Contribution of age and gender to outcome of blunt splenic injury in adults: multicenter study of the eastern association for the surgery of trauma

BACKGROUND

The purpose of this study was to examine the contribution of age and gender to outcome after treatment of blunt splenic injury in adults.

METHODS

Through the Multi-Institutional Trials Committee of the Eastern Association for the Surgery of Trauma (EAST), 1488 adult patients from 27 trauma centers who suffered blunt splenic injury in 1997 were examined retrospectively.

RESULTS

Fifteen percent of patients were 55 years of age or older. A similar proportion of patients > or = 55 went directly to the operating room compared with patients < 55 (41% vs. 38%) but the mortality for patients > or = 55 was significantly greater than patients < 55 (43% vs. 23%). Patients > or = 55 failed nonoperative management (NOM) more frequently than patients < 55 (19% vs. 10%) and had increased mortality for both successful NOM (8% vs. 4%, p < 0.05) and failed NOM (29% vs. 12%, p = 0.054). There were no differences in immediate operative treatment, successful NOM, and failed NOM between men and women. However, women > or = 55 failed NOM more frequently than women < 55 (20% vs. 7%) and this was associated with increased mortality (36% vs. 5%) (both p < 0.05).

CONCLUSION

Patients > or = 55 had a greater mortality for all forms of treatment of their blunt splenic injury and failed NOM more frequently than patients < 55. Women > or = 55 had significantly greater mortality and failure of NOM than women < 55.

Surgery induces human mononuclear cell arginase I expression

BACKGROUND

Arginase is a metabolic enzyme for the amino acid arginine that participates in the immune response to trauma. We hypothesize that surgical trauma induces arginase expression and activity in the human immune system.

METHODS

Peripheral mononuclear cell (MNC) arginase activity and expression and plasma nitric oxide metabolites and interleukin (IL)-10 were measured in patients undergoing elective general surgery. Twenty-two healthy volunteers served as a comparison population.

RESULTS

MNC arginase activity increased within 6 hours of surgery (p < 0.05) and coincided with increased arginase I protein expression. Plasma nitric oxide metabolites decreased significantly postoperatively (p < 0.05). Patients lacking an elevation in IL-10 failed to demonstrate increased MNC arginase activity.

CONCLUSION

Increased MNC arginase expression may contribute to postsurgical immune dysfunction by affecting arginine use and availability and nitric oxide metabolism in the immune system. Plasma IL-10 may play a role in regulating MNC arginase activity.

The routine use of sonography in penetrating torso injury is beneficial

BACKGROUND

Torso sonography (focused assessment with sonography for trauma [FAST]) has been added to our protocols for the evaluation of penetrating torso injury. The purpose of this study was to evaluate our recent experience and determine whether the use of FAST is beneficial.

METHODS

From January 1999 to January 2000, patients with penetrating torso injury and no clinical indication for surgery were evaluated by sonography with a selective use of other investigations. FAST consisted of sonographic views of the peritoneum and/or pericardium to determine the presence or absence of fluid.

RESULTS

During the study period, there were 238 victims of penetrating injury assessed by our trauma service, and sonography was performed in 72 (30%) patients as per our protocols. There were 31 stab, 37 gunshot/shotgun and, and 4 puncture wounds. Thirty-eight patients had peritoneal views, 6 patients had pericardial views, and 28 patients had both pericardial and peritoneal views obtained. Thirteen of 66 patients had free fluid in the peritoneal cavity and 12 of the 13 patients had a therapeutic laparotomy. No peritoneal fluid was seen in 53 of 66 patients, of whom 6 had abdominal injuries, 5 requiring surgery for diaphragm or bowel injuries. The sensitivity of FAST alone for abdominal injury was 67%, specificity was 98%, positive predictive value was 92%, and negative predictive value was 89%. Pericardial fluid was seen in 3 of 34 patients; one had a heart wound and two had negative pericardial windows. All 31 patients without pericardial fluid recovered without surgery.

CONCLUSION

The routine use of sonography in penetrating torso injury is beneficial. The detection of pericardial or peritoneal fluid is clinically useful. However, a negative FAST examination does not exclude abdominal injury, such as a diaphragm or hollow viscus wound, and further investigation or close follow-up is required.

Alterations in arginine metabolic enzymes in trauma

Arginine is the sole substrate for nitric oxide (NO) synthesis by NO synthases (NOS) and promotes the proliferation and maturation of human T-cells. Arginine is also metabolized by the enzyme arginase, producing urea and ornithine, the precursor for polyamine production. We sought to determine the molecular mechanisms regulating arginase and NOS in splenic immune cells after trauma. C3H/HeN mice underwent laparotomy as simulated moderate trauma or anesthesia alone (n = 24 per group). Six, 12, 24, or 48 h later, 6 animals from each group were sacrificed, and splenectomy was performed and plasma collected. Six separate animals had neither surgery nor anesthesia and were sacrificed to provide resting values (t = 0 h). Spleen arginase I and II and iNOS mRNA abundance, arginase I protein expression, and arginase activity were determined. Plasma NO metabolites (nitrite + nitrate) were also measured. Trauma increased spleen arginase I protein expression and activity (P = 0.01) within 12 and for at least 48 h after injury and coincided with up-regulated arginase I mRNA abundance at 24 h. Neither arginase II nor iNOS mRNA abundance in the spleen was significantly increased by trauma at 24 h. Plasma nitrite + nitrate was decreased in animals 48 h post-injury compared to anesthesia controls (P < 0.05). Trauma induces up-regulation of arginase I gene expression in splenic immune cells within 24 h of injury. Arginase II is not significantly up-regulated at that time point. Arginase I, rather than iNOS appears to be the dominant route for arginine metabolism in splenic immune cells 24 h after trauma.

L-Arginine regulates the expression of the T-cell receptor zeta chain (CD3zeta) in Jurkat cells

L-Arginine is a versatile amino acid that plays a central role in the normal function of several organ systems including the immune system. Its availability is tightly controlled and varies significantly in different organs and tissues in the body. L-Arginine plays an important role in supporting T-cell proliferation. Its depletion in certain disease states results in a diminished T-cell response. The main purpose of this study was to determine the effect of the depletion of L-arginine on the expression of the T-cell receptor (TCR) proteins. When the helper T-cell line Jurkat was cultured in arginine-free medium, there was a preferential decrease in the expression of the TCR zeta chain (CD3zeta). The reduced expression of CD3zeta was observed within 24 h of culture in L-arginine-free medium and was completely reversed with the replenishment of L-arginine. Furthermore, the absence of L-arginine blocked the normal re-expression of the TCR that had been internalized after antigen stimulation. There also was a significant decrease in proliferation of Jurkat cells in the absence of L-arginine; however, L-arginine depletion did not prevent the up-regulation of the interleukin 2 receptor chains upon stimulation, nor did it significantly diminish the production of interleukin 2. The changes in the expression of CD3zeta chain were not induced by apoptosis. Thus, the availability of L-arginine in the microenvironment may play a significant role in regulating the expression of the TCR.

