormal first-trimester gestations. Included in the study were 40 blighted ova, 35 missed abortions, 10 trophoblastic diseases, and 3 ectopic gestations. Normal gestations served as a control group. Flow was detected more frequently in the blighted ova than in the missed abortions. Flow was detected in all cases of trophoblastic disease and ectopic gestations. Resistance to flow was significantly lower in the trophoblastic group as compared to the other groups.

Bronchoalveolar lavage and transbronchial biopsy in children following heart-lung and lung transplantation

Between July 1985 and March 1992, 20 children received either heart-lung (11), double lung (8), or single lung (1) transplants at our center. Since 1988, flexible fiberoptic bronchoscopy with bronchoalveolar lavage and transbronchial biopsy have been carried out to monitor for rejection or infection in these patients. As of March 31, 1992, we have performed a total of 112 transbronchial biopsies in our patients, who ranged from 6.8 to 18 years of age and 19.3 to 67.3 kg in weight. All but two of these procedures were carried out using conscious sedation and a transnasal approach. Four to seven biopsy samples were obtained at each procedure. One patient had hemorrhage (< 100 ml) and no patient had pneumothorax as a complication. Of the biopsy samples, 72.4 percent had a surface area of greater than 2 mm2, and 89.5 percent of the biopsy samples were deemed adequate for pathologic interpretation. We believe that for the majority of pediatric lung or heart-lung recipients, flexible bronchoscopy and transbronchial biopsy using conscious sedation and a transnasal approach is safe and permits the recovery of adequate tissue for pathologic evaluation. The avoidance of general anesthesia, endotracheal intubation, and mechanical ventilation at the time of bronchoscopy and transbronchial biopsy probably decreases the likelihood of pneumothorax as a complication of the procedure.

Cleft palate: confirmation of prenatal diagnosis by colour Doppler ultrasound

We present a case of a twin with trisomy 47,XX+i(9p) in whom the diagnosis of cleft palate was confirmed by colour Doppler imaging demonstrating abnormal fluid flow across the fetal pharyngeal bone defect. Application of this technique in cases predisposed for this congenital lesion may prove beneficial in the diagnosis of the more subtle types of isolated cleft palate.

Mutation at codon 249 of p53 gene in a human hepatoblastoma

G-to-T transversion at codon 249 of the p53 gene has been shown to be specifically associated with human hepatocellular carcinomas, particularly that subset associated with exposure to the chemical hepatocarcinogen aflatoxin B1. We surveyed 47 North American adult hepatocellular carcinomas and three childhood liver tumors for codon 249 mutation. We report here a case of childhood hepatoblastoma in a patient, without known exposure to aflatoxin B1 or hepatitis B or C virus, whose tumor had a mutation at codon 249 involving G-to-T transversion.

Granulomatous hepatitis in three children due to cat-scratch disease without peripheral adenopathy. An unrecognized cause of fever of unknown origin

OBJECTIVE

To report the clinical experience of three patients with fever of unknown origin ultimately diagnosed as having cat-scratch granulomatous hepatitis in the absence of peripheral adenopathy.

DESIGN

Case-control study.

SETTING

Referral center at university-based referral practice.

PATIENTS

Three children with fever of unknown origin. Follow-up following presentation was 6 months for each patient.

MEASUREMENT AND RESULTS

All three patients with fever of unknown origin were diagnosed radiographically to have multiple hepatic defects. The defects were shown histologically to be granulomatous. Two of the three patients had Warthin-Starry staining bacilli in the granulomas consistent with a diagnosis of Afipia felis. All three had positive cat-scratch skin test results.

CONCLUSIONS

Cat-scratch disease in the absence of peripheral adenopathy is a heretofore unrecognized cause of fever of undetermined origin and may account for a small, but significant, percentage of children presenting with it.

Color Doppler imaging and in vivo assessment of the anatomy and physiology of the early uteroplacental circulation

OBJECTIVE

To evaluate in vivo the anatomy and physiology of the normal early uteroplacental circulation.

DESIGN

Forty-six women were included, all of whom continued their pregnancy into the second trimester. Color Doppler was used to identify peritrophoblastic flow, and spectral Doppler was used to analyze waveforms obtained from the different segments of the uteroplacental circulation.

