Somatic growth outcomes in response to an individualized neonatal sodium supplementation protocol

Objective

Evaluate the impact of a sodium (Na) supplementation protocol based upon urine Na concentration on growth parameters and morbidities.

Study Design

Retrospective cohort study of infants 260/7-336/7 weeks gestational age (GA) cared for before (2012-15, n = 225) and after (2016-20, n = 157) implementation of the protocol. Within- and between-group changes over time were assessed using repeated measures generalized linear models.

Results

For infants 260/7-296/7 weeks GA, utilization of the protocol was associated with increased mean body weight z-score at 8-weeks postnatal age, increased mean head circumference z-score at 16-weeks postnatal age, and decreased time on mechanical ventilation (all p < 0.02). No impact on growth was identified for infants 30-336/7 weeks GA. Incidences of hypertension, hypernatremia, bronchopulmonary dysplasia, and culture positive sepsis were unaffected by the protocol.

Conclusion

Protocolized Na supplementation results in improved growth and reduced time on invasive mechanical ventilation in extremely preterm infants without increasing incidence of morbidities.

Persistent increase in mitochondrial superoxide mediates cisplatin-induced chronic kidney disease

Severe and recurrent cisplatin-induced acute kidney injury (AKI) as part of standard cancer therapy is a known risk factor for development of chronic kidney disease (CKD). The specific role of superoxide (O₂^•-)-mediated disruption of mitochondrial oxidative metabolism in CKD after cisplatin treatment is unexplored. Cisplatin is typically administered in weekly or tri-weekly cycles as part of standard cancer therapy. To investigate the role of O₂^•- in predisposing patients to future renal injury and in CKD, mice were treated with cisplatin and a mitochondrial-specific, superoxide dismutase (SOD) mimetic, GC4419. Renal function, biomarkers of oxidative stress, mitochondrial oxidative metabolism, and kidney injury markers, as well as renal histology, were assessed to evaluate the cellular changes that occur one week and one month (CKD phase) after the cisplatin insult. Cisplatin treatment resulted in persistent upregulation of kidney injury markers, increased steady-state levels of O₂^•-, increased O₂^•--mediated renal tubules damage, and upregulation of mitochondrial electron transport chain (ETC) complex I activity both one week and one month following cisplatin treatment. Treatment with a novel, clinically relevant, small-molecule superoxide dismutase (SOD) mimetic, GC4419, restored mitochondrial ETC complex I activity to control levels without affecting complexes II–IV activity, as well as ameliorated cisplatin-induced kidney injury. These data support the hypothesis that increased mitochondrial O₂^•- following cisplatin administration, as a result of disruptions of mitochondrial metabolism, may be an important contributor to both AKI and CKD progression.

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Cisplatin-induced AKI and CKD have a negative impact in long-term renal function.

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Cisplatin-induced CKD disrupts mitochondrial metabolism and increases O₂^•- levels.

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SOD mimetic, GC4419 mitigates renal damage and mitochondrial metabolism disruptions.

Cholesteatoma--pathology and treatment

(1) The prerequisite for development of cholesteatoma is a cholesteatoma bed, that is a loose subepithelial connective tissue layer which acts as a nutrient bed and makes papillary growth of squamous epithelium possible. (2) The formation of cholesteatoma is facilitated by disturbed tubal function with reduced ventilation of the middle ear. (3) The progression of cholesteatoma, especially the bone destruction, is due to enzyme-activated cell groups. The epidermal layer in the postero-superior area of the tympanic membrane has a higher papillary content and during an inflammatory process there is a marked vascular reaction. This particular area has a special nutritional zone and the epidermis is especially well nourished [Lange, 1925]. The main artery to the tympanic membrane travels along the handle of the malleus and gives off branches. In our animal experiments epithelial cones grew into this well-nourished subepithelial zone and formed cholesteatoma. The importance of tubal function as regards cholesteatoma formation can be seen in everyday clinical practice. In stapedectomy patients, the lateral attic wall is usually removed to allow full visualisation of the stapes, but retraction pockets in this area are never seen at subsequent follow-up. However, if the lateral attic wall is removed during surgery for chronic otitis media, reconstruction with cartilage or ceramic is necessary to prevent retraction. This adds weight to the hypothesis that tubal dysfunction is an important aetiological factor in cholesteatoma. This is further supported by the 30 times greater incidence of retraction pockets in patients with cleft palate.

