Clinics in diagnostic imaging (122)

A 37-year-old Indian man presented with a two-year history of right hip pain. Radiographs showed small faint dense nodules at the inferomedial aspect of the right hip joint. Diagnosis of synovial osteochondromatosis was made on MR imaging, where multiple ossified loose bodies surrounded by a joint effusion, as well as enhancing synovium, were seen. Synovectomy and removal of 31 loose bodies were performed, and the diagnosis was confirmed histologically. The clinical manifestations and imaging features of synovial osteochondromatosis are discussed.

Hypospadias repair using a double onlay preputial flap

From an anatomical view, a more reasonable blood supply can be achieved in hypospadias repair using a double-faced onlay flap. A urethroplasty was performed in 15 patients with middle or posterior hypospadias using a double-faced onlay preputial flap (DOPF). In this method, the urethral plate is preserved and a double-faced preputial flap is developed. The inner face of the flap is sutured to the urethral plate to create the neourethra and the outer face together with the rest of the dorsal prepuce is used for ventral skin coverage. Postoperative complications occurred in 2 patients: 1 developed a fistula in the subcoronal region and 1 had dorsal skin necrosis and suture disruption of the glanular wings. The overall complication rate was 13%. The DOPF provides a well-vascularized ventral skin cover and reduces the area of avascular dorsal skin. The viability of the neourethra can be evaluated by simply looking at the outer face of the flap. However, the complication rate is similar to that of other techniques.

White paper on herbal products. American College of Clinical Pharmacy

Individuals increasingly are taking a more active role in their health care, and herbal products have emerged as a common choice among self-care therapies. Pharmacists are active participants in the care of patients who are taking herbal products. Currently, most pharmacists are not educated adequately about herbal products and other types of alternative medicine. Furthermore, good information about many of these products is not available. These combined factors present a challenge for pharmacists as they seek to provide optimal care and counseling to patients who use herbs or supplements. We recommend the following actions to place pharmacists in better positions as effective agents protecting public safety: Regulations should be implemented at a federal level to require basic levels of standardization and quality control in the manufacture of herbal products. Indexing terms in medical bibliographic systems should be expanded to target herbal products. Funding should be increased for scientific research evaluating herbal products. Pharmacy schools should include a competency statement in their curricula regarding herbal medicines. Continuing education in herbal products should be available and encouraged for all pharmacists. Pharmacists should approach the use of all therapeutic interventions with scientific rigor, whether they are traditional or complementary in nature. Patients will benefit as more information is known and widely disseminated. By actively embracing the responsibility for counseling individuals on the appropriate use of herbal products, pharmacists will become a recognized source of expert information in this rapidly growing area, yielding important improvements in the quality of care.

Immunosuppressive and cytotoxic effects of furosemide on human peripheral blood mononuclear cells

BACKGROUND

We have previously shown that children with mild asthma have a modest improvement in their pulmonary function tests after aerosolized furosemide. The mechanism of action is not known. The observation that furosemide possesses a similar profile of protection as sodium cromoglycate and nedocromil sodium suggests that furosemide may inhibit mediator production and release.

OBJECTIVE

We studied the in vitro effects of furosemide on cytokine release from normal human peripheral blood mononuclear cells (PBMC) induced by E. coli lipopolysaccharide (LPS).

METHODS

Peripheral blood mononuclear cells were isolated by density gradient centrifugation, stimulated with LPS and incubated at 37 degrees C with varying concentrations of furosemide, hydrocortisone, sodium cromoglycate, and nedocromil sodium for 24 hours. Supernatants were extracted and study for levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and interleukin-8 (IL-8). Intracellular IL-6 and TNF-alpha concentrations were also measured by cell cytometry. Cell viability was examined using XTT cell proliferation test and-measuring the release of lactate dehydrogenase (LDH).

RESULTS

There was a significant reduction in levels of TNF-alpha and IL-6 at a furosemide concentration of 0.5 x 10(-2) M and a reduction in IL-8 levels at 10(-2) M. This inhibition was comparable to that found with equivalent molar concentrations of hydrocortisone. These findings were also confirmed with measurements of intracellular IL-6 and TNF-alpha by cell cytometry. High concentration of furosemide at 10(-2) M caused significant cellular cytotoxicity.

CONCLUSION

These data suggest that furosemide may exhibit an anti-inflammatory effect. Specifically, the addition of furosemide resulted in decreased production of cytokines. This effect may be due to an immunosuppressive activity on monocytes as well as a direct cytotoxic effect at high furosemide concentrations.

Testicular yolk sac tumors in children

BACKGROUND

Testicular tumors in children are uncommon, comprising about 1% of pediatric malignancies. Yolk sac tumor is the most common malignant testicular tumor in children. Because yolk sac tumor in children is rarely seen, its treatment has been controversial. We reviewed the records of 15 children with testicular yolk sac tumor treated at our hospital in order to evaluate optimal management and treatment outcome.

METHODS

From February, 1981, to August, 1996, 15 children with testicular yolk sac tumor were treated. Mean patient age at diagnosis was 15.8 months (range, 7-22 months). Fourteen patients presented with stage I disease and one presented with stage III disease. Mean follow-up was 88 months (range, 2-156 months).