Arginase I expression and activity in human mononuclear cells after injury

OBJECTIVE

To determine the effect of trauma on arginase, an arginine-metabolizing enzyme, in cells of the immune system in humans.

SUMMARY BACKGROUND DATA

Arginase, classically considered an enzyme exclusive to the liver, is now known to exist in cells of the immune system. Arginase expression is induced in these cells by cytokines interleukin (IL) 4, IL-10, and transforming growth factor beta, corresponding to a T-helper 2 cytokine profile. In contrast, nitric oxide synthase expression is induced by IL-1, tumor necrosis factor, and gamma interferon, a T-helper 1 cytokine profile. Trauma is associated with a decrease in the production of nitric oxide metabolites and a state of immunosuppression characterized by an increase in the production of IL-4, IL-10, and transforming growth factor beta. This study tests the hypothesis that trauma increases arginase activity and expression in cells of the immune system.

METHODS

Seventeen severely traumatized patients were prospectively followed up in the intensive care unit for 7 days. Twenty volunteers served as controls. Peripheral mononuclear cells were isolated and assayed for arginase activity and expression, and plasma was collected for evaluation of levels of arginine, citrulline, ornithine, nitrogen oxides, and IL-10.

RESULTS

Markedly increased mononuclear cell arginase activity was observed early after trauma and persisted throughout the intensive care unit stay. Increased arginase activity corresponded with increased arginase I expression. Increased arginase activity coincided with decreased plasma arginine concentration. Plasma arginine and citrulline levels were decreased throughout the study period. Ornithine levels decreased early after injury but recovered by postinjury day 3. Increased arginase activity correlated with the severity of trauma, early alterations in lactate level, and increased levels of circulating IL-10. Increased arginase activity was associated with an increase in length of stay. Plasma nitric oxide metabolites were decreased during this same period.

CONCLUSIONS

Markedly altered arginase expression and activity in cells of the human immune system after trauma have not been reported previously. Increased mononuclear cell arginase may partially explain the benefit of arginine supplementation for trauma patients. Arginase, rather than nitric oxide synthase, appears to be the dominant route for arginine metabolism in immune cells after trauma.

Effects of L-arginine on the proliferation of T lymphocyte subpopulations

BACKGROUND

Dietary supplementation of L-arginine as a mechanism to enhance cellular immune response (T lymphocytes), has slowly gained approval, and appears especially important during critical illness. Despite its clinical use, little is known as to the direct effects of L-arginine on the different T lymphocyte subpopulations.

METHODS

Lymphocytes were harvested from spleens of C57 B1/6 mice, and proliferation was induced with anti-CD3 in the presence of different concentrations of L-arginine ranging from 0 to 1000 micromol/L. Flow cytometry was used to evaluate the effect of L-arginine on T lymphocyte subpopulations. Interleukin-2 production was measured by ELISA and gene expression by RT-PCR.

RESULTS

L-Arginine at or greater than 100 micromol/L significantly enhanced anti-CD3 stimulated T lymphocyte proliferation (p = .01). L-Arginine was essential for adequate T lymphocyte (CD3+) cellular maturation (p = .01). Proliferation of Helper T cells (CD4+) was not dependent on L-arginine. In contrast, Cytotoxic T cells (CD8+) showed a dose dependent proliferation in response to L-arginine (p = .01). Of the CD8+ cells, an increase in the CD45RA negative CD8 positive (memory) T cell subpopulation was observed with the addition of L-arginine. In addition, the number of cell surface CD8 receptors (CD8R) and CD3 receptors (CD3R) increased in the presence of L-arginine (p = .01, p = .04). Interleukin-2 receptor (IL-2R) expression was not up-regulated by L-arginine. L-Arginine modestly increased IL-2 production and had pronounced effects on its disappearance from the culture media (p < .0001). Interleukin-2 mRNA expression was not dependent on L-arginine.

CONCLUSIONS

The requirements for L-arginine for the proliferation of CD3 stimulated T lymphocytes vary widely, and have to be taken into account when studying the mechanism of how L-arginine enhances cellular proliferation. L-Arginine may increase cellular proliferation by increasing specific receptor expression and the utilization of interleukin-2.

Blunt splenic injury in adults: Multi-institutional Study of the Eastern Association for the Surgery of Trauma

BACKGROUND

Nonoperative management of blunt injury to the spleen in adults has been applied with increasing frequency. However, the criteria for nonoperative management are controversial. The purpose of this multi-institutional study was to determine which factors predict successful observation of blunt splenic injury in adults.

METHODS

A total of 1,488 adults (>15 years of age) with blunt splenic injury from 27 trauma centers in 1997 were studied through the Multi-institutional Trials Committee of the Eastern Association for the Surgery of Trauma. Statistical analysis was performed with analysis of variance and extended chi2 test. Data are expressed as mean +/- SD; a value of p < 0.05 was considered significant.

RESULTS

A total of 38.5 % of patients went directly to the operating room (group I); 61.5% of patients were admitted with planned nonoperative management. Of the patients admitted with planned observation, 10.8% failed and required laparotomy; 82.1% of patients with an Injury Severity Score (ISS) < 15 and 46.6% of patients with ISS > 15 were successfully observed. Frequency of immediate operation correlated with American Association for the Surgery of Trauma (AAST) grades of splenic injury: I (23.9%), II (22.4%), III (38.1%), IV (73.7%), and V (94.9%) (p < 0.05). Of patients initially managed nonoperatively, the failure rate increased significantly by AAST grade of splenic injury: I (4.8%), II (9.5%), III (19.6%), IV (33.3%), and V (75.0%) (p < 0.05). A total of 60.9% of the patients failed nonoperative management within 24 hours of admission; 8% failed 9 days or later after injury. Laparotomy was ultimately performed in 19.9% of patients with small hemoperitoneum, 49.4% of patients with moderate hemoperitoneum, and 72.6% of patients with large hemoperitoneum.

CONCLUSION

In this multicenter study, 38.5% of adults with blunt splenic injury went directly to laparotomy. Ultimately, 54.8% of patients were successfully managed nonoperatively; the failure rate of planned observation was 10.8%, with 60.9% of failures occurring in the first 24 hours. Successful nonoperative management was associated with higher blood pressure and hematocrit, and less severe injury based on ISS, Glasgow Coma Scale, grade of splenic injury, and quantity of hemoperitoneum.

[Burns in childhood. Social implications in the eve of the year 2000]

INTRODUCTION

The thermic wounds in childhood are the third cause of morbility at hospital in our ambiance. The knowledge about incidence, the causal agents more frequent, and the detailed analysis of different variants about the subject are the unique manner to try to establish precautions against. The aim of this project is to analyse the factors and situations associated with thermic wound, through the retrospective study about the patients admitted.

MATERIALS AND METHODS

During three years, 362 patients were admitted at hospital, between 0 and 14 years old, following the criterion: barge burn size more than 10%, critical location (hands, face, neck), causal agent (electricity, chemical) or social situation. Different facts were analyzed about provenance, place, causal agent, burned part of the body, degree of lesion and the average stay at hospital.

