Biofunctional properties of caseinophosphopeptides in the oral cavity

Caseinophosphopeptides (CPPs), bioactive peptides released from caseins, have the ability to enhance bivalent mineral solubility. This is relevant to numerous biological functions in the oral cavity (promotion of tooth enamel remineralisation, prevention of demineralisation and buffering of plaque pH). Therefore, CPPs may play a positive role as prophylactic agents for caries, enamel erosion and regression of white spot lesions. Most in vitro and in situ studies demonstrate strong evidence for the bioactivity of CPPs in the oral cavity. Nevertheless, relatively little is known concerning their use as adjuvants for oral health and more particularly regarding their long-term effects on oral health.

Abdominopelvic mesh compartmentalization reduces the complications of radiotherapy in children: a preliminary report

AIM

The aim of this report was to assess the effects of radiotherapy (RT) in children with abdominopelvic tumours in whom a biodegradable (Polyglactin 910) mesh had been inserted prior to commencement of radiotherapy.

METHODS

Retrospective analysis was carried out of four patients with abdominopelvic tumours who underwent radiotherapy between 2000 and 2002 as part of their management.

RESULTS

All children tolerated radiotherapy well with no evidence of acute or chronic radiation enteritis. One child developed prolonged postoperative ileus and a second child developed infective diarrhoea and fever, not related to radiation.

CONCLUSION

We have highlighted a good tolerance of radiotherapy in children following the insertion of a Polyglactin 910 mesh prior to starting radiation and would recommend further larger studies with longer follow-up to support this.

Post traumatic intra-abdominal pseudo-aneurysms in children

Pseudoaneurysms are uncommon following blunt abdominal trauma. A review of the literature has shown that such cases are usually managed aggressively. We report our experience of two cases of post traumatic intra-abdominal pseudoaneurysms which were managed conservatively.

Proteolytic enzyme activities in Cheddar cheese juice made using lactococcal starters of differing autolytic properties

AIMS

To determine proteolytic enzyme activities released in Cheddar cheese juice manufactured using lactococcal starter strains of differing autolytic properties.

METHODS AND RESULTS

The activities of residual chymosin, cell envelope proteinase and a range of intracellular proteolytic enzymes were determined during the first 70 days of ripening when starter lactococci predominate the microbial flora. In general, in cell free extracts (CFE) of the strains, the majority of proteolytic activities was highest for Lactococcus lactis HP, intermediate for L. lactis AM2 and lowest for L. lactis 303. However, in cheese juice, as ripening progressed, released proteolytic activities were highest for the highly autolytic strain L. lactis AM2, intermediate for L. lactis 303 and lowest for L. lactis HP.

CONCLUSIONS

These results indicate that strain related differences in autolysis influence proteolytic enzyme activities released into Cheddar cheese during ripening. No correlation was found between proteolytic potential of the starter strains measured in CFE prior to cheese manufacture and levels of activities released in cheese juice.

SIGNIFICANCE AND IMPACT OF THE STUDY

The findings further support the importance of autolysis of lactococcal starters in determining the levels of proteolytic activities present in cheese during initial stages of ripening.

Cheddar cheese cooking temperature induces differential lactococcal cell permeabilization and autolytic responses as detected by flow cytometry: implications for intracellular enzyme accessibility

AIMS

To determine the influence of cheese cooking temperature on autolysis and permeabilization of two lactococcal starter strains in broth and in Cheddar cheese juice during ripening.

METHODS AND RESULTS

Flow cytometry (FCM) was used to identify and enumerate intact and permeabilized cells in broth and in Cheddar cheese juice. Levels of intracellular enzyme activities were quantified concurrently. Permeabilized cell numbers increased for both strains in broth following a temperature shift from 32 to 38 degrees C and was accompanied by an increase in the level of accessible intracellular enzyme activities. The relative proportions of intact and permeabilized cell populations, as detected by FCM in cheese juice, changed during 42-day ripening. Permeabilized cell populations increased during ripening for both strains; however, an increase in accessible intracellular enzyme activity was observed only for the highly autolytic strain Lactococcus lactis AM2.

CONCLUSIONS

Differences in the autolytic and permeabilization response induced by cooking temperature in two lactococcal strains affects intracellular enzyme accessibility in Cheddar cheese.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study highlights the importance of the autolytic and permeabilization properties of lactic acid bacteria starter strains and their impact on cheese ripening.