RESULTS

All 15 patients received radical inguinal orchiectomy as initial treatment. Serum alpha-fetoprotein (AFP) concentrations were measured in 14 stage I patients preoperatively and were elevated in all of them. During follow-up, the one stage III patient died of the disease. Of the remaining 14 patients, two (14.3%) had recurrence with elevated AFP at three months and 10 months postorchiectomy, respectively. These patients were managed with cisplatin-based combination chemotherapy. To date, they are both alive with no further recurrence, and AFP concentrations returned to normal after chemotherapy. Overall, of the 15 patients with testicular yolk sac tumor, 14 (93.3%) survived without disease.

CONCLUSIONS

Our results suggest that testicular yolk sac tumor in children is a tumor with a favorable prognosis. Serum AFP concentration is extremely useful in diagnosis and monitoring of treatment response. Radical inguinal orchiectomy alone seems adequate for patients with stage I disease if serum AFP concentrations return to normal postoperatively. Cisplatin-based combination chemotherapy should be administered in patients with tumor recurrence or metastasis.

Value of gamma-glutamyl transpeptidase for early diagnosis of biliary atresia

BACKGROUND

Early diagnosis of congenital biliary atresia (BA) is important because the prognosis is closely related to timing of a hepaticoportoenterostomy. In this study, we discuss whether the elevation of serum gamma-glutamyl transpeptidase (GGT) is accurate for the early differentiation of BA from neonatal hepatitis (NH).

METHODS

The effectiveness of using GGT before the age of 10 weeks and other tools in the differential diagnosis of BA and NH were analyzed retrospectively by reviewing the charts of 29 BA and 12 NH patients. The results of serial liver enzyme studies, abdominal sonography, hepatobiliary scintigraphy and transcutaneous liver biopsy were compared between both groups.

RESULTS

The peak GGT value in BA before 10 weeks of age was significantly higher than that in NH (622.5 +/- 211.9 U/l vs 168.8 +/- 100.3 U/l, respectively, p < 0.001). When a serum GGT concentration greater than 300 U/l was used as a diagnostic criterion for BA in patients younger than 10 weeks of age, the diagnostic accuracy was 85%. When an increase in GGT value (in serial measurements) of greater than 6 U/l/day was used as a criterion, the accuracy was 88%. The diagnostic accuracy of abdominal sonography, hepatobiliary scintigraphy and liver biopsy was 68%, 67% and 79%, respectively.

CONCLUSIONS

GGT concentration is diagnostically valuable when the results of other diagnostic methods are not available, or are controversial, in differentiating between BA and NH.

Intraoperative non-puncture laparoscopic examination of contralateral internal inguinal rings is feasible in children with unilateral hydrocele

BACKGROUND

Intraoperative non-puncture laparoscopic examination using the hernia sac as the scope entrance has been successfully conducted in children with unilateral inguinal hernia. This technique selects patients for contralateral inguinal exploration. In spite of the thin and narrow processus vaginalis, children with unilateral hydrocele encounter the same problem of subsequent contralateral inguinal hernia or hydrocele. In this study, we discuss the feasibility of this technique in children with unilateral hydrocele.

METHODS

From July 1993 to September 1995, 91 children with unilateral hydrocele were examined during surgery at our institution. The results, including success rate, complications, patent rate of contralateral internal ring and contralateral subsequent hernia or hydrocele, at at least one year follow-up, were compared with those of 329 children with unilateral hernia undergoing the same examination during this period.

RESULTS

A patent contralateral processus vaginalis was recognized in 31 children and all were confirmed by surgical exploration. The examination failed in three patients, of whom two had a tear in the processus vaginalis and one had retroperitoneal air dissection as a result of false insertion of the laparoscopic sheath. One patient had a postoperative wound infection. No patient with contralateral obliterated processus vaginalis developed inguinal hernia or hydrocele during follow-up of at least one year. The results were similar to those of the 329 children with hernia who underwent the same procedure in the same period.

CONCLUSIONS

Intraoperative non-puncture laparoscopic examination is feasible in children with unilateral hydrocele.

RADIOLOGICAL AND SURVIVAL COMPARISON OF FOUR METHODS OF FIXATION OF A PROXIMAL FEMORAL STEM

We compared the radiological appearances and survival of four methods of fixation of a femoral stem in 538 hips after follow-up for five or ten years. The fixation groups were: 1) press-fit shot-blasted smooth Ti-Al-V stem; 2) press-fit shot-blasted proximally ridged stem; 3) proximal hydroxyapatite (HA) coating; and 4) cementing.

Survival analysis at five to ten years showed better results in the HA-coated (100% at five to six years) and cemented stems (100% at 5 to 6 years) than in the two press-fit groups. There was a higher mean rate of migration in the smooth and ridged Ti-Al-V shot-blasted press-fit groups (0.8 mm/year and 0.6 mm/year, respectively) when compared with the HA-coated and cemented prostheses (both 0.3 mm/year). More radiolucent lines and osteolytic lesions were seen in the press-fit groups than in either the HA-coated or cemented implants, with a trend for a lower incidence of both in the HA compared with the cemented group. Proximal osteopenia increased in the press-fit and cemented prostheses with time, but did not do so in the HA group. There was a higher incidence of resorption of the femoral neck with time in the cemented group than in the other three.

We conclude that the HA and the cemented interfaces both provide secure fixation with a trend in favour of HA. The cemented prosthesis meets the suggested National Institutes of Health definition of ‘efficacious’ at ten years.