Der Einfluss des Geschlechts auf die Selbstbeschreibung kindlicher ADHS-Symptome

Diagnosing attention deficit hyperactivity disorder (ADHD) in adults requires retrospective assessment of ADHD symptoms in childhood. The Wender Utah Rating Scale (WURS) and its German validated version (WURS-k) may offer a helpful tool to acertain relevant childhood problems associated with ADHD. Up to now validating data of the WURS-k were limited to male population. In a population of 69 female adult ADHD patients and 97 controls, ROC analysis indicated a sensitivity of 93% and specificity of 92% at a cut-off of 30 points in the WURS-k. This cut-off value is equivalent to those of males. Symptom report varies significantly by gender and females describe more internalizing problems while males report more externalizing behaviour. Regarding different subtypes according to DSM-IV males and females did not differ in the items of the WURS-k.

Different endogenous opioid effects on delta- and mu-receptor subtypes in antral and duodenal motility of conscious dogs

To evaluate the role of endogenous opioids in regulation of upper gastrointestinal motility in unanesthetized dogs and to differentiate the actions on mu- and delta-opioid receptors, seven strain gauges and five platinum electrodes were chronically implanted at the serosa along the antrum and duodenum and connected to a plug in the neck of the dog. Signals were processed by a Hellige AC amplifier, a rectilinear recorder, and a data aquisition system. A motility index (MI) was calculated and together with the electrical data a contractile activity percentage (CAP) was determined for consecutive 30 min periods. The delta-opioid antagonist ICI 741 864 and the mu-receptor blocker naloxone were injected intraarterially through a chronic Groshong catheter placed in the pyloric region and connected to a subcutaneous port. After a meal of solid food, ICI 174 864 increased motility relative to controls in the antrum averaged over 5 hr by 144.4%+/-26 for the MI and 73%+/-26 for CAP; after naloxone MI increased by 222%+/-60 and CAP 121%+/-76. In the duodenum, ICI 174 864 decreased MI over a range of 57% to 22% (P < 0.05). Naloxone increased MI and CAP significantly after 2.5 hr. We interpreted the results of ICI 174 864 in the duodenum to reflect suppression of a tonic opioid influence at the delta-receptor mainly at the prevertebral ganglion. In the interdigestive state in 56% of the dogs, naloxone delayed the occurrence of phase III of the migrating myoelectric complex (MMC) for up to 370 min, while under ICI 174 864, normal interdigestive cycles were present. Disturbance of the timing of the interdigestive cycles at central mu-opioid receptors may by involved in the effect.

High performance DNA sequencing, and the detection of mutations and polymorphisms, on the Clipper sequencer

The Visible Genetics Clipper sequencer is a new platform for automated DNA sequencing which employs disposable MicroCel cassettes and 50 microm thick polyacrylamide gels. Two DNA ladders can be analyzed simultaneously in each of 16 lanes on a gel, after labeling with far-red absorbing dyes such as Cy5 and Cy5.5. This allows a simultaneous bidirectional sequencing of four templates. We have evaluated the Clipper sequencer, by cycle-sequencing of an M13 single-stranded DNA standard, and by coupled amplification and sequencing (CLIP) of reverse-transcribed human immunodeficiency virus (HIV-1) RNA standards and clinical patient samples. (i) Limitations of instrument. We have examined basic instrument parameters such as detector stability, background, digital sampling rate, and gain. With proper usage, the optical and electronic subsystems of the Clipper sequencer do not limit the data collection or sequence-determination processes. (ii) Limitations of gel performance. We have also examined the physics of DNA band separation on 50 microm thick MicroCel gels. We routinely obtain well-resolved sequence which can be base-called with 98.5% accuracy to position approximately 450 on an 11 cm gel, and to position approximately 900 on a 25 cm gel. Resolution on 5 and 11 cm gels ultimately is limited by a sharp decrease in spacing between adjacent bands, in the biased reptation separation regime. Fick's (thermal) diffusion appears to be of minor importance on 6 cm or 11 cm gels, but becomes an additional resolution-limiting factor on 25 cm gels. (iii) Limitations of enzymology. Template quality, primer nesting, choice of DNA polymerase, and choice between dye primers and dye terminators are key determinants of the ability to detect mutations and polymorphisms on the Clipper sequencer, as on other DNA sequencers. When CLIP is used with dye-labeled primers and a DNA polymerase of the F667Y, delta(5'--> 3' exo) class, we can routinely detect single-nucleotide mutations and polymorphisms over the 0.35-0.65 heterozygosity range. We present an example of detecting therapeutically relevant mutations in a clinical HIV-1 RNA isolate.

