Bronchoscopic Lobar Lavage in the Treatment of a Single Lung Transplant Recipient With Pulmonary Alveolar Proteinosis: A Case Report

Pulmonary alveolar proteinosis is a rare disorder that results from impaired clearance of surfactant. There are few case reports in lung transplant recipients. We report the case of a 57-year-old man with chronic hypersensitivity pneumonitis who underwent left single lung transplantation. Approximately 1 year after transplant, he was diagnosed as having pulmonary alveolar proteinosis by surgical lung biopsy. He was successfully treated with bronchoscopic lobar lavage of his allograft but later was diagnosed as having peritoneal mesothelioma. We highlight the challenges in the diagnosis, discuss potential etiologies, and describe a unique therapy of this rare disorder in lung transplant recipients.

Dietary adequacy of children with autism compared with controls and the impact of restricted diet

OBJECTIVE

Children with autism (AUT) may consume a restricted diet relative to typical peers, whether due to therapeutic measures or sensory sensitivities. The objective of this study was to compare children with AUT with both typically developing (TYP) and developmentally delayed children on nutrient and food group intake and overall diet quality and to evaluate the impact of diet restriction.

METHODS

Three-day food records and interview information were analyzed from 69 children with AUT, 14 children with developmental delay, and 37 TYP children, drawn from a larger longitudinal study.

RESULTS

Children with AUT did not differ significantly from children with other developmental delays on any dietary measures. Although there were differences in the average intake of some nutrients between AUT and typical controls, only calcium and dairy were also less likely to be consumed in adequate amounts by the AUT group. Intentional diet restriction accounted for most of the differences between AUT and typical controls. On average, all groups had inadequate fiber, vitamin D, and vegetable intake. Inadequate intake of folate, grains, and dairy was noted for the AUT subgroup with intentional diet restrictions. Children in the AUT group not following a restricted diet received significantly worse Healthy Eating Index-2005 scores than those following a restricted diet and typical controls. These differences were not nutritionally significant.

CONCLUSIONS

When evaluating nutritional adequacy of children with AUT, special consideration should be given to calcium, folate, dairy, and grains. Diets of all children with AUT should be evaluated for idiosyncratic deficiencies because of unique dietary patterns.

Surgery in severe factor XIII deficiency: report of a case of epilepsy neurosurgery and review

Factor XIII (FXIII) deficiency is a rare autosomal recessive congenital disorder of haemostasis, associated with a high risk of intracranial haemorrhage. Intracranial haemorrhage can result in neurological sequelae including seizure disorders. In some cases, medically intractable epilepsy led to epilepsy surgery. Little has been reported on the management of FXIII deficiency during surgery, and there is only a few data on the management, safety and efficacy of epilepsy surgery in the patients with haemostatic disorder. We report here an epilepsy neurosurgery in a case of severe FXIII deficiency.

Incidence of arrhythmias after thoracic surgery: thoracotomy versus video-assisted thoracoscopy

PURPOSE

Atrial arrhythmias, especially supraventricular tachycardia (SVT) and atrial fibrillation, are common after thoracotomy and lung surgery. There are few existing data on the incidence of postoperative arrhythmias after video-assisted thoracoscopy (VAT). The purpose of the present investigation was to retrospectively determine the incidence of postoperative arrhythmias in patients who underwent VAT compared with those who underwent thoracotomy, and which factors are associated with an increased risk for arrhythmias in both groups.

DESIGN

A retrospective investigation.

SETTING

A metropolitan university hospital.

PARTICIPANTS

The medical records of 124 patients who underwent thoracotomy and 81 patients who underwent VAT over a 2-year period were reviewed.

MEASUREMENTS AND MAIN RESULTS

There was a 17% incidence of atrial arrhythmias after thoracotomy and 10% after VAT, but the difference was not statistically significant. In both groups, atrial fibrillation was the most common atrial arrhythmia.

CONCLUSION

Patients receiving digoxin were at higher risk for postoperative arrhythmias. Patients older than 65 years were at risk for arrhythmias after thoracotomy and patients older than 80 years were at risk for arrhythmias after VAT. Patients who had postoperative arrhythmias had prolonged hospital stays compared with patients who did not have arrhythmias.

