[MAXILLOFACIAL TRAFFIC INJURIES RELATED TO MOTOR VEHICLE ACCIDENTS IN JERUSALEM 2000-2013: CHARACTERISTICS AND ETHNIC COMPARISONS]

BACKGROUND

The aim of this study is to review motor-vehicle accident-related maxillofacial injuries (MVA-MFI) trauma cases and to investigate whether the growing population and traffic congestion, as well as differences in driving practice, vehicle safely devices and infrastructure facilities might differentially affect the pattern of MVA-MFI among Jewish and Arab populations.

METHODS

This retrospective study reviews maxillofacial injuries (MFI) identified among all trauma patients who were admitted to Hadassah Ein Kerem hospital, Jerusalem, between the years 2000 to 2013.

RESULTS

Out of 29,997 trauma patients, 1,720 presented with MFI, with motor-vehicle accident (MVA) being the major cause of injury (705 patients, 41%). Their mean age was 29.9±21.0 years with a prominent male and Jewish predominance (4.3:1 and 1.8:1, respectively). Most MVA-MFI casualties were car drivers (41%), followed by pedestrians (30%). Pedestrians with MVA-MFI were mainly children and aged persons, whereas drivers were mainly adults. Males and Arabs were more likely to present with higher injury severity score (ISS). Safety belts were not used in the majority of car MVA-MFI patients (54%). Yet, the ISS score did not correlate with the use of safety devices. Mandibular fractures were the most common (21%), followed by nasal bones (20%), zygoma (17%), orbit (16%), maxilla (15%) and teeth (11%). Age was significantly associated with increased maxillary and nasal fractures and with decreased incidence of mandibular and teeth fractures.

DISCUSSION

Based on our review, young males and specifically Arab patients suffered from MFI and high ISS scores as a result of MVA. The findings and their interpretations are discussed.

Emerging role of fecal microbiota therapy in the treatment of gastrointestinal and extra-gastrointestinal diseases

In the recent decade our understanding of the role of the human gut microbiome has been revolutionized by advances in development of molecular methods. Approximately, up to 100 trillion (10(14)) microorganisms per human body colonize the intestinal tract making an additional acquired organ that provides many vital functions to the host. A healthy gut microbiome can be defined by the presence of the various classes of microbes that enhance metabolism, resistance to infection and inflammation, prevention against cancer and autoimmunity and that positively influence so called braingut axis. Diet represents one of the most important driving forces that besides environmental and genetic factors, can define and influence the microbial composition of the gut. Aging process due to different changes in gut physiology (i.e. gastric hypochlorhydria, motility disorders, use of drugs, degenerative changes in enteric nervous system) has a profound effect on the composition, diversity and functional features of gut microbiota. A perturbed aged gut microbiome has been associated with the increasing number of gastrointestinal (e.g. Clostridium difficile infection - CDI) and non-gastrointestinal diseases (metabolic syndrome, diabetes mellitus, fatty liver disease, atherosclerosis etc.). Fecal microbiota transplantation (FMT) is a highly effective method in the treatment of refractory CDI. FMT is the term used when stool is taken from a healthy individual and instilled during endoscopy (colonoscopy or enteroscopy) into a gut of the sick person to cure certain disease. FMT represents an effective therapy in patient with recurrent CDI and the effectiveness of FMT in the prevention of CDI recurrence had reached approx. 90%. There is also an increasing evidence that the manipulation of gut microbiota by FMT represents a promising therapeutic method in patients with inflammatory bowel disease and irritable bowel syndrome. There is also an increased interest in the role of FMT for the treatment of metabolic syndrome and obesity which collectively present the greatest health challenge in the developed world nowadays. Targeting of gut microbiota by FMT represents an exciting new frontier in the prevention and management of gastrointestinal and non-gastrointestinal diseases that awaits further studies in preclinical and clinical settings.

Is FNAC (fine needle aspiration cytology) a useful tool in detection of malignancy in thyroid surgery? A single institution experience

OBJECTIVE

To evaluate if FNAC (Fine Needle Aspiration Cytology) is a useful tool in the detection of malignancy in thyroid surgery. FNAC is used routinely as a preoperative diagnostic technique and surgical strategy is often adapted. But is FNAC such a good technique in defining surgical strategy?

