Benign transient hyperphosphatasemia in infants and children: a retrospective database study

Benign transient hyperphosphatasemia is a condition characterized by greatly increased serum alkaline phosphatase (ALP) without laboratory or clinical evidence of underlying bone or liver disease. It is usually identified incidentally during routine blood testing. We describe the demographic and clinical characteristics of benign transient hyperphosphatasemia in a cohort of healthy infants and children. We performed a retrospective review of electronic medical records on all children aged 1 day to 18 years with a diagnosis of benign transient hyperphosphatasemia, who were registered at 3 central districts in Israel from January 1, 2000, to December 31, 2020. The demographic and clinical characteristics were retrieved from the medical files. The study group comprised 382 infants and children aged from 2 months to 14 years who had serum ALP > 1000 U/L (mean 2557 U/L, range 1002-14,589 U/L). The majority of participants (87%) were aged up to 24 months (median age 14 months, IQR 10-18 months). Fifty-four percent of the study participants were male. In many patients, there was a history of recent fever, gastroenteritis or diarrhea, acute otitis media, and viral infection. A seasonal peak was observed in autumn-early winter, but this may be a detection bias.

CONCLUSION

Benign transient hyperphosphatasemia seems to be a disorder described among otherwise healthy infants and children, which resolves spontaneously. Other known causes of markedly elevated serum ALP should be excluded, especially bone and liver disease. Higher awareness and recognition of this benign condition are important in order to avoid unnecessary tests and parental anxiety.

WHAT IS KNOWN

• Benign transient hyperphosphatasemia is a benign condition characterized by greatly increased serum alkaline phosphatase without laboratory or clinical evidence of underlying bone or liver disease, which usually resolves spontaneously, with no intervention.

WHAT IS NEW

• In the case of an incidental finding of high serum alkaline phosphatase in an otherwise healthy infant or child with no other clinical or laboratory suspicion of bone or liver disease, we recommend repeating the alkaline phosphatase level within a few months in order to confirm the resolution of this condition. • When benign transient hyperphosphatasemia is suspected, a "wait and see" approach is optimal in order to avoid unnecessary investigations and parental anxiety.

Validity and Inter-observer Reliability of the TURN 180 Test to Identify Older Adults Who Reported Falls

BACKGROUND

Falls while turning are associated with increased risk of hip fracture in older adults. Reliable and clinically valid methods for turn ability assessments are needed.

OBJECTIVES

To explore the inter-observer reliability and known group validity of the TURN 180 test.

METHODS

We divided 78 independent older adults (mean age 76.6 ± 6.5 years) into three groups: non-fallers, infrequent fallers (1-2 falls per year), and recurrent fallers (> 2 falls per year). Participants underwent performance-based tests: Timed Up and Go (TUG), Performance Oriented Mobility Assessment (POMA), and Berg Balance Scale (BBS). TUG was videotaped for later analysis of the TURN 180 test by two blinded observers.

RESULTS

A significant difference was found in the TURN 180 test parameters among the groups (P < 0.04). TURN 180 was highly correlated with TUG (r = 0.81-0.89, P < 0.001) and BBS (r = -0.704-0.754, P < 0.0001) and moderately with POMA (r = -0.641-0.698, P < 0.0001). The number of steps was found to be the strongest parameter to determine fallers among older adults (specificity 96.3%, sensitivity 40%). Inter-rater reliability (intraclass correlation coefficient 0.91-0.96, P < 0.0001) was found to be excellent for the number of steps, time taken to accomplish a turn, and total test score categories.

CONCLUSIONS

The TURN 180 test is highly reliable and can identify the older adults who fall. Our results show that the TURN 180 test can serve as a good performance-based examination for research or clinical setting.

[General recommendations for the initial management of primary monosymptomatic nocturnal enuresis in children]

Bedwetting is a very common condition affecting about 15% of children 6 years of age, and is considered one of the main reasons for referrals to pediatricians. Bedwetting is a medical situation and should be managed by physicians. A child wetting his bed is distressing and this has a deep impact on the child's behavior and it is also very stressful for the parents. The causes of bedwetting are not fully understood. Bedwetting can be considered to be a symptom that may result from a combination of different factors. This guideline presents recommendations on the assessment and management of bedwetting in children.

Enzyme replacement therapy stabilizes obstructive pulmonary Fabry disease associated with respiratory globotriaosylceramide storage

Fabry disease is an X-linked glycosphingolipidosis caused by a deficiency of α-galactosidase A, a lysosomal enzyme. Symptoms in hemizygous males and heterozygous females are due to lysosomal storage of globotriaosylceramide in the central and peripheral nervous system, vascular endothelium, cardiac valves and myocytes, gastrointestinal tract, and renal epithelium. Pulmonary involvement is also a recognized manifestation of Fabry disease, but histopathological evidence of pulmonary lysosomal storage is scant. We report a 51-year-old woman with a G43R α-galactosidase A mutation and normal spirometry testing 2.5 years prior to presentation, who experienced a dry, nonproductive cough that persisted despite treatment with antibiotics and bronchodilators. Spirometry demonstrated a mixed restrictive/obstructive pattern as well as impaired gas exchange. Patchy ground-glass pulmonary interstitial infiltrates were found on plain radiography and computerized tomography. She underwent an open lung biopsy that demonstrated peribronchiolar fibrosis and smooth-muscle hyperplasia. Prominent inclusion bodies of the bronchiolar/arteriolar smooth muscle and endothelium were present. Electron microscopy indicated the inclusion bodies were lamellated zebra bodies consistent with globotriaosylceramide storage. Enzyme replacement therapy (ERT) with agalsidase-beta was instituted. Since initiation of therapy, she occasionally has a dry cough but markers of obstructive lung disease have remained stable in the past 4 years. This report demonstrates that pulmonary involvement in Fabry disease is due to lysosomal storage, and suggests that ERT is capable of stabilizing pulmonary Fabry disease. However, progressive worsening of her total lung capacity indicates that ERT cannot reverse the ongoing process of fibrosis also seen in Fabry disease.

Metamorphosis-related changes in the lateral line system of lampreys, Petromyzon marinus

Lamprey metamorphosis leads to considerable changes in morphology and behavior. We have recently reported that larval lampreys possess a functional lateral line system. Here we investigated metamorphic morphological changes in the lateral line system using light and electron microscopy. Functional modifications were studied by recording the trunk lateral line nerve activity of larvae and adults while stimulating neuromasts with approximately sinusoidal water motion. We found a general re-patterning of neuromasts on the head and trunk including an increase in numbers, redistribution within the pit lines, and shifts of the pit lines relative to external features. The trunk lateral line nerve response was qualitatively similar in adults and larvae. Both showed two neuronal populations responding to opposite directions of water flow. Magnitude of the response increased monotonically with stimulus amplitude. At low frequencies, the response lag relative to the stimulus maximum was approximately 220 degrees , and the gain depended approximately linearly on frequency, confirming that superficial neuromasts are velocity detectors. Changes in phase lag with increasing stimulus frequency were steeper in larvae, suggesting slower afferent conductance. The response gain with frequency was smaller for adults, suggesting a narrower frequency discrimination range and decreased sensitivity. These changes may be adaptations for the active lifestyle of adult lampreys.