New funds plant seeds for genome research effort

Melbourne—As biologists Down Under prepared last month to head off for a Christmas of sun and surf, they had an extra reason for holiday cheer: two government decisions that will add meat to the country's innovative but meagerly funded foray into the world of genome research.

Impact of childhood brain injury on work and family finances

Parents of children who suffer brain injuries are often surprised by the extent to which work and family finances are disrupted. In this paper, work and financial problems are described, predictors are identified, and ways to minimize problems are discussed. Eighty-two children treated at two Massachusetts trauma centres were given an extensive battery of medical, functional, and psychosocial tests during hospitalization. At 1 and 6 months post-discharge they were retested and their parents were surveyed about work and financial difficulties. Trouble maintaining regular work schedules and injury-related financial problems were common. At highest risk for work and financial problems were families of children with severe injuries who had four to nine impairments, along with children hospitalized > 2 weeks who were not discharged to home. Surprisingly, families with HMO coverage reported significantly fewer financial problems, and this relationship was not due to differences in socioeconomic status or injury severity. Health-care providers need to pay more attention to the potential impact of injury on work and family finances. Providers can help at-risk families muster child-care services, deal effectively with employers and insurance companies, and plan for the future.

Pediatric trauma: impact on work and family finances

OBJECTIVES

National data now exist on incidence, prevalence, and cost of injury. However, the personal impact of injury on work and family finances has not been thoroughly studied. We examine the extent and nature of work and financial problems after pediatric trauma and identify predictors. Clinicians are alerted so they can better counsel parents about potential postinjury work and financial difficulties.

METHODS

Staff collected comprehensive data on the acute care and short-term rehabilitation of 182 Massachusetts children with injuries. Consenting parents were surveyed and their children were given a battery of medical, functional, and psychosocial tests. Information on work and financial impact at 1 and 6 months postinjury was available from 120 parents.

RESULTS

Given these children's generally mild injuries, the impact on work and family finances was remarkable. For many families work and financial problems were short-lived; however, for others serious problems remained at 6 months postdischarge. Families whose children were severely injured were at highest risk for work and financial problems. Middle-class parents and parents on public assistance or in our other insurance category reported more work and financial problems than those in health maintenance organizations. Long acute hospital stay and four or more impairments at discharge were also strong predictors.

CONCLUSION

Childhood injury can lead to serious work and financial problems for families. Given the central role of the family in pediatric rehabilitation, clinicians and policymakers involved in acute trauma care and rehabilitation should pay greater attention to the financial repercussions of injury.

Surface projection of murine major histocompatibility determinants induced by hydrostatic pressure and cytokines

Augmentation of surface presentation of the major histocompatibility complex (MHC) is a leading trend for preparation of tumor vaccines. Exposure of weakly immunogenic tumor cells, such as murine B16 melanoma, to hydrostatic pressure (P) in the presence of the membrane-impermeable protein crosslinker (CL) 2',3'-adenosine dialdehyde, was previously shown to induce a substantial increase in surface presentation of MHC molecules. When B-16 melanoma cells, used here as a model, were first treated for 72 h with interferon-gamma or tumor necrosis factor-alpha at concentrations of 10 and 100 units/ml, respectively, followed by application of pressure and cross-linking (PCL), the surface presentation of H2b molecules increased by 40% compared to treatment with cytokines alone, and by up to 1,700% when compared to treatment with PCL alone. Neither P nor CL alone enhanced the MHC presentation when cells were pretreated with these cytokines. The changes in MHC observed after the cytokine treatment were transient and decayed within several hours. However, the changes induced by the sequential treatment with cytokines and PCL were sustained for at least 96 h post-PCL which is of prime importance for immunogenic expression. A series of analogous experiments in the presence of cycloheximide indicated that approximately 50% of the observed PCL-induced increase in MHC projection originates from protein synthesis while the other 50% corresponds to passive translocation of MHC compartments. B16 melanoma cells, modified by the sequential treatment of cytokines and PCL, proved to be substantially more immunogenic by an in vitro sensitization assay than cells treated by either one of these treatments alone. These results may provide a guideline for the preparation of tumor vaccines which could be applied in immunotherapy treatment of cancer.