In Vitro Generation and Stability of the Lactokinin β-Lactoglobulin Fragment (142–148)

The objectives of this study were to investigate the generation of beta-lactoglobulin fragment (142-148) (beta-LG f(142-148) during the hydrolysis of whey proteins, and the in vitro stability of this fragment upon incubation with gastrointestinal and serum proteinases and peptidases. An enzyme immunoassay (EIA) protocol was developed for the quantification of beta-LG f(142-148) in whey protein hydrolysates and in human blood serum. The minimum detection limit was 3 ng/mL. The level of the peptide in whey protein hydrolysates was influenced by the degree of hydrolysis (DH). As expected, highest levels of this peptide were found in hydrolysates generated with trypsin. Sequential incubation of hydrolysates at different DH values with pepsin and Corolase PP, to simulate gastrointestinal digestion, generally resulted in the degradation of beta-LG f(142-148) as determined by EIA. Reversed-phase HPLC and angiotensin-I-converting enzyme (ACE) activity assays demonstrated that synthetic beta-LG f(142-148) was rapidly degraded upon incubation with human serum. Furthermore, beta-LG f(142-148) could not be detected by EIA in the sera of 2 human volunteers following its oral ingestion or in sera from these volunteers subsequently spiked with beta-LG f(142-148). These in vitro results indicate that beta-LG f(142-148) is probably not sufficiently stable to gastrointestinal and serum proteinases and peptidases to act as an hypotensive agent in humans following oral ingestion. The in vitro methodology described herein has general application in evaluating the hypotensive potential of food protein-derived ACE inhibitory peptides.

In vitro generation and stability of the lactokinin beta-lactoglobulin fragment (142-148)

The objectives of this study were to investigate the generation of beta-lactoglobulin fragment (142-148) (beta-LG f(142-148) during the hydrolysis of whey proteins, and the in vitro stability of this fragment upon incubation with gastrointestinal and serum proteinases and peptidases. An enzyme immunoassay (EIA) protocol was developed for the quantification of beta-LG f(142-148) in whey protein hydrolysates and in human blood serum. The minimum detection limit was 3 ng/mL. The level of the peptide in whey protein hydrolysates was influenced by the degree of hydrolysis (DH). As expected, highest levels of this peptide were found in hydrolysates generated with trypsin. Sequential incubation of hydrolysates at different DH values with pepsin and Corolase PP, to simulate gastrointestinal digestion, generally resulted in the degradation of beta-LG f(142-148) as determined by EIA. Reversed-phase HPLC and angiotensin-I-converting enzyme (ACE) activity assays demonstrated that synthetic beta-LG f(142-148) was rapidly degraded upon incubation with human serum. Furthermore, beta-LG f(142-148) could not be detected by EIA in the sera of 2 human volunteers following its oral ingestion or in sera from these volunteers subsequently spiked with beta-LG f(142-148). These in vitro results indicate that beta-LG f(142-148) is probably not sufficiently stable to gastrointestinal and serum proteinases and peptidases to act as an hypotensive agent in humans following oral ingestion. The in vitro methodology described herein has general application in evaluating the hypotensive potential of food protein-derived ACE inhibitory peptides.

Gastric stromal tumors in children

Gastrointestinal stromal tumors (GIST) in children are rare and their behavior has been regarded as difficult to predict on pathological criteria. We report our experience with two gastric GISTs in children aged 10 and 11 years. Both remain alive and free of disease at 5 years and 2 years respectively. Comparison of the pathological features in the resected specimens with a recently proposed guidelines for predicting outcome in this group of tumors is reported.

Twelve-year experience in the investigation and treatment of paragangliomas

We report a 12-year laboratory experience in the diagnosis of 37 patients with phaeochromocytoma, one with malignant paraganglioma and one with ganglioneuroblastoma. Surgery was performed in eight different hospitals, which underlines the difficulty of ensuring uniformity of investigations. Of the 37 with phaeochromocytoma, 15 were in the right adrenal gland, 12 were on the left, seven were bilateral and three were extra adrenal. Twenty-three were male and 15 were female; the median age was 36 years. Four of five patients with von Hippel-Lindau disease had bilateral adrenal tumours and four had neurofibromatosis. None had multiple endocrine neoplasia. Using essential hypertensive patients as a reference population, diagnostic sensitivity was 80% for noradrenaline, 54.4% for adrenaline, 19.1% for dopamine, 93.3% for total normetanephrine, 33.3% for total metanephrine, 78.7% for 3-methoxy-4-hydroxymandelic acid (HMMA) and 23.5% for homovanillic acid (HVA). However, if each patient's results were taken as a package, the sensitivities were 100% for noradrenaline, 63.6% for adrenaline, 30.3% for dopamine and 89% for HMMA. Seven recent patients had gene analysis. There were six (15.4%) deaths due directly or indirectly to the paraganglioma. Postoperative blood pressures were normal in 74%. The decrement in catecholamine values post-surgery is shown. Urinary noradrenaline values fell by a mean of 94.5% and the use of urinary noradrenaline as a tumour marker is also demonstrated.