Larval lampreys possess a functional lateral line system

Morphology of larval lampreys' neuromasts was found to be very similar to that of adults. Activity in the lateral line nerve, elicited by a vibrating ball, indicated a functional lateralis system. Analysis revealed at least two populations of afferents, responding to opposite directions of water flow, with adapting responses. The response magnitude increased monotonically with stimulus amplitude. Larval lampreys' neuromasts were less sensitive than those of teleosts. At low frequencies the response showed a phase lead of 200-220 degrees with respect to the maximum of the ball displacement and a gain that was approximately linearly proportional to frequency.

Job structure and burnout among primary care pediatricians

BACKGROUND

Burnout is an occupational disease that impairs both quality of health care and physicians' health. It is associated with emotional distress, absenteeism, reduction in personal effectiveness, and increased risk for health problems. Burnout has rarely been investigated among pediatricians.

OBJECTIVES

We investigated the association between work structure and burnout among primary care pediatricians. Work structure was conceptualized as the discrepancy between perceived workload and satisfaction from specific professional activities.

METHODS

126 Israeli pediatricians at child healthcare community clinics (63% response rate) responded anonymously to a self-report questionnaire assessing workload, satisfaction and burnout.

RESULTS

Burnout was associated significantly with workload/satisfaction discrepancy. The highest discrepancy involved administrative duties and the lowest was found for regular office visits, consultations concerning child development and inoculations, and continuing medical education.

CONCLUSIONS

Burnout was associated with infrequent performance of satisfying activities (e.g. research, tutoring medical students); and frequent engagement in disliked duties (e.g. administrative work). Burnout may be reduced by modifying work structure to include more involvement in professional interactions with other professionals, more varied and challenging activities such as teaching medical students, participating in research and community health promotion.

[Immunopathology of acute rejection]

Acute transplant rejection may be the result of two immunologic mechanisms, T-cell-mediated and antibody-mediated processes, acting alone or together. Cell-mediated rejection occurs as T cells react to donor alloantigens which are expressed in context of MHC. The major forms of cellular rejection may affect tubulo-interstitium, arteries and glomeruli. The former type is characterized by infiltration of the interstitium and tubules with activated T cells. Typically less than 50% of the cells are CD3 (T3), while the majority are usually CD8 (T8) cells. In the tubulo-interstitial form, lymphocytes migrate from peritubular capillaries into the interstitium and into the walls of tubules (tubulitis). The arterial form is characterized by the accumulation of lymphocytes and monocytes beneath endothelial cells of arteries. Endarteritis is mediated by T cells and affected arteries are devoid of antibody or complement deposits. There are two distinctive forms of acute antibody-mediated rejection, affecting different vascular beds: arterial and peritubular capillary. The arterial form is characterized by mural necrosis and inflammation. In contrast, the peritubular capillary form may have little or variable morphologic changes; it is diagnosed by identifying C4d, a stable breakdown product of complement and an indicator of immune complex deposition, in peritubular capillary walls. C4d deposition correlates with circulating antidonor antibodies.

Child health care centres: an academic model for comprehensive child health care in the community

The challenge of the discipline of paediatrics in the 21st century is to promote health and development of children in a way that will enable them to maximize their biological and social potential. The community child health centre (CHC) in Israel is a model of community health care service built to provide comprehensive health care to children and adolescents, as well as an academic setting for under- and postgraduate paediatric training. Today there are 34 CHCs in Israel, serving a population of 220 000 children from birth to 18 years of age. The CHC combines the advantages of group practice with those of an academic medical centre and enables flexibility and mutual learning. Further expansion and development are required to realize the CHC's mission of a true comprehensive academic centre for paediatric community health.

Are burnout levels increasing? The experience of Israeli primary care physicians

BACKGROUND

Burnout is a professional occupational disease that puts both physicians and patients at risk. Triggered by the increase in burnout levels among physicians, the European Forum of Medical Associations and the World Health Organization issued a statement in February 2003 expressing serious concerns about the situation, urging all national medical associations to increase awareness of the problem, monitor it and study its causes in order to develop preventive strategies.

OBJECTIVES

To compare burnout levels in two separate samples of primary care physicians measured in the mid-1990s, with burnout levels in a similar but small and independent sample, assessed in 2001; and to outline the theoretical bases of burnout.

METHODS

Altogether, 508 primary care physicians employed by Clalit Health Services responded anonymously to a self-report questionnaire. The samples were not representative and included family physicians, pediatricians and clinic directors.

RESULTS

Burnout levels were significantly higher in the 2001 sample than in the mid-1990s samples, especially among clinic directors.

CONCLUSIONS

Despite methodologic limitations of the study, the findings suggest that burnout levels may be increasing among primary care physicians in Israel. This may be due to substantial increases in workload and role conflicts following implementation of the Health Insurance Law and Patients' Rights Act. Because these findings are consistent with the trend in Europe, this situation cannot be ignored and systematic studies of burnout among all medical specialties should be carried out to uncover current sources of the syndrome and to devise measures of prevention and treatment.

Emphysematous pyometra in a dog

An 8-year-old intact female West Highland White Terrier was examined for anorexia, vomiting, abdominal distension, and mild purulent vulvar discharge. The results of physical examination, laboratory testing, and radiography are presented. Emphysematous pyometra was suspected and confirmed at surgery. Clostridium perfringens was isolated from the uterine lumen. A brief discussion of emphysematous pyometra is presented.

Isolation, characterization, and transplantation of bone marrow-derived hepatocyte stem cells

Recently it was shown that a population of cells in the bone marrow-expressing hematopoietic stem cell antigens could differentiate into hepatocytes. However, explicitly committed hepatocyte progenitors, which exhibit highly differentiated liver functions, immediately upon isolation, have not yet been isolated from bone marrow. After studying common antigens on blast-like cells in fetal and adult regenerating cholestatic rat livers and human regenerating and malignant livers, we hypothesized that beta-2-microglobulin-negative (beta(2)m(-)) cells might represent dedifferentiated hepatocytes and/or their progenitors. Utilizing a two-step magnetic bead cell-sorting procedure, we show that in bone marrow from rat and human, beta(2)m(-)/Thy-1(+) cells consistently express liver-specific genes and functions. After intraportal infusion into rat livers, bone marrow-derived hepatocyte stem cells (BDHSC) integrated with hepatic cell plates and differentiated into mature hepatocytes. In a culture system simulating liver regeneration and containing cholestatic serum, these cells differentiated into mature hepatocytes and metabolized ammonia into urea. This differentiation was dependent on a yet nondescript humoral signal existing in the cholestatic serum. Transmission electron microscopy and three-dimensional digital reconstruction confirmed hepatocyte ultrastructure of cultured BDHSC.