Plester's Angled Prosthesis for Ossicular Chain Reconstruction

Reconstruction of a defect of the long process of the incus by means of bone chips, cartilage grafts or other material do not give satisfactory long term results. Plester developed therefore an angled prosthesis to reconstruct the defect. It consists of a cross-slit gold bell which is connected with a double band titanium cuff by a tiny gold wire. The prosthesis crimped on the stamp of the long process with open tatanium bands, the bell is kept overthe head of the stapes, The authors have inserted 81 angled prosthesis. In 63 cases, the post operative conductive hearing loss amounted to 15 dB on an average.

Effect of 17-norleucine-VIP on gastroduodenal motility relative to serum VIP concentration and blockade of NOS

Mechanical and electrical activity in the antrum, pylorus, and duodenum was evaluated in the conscious dog, instrumented with seven strain gauges and five platinum electrodes. 17-Norleucine-vasoactive intestinal peptide (17-N-Leu-VIP) or 17-N-Leu-VIP plus NG-nitro-L-arginine methyl ester (L-NAME) was injected intra-arterially close to the pylorus to identify influences of nitric oxide (NO) on effects of VIP. VIP concentration was measured by radioimmunoassay in serum samples collected from the cubital and portal veins before and up to 2 h after VIP injection. VIP (0.004-0.006 mg.kg-1.10 min-1) abolished phasic contractions in the interdigestive state for 16.8 min and in the digestive state for 14.4 min, whereas whole serum VIP concentration rose above 42.4 +/- 13 pmol/l. Administration of L-NAME did not significantly influence the effects of VIP. Aftereffects of VIP, consisting of a reduced motility index, lasted 33 +/- 10.6 min in the interdigestive state and 44.5 +/- 42 min in the digestive state. This VIP aftereffect in the interdigestive state was shortened in time by the addition of L-NAME. The results overall suggest that NO release is a factor only in the aftereffects of VIP.

Intrinsic corporoantropyloric coordination of motility and gastric emptying

This study examined changes in gastric motility after interruption of the intramural nervous circuitry from the proximal portion of the stomach to the antrum by a circumferential gastric myotomy. Seven extraluminal strain gauge force transducers and five platinum electrodes were implanted along the antropyloroduodenal region, and gastric emptying was studied by X-ray after a 280-g solid meat meal mixed with barium. The motility index increased aboral to the myotomy by 106 and 69% in the distal antrum and pylorus, respectively, in the first postprandial 30-60 min because of the loss of an inhibitory neural influence from the proximal part of the stomach. Destabilization of the basic electrical rhythm occurred in 50% of the dogs. This was apparent as tachyarrhythmia or bradyarrhythmia and an early postprandial 2-11% decrease in slow-wave frequency and a 100% increase in slow-wave amplitude. Coordination of corporoantropyloric contractions was disorganized. Frequent segmenting and antidromic contractions were associated with reduced periods of optimal emptying and disturbed intragastric chyme transport into the constricted antrum. A 10-30% gastric emptying delay of approximately 50 min was a consequence of myotomy despite an increased antroduodenal motor gradient after myotomy. The overall results suggest that intact intramural innervation and muscular continuity are essential for coordination of corporoantropyloric motility and normal gastric emptying.

Effects of erythromycin in the dog upper gastrointestinal tract

The effects of erythromycin on motor and electrical behavior of the antrum, pylorus, and duodenum were determined in chronically instrumented, awake dogs. Erythromycin infusion resulted in an abrupt, powerful increase in motility. The motility index increased 18-fold in the antrum, 15-fold in the pylorus, and 8-fold in the duodenum. Bradyarrhythmia with a 30% decrease in slow-wave frequency occurred in all animals. Retrograde giant contractions in association with retching and vomiting occurred in 88% of the dogs. Neostigmine was less potent than erythromycin in increasing motility. Hexamethonium given intra-arterially during erythromycin infusion abolished motility for 7.2 +/- 2.9 min and intra-arterial atropine did so for 51 +/- 25 min. Hexamethonium or atropine restored the electrical slow-wave frequency. The results provide evidence that erythromycin action involves cholinergic pathways including ganglionic transmission.