Radiological and survival comparison of four methods of fixation of a proximal femoral stem

We compared the radiological appearances and survival of four methods of fixation of a femoral stem in 538 hips after follow-up for five or ten years. The fixation groups were: 1) press-fit shot-blasted smooth Ti-A1-V stem; 2) press-fit shot-blasted proximally ridged stem; 3) proximal hydroxyapatite (HA) coating; and 4) cementing. Survival analysis at five to ten years showed better results in the HA-coated (100% at five to six years) and cemented stems (100% at 5 to 6 years) than in the two press-fit groups. There was a higher mean rate of migration in the smooth and ridged Ti-A1-V shot-blasted press-fit groups (0.8 mm/year and 0.6 mm/year, respectively) when compared with the HA-coated and cemented prostheses (both 0.3 mm/year). More radiolucent lines and osteolytic lesions were seen in the press-fit groups than in either the HA-coated or cemented implants, with a trend for a lower incidence of both in the HA compared with the cemented group. Proximal osteopenia increased in the press-fit and cemented prostheses with time, but did not do so in the HA group. There was a higher incidence of resorption of the femoral neck with time in the cemented group than in the other three. We conclude that the HA and the cemented interfaces both provide secure fixation with a trend in favour of HA. The cemented prosthesis meets the suggested National Institutes of Health definition of 'efficacious' at ten years.

Malignant epithelial neoplasm consistent with primitive cystic hepatic neoplasm with mesothelial differentiation: a case report

Mesothelioma are primary tumors of the celiomic cavity and are seen more often in adults than in children: only an estimated 2-5% of all cases present within the first two decades of life. To best knowledge of the reviewing world literature reported to date, no more than 80 proved cases of this tumor have occurred in children. One-third of mesothelioma originate in the peritoneum and two-thirds arise in the pleural cavity. Mesothelioma of the liver are extremely rare; a review of the English literature shows only three adult cases that have been reported as fibrous mesothelioma of the liver; experience with these cases suggests a high potential for recurrence, but no progression to malignancy. Cystic mesothelioma occur mainly in adults and are considered to be benign and curable. We describe a case of malignant epithelial neoplasm consistent with primitive cystic hepatic neoplasm with mesothelial differentiation arising in a 3-year-old boy, a condition which has never before been reported in childhood. Malignant primitive cystic mesothelioma is possible that some cases of intraabdominal mesenchymoma or hamartoma with malignant differentiation may have been misdiagnosed in the past; future cases should be fully evaluated, to establish the true incidence of mesothelioma disease in children.

Successful surgical treatment of bilateral congenital chylothorax: a case report

A male infant was diagnosed at 19 days old to have a right chylothorax. Conservative management, including median-chain triglyceride (MCT) diet, total parenteral nutrition (TPN) and chyle drainage, were unsuccessful. The boy received a right thoracotomy with ligation of the thoracic duct and sutures of leaking lymphatic ducts at the age of 65 days. The result of the operation was satisfactory but left chylothorax developed six days later. Left thoracotomy was performed eight days later to suture the leaking lymphatic chains and finally the patient recovered well. Followed for one year, the patient's physical development was satisfactory. Prompt surgical intervention for congenital chylothorax is strongly recommended, if medical treatment fails.

Prevalence of Legionella pneumophila infection in children and its role in pediatric community-acquired atypical pneumonia

The infection status of Legionella pneumophila in children and its role in pediatric community-acquired pneumonia were investigated. Because exposure to Legionella pneumophila may be highly variable and there has been no unanimously agreed-upon cut-off values in previous seroprevalence studies, 60 serum samples collected from infants aged 12 to 18 months were examined using immunofluorescence antibody test to determine the cut-off titer which represents past Legionella pneumophila infection. An IFA titer of greater than or equal to 32 was found to be suitable to represent past L. pneumophila infection. A seroepidemiological study of the prevalence of L. pneumophila in 180 children showed the prevalences in children aged 7 to 18 years to be between 28.4 and 35%. Fifty-three paired sera were tested to determine the role of Legionella pneumophila in pediatric, community-acquired, atypical pneumonia. The frequency of confirmed disease was 0% and of presumptive cases was 5.7%. Legionella pneumophila was not a common etiologic agent of pediatric pneumonia in Taiwan.

Arthroscopic treatment of osteochondral lesion of the talus

A retrospective study of the arthroscopic treatment of osteochondral lesions of the talus in 25 patients was conducted. The follow-up period ranged from 1 to 4 years with an average of 2 years. Of the 25 patients, 20 could recall a history of injury. The diagnosis could be made by standard anteroposterior and lateral X-rays in 22 out of 25 patients. The standard anteromedial and anterolateral portals were usually sufficient. Patients with stage I and II lesions did well uniformly. In the 16 patients with stage III and IV lesions, good results were obtained in 12 and fair in 4. Morbidity was minimal.

Tarsometatarsal (Lisfranc's) injuries--results of open reduction and internal fixation

Injuries of the tarsometatarsal (Lisfranc's) joint are uncommon and are potentially associated with chronic disability. The aim of our study was to review retrospectively the results of open reduction with Kirschner wire internal fixation of tarsometatarsal injuries. In this study, 12 patients with Lisfranc's injuries treated between January 1986 and March 1993 were reviewed at an average of 36 months after the injuries. Majority of the patients suffered from type B injuries (Hardcastle's classification, 1982). There were 9 closed and 3 open injuries. All were high energy injuries sustained in motor vehicle accidents, fall from a height or crush force. All were treated with open reduction and internal fixation with Kirschner wires. Anatomical reduction was achieved and maintained. There was no postoperative redisplacement. During follow-up, most patients developed radiological evidence of post-traumatic osteoarthritic changes. However, majority of the patients were pain-free or had very little foot pain, and were able to return to their previous occupation. Our study showed that open reduction with Kirschner wire internal fixation offered satisfactory anatomical and functional results.