METHODS

We retrospectively reviewed all files of 703 patients operated from 1997 till today. We obtained the results of the FNAC, the final pathological diagnosis and these data were analyzed.

RESULTS

There were 161 male and 542 female patients. 72 out 703 patients had a malignancy. 241 patients (34.3%) had a preoperative FNAC-procedure. Male patients had significantly more malignancies (p = 0.006). In 183 patients (75.9%) the FNAC was benign, 28 patients (11.6%) showed malignancy, in 15 patients (6.2%) only blood was found and 15 patients (6.2%) showed an inconclusive result. 70.1% of the patients were true negative, 5.8% were true positive, 5.8% false positive, 5.8% false negatives, 5.8% of inconclusive results were malignant on pathology. This gives a sensitivity of 50% and specificity of 92.4%.

CONCLUSIONS

The specificity of FNAC in malignancy is high (92.4%) but a sensitivity of 50% is low. With these results adaptation of surgical strategy (hemithyroidectomy or total thyroidectomy) secondary to the results of the FNAC is not recommended. Free hand FNAC might be a reason for the relatively high percentage of inconclusive results. Ultrasound guided FNAC can improve the yield of the puncture. On top of that pathological interpretation of the cytology is not always straight forward.

Intrathymic parathyroid adenoma presenting with seizures

A 59-year-old diabetic patient was admitted with loss of consciousness and convulsions. Hypercalcaemia and hypoglycaemia were discovered. Computed tomographic and technetium scans revealed a retrosternal paramedian nodule. Radical thymectomy was performed by median sternotomy. Diagnosis of intrathymic parathyroid adenoma was made. One year later the patient had good diabetes control without clinical symptoms.

Differential regulation of ET(A) and ET(B) in the renal tissue of rats with compensated and decompensated heart failure

Endothelin-1 (ET-1) exerts its biological actions through two receptor subtypes: endothelin-A (ETA) receptor and endothelin-B (ETB) receptor. We demonstrated previously that ET-1 induces systemic and renal cortical vasoconstriction via ETA whereas ETB mediates medullary vasodilation. Congestive heart failure (CHF) is characterized by increased vascular resistance and impaired renal hemodynamic and excretory function. While the pathophysiological effects of ET-1 in CHF are well established, the status of ETA and ETB in the kidney is poorly characterized. The present study examined the immunostaining and localization of ETA and ETB in the renal cortex and medulla of rats with experimental CHF induced by aorto-caval fistula. Rats with CHF were further subdivided, based on their daily urinary sodium excretion, into rats with compensated (urinary sodium excretion > 1200 microEq/day) and decompensated CHF (urinary sodium excretion < 200 microEq/day). ETA is predominantly localized to the cortex mainly in the peritubular capillaries, and is upregulated in rats with compensated and decompensated CHF compared with sham controls. In contrast, ETB is preferentially expressed in the outer and inner medulla, mainly in the vasa recta, the thick ascending limb of Henle's loop and the collecting duct. While compensated CHF is associated with upregulation of ETB in the collecting duct and vasa recta, decompensated CHF is accompanied with enhanced ETB abundance in the vasa recta and remarkable downregulation of this receptor subtype in the collecting duct. The findings suggest that upregulation of ETA may lead to a decrease in cortical blood flow while upregulation of ETB in the vasa recta probably contributes to the preservation of medullary blood flow. Furthermore, downregulation of ETB in the collecting duct, only in rats with decompensated CHF, could contribute to sodium retention in that subgroup.

Ewing's sarcoma: imaging features

AIM

To define an imaging prototype of Ewing's sarcoma (ES).

MATERIALS AND METHODS

Sixty-four patients with a histopathologically and/or genetically proven diagnosis of ES were analyzed for clinical parameters (age, gender and location), radiographic and CT appearance (distribution, matrix, margins, periosteal reaction, articular extension, cortical reaction and the presence of a pathologic fracture). Size, local extension, signal intensity, degree and pattern of enhancement, and the presence of skip metastases were evaluated on MRI. Distant metastases were recorded on bone scintigraphy and chest CT scan.