Bronchiolitis obliterans in the 1990s in Korea and the United States

STUDY OBJECTIVES

Our current knowledge of pediatric bronchiolitis obliterans (BO) is based largely on a few small series of patients that were reported in the older literature. In these older cases, the mortality rate was high. This study was conducted to investigate the characteristics of pediatric BO cases in two different countries.

DESIGN

We extracted specific information regarding predisposing factors, symptoms and signs, diagnostic studies, treatment, and outcome from the medical records of 31 children who received diagnoses of BO at four university medical centers in Korea and the United States in the 1990s.

RESULTS

The large number of Asian children reflects a clustering of cases in Korea due to adenovirus and Mycoplasma pneumoniae epidemics. The characteristic diagnostic features of BO were present in 29 of 30 high-resolution CT (HRCT) studies. Seven of nine children who underwent biopsies had histologic confirmations of BO. In two patients whose biopsy results were nondiagnostic, the diagnosis was established by HRCT together with pulmonary function testing results that were consistent with nonreversible small airways obstruction. Fifteen children (48.4%) had evidence of hypoxemia. At present, all but one are alive. Patients with elevated severity-of-illness scores were observed to have increased likelihoods of lung transplantation or death.

CONCLUSIONS

We conclude that BO has a good overall prognosis and that the mortality rate has declined over the past decade. This could be related primarily to the use of HRCT for accurate diagnosis and the availability of pediatric lung transplantation. BO cases in Korea were associated with infectious epidemics, whereas those in United States had variable predisposing factors.

Impact of movement and movement-related feedback on the lamprey central pattern generator for locomotion

A semi-reduced, minimally restrained lamprey preparation was used to investigate the impact of movement and movement-related feedback during d-glutamate-induced locomotion. The preparation consisted of the trunk alone with the spinal cord exposed to the bathing solution. Two conditions were compared using electromyography or nerve recording: (i) muscle and spinal cord, (ii) spinal cord alone supported by the notochord. Compared with the isolated spinal cord, movement in the presence of muscle consistently and significantly increased the frequency of the motor output and reduced the phase delay among the segments. In moving preparations, coupling among the segments was reduced by two staggered hemisections to permit the strength and direction of intersegmental coupling to be estimated. The estimates revealed that movement increased the total intersegmental coupling strength and increased the proportion of the coupling that was descending over those of the isolated spinal cord.

The effects on the phase and frequency of bursting can be explained in the light of the excitation evoked by bending that we have reported previously. Thus, we demonstrate that movement and movement-related feedback that arise from spinally induced motor patterns can alter the form of the movement and the functional coupling strength among the segments of the lamprey spinal cord.

Immediate post-transplant nephrosis in a patient with congenital nephrotic syndrome

A 19-month-old girl with congenital nephrotic syndrome of the Finnish type underwent a living-related renal transplant; 24 h after transplantation she became massively nephrotic. She did not respond to steroids, plasmapheresis, and high-dose cyclosporine. A month later, a renal biopsy showed only glomerular foot process effacement. She was treated with high-dose methylprednisolone pulses and oral cyclophosphamide. She rapidly went into complete remission with no further relapses. Graft function has been stable 2 years after transplantation.

Association of parvovirus B19 infection with idiopathic collapsing glomerulopathy

BACKGROUND

Collapsing glomerulopathy (CG), a disorder with severe glomerular and tubular involvement, occurs either as an idiopathic lesion or in some patients with human immunodeficiency virus (HIV) infection known as HIV-associated nephropathy (HIVAN). We previously reported a renal transplant recipient with de novo CG and red cell aplasia in association with persistent parvovirus B19 (PVB19) infection. This prompted us to look for an association between PVB19 infection and CG.

METHODS

DNA from archived biopsies of patients with CG was analyzed for PVB19 by polymerase chain reaction (PCR). Results were compared with HIVAN, idiopathic focal segmental glomerulosclerosis (FSGS), and controls. In situ hybridization (ISH) was done to localize PVB19 in renal biopsies. Peripheral blood specimens of patients with CG, HIV infection, healthy controls, and randomly selected hospitalized patients (sick controls) were also analyzed for PVB19.

RESULTS

PVB19 DNA was detected in renal biopsies of 18 out of 23 (78.3%) patients with CG, 3 out of 19 (15.8%) with HIVAN, 6 out of 27 (22.2%) with FSGS, and 7 out of 27 (25.9%) controls (P < 0.01, CG vs. HIVAN, FSGS, and controls). PVB19 was detected in peripheral blood of 7 out of 8 (87.5%) CG patients, 3 out of 22 (13.6%) with HIV infection, 4 out of 133 (3%) healthy controls, and 2 out of 50 (4%) sick controls (P < 0.001, CG vs. HIV infected, healthy, and sick controls). PVB19 was identified in glomerular parietal and visceral epithelial and tubular cells by ISH.

CONCLUSIONS

The significantly higher prevalence of PVB19 DNA in renal biopsies and peripheral blood of CG patients suggests a specific association between PVB19 infection and CG. In susceptible individuals, renal epithelial cell infection with PVB19 may induce CG.

Bending the lamprey spinal cord causes a slowly-decaying increase in the frequency of fictive swimming

It is well known that rhythmic lateral bending of the isolated lamprey spinal cord/notochord can entrain the central pattern generator (CPG) for locomotion. During entrainment, the CPG's frequency is equal to the bending frequency. We report here that bending can also have a slowly-decaying excitatory effect on the CPG's frequency. Experiments were performed in which the caudal end of a 30-50 segment piece of spinal cord/notochord was repeatedly rhythmically bent for 0.5-12 cycles. A slowly-decaying excitation was said to be present if after the termination of bending the CPG's frequency was significantly greater than baseline and decayed back to baseline with a time constant of one or more cycles. In 14 of 16 animals, a slowly-decaying excitation could be evoked by bending. In five of the nine animals tested, this slowly-decaying excitation could be evoked with bending frequencies both faster and slower than the baseline frequency. Depending on the animal, the slowly-decaying excitation could be elicited by as little as one-half cycle of bending and by bending amplitudes as small as 6-21 degrees peak deflection. We interpret these data as evidence of a second effect of bending distinct from the phase-dependent effect that produces entrainment.