Effects of an acidic beverage (Coca-Cola) on absorption of ketoconazole

Absorption of ketoconazole is impaired in patients with achlorhydria. The purpose of this study was to determine the effectiveness of a palatable acidic beverage (Coca-Cola Classic, pH 2.5) in improving the absorption of ketoconazole in the presence of drug-induced achlorhydria. A prospective, randomized, three-way crossover design with a 1-week wash-out period between each treatment was employed. Nine healthy nonsmoking, nonobese volunteers between 22 and 41 years old were studied. Each subject was randomized to receive three treatments: (A) ketoconazole 200-mg tablet with water (control), (B) omeprazole (60 mg) followed by ketoconazole (200 mg) taken with water, and (C) omeprazole (60 mg) followed by ketoconazole (200 mg) taken with 240 ml of Coca-Cola Classic. The pH values of gastric aspirates were checked after omeprazole was administered to confirm attainment of a pH of > 6. Multiple serum samples were obtained for measurements of ketoconazole concentrations by high-pressure liquid chromatography. The mean area under the ketoconazole concentration-time curve from zero to infinity for the control treatment (17.9 +/- 13.1 mg.h/liter) was significantly greater than that for treatment B (3.5 +/- 5.1 mg.h/liter; 16.6% +/- 15.0% of control). The mean peak concentration was highest for the control treatment (4.1 +/- 1.9 micrograms/ml), for which the mean peak concentration showed a significant increase over that for treatment B. The absorption of ketoconazole was reduced in the presence of omeprazole-induced achlorhydria. However, drug absorption was significantly increased, to approximately 65% of the mean for the control treatment, when the drug was taken with an acidic beverage, such as Coca-Cola.

Surgical treatment of symptomatic accessory navicular

The accessory navicular is a known cause of foot pain. When symptomatic and conservative measures have failed, surgical intervention may be required. Simple excision of the ossicle or the Kidner procedure with transplantation of tibialis posterior tendon to the undersurface of the navicular bone may be done. Eighteen patients with symptomatic accessory navicular were reviewed at the Singapore General Hospital, Department of Orthopaedic Surgery 'O' Unit. All 18 patients had foot pain and restriction of activities. Thirteen noticed a prominence on the medial side of the affected foot and 7 had difficulty with shoe fitting. Nine underwent simple excision of the ossicle while the other 9 had the Kidner procedure done. The average follow-up period was 3.1 years. Both the simple excision and the Kidner procedure were equally successful in relieving symptoms in 15 out of the 18 cases. The Kidner procedure did not confer any particular advantage over simple excision.

Pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients

Current dosage regimens of trimethoprim-sulfamethoxazole used to treat Pneumocystis carinii pneumonia in AIDS patients have been based on data from healthy subjects or patients without AIDS. The clearance and absorption characteristics of the drugs may potentially be different between patients with and without AIDS. This study was conducted to assess the pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients treated for P. carinii pneumonia. Patients received trimethoprim at 15 mg/kg of body weight and sulfamethoxazole at 75 mg/kg of body weight daily intravenously in three to four divided doses and were switched to the oral route when the regimen was tolerated. Serum samples for determination of drug concentrations were obtained over 12 h after intravenous and oral dosing. The pharmacokinetics of trimethoprim and sulfamethoxazole were compared in eight critically ill versus nine non-critically ill male patients and were as follows, respectively: clearance, 1.88 +/- 0.44 versus 1.73 +/- 0.64 ml/min/kg for trimethoprim and 0.40 +/- 0.12 versus 0.34 +/- 0.11 ml/min/kg for sulfamethoxazole; volume of distribution, 1.6 +/- 0.5 versus 1.5 +/- 0.5 liters/kg for trimethoprim and 0.5 +/- 0.3 versus 0.4 +/- 0.1 liters/kg for sulfamethoxazole; and half-life, 10.9 +/- 7.4 versus 11.3 +/- 4.0 h for trimethoprim, and 15.5 +/- 9.5 versus 14.3 +/- 4.7 h for sulfamethoxazole. No significant differences (P > 0.05) were observed between patient groups, although there was wide intersubject variability. Absorption appeared to be similar between the critically ill and non-critically patients: bioavailability was 97.5% +/- 22.4% versus 101.8% +/- 22.7% for trimethoprim and 86.2% +/- 17.9% versus 99.1% +/- 20.5% for sulfamethoxazole, respectively. Because of the similar pharmacokinetics of trimethoprim-sulfamethoxazole in critically ill and non-critically ill AIDS patients, the two groups of patients may receive similar dosages. Dosage adjustment does not appear to be required when switching from the intravenous to the oral route.

Histiocytosis X involving thyroid gland: a case report

Diffuse histiocytosis X involving thyroid gland is rare. A 10-year-old boy with progressively enlarged neck mass, skin rash over scalp and face, splinter hemorrhage, otitis externa, episodes of pneumothorax and abnormal liver function was hospitalized. Thyroid scan showed a nonfunctioning mass in the right lobe of the thyroid and needle aspiration biopsy suspected histiocytosis X. Right thyroid lobectomy was performed and revealed histiocytosis X in light and electron microscopic examinations.