RESULTS

Patient's age ranged between 7-67 (mean 17.9). Male/female ratio was 2.4/1. Location in the pelvis was most frequent (31%), followed by the femur (20%) and tibia (11%). Most tumors were mixed lytic-sclerotic (75%), and purely lytic in 25%. Plain films and CT scan showed a spiculated periosteal reaction in 50%. A Codman's triangle was seen in 27%. Articular extension was difficult to assess on radiographs. Cortical permeation and destruction is seen in respectively 31 and 42%, whereas cortical thickening is seen in 20%. Pathologic fracture occurred in 7.8%. MRI showed a large mass, with a soft tissue component of more than 50% in 67%. Degree and pattern of enhancement pattern was variable. Signal intensity on T1- and T2-WI was non-specific. Joint involvement was seen in 23%. Isolated involvement of the soft tissue (extraskeletal ES) was seen in 1.5%. Skip metastases at initial presentation were present at initial presentation in 14% and distant metastases in 22%.

CONCLUSIONS

ES occurs in young patients. On radiographs/CT, 37.5% are located in the axial skeleton and 62.5% in the peripheral skeleton. ES is mostly mixed sclerotic-lytic. A spiculated periosteal reaction is most frequent. The most characteristic finding on MRI is the presence of a large soft tissue mass.

Medical relief operation in rural northern Ethiopia: addressing an ongoing disaster

BACKGROUND

Following the recent drought in Ethiopia, the Jewish Agency, aided by the Israel Ministry of Foreign Affairs, launched a medical relief mission to a rural district in Ethiopia in May-August 2000.

OBJECTIVES

To present the current medical needs and deficiencies in this representative region of Central Africa, to describe the mission's mode of operation, and to propose alternative operative modes.

METHODS

We critically evaluate the current local needs and existing medical system, retrospectively analyze the mission's work and the patients' characteristics, and summarize a panel discussion of all participants and organizers regarding potential alternative operative modes.

RESULTS

An ongoing medical disaster exists in Ethiopia, resulting from the burden of morbidity, an inadequate health budget, and insufficient medical personnel, facilities and supplies. The mission operated a mobile outreach clinic for 3 months, providing primary care to 2,500 patients at an estimated cost of $48 per patient. Frequent clinical diagnoses included gastrointestinal and respiratory tract infections, skin and ocular diseases (particularly trachoma), sexually transmitted diseases, AIDS, tuberculosis, intestinal parasitosis, malnutrition and malaria.

CONCLUSIONS

This type of operation is feasible but its overall impact is marginal and temporary. Potential alternative models of providing medical support under such circumstances are outlined.

Biliary scintigraphy in children with sickle cell anemia and acute abdominal pain

The patterns of radionuclide hepatobiliary scans in nine children with sickle cell disease and acute right upper quadrant abdominal pain were reviewed. The most common pattern observed was delayed gall bladder visualization, consistent with chronic cholecystitis. The value of hepatobiliary imaging in distinguishing acute cholecystitis from crisis is presented.

131I MIBG therapy in neuroblastoma: mechanisms, rationale, and current status

131I MIBG has been used as palliative treatment of neuroblastoma patients with recurrent or persistent disease who failed other modalities of treatment. Since the results were promising, the concept arose of using it in conjunction with other modalities, either as an up-front treatment or as combination therapy. This article reviews the principle of 131I MIBG treatment, in conjunction with other modalities currently used for the treatment of neuroblastoma, in an attempt to improve the final outcome.

Pretreatment bone scan in SCFE: a predictor of ischemia and avascular necrosis

Sixty-two consecutive patients with 73 slipped capital femoral epiphyses (SCFEs) underwent pretreatment planar technetium bone scan to identify the presence of ischemia of the femoral head. The relationship of pretreatment ischemia and the development of avascular necrosis (AVN) was evaluated after a minimum follow-up of 12 months. All patients were treated with spica casting or pinning across the physis. No forceful manipulation was performed. None of the 63 stable SCFEs demonstrated ischemia by bone scan, and none developed AVN. Of the 10 unstable SCFEs, six demonstrated ischemia by bone scan, and five of the six developed AVN. None of the four unstable SCFEs without ischemia on bone scan developed AVN. Pretreatment bone scan is a sensitive predictor for development of AVN in unstable SCFEs and may provide a method for evaluating interventional treatments for AVN associated with SCFE.

Gastric emptying in children

This article reviews the evaluation of gastric emptying in children with emphasis on scintigraphic techniques. The mechanism of emptying as well as how quantitation may vary with patient positioning, the composition of the standard meal and possibly the size of the meal are discussed. Preliminary data suggest that for children under the age of 2 yr, meal size is less critical. Although normal ranges need to be determined by individual laboratories, values reported in the literature may be used as a guide. Quantitation is useful for the follow-up of patients on therapy.