RESULTS

There were 59.6% males, and 40.3% females. Children between 1 and 5 years old, represented the largest group of patients, 205 cases. The 66% were from other hospital were they receive the first aid. The 98.7% were burned at home, and the place more frequent was kitchen, 51%. The causal agent was liquid in 65.4%, specially scald with water about 104 cases. The zones more affected were the face (39.2%), and the superior extremities, about 81% second degree superficial or deep. The size was 10 to 20% in 19% of patients, and more than 40% in 0.2% of children. The average stay was 17.47 days at hospital.

[Bile duct atresia: outline for a solution]

Biliary atresia continues to be a serious and relatively rare disease (1/50,000 newborns) and whose long-term prognosis has changed drastically since the appearance of liver transplant (LT) as a therapeutic weapon. The combination of two factors, early diagnosis and correct application of Kasai's surgical technique, is essential to obtain acceptable results and sufficient biliary drainage allowing the children to overcome the critical 7 kg barrier and place them in the lesser morbi-mortality range in relation to a possible LT. But we must keep in mind that despite its critics, Kasai's technique can guarantee, both in our own experience and in the literature, ten years survival percentages over 50% with correct hepatic function, as well as clinical normality and a quality of life clearly superior to first years post-LT. We present the evolution of a group of 20 patients affected with biliary atresia, diagnosed in our center since 1985, the year when pediatric LT began to be used as a therapeutic procedure in this country. We valued the age of intervention, technique, immediate and long-term results and the evolution and necessity of LT. All 20 patients were analyzed individually, and they currently have an age range from 2-14 years and were all operated by Kasai's technique. We classified the patients as having good, regular or poor results with regards to biliary flow, normalization of billirubin levels and clinical evolution. Sixteen patients presented biliary flow of such an extent that 14 of them, classified as good, completely normalized the billirubin levels. Two others, presently aged 14 and 8 years respectively, present average levels of 2.5-5.5 mg/100 ml and are classified as regular in a situation of advisable transplant, although with an acceptable hepatic function. Only one case, the first in the poor group, did not initially present biliary elimination and died at age six months while on the waiting list. Three other cases in the same group presented insufficient biliary elimination and were transplanted with 7, 11 and 12.5 kg, respectively. The second died in the first year post-transplant.

CONCLUSIONS

In our opinion, action in biliary atresia must be early and based on the correct application of Kasai's technique, seeking to achieve a biliar flow that eliminates or distances the patient as far as possible from the necessity of a future LT. Three lines come together to obtain this target: an early diagnosis, a correct application of Kasai's technique, and an implication in the follow-up and treatment of these children by the hepatic transplant groups. All this advises us, as is done in other countries, to create reference centers for the study of neonatal cholestasis where an accumulated experience of a relatively rare pathology can be taken advantage of.

A single-center 8-year experience with percutaneous dilational tracheostomy

OBJECTIVE

To determine surgical, postoperative, and postdischarge complications associated with percutaneous dilational tracheostomy (PDT) in an 8-year experience at the University of Kentucky.

SUMMARY BACKGROUND DATA

There are known risks associated with the transport of critically ill patients to the operating room for elective tracheostomy, and less-than-optimal conditions may interfere with open bedside tracheostomy. PDT has been introduced as an alternative to open tracheostomy. Despite information supporting its safety and utility, the technique has been criticized because advocates had not provided sufficient information regarding complications.

METHODS

A prospective database was initiated on all patients who underwent PDT between September 1990 and May 1998. The database provided indication, procedure time, duration of intubation before PDT, and intraoperative and postoperative complications. Retrospective review of medical records and phone interviews provided long-term follow-up information.

RESULTS

In the 8-year period, 827 PDTs were performed in 824 patients. Two patients were excluded because PDT could not be completed for technical reasons. There were 519 male and 305 female patients. Mean age was 56 years. Prolonged mechanical ventilatory support was the most common indication. Mean procedure time was 15 minutes, and the average duration of intubation before PDT was 10 days. The intraoperative complication rate was 6%, with premature extubation the most common complication. The procedure-related death rate was 0.6%. Postoperative complications were found in 5%, with bleeding the most common. With a mean follow-up of greater than 1 year, the tracheal stenosis rate was 1.6%.

CONCLUSIONS

On the basis of this large, single-center study, the authors conclude that when performed by experienced surgeons, PDT is a safe and effective alternative to open surgical tracheostomy for intubated patients who require elective tracheostomy.

[Neuroblastoma: biological markers, surgery, and clinical course]

INTRODUCTION

The treatment of neuroblastoma is basically chemotherapy, and surgery, in spite of advances, this kind of tumor is nowadays a surgical challenge.

PURPOSE

The aim of this study was to evaluate the impact of our therapy in this kind of pediatric tumors.

MATERIAL AND METHODS

32 consecutive patients with abdominal neuroblastoma, aged between 1 month and 10 years old, median age 3 years old, observed from 1993 through 1997 have been studied. Several parameters: age, ferritin, deletion of the chromosome 1p36, chromosomic ploidy, LDH, N-myc gene amplification and enolase neuron specific were studied and were related with the histology by Joshi and the International Neuroblastoma Staging System (INSS) in order to know the prognosis. All the patients were treated by means of chemotherapy and surgery, and some cases with radiotherapy and bone marrow transplantation.

RESULTS

Two patients presented the tumor in stage I (INSS) and three in stage II. All the patients had a total resection and they live free of disease. In the state III, two patients did not maintain the follow-up; five live with disease (two with QT without surgery yet, two local recurrences, and one metastasis), and four live free of disease. In the stage IV: five died, two live with disease (1 local recurrence and one metastasis), five live free of disease, and one did not maintain the follow-up. In the stage IV-S, the three patients live free of disease. The method of Kaplan-Meier at 5 years shows a mean of 49 months and a median of 60 months.

CONCLUSIONS

1. Of all the parameters studied, we consider the ones with biggest prognostic efficacy are, the age, the stage INSS, the histology Shimada and the N-myc amplification. 2. The total resection of the tumor keeps being essential for a more favourable prognostic.

Trauma increases extrahepatic arginase activity

BACKGROUND

Although expressed primarily in the liver, arginase activity also is present in extrahepatic tissues and specifically in macrophages, where it may play diverse physiologic roles in wound healing, cellular proliferation, and the regulation of nitric oxide production. Arginase activity in immune cells is upregulated by certain cytokines such as IL-4, IL-10, and TGF-beta and by catecholamines. Since the release of these substances is increased after trauma, we hypothesized that arginase activity would also be increased in immune cells after trauma. The current work tests this hypothesis.

METHODS

A model of surgical trauma was created in C3H/HeN mice by performing an exploratory laparotomy. Tissue arginase activity and arginase I protein expression were determined. As a control, arginase activity and expression were also stimulated with the use of endotoxin. In addition, we evaluated the expression of inducible nitric oxide synthase and the accumulation of nitric oxide metabolites in plasma.