Familial pulmonary nodular lymphoid hyperplasia

We describe three persons in one family with diffuse lung infiltrates, digital clubbing, and chronic hypoxia. Elevated immunoglobulin levels and antinuclear antibodies were found in all patients; pathologic findings included hyperplastic lymphoid follicles infiltrating the epithelium of the small airways. These cases may represent a familial systemic autoimmune disorder seen primarily with pulmonary compromise.

Case report: treatment of blastomycosis with fluconazole

The authors present two cases of systemic blastomycosis successfully treated with fluconazole. In one case, the disease involved the respiratory tract, and the central nervous system was presumed to be involved. The second case consisted only of pulmonary blastomycosis. Both patients were treated with oral fluconazole 200 mg twice per day for 9 and 6 months, respectively. Treatment with this new triazole antifungal agent resulted in the complete resolution of the disease in both patients. They have remained asymptomatic for more than 6 months after the completion of therapy.

Catheter-related complications of continuous ambulatory peritoneal dialysis

OBJECTIVE

To assess the effectiveness of continuous ambulatory peritoneal dialysis (CAPD) with particular reference to morbidity.

DESIGN

Open study.

SETTING

Two city general hospitals.

SUBJECTS

104 Adults and 11 children with end stage renal failure.

MAIN OUTCOME MEASURE

Morbidity.

RESULTS

There were 29 complications (25%), the most common being obstruction of the tube (n = 8, 7%), and migration of the tube (n = 7, 6%). Others were peritonitis (n = 5), haemorrhage (n = 4), infection at the exit site (n = 3), and leakage of fluid (n = 2). All were readily treatable.

CONCLUSIONS

Fixing the catheter in two places may prevent its migration. The complication rate of CAPD is acceptable, and in children with end stage renal failure it is a suitable alternative to haemodialysis while they are waiting for renal transplantation.

Detrimental effect of hypotonic cromolyn sodium

In a randomized, double-blind, placebo-controlled, crossover study, inhalation of the commercially available nebulized form of cromolyn sodium resulted in a significant decrease in forced midexpiratory flow rate between the 25th and 75th percentile points, equivalent to that observed for distilled water, in children with chronic asthma. We conclude that inhalation of the current hypotonic concentration of cromolyn sodium may be detrimental.

Recombinant human mullerian inhibiting substance inhibits human ocular melanoma cell lines in vitro and in vivo

Since Mullerian Inhibiting Substance (MIS) causes regression of the Mullerian duct, the anlagen of the uterus, vagina, and fallopian tube, we expected and have previously observed that purified recombinant human MIS causes regression of gynecological tumors. However, recent experiments indicating that neural crest derivatives might be responsive to MIS prompted study of a group of human ocular melanoma cell lines in 4 in vitro inhibition assays, and a subrenal capsule assay in vivo. Ocular melanoma cell lines that grew well in a respective assay were studied with MIS to determine whether this biological modifier could inhibit growth. Three human ocular melanomas, OM431 (P less than 0.01), OM467 (P less than 0.02), and OM482 (P less than 0.03), were growth-inhibited by highly purified human recombinant MIS in soft agarose. A dose-dependent tumor inhibition was noted when OM431 cells were incubated with MIS in a liquid colony inhibition assay (P less than 0.05). In addition, OM467 was inhibited (P less than 0.05) by MIS in a multicellular tumor spheroid assay. Cell cycle analysis indicated that OM431 cells were inhibited in monolayer by MIS while in G1. At 100-fold lower serum concentrations than required in the media of in vitro assays, MIS delivered via i.p. osmotic pumps inhibited (P less than 0.05) in vivo the growth of OM431 implanted beneath the renal capsule of nude and CD-1 irradiated mice when compared to mice given implants of pumps containing no MIS. The responsiveness of ocular melanoma to MIS broadens the spectrum of tumors that might be treated with MIS and suggests further investigation of other neural crest tumors.

Computer-aided cell colony counting

Counting cell colonies is a tedious task when performed with the light microscope. Moreover, unless strict double-blind protocols are adhered to, biased counts are difficult to avoid. Presented here is a computer software application that performs accurate, reproducible cell colony counts with a minimum of user generated bias. The application is based upon the Apple IICX computer system with Image software and AppleScan. Colonies are grown on 24-well plates and prepared in such a way as to permit good quality scanning. The scans are then transferred to Image and the individual colonies in each well are counted. Good correlation with counts done by light microscopy is achieved.

Human müllerian inhibiting substance inhibits tumor growth in vitro and in vivo

Müllerian inhibiting substance (MIS) causes regression of the müllerian duct in the male fetus. Bovine MIS has been reported to inhibit the growth of some gynecological tumors. Recombinant human MIS (rhMIS) produced in transfected Chinese hamster ovary cells has been highly purified by immunoaffinity chromatography. The introduction of a salt wash prior to elution of MIS from the affinity column removes a growth-stimulating factor(s) derived from Chinese hamster ovary cells. This immunopurified rhMIS caused significant inhibition (34-59% survival) of A431 (a vulvar epidermoid carcinoma), HT-3 (a cervical carcinoma), HEC-1-A (an endometrial adenocarcinoma), NIH:OVCAR-3 (an ovarian adenocarcinoma), and OM431 (an ocular melanoma) human cell lines in colony inhibition assays. Two cell lines, Hep 3B (a hepatocellular carcinoma) and RT4 (a bladder transitional cell papilloma), were unresponsive to immunopurified rhMIS. Using an in vivo subrenal capsule assay in irradiated CD-1 mice, the growth of A431 and OM431 cells was inhibited by immunopurified rhMIS. We conclude that rhMIS inhibits the growth of certain tumor cell lines in vitro and in vivo.