Posttransplant lymphoproliferative disease in children: correlation of histology to clinical behavior

PURPOSE

To determine whether the morphologic features of posttransplant lymphoproliferative disease (PTLD) correlated to a response to therapy.

PATIENTS AND METHODS

We reviewed our experience with PTLD in the pediatric population. We identified 32 patients with a total of 36 episodes of PTLD. The diagnosis was confirmed by tissue examination and classified according to the degree of monomorphic features of the lesion. Thirty-four of 36 episodes were managed with immunosuppression reduction, and the patients were assessed for their response to this strategy. Chemotherapy was used to treat 10 of 15 patients who had progressive disease, and their subsequent course was also analyzed.

RESULTS

Sixteen of 17 (94%) patients with polymorphic morphology responded to immunosuppression reduction compared with only 5 of 17 (29%) patients with monomorphic features (P < 0.001). All of the patients with progressive disease who did not receive additional therapy died. Standard chemotherapy regimens for lymphoma were administered to 10 patients with progressive disease, with a high response rate (90%), durable remissions, and acceptable toxicity.

CONCLUSIONS

We conclude that the morphologic characteristics of PTLD provide information to potentially help guide treatment strategies in the management of this disease. Standard chemotherapy regimens for malignant lymphoma appear to be a viable treatment option for patients with progressive disease, although further investigation is needed.

Modeling alternation to synchrony with inhibitory coupling: a neuromorphic VLSI approach

We developed an analog very large-scale integrated system of two mutually inhibitory silicon neurons that display several different stable oscillations. For example, oscillations can be synchronous with weak inhibitory coupling and alternating with relatively strong inhibitory coupling. All oscillations observed experimentally were predicted by bifurcation analysis of a corresponding mathematical model. The synchronous oscillations do not require special synaptic properties and are apparently robust enough to survive the variability and constraints inherent in this physical system. In biological experiments with oscillatory neuronal networks, blockade of inhibitory synaptic coupling can sometimes lead to synchronous oscillations. An example of this phenomenon is the transition from alternating to synchronous bursting in the swimming central pattern generator of lamprey when synaptic inhibition is blocked by strychnine. Our results suggest a simple explanation for the observed oscillatory transitions in the lamprey central pattern generator network: that inhibitory connectivity alone is sufficient to produce the observed transition.

Membranous nephropathy with anti-tubular basement membrane antibody may be X-linked

The association of membranous nephropathy with Fanconi syndrome and anti-tubular basement antibodies appears to be a distinct subset of familial membranous nephropathy. We studied two Chinese families with four affected boys to evaluate the mode of inheritance of disease. HLA haplotype analysis of the family members in these two pedigrees did not reveal any significant linkages. However, microsatellite analysis of both pedigrees using markers on the X chromosome suggested linkage to the long arm of the X chromosome between the microsatellite markers DXS1001 and DXS1227. Identification and analysis of additional pedigrees may allow more precise mapping of the disease gene for anti-tubular basement membrane antibody-associated membranous nephropathy.

Continuing medical education and primary physicians' job stress, burnout and dissatisfaction

OBJECTIVES

The association between opportunities for continuing medical education (CME) and primary physicians' job stress, burnout and job dissatisfaction has not been investigated. It was hypothesized that participation in CME activities and perceived opportunities at work for keeping up-to-date with medical and professional developments would be correlated negatively with job stress and burnout, and positively with job satisfaction.

METHOD

309 primary care physicians (183 family physicians and 126 paediatricians) employed in health maintenance organizations in Israel responded to a mailed questionnaire. The independent variables were the extent of engagement in CME activities and perceived opportunities at work for professional updating. The dependent variables were job stress, burnout and job satisfaction. Multiple regression analyses were employed.

RESULTS

After controlling for age, sex and professional status, participation in CME activities was associated negatively with job stress and positively with job satisfaction, among family physicians. Among paediatricians, CME was associated negatively with burnout. Perceived opportunities for professional updating were associated negatively with burnout and (marginally) with stress among family physicians, and negatively with stress and positively with satisfaction among paediatricians. A third of the paediatricians and a quarter of the family physicians wanted to increase their involvement in CME.

DISCUSSION

In this cross-sectional study, causality cannot be established and the CME measures should be refined. However, the results are consistent with the study's hypotheses and suggest that opportunities for CME and professional updating may reduce physicians' job distress and dissatisfaction.

High incidence of posttransplant lymphoproliferative disease in pediatric patients with cystic fibrosis

A major cause of morbidity and mortality following lung transplantation is posttransplant lymphoproliferative disease (PTLD). In a retrospective cohort analysis of pediatric patients, we evaluated the risk factors associated with PTLD in 128 first-time lung transplant recipients from 1990 to 1997. The greatest risk factor for PTLD was a diagnosis of cystic fibrosis (CF). Of the 16 patients in our analysis who had PTLD, 13 had a diagnosis of CF (odds ratio [OR]: 5.8; confidence interval 95% [CI]: 1.6 to 21.4). Because of the high frequency of PTLD in patients with CF (13 of 61; 23%), we performed a retrospective cohort analysis in which patients with CF and PTLD were designated as cases and patients with CF and without PTLD served as controls. In patients with CF, the only risk factor associated with PTLD was two or more episodes of acute rejection within 3 mo after transplantation (OR: 11.0; 95% CI: 2.7 to 55.7). Age, recipient Epstein-Barr virus or cytomegalovirus status, induction with antilymphocyte globulin or antithymocyte globulin (ATG), or use of ATG or OKT3 for acute rejection episodes were not risk factors for PTLD. The high frequency of PTLD in the subgroup of patients with two or more episodes of graft rejection within 2 mo after lung transplantation was unexpected, and warrants further investigation in prospective clinical studies and basic laboratories.

Raynaud's phenomenon as a manifestation of parvovirus B19 infection: case reports and review of parvovirus B19 rheumatic and vasculitic syndromes

Infection with human parvovirus B19 is manifested as erythema infectiosum, transient aplastic crisis, or hydrops fetalis. Rheumatic manifestations include arthropathy and various vasculitic syndromes. Isolated Raynaud's phenomenon due to parvovirus B19 has never been described. We report on 2 previously healthy sisters with new-onset Raynaud's phenomenon accompanied by severe generalized polyarthralgia. A full workup was negative, except serology for parvovirus B19, which was positive. All symptoms gradually subsided within 3-5 months, and no recurrence has been noted during the 3 years since onset. We review all the studies in the English-language literature on parvovirus B19-induced rheumatic and vasculitic syndromes. We hypothesize that the pathogenesis of Raynaud's phenomenon in our patients involved immune-mediated endothelial damage leading to platelet activation and vasoconstriction. We recommend that in cases of unexplained Raynaud's phenomenon, serology for parvovirus B19 be included in the evaluation.