RESULTS

Surgical trauma was associated with a significant increase in arginase activity in splenic and renal tissues (P < .05). Splenic macrophages from trauma animals exhibited arginase activity levels approximately 10 times those of controls (P < .05). Endotoxin alone increased arginase activity in the spleen, but this increase was less than that of trauma alone (P < .05). Arginase activity remained elevated after trauma for up to 4 days and normalized by day 7. Arginase I expression was upregulated by trauma in both splenic and renal tissue and by endotoxin in the spleen only. Despite upregulation of inducible nitric oxide synthase in trauma animals, circulating nitric oxide metabolites were decreased 2 days after trauma compared with controls (P < .05). Endotoxin-induced nitric oxide metabolites were also reduced in trauma animals compared with endotoxin treatment alone (P < .05), but this normalized by day 4.

CONCLUSIONS

Extrahepatic arginase expression and activity is increased after trauma and may provide the necessary precursors for cellular proliferation and repair or may play a regulatory role in the production of nitric oxide.

Beta adrenoceptor regulation of macrophage arginase activity

BACKGROUND

Arginase, which metabolizes L-arginine within the urea cycle, is essential for production of polyamines and affects production of nitric oxide by depletion of L-arginine, the common substrate for both arginase and nitric oxide synthase. Having shown that trauma increases splenic macrophage arginase activity, we seek to define the mechanisms for this. RAW macrophage arginase activity and expression are increased by 8-bromo-cAMP in vitro. We hypothesize that since catecholamines increase cAMP, trauma-induced splenic arginase activity may be mediated by post-injury catecholamine release.

METHODS

RAW 264.7 macrophage arginase activity was measured in vitro in response to 4 catecholamines with or without propranolol or lipopolysaccharide (LPS). C57BL/6 mice underwent laparotomy as a model of moderate trauma after propranolol treatment, with and without intraperitoneal Escherichia coli LPS administration as a simulated pro-inflammatory stimulus.

RESULTS

Macrophage arginase activity increased in vitro in response to catecholamines or LPS (P < .05). Propranolol pretreatment blocked macrophage arginase activity induced by epinephrine (10 mumol/L) in vitro (P < .05). Trauma or LPS alone increased splenic arginase activity in vivo (P < .05). Propranolol did not alter LPS-induced splenic arginase activity but did significantly reduce trauma-induced splenic arginase activity (P < .05).

CONCLUSIONS

Catecholamines alone increase macrophage arginase activity through beta-adrenoceptor activation. Increased splenic arginase activity induced by moderate trauma is decreased by beta-adrenoceptor blockade, suggesting that trauma-induced arginase activity is partly mediated by endogenous catecholamines.

[Intraesophageal stent in the prevention of stenosis caused by caustic ingestion]

Esophageal stenosis is a frequent consequence of lye ingestion, and their treatment is of longstanding and complex matter. The search of new solutions for this problem is challenging and always attractive if its associated with less aggressiveness to the patient. The use of intraesophageal stents is not new in the treatment of stenosis, but it was anecdotal, until histocompatible material came out in the market. The stent is designed in the OR, having the same length as the stenosis, previously observed by endoscopy, its made out of a silicone tube 30 or 36 French, mounted over an ng tube 16, all this is fixed in the ends of the silicone tube, that way won't slip over the ng tube. It is placed with a laryngoscope assistant, the proximal end of the ng tube comes out the nasal nares. Once the location of the tube is checked, the stent is left in place for six weeks. Our experience, with seven patients, has shown excellent tolerance to the stent; at the third post procedure day the patients were eating soft diet by mouth, we believe that the esophageal spasm had resolved by this day. Once the stent was withdraw, five cases were free of esophageal lesions, in the other two small areas of bleeding were visualized. In the follow-up the five cases that were free of lesions, had a normal esophageal diameter, in the other two, one had a moderate restenosis and the other case was severe.

Conservative treatment of caustic esophageal injuries in children: 20 years of experience

The authors present their experience in the medical treatment of 1, 296 caustic esophageal injuries in children over the last 20 years in two study groups, one comprising the period up to 1989 and the other 1990 to 1996, comparing the different treatments used in each group. The treatment was based fundamentally on dilatations with anterograde mercury bougies, Savary bougies, or retrograde thread-guided bougies with gastrostomy. Pneumatic balloons or stenting procedures have also been employed in the last 3 years. Early fiberendoscopy was used systematically in the second group, which provides a more accurate evaluation of the esophageal lesions. Antibiotic coverage was done systematically during the first 10 days in all serious cases, while steroids were employed routinely only in the last 3 years. The results were similar in both groups, with a dilatation average of 32 in the first and 30 in the second group and an initial dilatation interval of 3 to 4 weeks in both. Using updated exploration and dilatation techniques, we drastically reduced the number of gastrostomies needed for retrograde thread-guided dilatations from 51 in the first group to 5 in the second, consequently improving the patients' life quality. There was no mortality and only five esophageal perforations, which did not require surgical treatment.

[Laparoscopy for the undescended testis]

The authors show their experience in the use of the laparoscopic approach in 18 cases of unilateral exploratory anorchia. They highlight the advantages that this method offers in efficiency, speed, security and minimal aggression compared with conventional exploration of the inguinal channel in the search of the undetectable testis. In the 18 cases studied through the insertion of 5 mm lense in the umbilical area, it was established that a testicular hypoplasia was present in 8 cases. In another 5 cases testicular agenesia was diagnosed, and in the remaining 5, intraabdominal testis were found. In four of these testicles, a laparoscopic approach helped in their correct placement and also in the removal of the fifth in a patient with recurrent leukemia.

[Bilateral Wilms tumor]

The incidence of bilateral involvement it is generally estimated to be 5% to 10%. It shows association with certain congenital anomalies and it has an increased occurrence of familial cases. The records of 9 children (5 boys, 4 girls) diagnosed at Vall d'Hebron Hospital with bilateral Wilms tumor between 1976-1995 were analyzed. Six patients had synchronous tumors and 3 had metachronous lesions. Genitourinary malformations were present in 4 children and another had hemihypertrophy. Two children were brothers. Eight patients underwent pre-operative radiation therapy and/or chemotherapy. Five patients had nephrectomy on one side (3 of them had metachronous presentation) and partial nephrectomy on the other side. The other children had bilateral partial nephrectomy or tumorectomy. Seven out of the nine patients are alive (78%). The two children who died presented with stage IV tumors and high grade malignant. One boy suffers cardiomyopathy. All survivors have normal renal function. With the proven efficacy of chemotherapy, bilateral renal salvage procedures were demonstrated to be effective in controlling disease without compromising renal function or survival. The innovative approaches developed for the treatment of bilateral Wilms tumor may influence the treatment of unilateral Wilms.