Mucosal intussusception to avoid ascending cholangitis

Many methods have been devised to prevent ascending cholangitis following Kasai's hepatic portoenterostomy for biliary atresia. To investigate the effectiveness of mucosal intussusception in preventing ascending cholangitis, 20 mongrel dogs were randomized to undergo Roux-en-Y cholecystjejunostomy and common bile duct ligation with or without mucosal intussusception. Aeromonas hydrophila was instilled into the gastrointestinal tract. Bacterial cultures were grown from samples taken from the gallbladders and lower jejunum, and blood chemistry and barium studies were performed. The barium studies showed satisfactory lack of reflux in all ten dogs with mucosal intussusception. Only two of them had positive cultures for Aeromonas from the gallbladder 3 days after bacterial instillation into the jejunum. All ten dogs in the control group had positive cultures for Aeromonas from the gallbladder. Our results showed that the mucosal intussusception group had a significantly lower rate of recovery of organisms from the gallbladder compared with the control group when the organisms were instilled into distal intestine (P less than 0.05). The method is worthy of clinical trial as a means of preventing or treating ascending cholangitis.

Lip and intraoral tumours: a local perspective

Lip and intra-oral cancer is an uncommon disease in Singapore among the local population. The incidence is less than 1.5% of all cancers reported to the Singapore Cancer Registry which recorded a total of 18,049 cases of all types of cancer in a 5-year period from 1978 to 1982. The Department of Plastic Surgery at Singapore General Hospital has been conducting a multidisciplinary clinic for the management of head and neck tumours since 1984. The results of the distribution, age, sex and racial differences, risk factors and modalities of treatment of the various types of cancer affecting the lip and intraoral region were analysed in a prospective study. A total of 69 cases were analysed and of these 59 (85.5%) were squamous cell carcinoma (SCC) of varying grades of malignancy, the remaining comprising adenoidcystic and mucoepidermoid carcinoma, malignant melanoma and a single case of ameloblastoma. A number of predisposing factors such as smoking, alcohol and the chewing of betel nuts could be identified in the history of patients suffering from cancers involving the buccal mucosa and tongue. As the numbers involved in non-SCC are small in this study, the discussion will be confined to patients presenting with squamous cell carcinoma only.

Lymphokine-activated killer cells in primary immunodeficiencies and acquired immunodeficiency syndrome

Cytotoxic mechanisms (e.g., natural killer (NK) lysis, antibody-dependent cellular cytotoxicity, and cytotoxic T lymphocyte lysis) play an important role in host defense against various infections and neoplasms. Lymphokine-activated killer (LAK) cytotoxicity, induced in vitro by incubating mononuclear cells with interleukin 2 (IL-2) for 2-5 days, may also represent an important component of the body's cytotoxic repertoire. In 10 patients with congenital cellular immunodeficiencies, including 5 with severe combined immunodeficiency, the mean LAK activity in a 3-hr chromium release assay against Raji target cells was 44 +/- 8.1%, which is equivalent to that observed in normal adults and neonates. In only one case, a patient with reticular dysgenesis, was there absent LAK cell generation. Haploidentical T cell-depleted bone marrow transplantation (BMT) restored LAK activity in this patient. LAK activity was first observed in this patient and two others 3-6 weeks following BMT, prior to other evidence of immunologic engraftment such as lymphocyte proliferation to mitogens, NK activity, or interferon-gamma production. One patient with adenosine deaminase deficiency showed normal levels of LAK activity despite absent NK activity. Three patients with chronic granulomatous disease also had normal LAK activity (57 +/- 14% specific lysis). In 9 patients with acquired immunodeficiency syndrome (AIDS), IL-2 activation resulted in a mean cytotoxic activity of 56 +/- 8.7% toward Raji targets. In addition, 9 patients with pre-AIDS complex also showed normal levels of cytotoxicity (37 +/- 3.3% toward Raji targets), equivalent to that of 8 normal controls, including two healthy homosexual males (mean lysis 38 +/- 3.9%). These results indicate that LAK cells appear early in immunologic ontogeny. Further, the mechanism of lysis is not oxygen dependent since LAK activity was present in the 3 patients with chronic granulomatous disease. The ability to generate LAK in a wide spectrum of immunodeficiencies may indicate that IL-2 could be used in therapy of such disorders.