Unexplained fever in neonates may be associated with hepatitis B vaccine

AIM

To investigate whether hepatitis B vaccination has increased the number of cases of unexplained neonatal fever.

METHOD

The files of all infants born from 1 January 1991 to 31 December 1992, in whom a diagnosis of "injected antibiotic" or "disease of temperature regulation" was recorded, were reviewed. Those who had unexplained fever of 38 degrees C or higher during the first three days of life were divided into two groups: infants who did not receive the hepatitis B vaccine (1991) and infants who did (1992).

RESULTS

In 1992 the incidence of unexplained fever in hepatitis B vaccinated neonates was significantly higher than in the 1991 group of pre-vaccination neonates (35 out of 5819 (0.6%) vs 14 out of 5010 neonates (0.28%) respectively, p=0.013).

CONCLUSIONS

The increase in the number of cases of unexplained neonatal fever seems to be associated with the introduction of routine hepatitis B vaccination on the first day of life. The possibility that an excess number of neonates will undergo unnecessary procedures and treatment to diagnose unexplained fever justifies planning a controlled study to determine whether these preliminary findings point to a significant problem.

Distinguished Scientists Lecture Series. HIV-associated nephropathy

HIV-associated nephropathy is manifested by heavy proteinuria and renal insufficiency and characterized pathologically by the collapsing variant of focal and segmental glomerulosclerosis with acute tubular necrosis and mild interstitial inflammation. Untreated, it may result in end-stage renal disease in as little as 4 months. It may present in patients with any manifestation of HIV infection, and affects predominantly black individuals. Insights into pathogenesis have come from a transgenic mouse model, renal cell cultures, and from study of human biopsy material. Although the pathogenesis is not completely understood, current considerations revolve around the role of HIV or protein in renal epithelium and the effects of cytokines, including transforming growth factor-beta and basic fibroblast growth factor, on renal structures. Therapy with zidovudine, corticosteroids, or angiotensin-converting enzyme inhibitors has met with modest success; to date, protease inhibitors have not been assessed.

Intestinal obstruction after lung transplantation in children with cystic fibrosis

BACKGROUND/PURPOSE

Distal intestinal obstruction syndrome (DIOS) occurs in 15% of patients with cystic fibrosis (CF). The authors reviewed their experience to determine the incidence, risk factors, and natural history of adhesive intestinal obstruction and DIOS after lung transplantation.

METHODS

Eighty-three bilateral transplants were performed in 70 CF patients between January 1990 and September 1998. All were on pancreatic enzymes preoperatively, and none had preoperative bowel preparation. Fifty-six patients (80%) had prior gastrostomy (n = 54) or jejunostomy (n = 2). Eighteen patients (25.7%) had a previous laparotomy for meconium ileus (n = 8), fundoplication (n = 4), liver transplant (n = 1), jejunal atresia (n = 1), Janeway gastrostomy takedown (n = 1), pyloromyotomy (n = 1), free air (n = 1), or appendectomy (n = 1).

RESULTS

After lung transplantation, 7 patients (10%) required laparotomy for bowel obstruction (6 during the same hospitalization, and 1 during a subsequent hospitalization). The causes of obstruction were adhesions only (n = 1), DIOS only (n = 2), and a combination of DIOS and adhesions (n = 4). Adhesiolysis was performed in the 5 patients with adhesions, and a small bowel resection was also performed in 1 patient. DIOS was treated by milking secretions distally without an enterotomy (n = 3) with an enterotomy and primary closure (n = 1) or with an end ileostomy and mucus fistula (n = 2). Five had recurrent DIOS early postoperatively. One resolved with intestinal lavage, 2 were treated successfully with hypaque disimpaction, and 2 underwent reoperation; 1 required an ileostomy. The most important risk factor for posttransplant obstruction was a previous major abdominal operation. Obstruction occurred in 7 of 18 (39%) who had undergone a prior laparotomy versus 0 of 52 who had not (P < .001, chi2).

CONCLUSIONS

(1) The incidence of intestinal obstruction is high after lung transplantation in children with CF. (2) Previous laparotomy is a significant risk factor. (3) Recurrent obstruction after surgery for this condition is common. (4) Preventive measures such as pretransplant bowel preparation and early postoperative bowel lavage may be beneficial in these patients.

Successful eradication of mucormycosis occurring in a pulmonary allograft

The zygomycetes are saprophytic fungi that rarely cause disease in the normal human host. In immunocompromised individuals, these organisms can cause invasive infections, collectively called mucormycosis. Mucormycosis is associated with a high mortality rate, especially in organ transplant recipients. In this report, we describe the first case of successfully treated mucormycosis involving a pulmonary allograft. Treatment consisted of surgical excision of the affected lobe and chest wall and lipid-complex amphotericin B. The lipid complex formulation permitted a prolonged course of therapy that was likely critical to eradication of the infection.

Growth of lungs after transplantation in infants and in children younger than 3 years of age

We report serial measurements of lung volume and airflow in small children after lung transplantation. We expected that immature lungs could grow and develop normal volumes after transplantation, despite denervation and immunosuppression. At predetermined intervals, functional residual capacity (FRC) and forced expiratory flow were measured 86 times in 23 recipients younger than 3 yr of age (age at transplant, 13.2 +/- 8.4 mo; range, 2 to 30 mo). FRC was measured using open-circuit N2 washout. Maximal flow at FRC by rapid thoracoabdominal compression was used to distinguish between infants with and those without airflow obstruction. The slope of FRC (in milliliters) versus body length (in centimeters) for all 23 recipients studied was 8.63. For those children without obstruction (flow at FRC >/= 0.9 FRC/s, n = 16), the slope of FRC versus length was 6.61. The coefficient of variation for FRC measurements for all infants was 3.90 +/- 2.80% (range, 0.3 to 16.9%). We conclude that in the absence of significant airflow obstruction the volume of transplanted immature lungs increases at a rate similar to that reported in normal infants.

Pathology of renal complications in obesity

Morphologic changes in massive obesity in both humans and experiment animals are rather limited. Glomerulomegaly is common and often asymptomatic. Frequently, ensuing focal and segmental glomerulosclerosis may well be related to alterations in intraglomerular hemodynamics and may result in heavy proteinuria. Factors for the occurrence of segmental glomerulosclerosis have been assessed in animal models and include the influence of lipids. A consequence of surgical therapy for obesity (ie, jejunoileal bypass) is oxalosis with chronic interstitial nephritis, and this may necessitate a takedown of the bypass.