Assessment of gastro-esophageal dysfunction in children

Scintigraphic methods to assess esophageal transit, gastro-esophageal reflux and gastric emptying are widely used in pediatric patients. This review describes the methodology and considers the clinical application of these techniques as well as the utility of alternative diagnostic studies.

Reversed ventilation-perfusion mismatch involving a pediatric patient in congestive heart failure

Over the past 13 yr, at least 11 specific etiologies of reversed ventilation-perfusion mismatch have been reported in the literature. In this article, a case of reversed ventilation-perfusion mismatch involving a patient in congestive heart failure receiving dobutamine and milrinone therapy is presented. A brief review of the topic of reversed ventilation-perfusion mismatch is presented.

Gastric emptying of milk feedings in infants and children. Anterior versus conjugate counting

The radionuclide milk scan is a valuable tool for the evaluation of gastroesophageal reflux and gastric emptying in children. There is uncertainty as to whether anterior imaging alone is sufficient for determining gastric emptying in these patients.

METHODS

Twenty-five children underwent Tc-99m sulfur colloid milk scans with images acquired in the anterior and posterior projections. Calculations of the 1 hour and 2 hour percentage of gastric residual activity were performed using the anterior counts alone and the geometric mean of the anterior and posterior counts. The anterior and posterior images were visually assessed for the presence of gastroesophageal reflux.

RESULTS

The means of the absolute differences at 1 and 2 hours for the two methods of gastric residual calculation were 4.1% +/- 2.1% and 3.4% +/- 2.8%, respectively. There was good correlation between the two methods at 1 and 2 hours with r values of 0.991 and 0.997 respectively. Gastroesophageal reflux was more obvious in the anterior images and three small episodes were only seen on the anterior view.

CONCLUSION

Anterior images alone give reliable results for the determination of gastric emptying, and gastroesophageal reflux is more readily visualized anteriorly in the pediatric population.

Lung perfusion patterns after bidirectional cavopulmonary anastomosis (Hemi-Fontan procedure)

Perfusion lung scans were performed immediately prior to Fontan procedure in 45 patients with a functional single ventricle who underwent the hemi-Fontan procedure as an intermediate stage between the initial palliative shunt procedure and the final complete Fontan anastomosis. Symmetric pulmonary blood flow (PBF) distribution was found in 27% of patients, whereas moderately to severely abnormal PBF distribution was found in 35% of patients. The achieved systemic aortic saturation following the hemi-Fontan procedure was not affected by these abnormalities.

Volume-dependent pulmonary aspiration of a swallowed radionuclide bolus

The radionuclide salivagram was introduced as a simple physiologic technique to document the aspiration of saliva in patients with chronic lung disease. We previously reported positive studies to be prevalent in patients with neuromuscular incoordination, as with cerebral palsy, or after surgery involving the upper airway. Many patients referred for a salivagram, however, have an apparent intact swallowing mechanism and are better challenged with a tagged bolus.

Results of dacryoscintigraphy in massage of the congenitally blocked nasolacrimal duct

Between November 1990 and November 1993, 580 children with lacrimal outflow obstruction were examined at the Children's Hospital of Philadelphia. After excluding patients previously treated for nasolacrimal duct obstruction, we obtained a prospectively selected series of 20 children for this study. These patients underwent dacryoscintigraphy before and immediately after lacrimal sac massage to investigate the effect of external compression on fluid movement within the lacrimal outflow system. In 12 patients, tracer did not enter the lacrimal outflow system on the side(s) of obstruction. The absence of radiopharmaceutical correlated with clinical obstruction. In eight patients, tracer was noted to enter the lacrimal sac. After massage of the lacrimal sac, we observed progression of the tracer in five of the eight subjects. In these eight subjects, the pre- and postmassage tear column measurements showed a relative increase of 34.3%. Massage of eight clinically normal ducts showed a relative increase of 2.4% (p = 0.06). We conclude that progression of the tear column after lacrimal massage can be demonstrated on dacryoscintigraphy.