[Transjugular portosystemic shunt. An alternative in recurrent hemorrhage in portal hypertension in children]

The transjugular portosystemic bypass is a new technique for treating portal hypertension of an intrahepatic nature by inserting a multipurpose catheter through the jugular vein and vena cava as far as the suprahepatic vein, with the aid of a puncture device it is fed via the hepatic parenchyma into a portal branch. The passageway thus created is distended with a balloon to permit the insertion of an extensible metal mesh prosthesis or "stent" to maintain a permeable connection. Our experiment was conducted on a paediatric patient suffering from mucoviscidosis with severe pulmonary and hepatic involvement and recurrent bleeding in an uncontrollable position. After inserting the bypass, portal pressure dropped sharply and the bleeding stopped, the patient being discharged on the sixth day. Two months after the bypass, the coronary vein of the stomach, the seat of the gastric varicose veins, was selectively occluded through the stent via the femoral vein. Six months after follow-up, the digestive bleeding has not recurred.

[Passerini-Glazel technique of vulvovaginoplasty: a solution for upper outlet of the vagina]

Since 1988, we have performed the Passerini-Glazel technique, in 5 patients, between 7 months and 3 years old. All showed female pseudohermaphroditism with severe signs of masculinization, and consequently, high outlet of the vagina in the urethra, secondary to Congenital Adrenal Hyperplasia (CAH). The technique use is to get a functional and esthetically acceptable vagina at the expense of a urethral flap and two flaps of skin, coming from the hypertrophic clitoris. The results were excellent in all the patients. In one occasion it was necessary to insert a cylinder of vesical mucous to get a suture without tension of both hemivaginas. In one case there appeared a late vaginal stenosis that was solved with dilations. The present technique is indicated in those cases of CAH, with great testosterone impregnation, in which the vagina ends very high and her primary descent is difficult. It is also indicate in those cases in which there exists the risk of hurting the external sphincter, which would damage the urinary continence mechanism.

[Congenital lobar emphysema: report of 38 cases]

We present our experience of 38 patients suffering from congenital lobar emphysema (CLE) treated in the Department of Pediatric Surgery in our hospital between 1966-1991. 22 of these patients had to undergo surgical correction due to the severity of their respiratory symptoms. The other 16 presented mild respiratory symptoms: 8 of them received conservative treatment and the remainin 8 had to be operated on due to broncial compression caused by the vascular malformation. In most cases the main symptoms were dyspnea and cyanosis, which indicate the severity of the process. 20 cases presented during the patient's first month of life, 10 within the first 6 months and the remaining 8 between the first 6 months and 5 years. The different aetiologics forms in our study are analysed and compared with those described in the literature. The main diagnostic tested and revied, specially radiology tested led to a correct differential diagnosis and subsequently to an adequate therapeutic treatment. It is possible to carry out other tests since they do not actually help diagnosis, we have considered them unnecessary. All the surgical operations used are analysed as well as the complications observed. The clinical course of the patients has proved to be particularly good, since there was no mortality and the morbility rate was low.

[Considerations regarding the treatment of non-aganglionic congenital intestinal neuropathies]

Hyperganglionosis or neuronal intestinal dysplasias (NID) and hypoganglionosis (HO) are intestinal diseases of difficult diagnosis and treatment and diverse evolution, despite identical histologic findings. The aim of this study was to discuss the therapeutic problems derived from the patients differing clinical course. Retrospective review of 14 patients with regard to diagnosis, manometry and histology (hematoxylin-eosin, acetylcholinesterase activity, immunohistochemistry and Smith's silver stain) was done. Six patients presented intestinal occlusion or sub-occlusion from the first months of life with impeded oral feeding. Ileostomy was performed in 5 and total colectomy with anastomosis in 1. All patients required parenteral nutrition; cisapride was added in 2. Three died from sepsis (3 NID). Of the 3 survivors, 2 have ileostomies (2 NID) and the other ileo-rectal anastomosis (NID). Of the remaining patients, two presented aganglionism and the finding of proximal hyperganglionism occurred post-surgery. Surgery was repeated in one patient. The remaining 6 (1 HO, 5 NID) were diagnosed between 3 and 10 years of age because of constipation. Four are under treatment with cisapride and 2 required partial colic resection. No relationship can be established between histologic findings and clinical manifestations. In chronic clinical courses, treatment with cisapride and cleaning enemas should be tried first. Acute clinical pictures (occlusion-sub occlusion) should be treated by decompressive ileostomy. Partial colic resection may lead to new intestinal failure.

Nitric oxide production is inhibited in trauma patients

Elevated levels of nitrates/nitrites, the stable endproducts of nitric oxide (NO), were recently observed in septic patients. In this setting, NO maintains blood flow by vasodilation and inhibition of platelet aggregation. Trauma patients were found to have low plasma levels of nitrates/nitrites, even when they developed sepsis. The current study substantiated that trauma patients have suppressed production of NO; reductions in plasma nitrate/nitrite levels correlated with low urinary excretion of these endproducts. Nitric oxide production was upregulated in trauma patients with clinical infection compared with trauma patients without infection, but was still significantly suppressed compared with nitric oxide production in normal controls. The inability of trauma patients to produce NO may be an important component of the susceptibility of these patients to infection.

Nitric oxide synthesis serves to reduce hepatic damage during acute murine endotoxemia

BACKGROUND AND METHODS

Nitric oxide synthesis occurs both in vitro and in vivo in response to inflammatory stimuli and can have profound effects on the local cellular environment. Hepatocytes, Kupffer cells, and endothelial cells produce nitric oxide in vitro, but the in vivo role of this reactive mediator in the liver is unknown. We assessed the role of nitric oxide synthesis during endotoxemia in mice by inhibiting its synthesis with NG-monomethyl-L-arginine after lipopolysaccharide injection and by determining the effects of this inhibition on hepatic damage.

RESULTS

Injection of lipopolysaccharide in mice increased plasma nitrite and nitrate concentrations, the stable end products of nitric oxide metabolism, and caused mild hepatic damage as measured by increased circulating hepatocellular enzyme levels. NG-monomethyl-L-arginine decreased plasma nitrite and nitrate values, but increased the lipopolysaccharide-induced hepatic injury. NG-monomethyl-L-arginine caused no hepatic damage when given without lipopolysaccharide. The extent of hepatic damage with NG-monomethyl-L-arginine was proportional to the dose of lipopolysaccharide used and could be reduced with concurrent administration of L-arginine but not D-arginine.

CONCLUSIONS

Nitric oxide synthesis provides a protective function against lipopolysaccharide-induced liver injury that increases in importance as the degree of endotoxemia increases. The production of nitric oxide is, therefore, an important part of the liver's response to a systemic inflammatory stimulus.

[Abdominal trauma at a third-level pediatric hospital: study of 150 patients]

All paediatric patients with abdominal trauma admitted in our hospital from 1975 to 1989 were retrospectively studied. We present 150 children with ages ranging from 1 to 14 years, mean age 6 +/- 2.6 years. Sixty-five percent of them were male. Trauma was classified as severe (37%) and mild (63%) and relationated with associated extra-abdominal injuries. The 42% of patients could be attended in other less specialized centres. Since 1982, severe abdominal trauma patient with parenchymal lesions of liver, kidney and spleen were treated according to a non-surgical protocol without secondary complications.