Enhanced interferon production and lymphokine-activated cytotoxicity of human placental cells

The immunologic competence of human placental mononuclear cells was compared to that of adult and cord blood mononuclear cells. Mononuclear cells were isolated from fresh placentas by digestion with collagenase and DNase, followed by Ficoll-Hypaque and discontinuous Percoll separation. Placental cells incubated with phytohemagglutinin (PHA) synthesized significantly more interferon-gamma (IFN-gamma) at 2 days (29 +/- 5.5 IU/ml) and 5 days (46 +/- 8.5 IU/ml) than PHA-activated cord cells (3.6 +/- 0.6 IU/ml at 2 days and 2.7 +/- 0.7 IU/ml at 5 days) but less than PHA-activated adult cells (81 +/- 20 IU/ml at 2 days and 270 +/- 161 IU/ml at 5 days). Placental and adult cells, but not cord cells, also synthesized significant quantities of IFN-gamma following incubation with interleukin-2 (IL-2). There was synergism between IL-2 and PHA activation for IFN-gamma production for some cord samples. After a 5- to 7-day incubation with IL-2, the lymphocyte-activated killer (LAK cell) cytotoxicity of placental cells (measured in a 3-hr chromium-release assay at an E:T ratio of 40:1) was enhanced 13-fold against K562 target cells (6 +/- 2% to 77 +/- 4%) compared to a 4-fold increase in cord cells (16 +/- 4% to 68 +/- 3%) and a 2-fold increase in normal adult cells (35 +/- 4% to 65 +/- 3%. Against the natural killer (NK)-resistant Raji target, placental cells increased their LAK cytotoxic activity (3 +/- 1% to 59 +/- 7%) compared to a 7-fold increase with cord cells (6 +/- 1% to 43 +/- 3%) and a 3-fold increase with adult cells (11 +/- 2% to 38 +/- 4%). A notable degree of cytotoxic activity in the absence of IL-2 against Molt targets was noted in 11 of 14 (79%) placental cell samples at 5 days. Only 10 of 24 (42%) adult and 17 of 37 (40%) cord samples showed spontaneous cytotoxic activity equal to or greater than 10%. Some placental samples actually showed an increase in cytotoxic activity when incubated without IL-2. The ability of placental cells to produce significant levels of IFN-gamma, to develop considerable LAK activity, and to maintain or develop cytotoxic activity in the absence of IL-2 suggests a vigorous, active immune system of the placenta compared to the relatively dormant immune system of the neonate. These observations suggest that placental cells may have a primary role in fetal defense.

Corticosteroids in treatment of obstructive lesions of chronic granulomatous disease

Two patients with chronic granulomatous disease had obstructive lesions of the gastrointestinal tract, esophagus, and genitourinary tract, which were successfully treated with corticosteroids. These obstructive lesions, caused by local granuloma formation, have been reported in 18 other patients with chronic granulomatous disease, none of whom received steroids. Our first patient, a 3-year-old boy, had emesis and weight loss associated with antral narrowing and delayed gastric emptying at age 2 years. Antibiotic therapy was ineffective, but intravenous and oral corticosteroid therapy for 10 weeks resulted in clinical cure. One year later, dysuria associated with bladder neck obstruction was also treated successfully with corticosteroids. The second child, a 10-year-old boy, had dysphagia caused by distal esophageal stenosis. Corticosteroid therapy (with concomitant antibiotics) on two occasions reversed this obstruction. Granulomatous cystitis with ureteropelvic obstruction then developed, which also responded to treatment with corticosteroids and antibiotics. Despite the risk of increased susceptibility to infection, corticosteroid therapy is justified in preventing life-threatening obstruction of vital organs.

Cytotoxic studies in human newborns: lessened allogeneic cell-induced (augmented) cytotoxicity but strong lymphokine-activated cytotoxicity of cord mononuclear cells

Nonspecific cytotoxic responses such as natural killer activity can be increased in vitro by incubating effector cells with soluble factors or allogeneic cells. We sought to determine if newborn cells, known to be deficient in most cytotoxic responses, including resting NK activity, could develop enhanced cytotoxic responses following incubation with allogeneic cells (augmented cytotoxicity) or with lymphokines (lymphokine-activated cytotoxicity). Cord whole mononuclear cells (WMC) incubated with irradiated Raji cells for 5 days develop lower levels of cytotoxicity toward K562 targets at both a 20:1 effector:target (E:T) ratio (39 +/- 2.7% vs 49 +/- 3.6%) and a 10:1 E:T ratio (29 +/- 2.6% vs 40 +/- 3.6%) than do adult cells. Lessened specific cytotoxicity of cord cells developed toward the sensitizing Raji cells was also observed at both E:T ratios. Attempts to enhance the induced cytotoxicity by incubation with interferon or isoprinosine were unsuccessful. In contrast, lymphokine (i.e., interleukin 2)-activated killer (LAK) cytotoxicity is not deficient in cord WMC. Indeed, the level of LAK cytotoxicity is equivalent to that observed with similarly treated adult cells despite a lower baseline level of cytotoxicity toward the target cells. In the presence of purified IL-2 for 5 days, cord WMC cytotoxicity against K562 cells increased from 12 +/- 2.6 to 71 +/- 4.2% and against Raji cells increased from 9.6 +/- 2.5 to 48 +/- 6.7%. Similarly treated adult cells increased their killing against K562 from 23 +/- 4.2 to 61 +/- 4.5% and against Raji from 12 +/- 3.0 to 36 +/- 5.3%. This substantial lymphokine-activated cytotoxicity of newborn cells suggests the possibility of therapeutic intervention with purified lymphokines in neonatal infections or neoplasms.