Fetal mouse lung ultrastructural maturation is accelerated by maternal thyrotropin-releasing hormone treatment

Maternal administration of thyrotropin-releasing hormone, alone or in combination with corticosteroid, accelerates functional, morphologic and biochemical fetal lung maturation. However, the dose-response relationship of maternal thyrotropin-releasing hormone treatment and acceleration of fetal lung ultrastructural maturation or disaturated phosphatidylcholine content has not been investigated. We administered (i.p.) saline or thyrotropin-releasing hormone (0.2, 0.4 or 0.6 mg/kg/dose) to the pregnant Balb/c mouse on days 16 and 17 (b.i.d.) and on day 18 of gestation (1 h prior to killing). Morphometric ultrastructural analysis and quantitation of disaturated phosphatidylcholine content was done on the 18-day gestation fetal lung. Maternal thyrotropin-releasing hormone treatment resulted in an increase in the number of lamellar bodies and depletion of glycogen in fetal lung type II cells, and an increase in the lung airspace to parenchymal ratio. In addition, a striking difference in the pattern of lung growth was noted in the thyrotropin-releasing-hormone-treated (0.4 and 0.6 mg/kg/dose) groups. These lungs had larger air spaces, thinner alveolar septae and more air-blood barriers. Maternal thyrotropin-releasing hormone treatment did not influence fetal lung disaturated phosphatidylcholine content. We conclude that in the mouse, maternal thyrotropin-releasing hormone treatment enhances fetal lung structural maturation and propose that thyrotropin-releasing hormone plays a role in mammalian fetal lung growth.

Pediatric gastrointestinal motility studies

Radionuclide studies for evaluating gastrointestinal transit in adults have been adapted for use in infants and children for assessing esophageal transit, gastroesophageal reflux, and gastric emptying. However, the measurement of small- and large-bowel transit times in these patients has been limited.

Langerhans cell histiocytosis: presentation and evolution of radiologic findings with clinical correlation

Radiologic images and medical records of 42 children with Langerhans cell histiocytosis (LCH) (histiocytosis X) were reviewed to evaluate the presentation of the disease and the evolution of the radiologic findings. There were 26 male and 16 female patients aged 3 months to 18 years. Twenty-two patients presented with localized disease; 20 presented with multifocal disease. Four patients developed diabetes insipidus. Two patients had organ dysfunction. The radiologic findings were largely due to destructive bone lesions; 83% of the patients had at least one affected bone. Isolated soft-tissue masses, interstitial lung disease, and central nervous system abnormalities were also seen. Of patients in whom results of appropriate follow-up were available, 91% showed improvement in their lesions, 43% developed new lesions, and 92% had good clinical outcomes. LCH is usually a self-limited disease with a varied clinical and radiologic presentation. The prognosis is generally poor in children with organ dysfunction. In the absence of organ dysfunction, children with either localized or multifocal LCH have an excellent prognosis.

Radionuclide studies of the upper gastrointestinal tract in children with feeding disorders

The case of a female infant with a feeding disorder and with inadequate growth is described. In her workup, there was no evidence of an organic disorder. Barium studies of the upper GI tract showed normal anatomy and function. A radionuclide milk scan was helpful in demonstrating mild reflux and significantly delayed gastric emptying. There was a good response to therapy.

Direct vesicoureteral scintigraphy: quantifying early outcome predictors in children with primary reflux

This study quantifies some of the outcome predictors in a group of children with primary vesicoureteral reflux who were initially managed medically.

METHODS

We studied 133 patients with primary reflux for 7.1 +/- 2.2 yr. Direct vesicoureteral scintigraphy (DVS) was used to prospectively measure the absolute bladder volume at which reflux began and the maximum volume of urine refluxed into the ureters during the filling and voiding phases of their first two DVS studies. Findings were related to outcome as defined by spontaneous resolution or the eventual need for reconstructive surgery.

RESULTS

Medical management eventually failed in 35% of this sample. Patients who did not begin to reflux until their bladders had been filled to more than 60% total bladder capacity had a substantially smaller risk of surgery than those who began to reflux at smaller bladder volumes. Patients who refluxed a volume of urine back into their ureters that was less than about 2% of their total bladder capacity had a substantially smaller risk of surgery than those who refluxed more than 2%. The difference between groups was significant for both DVS variables (p < 0.001).

CONCLUSION

Quantitative DVS contributes to the assessment of prognosis in children with vesicoureteral reflux who are managed medically.