Efficacy of vision therapy for convergence insufficiency in an adult male population

BACKGROUND

Although vision therapy has reportedly been very successful in elimination of asthenopic symptoms in adults with convergence insufficiency, controlled studies have not been performed, and a clinical bias exists against prescribing vision therapy for adults with convergence insufficiency.

METHODS

Sixty adult males over the age of 40 years (median age, 65 years) with convergence insufficiency were divided into three treatment groups: office-based vision therapy with supplementary home therapy, home therapy only, and a control group.

RESULTS

Vision therapy was successful in 61.9% of patients who received in-office plus home therapy, in 30% of patients who received home therapy only, and in 10.5% of the control group. The success rate for patients who received active in-office vision therapy supplemented with home procedures was significantly greater than that for controls. Home therapy alone was less successful than in-office therapy. The success rate obtained with home therapy alone was not significantly greater than that demonstrated by controls.

CONCLUSIONS

Vision therapy is effective in eliminating asthenopia and improving convergence function in adult patients. In-office therapy combined with home therapy tends to produce better results than does home therapy alone.

Temperature can alter the function outcome of spinal cord regeneration in larval lampreys

Now that spinal cord regeneration has been demonstrated in mammals [Bregman B. S. et al. (1995) Nature 378, 498-501; Cheng H. et al. (1996) Science 273, 510-513], we must examine the consequences and look for means of avoiding negative outcomes. The larval lamprey, which readily regenerates cut spinal axons, offers a model for this important next step. In the present study, one group of larval lampreys with spinal lesions was kept at room temperature during recovery. Another group was returned to their usual cold room temperature. A majority of animals kept at room temperature recovered full locomotor behavioral function, while a majority of those that recovered at a colder temperature exhibited dysfunctional locomotor behavior. The dysfunction most often consisted of segments rostral and caudal to the lesion site lacking the usual coordination and apparently interfering with each. In both groups, there was a close association between the presence of dysfunction and the quality of the intersegmental coordination as assessed in the isolated spinal cord preparation. These results suggest that a relatively minor difference in conditions under which an animal recovers may drastically alter the likelihood of a favorable functional outcome.

Increased levels of transforming growth factor-beta in HIV-associated nephropathy

BACKGROUND

Human immunodeficiency virus-associated nephropathy (HIVAN) is a renal disease of unknown pathogenesis. Recent evidence suggests that the fibrogenic cytokine transforming growth factor-beta (TGF-beta) might be involved. We hypothesized that overproduction of TGF-beta in the kidney might be involved in the pathogenesis of HIVAN.

METHODS

The mRNA and protein expression of TGF-beta isoforms, TGF-beta 1, TGF-beta 2, and TGF beta 3, deposition of matrix proteins induced by TGF-beta, and levels of HIV Tat protein were studied in HIVAN. Controls included normal and diseased kidneys from HIV-positive and -negative patients. The ability of Tat to induce production of TGF-beta and matrix proteins was also studied in human mesangial cells.

RESULTS

Normal kidneys, thin basement membrane nephropathy, and minimal change disease were negative for the three TGF-beta isoforms and Tat. In HIVAN, levels of TGF-beta isoforms and Tat were significantly increased, along with the expression of TGF-beta mRNA and deposition of matrix proteins stimulated by TGF-beta. Increased levels of TGF-beta isoforms, but not Tat, were also found in other glomerular diseases characterized by matrix accumulation. HIV infection, in the absence of HIVAN, was not associated with an increase in TGF-beta or Tat expression. Tat stimulated the expression and production of TGF-beta 1 and matrix proteins by human mesangial cells.

CONCLUSIONS

Our findings suggest that overproduction of TGF-beta is involved in the pathogenesis of HIVAN.

Normal lung function in subjects heterozygous for surfactant protein-B deficiency

Inherited deficiency of surfactant protein-B (SP-B) is a fatal autosomal recessive disorder of lung cell metabolism caused most frequently by a frameshift mutation in codon 121 of the SP-B gene (121ins2) and is characterized by rapidly progressive respiratory failure immediately after birth. Lungs from genetically engineered heterozygous SP-B-deficient mice exhibit decreased compliance and mild air trapping. To determine whether pulmonary function of heterozygous SP-B-deficient humans is similarly affected, we studied nine heterozygous subjects 16 to 44 yr of age and two unaffected subjects 7 and 23 yr of age from five families of 121ins2 SP-B-deficient infants. An increase in residual volume was noted in one heterozygous family member and one unaffected family member. Compliance, maximal transpulmonary pressure, air flow, and gas exchange were normal in all heterozygous subjects tested. These data suggest that humans heterozygous for the 121ins2 mutation have normal pulmonary function through the first four decades of life. The impact of advancing age and environmental exposures on the lung function of heterozygotes remains to be determined.

Colchicine-induced myoneuropathy in childhood

Colchicine is used in the treatment of gouty arthritis, familial Mediterranean fever, amyloidosis, Behcet disease and dermatoses. Myoneuropathy is a rare side-effect reported either with intoxication or in elderly patients with chronic renal insufficiency causing elevated plasma drug levels. We report the first two cases of myoneuropathy in children, both taking appropriate doses of colchicine, and having normal renal function. The myoneuropathic changes were reversible after stopping treatment. The cause of colchicine myoneuropathy is unclear.

CONCLUSION

In children treated with colchicine, neuromuscular phenomena of unknown aetiology may be related to the drug, even with a lack of intoxication or renal insufficiency.

Bronchiolitis obliterans syndrome: thin-section CT diagnosis of obstructive changes in infants and young children after lung transplantation

PURPOSE

To characterize the thin-section computed tomographic (CT) appearance of bronchiolitis fibrosa obliterans syndrome in infants and young children after lung transplantation.

MATERIALS AND METHODS

Thin-section CT studies in six patients with bronchiolitis obliterans syndrome (age range, 2 months to 5 1/2 years) and in 15 control patients without obstructive airway disease (age range, 2 months to 7 years) who underwent bilateral lung transplantation were retrospectively reviewed. The thin-section CT scans were obtained during quiet sleep at a median of 24 months (range, 6-36 months) after transplantation. The CT studies were evaluated for mosaic perfusion, bronchial dilatation, bronchial wall thickening, and mucous plugging Final diagnoses in all patients were based pulmonary function test results.

RESULTS

Thin-section CT findings in the six patients with clinically proved bronchiolitis obliterans syndrome were mosaic perfusion in five (83%) bronchial dilation in three (50%), and bronchial wall thickening in one (17%). Of the 15 control patients with normal pulmonary function test results, six (40%) had mosaic perfusion; none had bronchial dilatation or bronchial wall thickening. Mucous plugging was not seen in either group. Only the association of bronchial dilatation with bronchiolitis obliterans syndrome was significant (P = .02).