RESULTS

Flow was detected in the spiral arteries of the peritrophoblastic region in all patients. Flow was detected within the intervillous space in only one case.

CONCLUSIONS

This study demonstrated that color Doppler imaging can be employed as an in vivo means of studying the uteroplacental circulation. The study confirmed the in vitro findings that trophoblastic invasion of the decidual spiral arteries occurs at 5 to 6 weeks' gestation. The study also confirmed the fact that there is no noticeable blood flow within the intervillous space during most of the first trimester of a normal pregnancy. Both of these findings may serve to protect the early gestation from the forces of arterial blood flow.

Twin-twin transfusion with abrupt onset of microcephaly in the surviving recipient following spontaneous death of the donor twin

We describe a case in which twin-twin transfusion with fetal death of the donor at 23 weeks was complicated by suspected intracranial embolic insult of the surviving recipient twin. Dynamic transient intracranial ultrasonographic findings were noted with complete resolution by 28 weeks. Subsequent severe microcephaly of the survivor with no further growth of any of the cranial parameters beyond 25 weeks was thought to be a result of this very unusual pathophysiologic mechanism.

The pharmacokinetics of recombinant human relaxin in nonpregnant women after intravenous, intravaginal, and intracervical administration

The pharmacokinetics of recombinant human relaxin (rhRlx) after intravenous (iv) bolus administration and the absorption of rhRlx after intracervical or intravaginal administration were determined in nonpregnant women. The study was conducted in two parts. In part I, 25 women received 0.01 mg/kg rhRlx iv. After a minimum 7-day washout period, these women were dosed intracervically (n = 10) or intravaginally (n = 15) with 0.75 or 1.5 mg rhRlx, respectively, in 3% methylcellulose gel. Part II was a double-blind, randomized, three-way crossover study in 26 women. At 1-month intervals, each woman received one of three intravaginal treatments consisting of 0 (placebo), 1, or 6 mg rhRlx in 3% methylcellulose gel. The serum concentrations of relaxin following iv administration were described as the sum of three exponentials. The mean (+/- SD) initial, intermediate, and terminal half-lives were 0.09 +/- 0.04, 0.72 +/- 0.11, and 4.6 +/- 1.2 hr, respectively. Most of the area under the curve was associated with the intermediate half-life. The weight-normalized clearance was 170 +/- 50 mL/hr/kg. The observed peak concentration was 98 +/- 29 ng/mL, and the weight-normalized initial volume of distribution was 78 +/- 40 mL/kg, which is approximately equivalent to the serum volume. If central compartment elimination was assumed, the volume of distribution at steady state (Vss/W) was 280 +/- 100 mL/kg, which is approximately equivalent to extracellular fluid volume. Vss/W could be as large as 1300 +/- 400 mL/kg without this assumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Massive hydronephrosis mimicking theca lutein cysts in association with partial hydatidiform mole

We present an unusual case of partial hydatidiform mole in which extensive, multiple cystic structures encompassing the entire right abdomen and pelvis, initially thought to represent theca lutein cysts, were subsequently shown to consist of massive unilateral right hydronephrosis. Percutaneous nephrostomy decompression bypassing the ureteropelvic obstruction revealed functional renal parenchyma.

Sonographic measurement of the fetal iliac bone: growth and relation to femur length in assessment of gestational age

Diagnostic ultrasonography has given us the opportunity to diagnose several congenital malformations in utero. Skeletal dysplasias is a heterogeneous group of disorders of the skeleton. Although disorders of bone growth are often diagnosed in utero, it is usually a general diagnosis because the exact syndrome cannot be specified. This is due to the fact that many anomalies of the skeleton have similar features. The wing of the iliac bone can be either affected or normal in skeletal dysplasias and its appearance may help in the differential diagnosis. This study was undertaken to establish values for the width of the iliac bone wing during normal gestations and thus enable us to use it in the evaluation of fetal growth and the recognition of specific congenital anomalies.