A continent colonic urinary reservoir: the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.

Proximal colostomy: still an effective emergency measure in obstructing carcinoma of the large bowel

Large bowel obstruction constitutes an emergency abdominal condition and necessitates prompt surgical treatment. The optimal approach is still controversial as to whether to perform a diverting colostomy only or a tumor resection with or without primary anastomosis. Seventy-one elderly and high-risk patients were treated by proximal diverting colostomy through a right upper abdominal incision. The operative mortality was 8.5%, with an additional morbidity of 20.5%. Stomal complications appeared in 6.1% of the survivors. Seventy-five percent of surviving patients underwent successful resection and closure of colostomy within 3 months without additional mortality. Others were not operated because of metastatic disease or severe concomitant disease. We conclude that although primary resection should be attempted in good risk patients, for those patients who are elderly and at high risk, a simple life-saving procedure, such as fecal diversion, could alleviate obstructions with relatively low morbidity and mortality and improve the patient's prospects for subsequent definitive surgery.

v-erbA specifically suppresses transcription of the avian erythrocyte anion transporter (band 3) gene

Previous work has established that the v-erbA oncogene inhibits the temperature-induced differentiation of chick erythroblasts transformed with temperature-sensitive oncogene mutants. Here we demonstrate that v-erbA in differentiating erythroblasts specifically arrests expression of the erythrocyte anion transporter (band 3) gene at the transcriptional level. The v-erbA-induced differentiation block can be overcome by inducing cells to differentiate at alkaline pH. Under these conditions, which possibly impair biological activity of v-erbA, the maturing cells now express the anion transporter gene at high levels. However, its transcription is specifically and rapidly suppressed if v-erbA activity is restored by culturing the cells at neutral pH. Similar but less pronounced inhibition of gene expression by v-erbA was observed for the delta-amino-levulinic acid synthase gene. Additional evidence obtained with an inhibitor of band 3 activity suggests that the v-erbA-induced inhibition of band 3 gene expression is at least partly responsible for the differentiation block caused by this oncogene.

Amino acid sequence of rabbit kidney neutral endopeptidase 24.11 (enkephalinase) deduced from a complementary DNA

Neutral endopeptidase (EC 3.4.24.11) is a major constituent of kidney brush border membranes. It is also present in the brain where it has been shown to be involved in the inactivation of opioid peptides, methionine- and leucine-enkephalins. For this reason this enzyme is often called 'enkephalinase'. In order to characterize the primary structure of the enzyme, oligonucleotide probes were designed from partial amino acid sequences and used to isolate clones from kidney cDNA libraries. Sequencing of the cDNA inserts revealed the complete primary structure of the enzyme. Neutral endopeptidase consists of 750 amino acids. It contains a short N-terminal cytoplasmic domain (27 amino acids), a single membrane-spanning segment (23 amino acids) and an extracellular domain that comprises most of the protein mass. The comparison of the primary structure of neutral endopeptidase with that of thermolysin, a bacterial Zn-metallopeptidase, indicates that most of the amino acid residues involved in Zn coordination and catalytic activity in thermolysin are found within highly honmologous sequences in neutral endopeptidase.

v-erbA cooperates with sarcoma oncogenes in leukemic cell transformation

The v-erbB, v-src, v-fps, v-sea, and v-Ha-ras oncogenes induce avian erythroid progenitor cells to self-renew in an erythropoietin-independent manner. These transformed erythroblasts retain both their capacity to differentiate into erythrocytes and their requirement for complex growth media. However, previous studies showed that erythroblasts transformed by v-erbB plus v-erbA (which by itself is not oncogenic) are blocked in differentiation and grow in standard media. Here we show that the introduction of v-erbA into erythroblasts transformed with v-src, v-fps, v-sea, or v-Ha-ras likewise induces a fully transformed phenotype. It also reduces the capacity of ts sea- and ts erbB-transformed erythroblasts to differentiate terminally in an erythropoietin-dependent manner after a temperature shift. Cooperativity involving v-erbA also occurs in vivo since chicks infected with a retroviral construct encoding v-erbA and v-src develop both acute erythroblastosis and sarcomas.