CONCLUSION

Infants and young children with bronchiolitis obliterans syndrome after lung transplantation are more likely to have CT abnormalities than those with normal pulmonary function test results.

Estimation of coupling strength in regenerated lamprey spinal cords based on a stochastic phase model

We present a simple stochastic model of two coupled phase oscillators and a method of fitting the model to experimental spike-train data or to sequences of burst times. We apply the method to data from lesioned isolated lamprey spinal cords. The remaining tracts at the lesion site are either regenerated medial tracts, regenerated lateral tracts, control medial tracts, or control lateral tracts. We show that regenerated tracts on average provide significantly weaker coupling than control tracts. We compare our model-dependent estimate of coupling strength to a measure of coordination based on the size of deflections in the spike-train cross-correlation histogram (CCH). Using simulated data, we show that our estimates are able to detect changes in coupling strength that do not change the size of deflections in the CCH. Our estimates are also more resistant to changes in the level of dynamic noise and to changes in relative oscillator frequency than is the CCH. In simulations with high levels of dynamic noise and in one experimental preparation, we are able detect significant coupling strength although there are no significant deflections in the CCH.

Lung retransplantation in children

BACKGROUND

Early primary graft failure due to reperfusion injury may occur in up to 10% of all patients undergoing lung transplantation. Late graft failure in the form of bronchiolitis obliterans progressively increases in frequency as posttransplantation follow-up increases. In both situations, the degree of pulmonary dysfunction may worsen and result in the death of the recipient. The only treatment in many instances is retransplantation. The results in adults are reasonably well established.

METHODS

We reviewed our experience in children. Of the 136 transplant procedures performed to date in children, 14 have been retransplantations. Six patients required retransplantation for early primary graft failure and 8 underwent retransplantation for bronchiolitis obliterans.

RESULTS

There were three early and three late deaths. The actuarial survival at 2 years is 58%. The retransplant procedures were more complex than the primary transplant operations as evidenced by the longer time on cardiopulmonary bypass (199 +/- 71 versus 150 +/- 41 minutes; p < 0.01) and the greater volume of blood transfused (1,303 +/- 936 versus 570 +/- 300 mL; p < 0.01). Two of the long-term survivors who received transplants for bronchiolitis obliterans have subsequently had development of this same condition and 1 died secondary to this. In four instances living related donors were used for the retransplant procedure. The most striking difference in these procedures compared with those transplantations performed with cadaveric donors was the shorter donor lung ischemic times (99.5 and 123.3 minutes for the two lungs for living related donors and 251 and 293 minutes for the first and second lung for the cadaveric donors; p < 0.01).

CONCLUSIONS

We believe that lung retransplantation in children is a reasonable therapy to offer in the circumstance of severe graft dysfunction. In the older child, the option of living donor transplantation offers advantages that might offset of the overall higher risk of this procedure.

Corticomedullary procollagen alpha1(IV) mRNA levels and localization after subtotal nephrectomy

The relationships between tubular hypertrophy/hyperplasia, procollagen alpha1(IV) mRNA levels, and the development of tubular basement membrane thickening were studied in male Sprague-Dawley rats subjected to subtotal renal ablation and sacrificed 2 or 15 days later. Tubular hypertrophy and hyperplasia were demonstrable at 2 days, however no increment in procollagen alpha1 (IV) mRNA levels was discerned at that time, demonstrating a dissociation between mRNA levels for classical type IV collagen and tubular enlargement. At 15 days, tubular procollagen alpha1(IV) mRNA levels did increase approximately 2-fold (p < 0.002), localizing predominantly in proximal tubules in the deep cortex and outer medullary stripe. At this time point, there was still no significant correlation to tubular enlargement, but there was a significant correlation to tubular basement membrane thickening (r = 0.89, p < 0.01). These studies demonstrated that an increase in mRNA for classical type IV collagen is not required for the development of hypertrophy, and that the increment is a better marker for matrix expansion than it is for hypertrophy.

TGF-beta in renal allograft rejection

The role of TGF-beta in pathological processes in the transplanted kidney is beginning to be investigated both in animal models and in humans. In both settings in acute cell-mediated rejection, TGF-beta, receptor, and message have all been documented to be elevated in the tubulointerstitium, likely a reflection of TGF-beta's role in recruiting leukocytes to areas of injury and downregulation of the inflammatory response. In chronic rejection, expression of TGF-beta, message, and induced proteins is elevated, especially in cortex. TGF-beta mRNA, unlike other inflammatory cytokine mRNAs, correlated very well with interstitial fibrosis, a hallmark of chronic rejection. Thus, a relationship between renal scarring and TGF-beta has been documented by most studies of transplant kidneys. Additionally, this growth factor also appears to have a role in the renal fibrosis associated with cyclosporine administration and perhaps in augmenting this drug's immunosuppressive effects.

Simultaneous postinfectious glomerulonephritis and thrombotic microangiopathy: a renal biopsy study

The simultaneous occurrence of postinfectious glomerulonephritis and thrombotic microangiopathy is described in renal biopsy specimens from three patients. Each presented with diverse manifestations: two patients had hypertension and acute renal failure, and in the third, it was unclear whether an atypical postinfectious glomerulonephritis or an atypical thrombotic microangiopathy was present. All biopsy specimens disclosed a combination of irregular granular complement and immunoglobulin deposits in mesangial regions and capillary walls along with fibrin in a linear pattern in capillary walls by immunofluorescence. Light microscopy showed diffuse hypercellularity in some glomeruli, endothelial cell swelling, luminal thrombi and mesangiolysis in others, and both types of changes in a third group. Ultrastructurally, subepithelial hump-shaped deposits coexisted with widened and lucent subendothelial spaces. Possible pathogenic mechanisms for the synchronous lesions include endothelial injury, perhaps triggered by infection and immunologic tissue damage.

Pediatric and adult lung transplantation for cystic fibrosis

OBJECTIVE

This paper was undertaken to review the experience at our institution with bilateral sequential lung transplantation for cystic fibrosis.

METHODS

Since 1989, 103 bilateral sequential lung transplants for cystic fibrosis have been performed (46 pediatric, 48 adult, 9 redo); the mean age was 21 +/- 10 years. Cardiopulmonary bypass was used in all but one pediatric (age <18) transplant, and in 15% of adults.