[Use of cartilage transplants in middle ear surgery. A histologic long-term study of cartilage implants]

30 autogenic and allogenic (homologous) cartilage grafts removed from the middle ear after an average time of 9 years and a maximal time of 25 years were studied by light microscopy. Half of the grafts showed signs of cellular vitality. Degeneration and avital cells are predominant in all grafts. Persisting residual vitality does not influence resorption and matrix necrosis in other areas of the graft. More than two thirds show structural changes by cellular resorption, infraction and vascularisation. These changes appear mainly independent of the time elapsed after transplantation. 5 grafts show bone new formation. Circumscript necrosis of the cartilage matrix was seen in 12 grafts. The study indicates that in comparison to ossicles or alloplastic material cartilage is less advisable to be used for the reconstruction of the ossicular chain due to the unpredictable degradation and loss of form stability.

[Ear ossicle transplants for reconstruction of sound transmission in the middle ear. A histologic long-term study]

In this study 130 ossicular middle ear transplants were studied. 33 remained in the middle ear for 10 years or longer, one for 21 years. The majority of the grafts show 5% to 40% bone new formation. Absence of vital bone or subtotal host bone replacement is exceptional. The amount of bone new formation appears independent the implantation time. 75% of the grafts show no bone resorption. In 15% sound transmitting might be impaired due to resorption. Grafts with a high degree of bone new formation show less resorption. 21% of the ossicles have signs of inflammation. Inflammation boosts bone turnover with resorption on one hand and new for resorption. Cholesteatoma is the main cause of resorption and inflammation. The critical phase for resorption of the graft are the first two to three years after transplantation. No considerable difference was found between autografts and allografts (homografts). Histological and metabolical properties of the ossicles seem to be responsible for the stability of the graft. Ossicular grafts have a good longterm stability which makes them very suitable for reconstruction of the ossicular chain.

[Therapy of Frey's syndrome with an anhidrotic gel]

In recent years we treated 53 patients suffering from Frey's syndrome with an antihidrotic gel. The active ingredient we used was aluminiumtrichloridhexahydrate. In addition to presenting a historic review we will also demonstrate and discuss our results. The study concludes, that this gel is effective in treating Frey's syndrome.

[Intratemporal facial neurinoma]

Two patients with intratemporally localised facial nerve schwannomas developed conductive hearing loss beside persisting facial nerve palsy. Tympanotomy revealed a tumour of the facial nerve that was totally removed. In one case reconstruction was performed with great auricular nerve interposition. The long-term follow-up (12 years) showed a good functional result. Facial nerve schwannomas present problems in detection, and reconstruction methods are not safe with regard to long-term prognosis.

[Extra-temporal localized facial neuromas]

Nine facial nerve schwannomas were observed in more than 1,350 operations on the parotid gland. Eight patients had a pre-operative diagnosis of pleomorphic adenoma without facial palsy. One patient who underwent extensive surgery without preservation of the facial nerve for a tumour present for more than 10 years had a pre-operative facial palsy. Facial nerve function recovered totally or partially in six peripheral schwannomas. In two cases with main trunk schwannoma no reinnervation was observed despite end-to-end anastomosis or interposition of the great auricular nerve. Histology showed eight typical schwannomas and one neurofibroma. Neurofibromas are extremely rare in the parotid gland. Clinical and operative experience with parotid gland schwannomas shows that recovery of facial nerve defects is mostly incomplete. Reconstructive methods should be used, but the long-term prognosis is uncertain.

[When should removed adenoids be studied histologically?]

Two children with nasopharyngeal rhabdomyosarcoma are used to discuss the relevance of the histopathological investigation of adenoid tissue. Histopathological investigation should only be omitted if there is complete agreement between symptoms, intra-operative findings and macroscopic findings. Histopathology is advised for very large adenoids, alteration of consistency and in older children or young adolescents.