Meckel's diverticulum: possible detection by combining pentagastrin with histamine H2 receptor blocker

A Meckel's scan was performed on a 7-yr-old boy because of rectal bleeding. He was premedicated with pentagastrin (6 micrograms/kg subcutaneously) followed by 259 MBq (7 mCi) [99mTc]pertechnetate intravenously. The study was essentially negative. Because of persistent rectal bleeding and a strong clinical suspicion of a Meckel's, a repeat study was performed 6 wk later. He received pentagastrin as before, but this time was also given a histamine H2 receptor blocker (zantac). A Meckel's diverticulum was clearly evident.

Delayed ultrastructural lung maturation in the fetal and newborn hypothyroid (Hyt/Hyt) mouse

Thyroid hormones influence fetal and neonatal lung growth and maturation. However, the effect of naturally occurring, genetically determined hypo- or hyperthyroidism on fetal or neonatal lung maturation has not been examined. In the hyt/hyt mouse, primary hypothyroidism, which is characterized by a high serum TSH concentration, is transmitted as an autosomal recessive trait. It occurs due to a mutational defect in the beta-subunit of the TSH receptor. We studied the lung ultrastructure of the fetal [18-d-gestation (term = approximately 19.5 d)] and neonatal (< 1-d-old) hyt/hyt mouse. In addition, disaturated phosphatidylcholine and total phospholipid contents of newborn hyt/hyt mouse lungs were determined. Male and female hyt/hyt mice with a high serum TSH concentration were made euthyroid by adding 3,5,3'-triiodothyronine to drinking water and then mated. Balb-c mice served as euthyroid controls. Fetal and neonatal hyt/hyt mice had a higher serum TSH concentration than the Balb-c controls. Fetal hyt/hyt mouse lungs showed a large amount of intracellular glycogen and fewer lamellar bodies in epithelial type II cells compared with Balb-c fetal mouse lungs. The neonatal hyt/hyt mouse also showed signs of lung immaturity such as persistent epithelial cell glycogen, few lamellar bodies, reduced disaturated phosphatidylcholine content, and absent tubular myelin. We conclude that fetal and neonatal lung maturation is delayed in the hyt/hyt mouse with primary hypothyroidism.

Ultrastructure of lung in surfactant protein B deficiency

Congenital alveolar proteinosis (CAP), a cause of respiratory failure in fill-term newborns, often leads to death in infancy despite medical therapy. We recently described an inherited deficiency of surfactant protein B (SP-B) (N. Engl. J. Med. 1993; 328:406-410) in two siblings with CAP. The SP-B deficiency was accompanied by marked abnormalities, both quantitative (increase) and qualitative (distribution), of SP-A and SP-C in the lungs of the affected infants. Ultrastructural studies of the lung of one of these infants and of a third affected sibling born in the index family showed abundant alveolar concentric multilamellated structures and membranous vesicles but no typical tubular myelin. In addition, membranous vesicles from type II cells and immunogold labeled SP-A and SP-C were found between type II cells and their basement membrane despite intact interepithelial cell junctions. These findings suggest an important role for SP-B in the directionality of surfactant secretion and in the formation of tubular myelin.

Molecular and phenotypic variability in the congenital alveolar proteinosis syndrome associated with inherited surfactant protein B deficiency

Congenital alveolar proteinosis (CAP) is an often fatal cause of respiratory failure in term newborn infants, which has been associated with a genetic deficiency of surfactant protein B (SP-B) as a result of a frameshift mutation (121ins2) in a family with three affected siblings. In the index cases the deficiency of SP-B was associated with qualitative and quantitative abnormalities of the surfactant proteins A and C. Immunostaining for lung surfactant proteins and a search for the 121ins2 mutation by restriction enzyme analysis of DNA extracted from paraffin-embedded lung tissue was performed for 7 additional affected infants from 6 families, bringing to 10 the total number of patients with CAP who have been studied. In six infants, the surfactant protein immunostaining pattern was similar to that of the index cases. Of these, three patients were homozygous for the 121ins2 mutation; one was a compound heterozygote with the 121ins2 in one allele and a different mutation in the other; and three patients lacked the mutation in both alleles. One infant had an abundance of SP-B, suggesting phenotypic heterogeneity in CAP. Lung ultrastructural abnormalities, such as a reduced number of lamellar bodies, absent tubular myelin, and basal secretion of surfactant lipids and proteins, suggest a significant derangement of surfactant metabolism. The phenotypic heterogeneity in infants with CAP raises the possibility that variable degrees of SP-B deficiency may be more common than previously suspected.