[The "abdominal zipper": a surgical surprise]

In our surgical department there are two kinds of mandatory reoperations: the second look and enterostomies. How many times are we thinking to use a zip in a laparotomy, for avoiding abdominal wall damage? The first experience using zip in a newborn with neonatal sepsis and intestinal ischemia is presented. This device allowed to check the bowel every day and to perform the appropriate surgery. Seven days after last surgery we removed the zip and closed the abdominal wall.

[Anorectal manometry in Hirschsprung disease]

To show the absence of inhibitory reflex of the anus (R.I.A.) by ano-rectal manometry is an important sign in the diagnosis of Hirschsprung's disease. Between 1989 and 1991, a series of 199 patients was studied. The patients were divided into two groups: 0-1 month and 1 month to 50 years. Both groups were subdivided into cases with or without clinical and radiological suspicion of aganglionism. In this series, R.I.A. was absent in 88 patients and present in 111. Histologic study and follow-up confirmed the existence of aganglionism in 86 patients, hyperganglionism in 1, anal stenosis in 8, cystic fibrosis in 4 and 1 coeliac disease; the rest were megarecta to a greater or lesser degree. There was 1 false negative, signifying a percentage of error of 0.5%.

Increased circulating nitrogen oxides after human tumor immunotherapy: correlation with toxic hemodynamic changes

BACKGROUND

Toxicity to interleukin-2 (IL-2) tumor immunotherapy is manifested principally by the vascular leak syndrome, hypotension, and a hyperdynamic response with low systemic vascular resistance. Nitric oxide (.N = O), a recently discovered biological mediator of vascular smooth muscle relaxation, is produced in increased amounts by numerous cell types exposed to a number of inflammatory cytokines.

PURPOSE

Our purpose was to determine if there is an increased production of .N = O in patients receiving IL-2 tumor immunotherapy, and, if so, whether increases in .N = O production correlate with hemodynamic instability.

METHODS

Twelve patients undergoing immunotherapy trials with IL-2 and anti-CD3 monoclonal antibody-activated lymphocytes (T-AK cells) were studied. Plasma levels of nitrate (NO3-), the stable end metabolic product of .N = O synthesis, were measured before and at the end of IL-2 treatment cycles.

RESULTS

We observed a ninefold increase in plasma levels of NO3- in patients after 7 days of treatment (P less than .0001). A significant decrease in both systolic and diastolic blood pressures was observed in all patients (P less than .001).

CONCLUSIONS

We propose that mediated induction of .N = O synthase enzyme leads to progressive increases in .N = O production which, in turn, produces clinically significant hypotension.

IMPLICATIONS

Since .N = O synthesis can be competitively inhibited by L-arginine analogues, a possible pharmacologic modulation of .N = O production could potentially contribute to better management of toxic side effects seen in IL-2 cancer therapies.

Evaluation of endothelium-derived nitric oxide mediated vasodilation utilizing ex vivo perfusion of an intact vessel

The traditional evaluation of the endothelium-derived nitric oxide (EDNO) pathway involves isolated aortic rings with attached strain gauges. This model is nonphysiologic and does not permit studies lasting longer than several hours. Our objective was to overcome the limitations of these "traditional" methods utilizing a physiologic, whole vessel model as a reproducible assay of EDNO. Canine carotid arteries (n = 4) were removed (maintaining in vivo arterial geometry), mounted in a specially designed, continuous-flow circuit, and perfused at 100 ml/min, 80 mm Hg with Medium-199/10% canine serum. Physiologic pH, pCO2, pO2, and temperature were precisely regulated. A non-contacting, helium-neon laser micrometer was interfaced with the current system to provide continuous measurement of vessel external diameter and to quantitate changes in vessel wall geometry in response to epinephrine (EPI; 2 x 10(-5) to 2 x 10(-3) mg/ml) and acetylcholine (ACh; 0.1 to 100 microM) challenge. Further characterization of the perfusion system included the use of a competitive inhibitor to EDNO production, NG-monomethyl-L-arginine (L-NMMA), and the effect of this compound on ACh-induced vasodilation. The reversibility of this blockade was verified via the sequential addition of L-arginine (L-ARG; 0 to 3 mM). Data are expressed as the ratio of steady-state vessel cross-sectional area (CSA) following administration of vasoactive substance to the CSA prior to vasoactive challenge. Our results indicate that EPI and ACh produced significant dose-dependent vasoconstrictive and vasodilatory responses, respectively (P less than 0.001, ANOVA).(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence that nitric oxide production by in vivo allosensitized cells inhibits the development of allospecific CTL

The oxidative metabolism of L-arginine to its bioactive product, nitric oxide (.N = O) has been shown to inhibit rat splenocyte mixed lymphocyte reactions. To determine if alloantigen-induced .N = O production might be operative in vivo, cells that had infiltrated a rat sponge matrix allograft were tested for de novo .N = O production as well as .N = O production upon restimulation with the sensitizing alloantigen. When graft-infiltrating cells were placed in culture, a peak in de novo .N = O production was observed by day 6 graft-infiltrating cells, the time when donor-specific CTL activity by the graft-infiltrating cells was first observed. Upon restimulation with alloantigen, allograft-infiltrating cells produced greatly increased levels of .N = O, and this production was associated with inhibition of lymphocyte cytolytic function. The addition of NG-monomethyl-L-arginine (NMA), the competitive inhibitor of oxidative L-arginine metabolism, inhibited .N = O production and promoted allospecific CTL development. Both observed effects of NMA were reversed by addition of excess L-arginine. Cytokine(s) able to induce proliferation of the IL-2-dependent T cell line CTLL-2 could be detected in alloantigen-stimulated cultures in both the presence and absence of NMA. However, proliferation of the graft-infiltrating cells in response to these cytokines was observed only in the presence of NMA. The immunosuppressive macrolide FK506 was a potent inhibitor of .N = O production in these cultures, presumably acting by inhibiting the production of those cytokines that induce the oxidative L-arginine pathway.

Association between synthesis and release of cGMP and nitric oxide biosynthesis by hepatocytes

Hepatocytes are known to synthesize nitric oxide (NO) from L-arginine via an inducible NO synthase. Studies were performed to determine the relationship between hepatocyte NO production and the stimulation of hepatocyte soluble guanylate cyclase. A combination of lipopolysaccharide (LPS), interferon-gamma, tumor necrosis factor, and interleukin-1 stimulates the biosynthesis of large quantities of nitrite and nitrate (NO2- + NO3-). Hepatocyte NO2- + NO3- production was associated with only small increases in intracellular guanosine 3',5'-cyclic monophosphate (cGMP) levels but much greater increases in extracellular cGMP release over an 18-h time period. This cGMP synthesis was dependent on the L-arginine concentration and was inhibited in a reversible manner by NG-monomethyl-L-arginine. The cytokines or LPS added alone induced small increases in nitrogen oxide production and concomitant minor elevations in cGMP release. Atrial natriuretic peptide also stimulated the release of cGMP by hepatocytes which appeared to be independent of the cytokine+LPS-induced cGMP release. The addition of probenecid reduced the cGMP release by 66%, while cell damage was excluded as a cause for the extracellular release. Addition of 3-isobutyl-1-methylxanthine, but not M&B 22948, increased hepatocyte intra- and extracellular cGMP levels after cytokine+LPS stimulation. Induction of nitrogen oxide synthesis by hepatocytes in vivo by injecting rats with killed Corynebacterium parvum resulted in increased cGMP levels in freshly isolated hepatocytes and increased cGMP release by the hepatocytes when placed in culture.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intestinal dysmotility-pseudo-obstruction]