Infectious complications of the primary immunodeficiencies

The primary manifestation of the immunodeficiencies is undue susceptibility to infection. This means too many, too severe, too prolonged, too complicated and too unusual infections. Infections in immunodeficiency have a characteristic cause depending on the nature of the immune deficiency. Antibody deficiencies are associated with infections with gram-positive infections. Cellular immune deficiencies are associated with mycobacterial, protozoan, fungus, virus, and opportunistic bacterial infection. Phagocytic disorders are associated with staphylococcal, fungal, and gram-negative organisms. Complement disorders are associated by neisserial infections. Infections have also been implicated in the pathogenesis of some immunodeficiencies in some circumstances. These include human T lymphotropic virus type III (HTLV-III), rubella virus, cytomegalovirus, and Epstein-Barr virus. Several infectious syndromes in specific immunodeficiencies have been identified. Examples include enteric cytopathic human orphan (ECHO) virus encephalitis in agammaglobulinemia, and meningococcal meningitis in C6 deficiency. Infections can also be induced by live vaccines given in immunodeficiency (e.g., paralytic polio in agammaglobulinemia.) Unusual infectious syndromes will be illustrated including parainfluenza infection in severe combined and immunodeficiency, Legionella pneumonia in chronic granulomatous disease, and Cryptosporidium infection in hyper-IgM immunodeficiency.

Absence of tachyphylaxis in gastric acid secretion during pentagastrin infusion

Tachyphylaxis to stimulation of gastric juice secretion during intravenous pentagastrin (PG) infusion has been reported in animal studies. We assessed the course of gastric response to PG 2 micrograms/kg/hr over eight hours in eight healthy subjects. Peak H+, pepsin, and volume secretions occurred during the second half hour of stimulation. Peak H+ output was 11.6 +/- 1.3 mmol/0.5 hr or 7.6 +/- 0.8% of the total eight-hour secretion. During subsequent half-hour collection intervals, there was no significant decline in response, and the average output was 10.3 +/- 0.4 mmol/0.5 hr (6.5 +/- 0.1%). Peak pepsin and volume secretions were respectively 10.0 +/- 1.4% (74.8 +/- 11.6 mg/0.5 hr) and 8.8 +/- 1.1% (146.3 +/- 17.4 mL/0.5 hr) of the total eight-hour secretion. Although there was a significant decline in pepsin and volume response subsequent to the peak output, the decline was not continuous, and pepsin and volume secretions were maintained, respectively, at 6.0 +/- 0.2% (46.1 +/- 2.5 mg/0.5 hr) and 6.2 +/- 0.1% (107.5 +/- 3.0 mL/0.5 hr) of the total eight-hour secretion. Our study did not demonstrate any tachyphylaxis in H+ response to continuous PG stimulation. This model appears to be a valid tool for the assessment of histamine-H2 antagonist effects on stimulated gastric juice secretion over 8 hours in humans.

Pharmacokinetics of cimetidine after subchronic administration

The influence of cimetidine on its own pharmacokinetics after subchronic administration was assessed in 8 healthy volunteers, aged 26-29 years. On control Day 1, each subject received cimetidine 300 mg i.v., and serum and urine samples were obtained. Each subject was initiated on cimetidine 600 mg b.i.d. orally for 2 weeks. There were 3 further study days repeated after 1 and 2 weeks of cimetidine dosing and 1 week after stopping cimetidine. There was no significant difference in the mean total body clearance of cimetidine among the 4 study days. Mean elimination t1/2 beta and V beta were similarly unchanged. However mean renal clearance (CLR) and fe were significantly increased following 2 weeks of drug dosing (CLR 5.41 ml X min-1 X kg-1; fe 0.61) compared to control (CLR 4.00 ml X min-1 X kg-1; fe 0.48). Although the non renal clearance was reduced from control values of 4.29 to 3.51 ml X min-1 X kg-1 following 2 weeks of dosing the difference was not significant. Dosage adjustment of cimetidine appears unnecessary after short-term dosing in the presence of normal renal function.

Cimetidine dynamics after repeated intravenous injection

Cimetidine dynamics were studied in six multiple-trauma patients receiving 300 to 600 mg every 6 hr for prevention of stress ulceration. Patients received cimetidine intravenously for a mean duration of 7.8 days. There was a positive correlation between cimetidine serum concentration and gastric pH; the correlation between intragastric cimetidine concentration and gastric pH was stronger. The association between therapeutic efficacy (pH greater than 4) and serum concentration over 1 mcg/ml was significant. The association with gastric cimetidine concentration above 2 mcg/ml was significant.

Cimetidine dynamics after single intravenous doses

Cimetidine dynamics were studied in nine multiple-trauma patients. Mean elimination half-life was 2.27 hr, mean volume of the central compartment was 0.29 l/kg, mean volume at steady state averaged 0.90 l/kg, and mean total body clearance was 9.02 ml/min/kg. After intravenous cimetidine, drug concentrated in gastric fluid reached a peak concentration in 3 hr. Gastric plasma cimetidine ratios after equilibration ranged between 3.0 and 4.3. There was a correlation between cimetidine gastric juice concentration and gastric pH (r = 0.50), but no correlation was found between plasma cimetidine concentration and pH (r = 0.13).

Quinidine pharmacokinetics in continuous ambulatory peritoneal dialysis

The clearance of quinidine was evaluated in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). The dialysis clearance of quinidine was 0.793 ml/min which represented only 0.61% of the total body clearance (154.21 ml/min) of the drug. The elimination half-life of quinidine was 5.44 hours. Based on our results, dosage adjustment of quinidine does not appear to be necessary for patients undergoing CAPD.