Nephrotic syndrome as an unusual paraneoplastic syndrome of Hodgkin's disease demonstrated on gallium-67 scan

Nephrotic syndrome, although rare, is recognized as one of the paraneoplastic syndromes. A patient with documented Hodgkin's disease showed increased uptake of Ga-67 in the cortex of both kidneys in addition to multiple sites of lymphomatous involvement. The patient was not receiving chemotherapy or any nephrotoxic drugs, and no other reasons that may account for renal uptake of gallium could be identified. The final clinical diagnosis was nephrotic syndrome as an unusual paraneoplastic syndrome of Hodgkin's disease. Gallium imaging was able to detect multiple sites of lymphoma and the renal uptake due to the associated nephrotic syndrome.

Hyperoxia induces interstitial (type I) and increases type IV collagenase mRNA expression and increases type I and IV collagenolytic activity in newborn rat lung

Oxygen toxicity is attributed to the reaction of oxygen metabolites with cellular components leading to cell destruction. Activation of latent human neutrophil interstitial collagenase by reactive oxygen species has been demonstrated. The potential role of collagenases in hyperoxic lung injury has not been investigated. We studied the effect of hyperoxia on newborn rat lung water content, morphology and ultrastructure, interstitial (type I) and type IV collagenase gene expression and type I and IV collagenolytic activity. We observed that hyperoxia causes pulmonary edema, alters newborn rat lung morphology in a sequential manner and produces ultrastructural alterations, induces type I and increases type IV collagenase mRNA expression, and increases type I and IV collagenolytic activity. A role for type I and IV collagenase in hyperoxic newborn lung injury or in the recovery following the injury is proposed.

Comparison of cardiac function tests after anthracycline therapy in childhood. Implications for screening

BACKGROUND

Numerous methods for evaluating cardiac function after cardiotoxic therapy have been suggested. A practical algorithm for screening a large patient population is needed.

METHODS

Seventy-three patients (median age, 15.3 years [range, 9-29 years) who received anthracyclines (median dose, 300 mg/m2 [range, 50-750 mg/m2) for a childhood malignancy underwent a battery of commonly used tests of cardiac function: (1) echocardiographic shortening fraction (ESF); (2) resting and exercise radionuclide scan (multiple gaited acquisition [MUGA]); (3) electrocardiogram (ECG); (4) 24-hour Holter monitor, and (5) questionnaire concerning exercise tolerance.

RESULTS

Patients with an abnormal resting ejection fraction on MUGA were more likely to have an abnormal ESF (P = 0.023), prolongation of the QTc interval (P = 0.014), and complaints of "difficulty" with exercise (P = 0.04). An abnormal results for a resting study was not predictive of an abnormal MUGA exercise response. There was no association between the presence of significant dysrhythmia on Holter monitor and any resting test. An algorithm was developed using a normal ESF and QTc interval, and a negative history of exercise intolerance to identify patients who need not undergo a MUGA. With the use of such an algorithm, 29 of the 73 patients would not have undergone the MUGA, only 2 of whom had an abnormal resting ejection fraction.

CONCLUSION

Patients at risk for cardiac damage after cancer therapy who have normal ESF and QTc interval results and no history of exercise intolerance are unlikely to have abnormal MUGA results. Significant dysrhythmia may be present in the absence of other abnormalities.

Immunogold localization of SP-A in lungs of infants dying from respiratory distress syndrome