Chronic intestinal pseudo-obstruction is defined as a syndrome related to any process which affects intestinal regulation and propulsion. Its origin may be muscular, neurogenic or hormonal, excluding Hirschsprung's disease or any known mechanical obstruction. Between 1989 and 1991, 11 patients with intestinal pseudo-obstruction were studied at our centre, and included nine hyperganglionisms B, and two hypoganglionisms) and two visceral myopathies (Berdon's syndrome). Diagnosis was established in all cases by histologic study. The techniques of haematoxylin-eosin, acetylcholinesterase, enolase, protein S-100 and Smith were used in neuropathies and haematoxylin-eosin and Masson's trichromic in myopathies. Intestinal motility was studied by ano-rectal and gastrointestinal manometry in seven and three cases respectively. Gastrointestinal manometry and radiology permitted differentiation of localized and diffuse forms of involvement. Medical treatment consisted of total parenteral nutrition when oral feeding was impossible, and in five cases, cisapride was given, with good results in four. Derivative surgery was performed in cases of diffuse involvement, and resection with anastomosis in those of localized forms. We conclude that: 1. Diagnosis is established according to histologic criteria. 2. Complementary examinations should be directed towards distinguishing localized from diffuse involvement. 3. Cisapride was effective in the treatment of neuropathies in the majority of cases.

Nitrogen oxide levels in patients after trauma and during sepsis

The mediators responsible for maintenance of the hyperdynamic state and the low systemic vascular resistance (SVR) observed in sepsis have not been elucidated. Nitric oxide (.N = O) is a mediator with numerous functions, including regulation of vascular tone and a role in macrophage-mediated cytostasis and microbiostasis. Thirty-nine critically ill trauma and septic patients were studied to determine the relationship between .N = O production and the hyperdynamic state. high plasma levels of NO2-/NO3- (the stable end products of .N = O) were observed in septic patients (p less than 0.02). Low SVR and high endotoxin levels were associated with high NO2-/NO3- values (p = 0.029, p = 0.002). Changes in .N = O levels may mediate the vasodilation seen in sepsis. Low NO2-/NO3- levels were observed in trauma patients (p less than 0.001) and remained low even in the presence of sepsis (p = 0.001).

Effect of exogenous and endogenous nitric oxide on mitochondrial respiration of rat hepatocytes

Although nitric oxide (.N = O) biosynthesis is inducible in rat hepatocytes (HC), the physiological significance of .N = O production by these cells is unknown. Short exposure of HC to authentic .N = O led to a concentration-dependent inhibition of mitochondrial aconitase, NADH-ubiquinone oxidoreductase, and succinate-ubiquinone oxidoreductase (complexes I and II of the mitochondrial electron transport chain). Most susceptible to .N = O inhibition was mitochondrial aconitase, in which a reduction in enzyme activity to 20.2 +/- 1.6% of control was observed. In contrast to mitochondrial aconitase, cytosolic aconitase activity was not inhibited by .N = O. After exposure to a maximal inhibitory concentration of .N = O, mitochondrial aconitase activity recovered completely within 6 h. Complex I did not fully recover within this incubation period. Endogenous .N = O biosynthesis was induced in HC by a specific combination of cytokines and lipopolysaccharide. After 18 h of incubation with these stimuli, a significant inhibition of mitochondrial aconitase activity to 70.8 +/- 2.4% of controls was detected. However, this was due only in part to the action of .N = O. A non- .N = O-dependent inhibition of mitochondrial function appeared to be mediated by tumor necrosis factor.

Antitumor effects of interleukin 2 liposomes and anti-CD3-stimulated T-cells against murine MCA-38 hepatic metastasis

The stimulation of murine splenocytes with the monoclonal antibody anti-CD3 and interleukin 2 (IL-2) results in the propagation of large numbers of cells (T-activated killer; T-AK) which demonstrate high therapeutic efficacy when infused with IL-2 into mice bearing pulmonary metastases. Interleukin 2 infusions are required to maintain the function of the adoptively transferred cells. Recent data demonstrate that the therapeutic efficacy can be enhanced by encapsulating IL-2 in liposomes. The present work tested the combination of T-AK cells with IL-2 liposomes in an immunotherapy model utilizing the MCA-38 murine colon adenocarcinoma. Expansion of murine splenocytes was achieved with anti-CD3 monoclonal antibody plus IL-2 and was consistently greater than 50-fold during a 9-day culture period. Cytolytic activity of the murine T-AK cells was mediated primarily by Lyt-2+ cells. In vivo results demonstrate synergistic therapeutic efficacy of the combination of IL-2 liposomes and T-AK cells. Evaluation of the in vivo distribution of these T-AK cells utilizing congenic mice demonstrates that Lyt-2+ cells from these in vitro cultures infiltrate hepatic metastases in vivo. The activation of lymphocytes with anti-CD3 monoclonal antibody and IL-2 appears to be a reproducible and convenient method of producing cells capable of producing antitumor effects in models of adoptive immunotherapy.

Effect of endogenous nitric oxide on mitochondrial respiration of rat hepatocytes in vitro and in vivo

Nitric oxide, a highly reactive radical, was recently identified as an intermediate of L-arginine metabolism in mammalian cells. We have shown that nitric oxide synthesis is induced in vitro in cultured hepatocytes by supernatants from activated Kupffer cells or in vivo by injecting rats with nonviable Corynebacterium parvum. In both cases, nitric oxide biosynthesis in hepatocytes was associated with suppression of total protein synthesis. This study attempts to determine the effect of nitric oxide biosynthesis on the activity of specific hepatocytic mitochondrial enzymes and to determine whether inhibition of protein synthesis is caused by suppression of energy metabolism. Exposure of hepatocytes to supernatants from activated Kupffer cells led to a 30% decrease of aconitase (Krebs cycle) and complex I (mitochondrial electron transport chain) activity. Using NG-monomethyl-L-arginine, an inhibitor of nitric oxide synthesis, we demonstrated that the inhibition of mitochondrial aconitase activity was due, in part, to the action of nitric oxide. In contrast, in vivo nitric oxide synthesis of hepatocytes from Corynebacterium parvum-treated animals had no effect on mitochondrial respiration. This suggests that inhibition of protein synthesis by nitric oxide is not likely to be mediated by inhibition of energy metabolism.

[Should the medico-surgical strategy for biliary atresia be changed in view of liver transplantation as a reality?]