RESULTS

Hospital mortality was 4.9%, with 80% of early deaths related to infection. Bronchial anastomotic complications occurred with equal frequency in the pediatric and the adult populations (7.3%). One- and 3-year actuarial survival are 84% and 61%, respectively (no significant difference between pediatric and adult age groups; average follow-up 2.1 +/- 1.6 years). Mean forced expiratory volume in 1 second increased from 25% +/- 9% before transplantation to 79% +/- 35% 1 year after transplantation. Acute rejection occurred 1.7 times per patient-year, with most episodes taking place within the first 6 months after transplantation. The need for treatment of lower respiratory tract infections occurred 1.2 times per patient in the first year after transplantation. Actuarial freedom from bronchiolitis obliterans was 63% at 2 years and 43% at 3 years. Redo transplantation was performed only in the pediatric population and was associated with an early mortality of 33%. Eight living donor transplants (four primary transplants, four redo transplants) were performed with an early survival of 87.5%.

CONCLUSION

Patients with end-stage cystic fibrosis can undergo bilateral lung transplantation with morbidity and mortality comparable to that seen in pulmonary transplantation for other disease entities.

Nephronophthisis associated with Ellis-van Creveld syndrome

Ellis-van Creveld (EvC) and Jeune's asphyxiating thoracic dystrophy (ATD) are related disorders characterized by narrow thoracic cage and short-limbed dwarfism. Some patients have overlapping features of both ATD and EvC, indicating that these syndromes may be a part of a disease spectrum. Nephronophthisis has been occasionally reported in patients with ATD, but not with EvC syndrome. We report a patient who was diagnosed with EvC syndrome at birth. He developed hypertension at 5 months of age and gradually progressive renal failure, requiring renal transplantation at 8 years. Histopathological findings in the nephrectomy specimen were indicative of nephronophthisis. The association of nephronophthisis in a patient with EvC syndrome has not been reported previously. This association further supports the hypothesis that ATD and EvC syndromes are related and represent a spectrum of disorders.

Evaluation of pathologic criteria for acute renal allograft rejection: reproducibility, sensitivity, and clinical correlation

This study was designed to evaluate the pathologic criteria used for acute renal allograft rejection that were developed by a panel of renal pathologists participating in the Cooperative Clinical Trials in Transplantation, a National Institutes of Health-supported, multicenter research group. The panel defined three categories of acute rejection. (1) Type I: mononuclear infiltrate in > or =5% of cortex, a total of at least three tubules with tubulitis in 10 consecutive high-power fields from the most severely affected areas, and at least two of the three following features: edema, activated lymphocytes, or tubular injury. (2) Type II: arterial, or arteriolar, endothelialitis with or without the preceding features. (3) Type III: arterial fibrinoid necrosis or transmural inflammation with or without thrombosis, parenchymal necrosis, or hemorrhage. Using these criteria, and without any knowledge of the clinical course or original diagnosis, a rotating panel of three pathologists agreed with the original study pathologist's diagnosis of the presence or absence of rejection in 259 of the 286 biopsies (91%) used for this analysis (kappa = 0.80). The sensitivity to establish the diagnosis of rejection was 91% for a single core and 99% for two cores. To validate the diagnostic criteria, the thresholds for number of tubules with tubulitis and the percent infiltrate were varied, and the pathologic diagnosis was compared with the clinical course. The greatest agreement occurred with a threshold of > or =1 tubule with tubulitis and > or =5% cortex with interstitial infiltrate (91%). Clinically severe rejection episodes were correlated with the type of rejection (type I, odds ratio [OR] 6.2; type II, OR 37.9). Type II rejection was more likely to be clinically severe than type I (OR 6.1). Analysis of other individual pathologic features revealed a correlation with clinical severity for endothelialitis (OR 13.2), interstitial hemorrhage (OR 13.2), and the presence of glomerulitis (OR 3.7) (all P < 0.05). The extent of tubulitis or of the interstitial infiltrate did not correlate with severity (P > 0.05). It is concluded that these criteria are simple, reproducible, and clinically relevant. These data should lead to further refinement of the diagnostic systems for renal allograft rejection.

Hereditary endotheliopathy with retinopathy, nephropathy, and stroke (HERNS)

We describe a Chinese American family with a hereditary syndrome consisting of retinopathy, nephropathy, and stroke, affecting 11 members spanning three generations. Ophthalmologic evaluations revealed macular edema with capillary dropout and perifoveal microangiopathic telangiectases. Several members had renal abnormalities with proteinuria and hematuria. Initial manifestations were visual impairment and renal dysfunction; neurologic deficits occurred in the third or fourth decade of life. Symptoms included migraine-like headache, psychiatric disturbance, dysarthria, hemiparesis, and apraxia. Neuroimaging consistently demonstrated contrast-enhancing subcortical lesions with surrounding edema. Ultrastructural studies showed distinctive multilaminated vascular basement membranes in the brain and in other tissues, including the kidney, stomach, appendix, omentum, and skin. Genetic analysis ruled out linkage to the CADASIL locus on chromosome 19. Distinct from CADASIL, hereditary endotheliopathy with retinopathy, nephropathy, and stroke (HERNS) is an autosomal dominant multi-infarct syndrome with systemic involvement.

Diagnostic value of transbronchial, thoracoscopic, and open lung biopsy in immunocompetent children with chronic interstitial lung disease

OBJECTIVES

To evaluate the diagnostic value of transbronchial biopsy (TBB), video-assisted thoracoscopy (VAT), and open lung biopsy (OLB) in immunocompetent children with chronic, diffuse infiltrates; to identify factors that may predict diagnosis in children requiring biopsy; to determine whether age, number of biopsies, or type of procedure are associated with diagnostic yield in children undergoing transthoracic biopsy; and to compare morbidity of VAT with that of OLB.

STUDY DESIGN

As part of a prospective, descriptive study to define the clinical spectrum of pediatric interstitial lung disease, 30 immunocompetent children required TBB, VAT, and/or OLB for diagnosis of diffuse infiltrates. We reviewed and analyzed the following clinical variables: age; preoperative diagnosis; type of procedure; number of lobes undergoing biopsies; durations of surgery, chest tube insertion, and hospitalization; tissue diagnosis; and complications.

RESULTS

Specific diagnoses were made in 50%, 60%, and 53% of patients undergoing TBB, VAT, and OLB, respectively. A variety of rare disorders was found, and tissue diagnosis confirmed the preoperative diagnosis in 25% of all procedures. For patients who underwent transthoracic biopsy, patient age of greater than 24 months was significantly associated with increased diagnostic yield, but the number of lobes biopsied and type of procedure were not. VAT was associated with shorter operating time, chest tube placement, and hospitalization when compared with OLB. The complications of VAT and OLB were comparable.

CONCLUSION

Lung biopsy is an important tool for the diagnosis of interstitial lung disease in immunocompetent children, but the diagnosis of many children, particularly those aged 2 years or younger, remains uncertain.