Pediatric lung transplantation. The years 1985 to 1992 and the clinical trial of FK 506

The application of lung transplantation to the pediatric population was a natural extension of the success realized in our adult transplantation program, which began in 1982. Twenty pediatric patients (age range 3 to 18 years) have had heart-lung (n = 11), double lung (n = 8), and single lung (n = 1) transplantation procedures. The causes of end-stage lung disease were primary pulmonary hypertension (n = 7), congenital heart disease (n = 5), cystic fibrosis (n = 4), pulmonary arteriovenous malformation (n = 2), graft-versus-host disease (n = 1), and desquamative interstitial pneumonitis (n = 1). Four (20%) patients had thoracic surgical procedures before the transplantation operation. The survival was 80% at a mean follow-up of 2 years. Immunosuppressive drugs included cyclosporine (n = 9) or FK 506 (n = 11) based therapy with azathioprine and steroids. Children were followed up by means of spirometry, transbronchial biopsy, and primed lymphocyte testing of bronchoalveolar lavage fluid. The mean number of treated episodes of rejection was 1.4 at 30 days, 0.5 at 30 to 90 days, and 1.4 at more than 90 days, and the first treated rejection episode occurred on average 28 days after the operation. Obliterative bronchiolitis developed in four (25%) of 16 patients surviving more than 100 days. Results of pulmonary function tests have remained good in almost all recipients. The greatest infectious risk was that of cytomegalovirus: one death and one case of pneumonia. Posttransplantation lymphoproliferative disease was diagnosed in two (12.5%) patients; both recovered. The most common complications were hypertension (25%) and postoperative bleeding (15%). Early results indicate that lung transplantation is a most promising therapy for children with severe vascular and parenchymal lung disease.

Expression of Epstein-Barr virus-encoded small RNA (by the EBER-1 gene) in liver specimens from transplant recipients with post-transplantation lymphoproliferative disease

BACKGROUND

Epstein-Barr virus (EBV)-associated post-transplantation lymphoproliferative disease (PTLD) develops in 1 to 10 percent of transplant recipients, in whom it can be treated by a reduction in the level of immunosuppression. We postulated that the tissue expression of the small RNA transcribed by the EBER-1 gene during latent EBV infection would identify patients at risk for PTLD.

METHODS

We studied EBER-1 gene expression in liver specimens obtained from 24 patients 2 days to 22 months before the development of PTLD, using in situ hybridization with an oligonucleotide probe. Control specimens were obtained from 20 recipients of allografts with signs of injury due to organ retrieval, acute graft rejection, or viral hepatitis in whom PTLD had not developed 9 to 71 months after the biopsy.

RESULTS

Of the 24 patients with PTLD, 17 (71 percent) had specimens in which 1 to 40 percent of mononuclear cells were positive for the EBER-1 gene. In addition, 10 of these 17 patients (59 percent) had specimens with histopathological changes suggestive of EBV hepatitis. In every case, EBER-1-positive cells were found within the lymphoproliferative lesions identified at autopsy. Only 2 of the 20 controls (10 percent) had specimens with EBER-1-positive cells (P < 0.001), and such cells were rare.

CONCLUSIONS

EBER-1 gene expression in liver tissue precedes the occurrence of clinical and histologic PTLD. The possibility of identifying patients at risk by the method we describe here and preventing the occurrence of PTLD by a timely reduction of immunosuppression needs to be addressed by future prospective studies.

Uterine remodelling following conservative myomectomy. Ultrasonographic evaluation

Uterine leiomyomata develop during the reproductive years and may interfere with fertility through mechanisms as yet not fully understood. A developing intramural or large submucosal leiomyoma causes hypertrophy of the myometrium. Conservative myomectomy, as opposed to hysterectomy, is the preferred surgical procedure for patients who wish to preserve their fertility. Ten patients were ultrasonographically evaluated at monthly intervals following myomectomy and the changes in uterine (myometrial) volume were assessed. There was a gradual decrease in uterine volume in all patients during the six months following removal of intramural and submucosal leiomyomata. The most remarkable decrease in size occurred during the initial two to three months for the majority of the patients. The impact of this process on fertility should be further evaluated. One of the intriguing questions is whether the period of uterine shrinkage represents the time of the healing process during which conception should be prevented.