Prematurely born infants can develop the neonatal respiratory distress syndrome (RDS) because of a deficiency of pulmonary surfactant. This lipoprotein complex synthesized by type II pneumocytes has different ultrastructural forms--intra- and extracellular lamellar bodies, which within the alveoli are transformed into tubular myelin, and this in turn gives rise to the surface monolayer, the functionally active form of surfactant. We have previously shown that at autopsy RDS lungs lack tubular myelin and have decreased immunoreactivity for antisera to surfactant protein A (SP-A), an important component of tubular myelin. Therefore, we proposed a role for SP-A in the conversion of lamellar bodies to tubular myelin and in the pathogenesis of RDS. To explore this possibility further, we compared in 14 RDS and 14 control lungs the distribution of SP-A in ultrathin sections, using affinity-purified rabbit anti-human-SP-A IgG and goat anti-rabbit IgG-conjugated with 10 nm colloidal gold particles. In controls, gold label was present in lamellar bodies, endoplasmic reticulum, on the cytoplasmic membrane of type II cells, and on lamellar bodies and tubular myelin either within alveoli or macrophages. In RDS lungs, reduced label was present in the same intracellular compartments and organelles, except in tubular myelin, which is absent. It is postulated that if SP-A is indeed necessary for the conversion of lamellar bodies to tubular myelin, in RDS either there is a deficiency of adequate amounts of functional SP-A or some other important component of surfactant is missing.

Orbital wall infarction in sickle cell disease: MR evaluation

Orbital wall infarction in a patient with sickle cell disease can present with periorbital swelling and subperiosteal collection and thus can mimic infection on CT. However, MR not only provides excellent morphologic information but, by characterizing the nature of the collection as containing blood, and by identifying bone marrow abnormality, can lead to the diagnosis of orbital wall infarction.

Managing apparent ureteropelvic junction obstruction in the newborn

A total of 97 newborns with apparent ureteropelvic junction obstruction was evaluated from mid 1984 to 1989. Evaluation and management are described. Of these patients 39 with an affected kidney showing good initial differential function (greater than 35%) by diethylenetriaminepentaacetic acid scan and 2 showing diminished function (less than 35%) were followed nonoperatively. Six patients (15%) eventually required pyeloplasty for diminishing function (4), urinary tract infections (1) or symptoms of colic (1). The 4 patients with diminishing function improved after pyeloplasty to at least the initial level. A total of 12 patients with good initial function (greater than 35%) of the affected kidney underwent early pyeloplasty (within 6 weeks of diagnosis). They were compared to the similar group of patients managed nonoperatively and followed by sequential renal scans. Eventual changes in percentage differential function in the nonoperative and early surgery groups were +2.8% and +4.1%, respectively. Changes in extraction factor were +0.8% (nonoperative group) and +0.9% (surgery group). No statistically significant difference was found. In the kidney with apparent ureteropelvic junction obstruction and good function, an initial nonoperative approach with sequential renal scan followup and pyeloplasty as needed appears to be reasonable and has resulted in no permanent loss of function.

Mechanism of glycine protection in hypoxic injury: analogies with glycine receptor

Addition of glycine to the recirculating perfusate of isolated perfused rat kidneys protects against hypoxic injury to the medullary thick ascending limb and slows functional deterioration in the course of perfusion. This effect is dependent on dose; the earliest significant protection is seen at 0.25 mM, and the protective effects increase as glycine concentration is increased to 2 mM, the highest level tested. Two specific agonists of the strychnine-insensitive (NMDA) glycine receptor in neural membranes, 1-aminocyclopropane carboxylic acid (ACC) and d-serine, also exerted a cytoprotective effect at a concentration of 2 mM. On the other hand, 1-serine and taurine, ineffective agonists of the NMDA-glycine receptor but effective agonists of the strychnine-sensitive glycine receptor, had no protective effect in this system. Two antagonists to glycine at its binding site on the N-methyl-D-Aspartate (NMDA) receptor, 7-chlorokynurenic acid (2 mM) and indole-2-carboxylic acid (12.5 mM), did not reverse the cytoprotective action of 0.25 mM glycine. The data are consistent with a ligand-acceptor type of interaction to account for cytoprotection. The configuration of the glycine acceptor may resemble, but is not identical with, that of certain glycine receptors in the nervous system.

Skeletal scintigraphy of pseudo-osteomyelitis in Gaucher's disease. Two case reports and a review of the literature

Two patients with known type 1 Gaucher's disease had signs and symptoms of osteomyelitis. Decreased perfusion and impaired uptake were seen on bone scan. Patient 1 had a culture-negative aspirate of the site. Patient 2 had no surgical procedures. Both improved on bed rest and nonsteroidal anti-inflammatory agents. It is difficult to distinguish osteomyelitis clinically from pseudo-osteomyelitis. The authors suggest that photopenia on bone scan performed within 1 to 3 days of presentation is suggestive of pseudo-osteomyelitis in Gaucher's disease.