[Surgically treated diseases of the parotid gland in childhood and adolescence]

Between 1969 and 1986 parotid gland surgery was performed on 86 children and adolescents in the ENT clinic of the University of Tübingen. Chronic recurrent parotitis was found to be the most common chronic inflammatory disease in our young patients. Total parotidectomy was done on 24 children. Because of the high incidence of potential complications the indication for a total parotidectomy in chronic parotitis should be carefully considered. A more hopeful attitude applies to the cystic tumours (haemangioma, lymphangioma and branchiogenic cysts). A solid tumour of the parotid gland in children and adolescents, however, necessitates surgical extirpation without delay because one-third of these tumours are malignant.

The formation of ultrastructural epithelial and subepithelial connective tissue changes in experimentally induced cholesteatomas in guinea pigs

Histoacryl-induced cholesteatomas were produced in guinea pigs at the posterosuperior part of the external ear canal adjacent to the tympanic membrane. Semithin and ultrathin tissue sections were used to study primary formation of the cholesteatoma as well as the influence of the altered epithelium upon the bordering zone of connective tissue. Quantitative and qualitative tissue changes were analyzed by electron microscopy and showed degradation and new formation of collagen and activation of fibroblasts. Our findings are similar to those previously reported on human cholesteatomas and indicate that the bordering subepithelial tissue seems to be influenced through the basilar membrane.

The effects of fibrin tissue adhesive on the middle ear

This study investigated the effects of fibrin glue ('Tissucol', Immuno Pty. Ltd.) in the middle and inner ear. Small amounts of the adhesive were used in 36 operations performed on 18 rabbits. The light microscopic examination of these ears four, eight and 12 weeks after surgery showed that the adhesive was well tolerated and that it did not have any toxic effect on the middle ear or membranous labyrinth. The fibrin tissue adhesive can therefore safely be used to facilitate reconstructive middle-ear surgery and, with the aid of fascia, also for the closure of labyrinthine fistulae; or to achieve a definite seal of oval window niche after stapes surgery.

[A light and electron microscopic study of the squamous epithelium of the external canal and drum in experimentally induced cholesteatoma in guinea pigs]

The skin of the postero-superior part of the meatus and drum of guinea pigs was treated with enbucrylate and examined via light microscope and electron microscope after three weeks. The squamous epithelium was thickened with extensive rete pegs in the subepithelial space. The epithelial cells were loosely arranged and their nuclei pathologically changed. In the oedematous perimatrix small finger-like epithelial proliferations and activated mesenchymal cells could be seen.

[Pathogenesis of chronic recurrent parotitis (author's transl)]

A combination of several factors is of importance in the pathogenesis of sialectatic parotitis. Stenson's duct is relatively long and its orifice is narrow. The flow of the saliva may be impaired, especially when mastication is abnormal or when the ductal lumen is scarred because of infection or trauma. Dental or oral mucosal disease may increase the number of pathogenic organisms which might then lead to a retrograde ascending infection. This is followed by epithelial desquamation and subsequent ductal obstruction. Allergic, genetic an racial factors in sialectatic parotitis are also discussed. The four characteristic progressive histologic stages of sialectatic parotitis are: a periductal inflammatory reaction, a diffuse lymphocytic sialadenitis with dilated ducts, fully developed sialectatic parotitis and, finally, fibrosis of the parotid gland. Conservative treatment will lead to an improvement of the clinical symptoms as well as the histopathological features in the first two stages, but in the two final stages total parotidectomy, with preservation of the facial nerve, is the treatment of choice.

[The value of labyrinthectomy in the treatment of Menière's disease (author's transl)]

Surgical labyrinthectomy in patients with Menière's disease produces unsatisfactory results in 10-70% of the cases. A pathological process in the vestibular nerve comprising an increase in connective tissue formation and the development of bony material within the nerve is possibly the reason for the pathological function of the vestibular system. This process may arise after a mechanical trauma to the labyrinth. Labyrinthectomy should be performed only for the treatment of Menière's disease if other therapeutical regimens or neurectomy under general anaesthesia cannot be tolerated by the patients.