Biliary atresia (BA) is the main source of candidates for paediatric liver transplantation (PLTx) with 64 per 100 of survival. The follow-up of 35 immediate candidates of BA, 19 of them transplanted, induced to the authors to change some details on the BA treatment. This disorder does not finish already with portoenterostomy. Eventually mortality causes are infection and chronic rejection. The functional loss of jejunal segment in the Roux en Y may explain the poor cyclosporin absorption and therefore chronic rejection. By other hand, chronic malnutrition presented by these patients before PLTx may favour infection. Authors recommend more aggressive medical treatment before PLTx and technical improvement in the portoenterostomy with the aim of previous surgery does not difficult posterior PLTx.

[Extrahepatic cholestasis of nonatretic origin. New diagnostic and therapeutic possibilities]

Nonatretic cholestatic disorders exhibit differential features in the pediatric age group, at times not too obvious but always discernible. These characteristic differences, with the aid of increasingly more precise exploratory techniques, make a rapid and sound diagnosis possible. At present, echography, transparietohepatic cholangiography and endoscopic retrograde cholangiography allow us, within a short time, to reach a diagnosis of disorders that not long ago were only roughly profiled and on occasion were left undiagnosed. At the Children's Hospital Valle de Hebrón, treatment has been afforded, in the last seven years, to seven patients with a choledochal cyst, four with a long common biliopancreatic duct, one with a choleperitoneum due to spontaneous perforation of a choledochal cyst and one patient with congenital stenosis of the common hepatic duct. In all cases where echography was performed, an intra- or extrahepatic bile duct dilatation could be demonstrated, or otherwise the diagnosis of a choledochal cyst was established. Furthermore, four transhepatic and three retrograde cholangiographic examinations were carried out, via a fiber duodenoscopy, in those cases that failed to show, on echography, the existence of a choledochal cyst.

Multiple cytokines are required to induce hepatocyte nitric oxide production and inhibit total protein synthesis

The etiology and mechanisms by which severe trauma or sepsis induce hepatic failure are unknown. Previously we showed that Kupffer cells (KC), the fixed macrophages of the liver, induce a profound decrease in hepatocyte (HC) total-protein synthesis when exposed to endotoxin. Furthermore we demonstrated that endotoxin-activated KCs induce these changes in HC protein synthesis through the induction of a novel L-arginine-dependent biochemical pathway within the HC. In this pathway, the guanido nitrogen of L-arginine is converted to the highly reactive molecule nitric oxide (NO.). To identify the KC factors that act as signals for induction of HC NO. biosynthesis, recombinant cytokines were added to HC cultures and HC nitrogen oxide production and protein synthesis levels were determined. We found that no single cytokine, but rather a specific combination of tumor necrosis factor, interleukin-1, interferon-gamma, and endotoxin, were required for maximal induction of HC nitrogen oxide production. This specific combination of cytokines induced a 248.8 +/- 26.0 mumol/L (micromolar) increase in HC nitrogen oxide production and simultaneously inhibited HC total protein synthesis by 36.1% +/- 3.1%. These data demonstrate that multiple cytokines, produced by endotoxin-activated KC, induce the production of NO. within HC, which in turn leads to the inhibition of HC total-protein synthesis.

[Total parenteral nutrition. A 1-year experience with 96 patients]

In 1987, ninety-six surgical patients, of whom 44 were premature or newborn babies and 52 were infants or older children, received total parenteral nutrition (T.P.N.) at our hospital. A peripheral venous line was utilized on forty patients in the first group and only on 9 in the second group. The excellent results yielded by T.P.N. are self-evident from the low mortality showed by these patients. Thirty-three out of the 44 neonates and premature infants with serious surgical problems survived, being noteworthy the occurrence of just 3 deaths within a series of 13 necrotizing enterocolitis. In the series of 52 infants and older children, composed of 13 digestive patients (with 5 liver transplants), 6 tumoral, 9 neurologic, 4 renal (2 transplantations), 18 cardiac, 1 thoracic and 1 burnt, only 9 patients died. The average duration of T.P.N. was 10 days in the group of premature and newborn infants and 6 days for the nursing infants and older children, save for the 8 patients in whom the treatment had to be prolonged for a few months. We conclude that T.P.N., when applied in time and of short duration should entail no risk at all. In neonate and premature infant a peripheral vein shall be the route of choice. In the nursing infant and older child a central venous line is preferable, if possible the superior vena cava or its major tributary veins.

[Bile peritonitis caused by idiopathic perforation of a choledochal cyst]

The case of a 8 month-old infant presenting with biliary peritonitis, mild icterus and slowly progressive ascites is reported. Diagnosis was made through paracentesis showing higher bilirubin levels in the ascitic fluid (18 mg/100 ml) than in serum, and abdominal ultrasonography which showed pictures suggestive of choledochal cyst. A perforated choledochal cyst was surgically removed. The biliary duct was reconstructed by means of a hepatic Roux-en-Y jejunostomy. Postoperative course was satisfactory.

[Biofeedback technic in incontinence in high ano-rectal atresia]

Authors have employed biofeedback in functional rehabilitation of fecal incontinence after surgical treatment of high anorectal atresia. 34 patients have treated with that technique, of whom 27 underwent an levator plasty and 7 a muscular transplant procedure using a gracilis sling. A four channels Recording connected with a Arhan catheter and a TV-monitor visible to the patient have been employed. After a period of time variable from case to case, all patients of the "levator plasty" group prolonged the "alert-time" to a socially acceptable value, and all the patients of the "gracilis transplant" group obtained a complete fecal continence.

[Clinical value of anorectal manometry in childhood]

Anatomy and physiology of the anorectum has been studied with manometric techniques in a normal group (n = 34) and in patients with anorectal pathology (n = 477). Authors comment manometric anomalies found in anorectal atresias, Hirschsprung's disease, constipation, neurogenic disorders (spina bifida, sacral agenesia) and the value in diagnosis, prognosis and therapeutic measures that this technique demonstrates.

[Cystic adenomatoid malformation of the lung (author's transl)]

Four cases of congenital cystic adenomatoid malformation are presented. The age of the patients ranged from 1 day to 7 years. All cases were treated surgically and 3 of them survived. The only death in the group corresponded to the neonatal case. The clinical, radiological and patological features of congenital cystic adenomatoid malformation are also reviewed. Occasionally the clinical manifestations will be hardly noticeable or non existent and the malformation may be diagnosed beyond the neonatal period in the course of a radiological examination performed as routine or because of repeated respiratory infections. Surgery is the treatment of choice. In the group of neonates where the cystic adenomatoid malformation doesn't cause respiratory difficulty the authors feel that it might be advisable to postpone surgery until a later date.

[Testicular tumours in infancy (author's transl)]

Eleven tumours of the testis are presented. Treatment is based in: surgery (gonadectomie and paraaortical lymphadenectomie), quimiotherapy, depending of its pathological pattern and in some cases radiotherapy. In methastasis, surgery if it is possible and poliquimiotherapy. Total mortality rate is 22% (2/11). The follow up is from two to seven years.