[A clinical and experimental study on precious metal ventilation tubes (author's transl)]

Incompatibility reactions which lead to a profuse aural discharge and often necessitate the removal of the ventilation tube occur in approximately 10% of patients if ventilation tubes made of synthetic materials are used. We have used golden and other precious metal alloy grommets in patients after extensive bacteriological and animal experiments. The most important advantage is the oligodynamic action which gives the surface of the ventilation tube repellent properties against bacteria. The drainage function is excellent due to the smooth surface structure and no incompatibility reactions were seen.

Middle ear tuberculosis

Fourteen cases of tuberculous otitis media are reported. With the declining incidence of pulmonary tuberculosis, the number of reported cases of tuberculous otitis media has become scanty. Nowadays the so-called classical signs of the lesion such as a profuse discharge, profound hearing loss, facial paralysis and multiple perforations, are hardly ever seen. Surgical intervention when done under cover of anti-tubercular drugs has no deleterious effect on the result of surgery. In order not to miss tuberculous otitis media, whenever the otologist is dealing with chronic middle ear disease, the following points should always be kept in mind: (a) A dull ache in the ear without obvious inflammatory signs. (b) A whitish-grey appearance of the mucosa. (c) Bulging of granulation tissue from the mastoid cells during surgery.

The effects of an adhesive in the middle ear

This study investigated the effects of enbucrilate (Histoacryl) on the middle ear. Small amounts of the adhesive were used in 81 middle-ear operations performed on 50 rabbits. Light microscopic investigation of these ears 1, 2, and 3 months after surgery showed bone necrosis and a granulation tissue reaction surrounded by foreign-body giant cells. Inner-ear changes were observed in a third of the cases. Therefore, enbucrilate should only be used with extreme care and in minute quantities and never near the labyrinthine capsule.

Experimental production of cholesteatoma in rabbits by using non-irritants (skin tolerants)

The application of various skin tolerant substances to the postero-superior and antero-inferior aspects of the external auditory canal of the rabbit, with an intact ear drum and middle ear, produced cholesteatomas in the skin of the auditory canal and in the tympanic membrane, particularly in the pars flaccida. At the antero-inferior insertion of the tympanic membrane, however, cholesteatoma growth could not be induced in these animal experiments. In severe diffuse otitis externa, secondary to the operative closure of the external auditory canal, cholesteatomas also develop preferentially in the pars flaccida. The relatively thick, loose intermediate layer of connective tissue allows a rapid expansion of epithelial ridges, thus favouring the formation of cholesteatoma in this region.

[Experimentally produced cholesteatoma (author's transl)]

Application of various mildly irritant substances to the posterosuperior and anteroinferior aspects of the external auditory canal of the rabbit, with intact ear drum and middle ear, produced cholesteatomas in the skin of the auditory canal, and the tympanic membrane particularly in the pars flaccida. At the anteroinferior insertion of the tympanic membrane, however, cholesteatoma growth could not be induced in these animal experiments. In severe diffuse otitis externa, secondary to the operative closure of the external auditory canal, cholesteatomas also preferably develop in the pars flaccida, the relatively thick, loose intermediate layer of connective tissue allows a rapid expansion of epithelial ridges thus favouring the formation of cholesteatoma in this region.

Histologic fate of tympanic membrane and ossicle homografts

1. The biologic behavior and usefulness of homologous incus grafts preserved in Cialit compare favorably with that of ossicular autografts. 2. Reconstruction of the transplanted incus correlates with the period of its immersion in preservative: the briefer the period of exposure to fixative, the more rapidly resorption and substitution occur. The longer the preservation time, the slower the rate of incus transplant reconstruction. 3. The preserved heterograft bone chip is unsuitable, since it disintegrates completely irrespective of the duration of its preservation. 4. The configuration of all bone chips is extensively altered after implantation. Autograft and homograft bone chips are both poorly tolerated. Chemical fixation does not alter this reaction. Fragments are shortened, softened, and rounded off. Heterologous bone chips are completely resorbed.

[Uncommon findings during surgery of the internal auditory canal (author's transl)]

The following cases are demonstrated:postoperative deafness probably caused by abnormal blood supply to the cochlea, clinical findings of an acoustic neuroma without tumor, atrophy of cochlear and vestibular nerves, bone-like tissue growth in the labyrinthine trauma, hearing improvement after removal of an arachnoid cyst from the internal auditory canal.