Translevator anal anomalies with cutaneous fistulae passing deep to the scrotum

METHODS

The authors present a series of 9 patients collected from 4 centers with translevator anal anomalies, each of which has a fistula tracking forward deep to the scrotum and opening at the peno-scrotal junction. Whereas some would appear to be covered ani in type, others are deeper and would appear to fit in with an intermediate type of classification emphasizing the idea of a "spectrum" of malformation.

RESULTS

The anatomic arrangement, associated anomalies (eg, 2 had hypospadias), and surgical management is described briefly in each case. Careful examination may be necessary to identify the fistula.

CONCLUSIONS

It is recommended that the surgery be individualized depending on the findings. On a theoretical embryologic basis there is abnormality in the formation of the outer genital folds, and there also may be abnormality in some cases of the inner genital folds.

Prophylactic thyroidectomy in the treatment of thyroid medullary carcinoma. Age for surgery?

Since the association of RET proto-oncogene mutations and medullary thyroid carcinoma in children there has been much discussion regarding timing of surgery. Our study group was formed from a brother and sister (8 and 5) and 3 brothers (9, 13, 16) selected on the basis of a positive family history for thyroid medullary carcinoma. Histological examinations of the thyroidectomy specimens showed that the 8- and 9-year old had microinvasive carcinoma and the remaining three had C-cell hyperplasia. Our recommendation is for prophylactic thyroidectomy for children with RET proto oncogene mutations at an early age, clearly before age 5.

Catecholamine secretion and ploidy in phaeochromocytoma

The aim was to evaluate 24 hr urine catecholamine, HMMA and HVA excretion in relation to ploidy in phaeochromocytoma. Data from five diploid and nine tetraploid tumours showed a significant reduction in urine noradrenaline (p = 0.02) and HMMA (p = 0.03) in diploid tumours but no difference in adrenaline, dopamine and HVA excretion using the Mann-Whitney U test. None of the patients showed recurrence after a mean of 5.7 years of follow up. A review of published ploidy studies in phaeochromocytoma shows that malignancy is more than six times more common in non-diploid tumours but diploidy does not equate with benignity. No biochemical marker is a reliable index of malignancy. All patients should undergo lifetime review for recurrence.

Purification and characterization of a lysine-p-nitroanilide hydrolase, a broad specificity aminopeptidase, from the cytoplasm of Lactococcus lactis subsp. cremoris AM2

A hydrolase activity that cleaves lysyl-p-nitroanilide (Lys-pNA) has been purified from the cytoplasm of Lactococcus lactis subsp. cremoris AM2 by chromatography on DE52, DEAE Affi-Gel Blue Gel, Hydroxyapatite Bio-Gel HTP and Phenyl Sepharose. The purified aminopeptidase was found to have a native M(r) of 50,000-55,000 by gel filtration chromatography and by FPLC gel filtration on Superose 12 and to be composed of a single polypeptide chain following SDS-PAGE. Enzyme activity was almost completely inhibited by EDTA, amastatin, puromycin and bestatin, while the sulphydryl-reactive agents p-chloromercuribenzoate and iodoacetamide were inhibitory. The enzyme was found to be very unstable during the purification procedures at 4 degrees C and its stability was greatly improved when 10 ml glycerol/l and 2 mM-dithiothreitol were included in the purification buffers. The purified enzyme was found to hydrolyse a wide range of dipeptides, tripeptides and longer peptides provided that proline was not present in the penultimate position from the N-terminus or that a pyroglutamyl residue was not present at the N-terminus. While neither Asp-pNA nor Pro-pNA was hydrolysed by the purified enzyme, the release of N-terminal acidic residues from peptides was observed in addition to the release of N-terminal proline from Pro-Leu-Gly-NH2, Pro-Leu-Gly-Gly and Pro-His-Pro-Phe-His-Leu-Phe-Val-Tyr. This ability of Lys-pNA hydrolase to release N-terminal proline residues was employed in concert with a purified aminopeptidase P preparation to release alternate N-terminal amino acids from Tyr-Pro-Phe-Pro-Gly. The complementary action of these enzymes represents an alternative mechanism to that of post-proline dipeptidyl aminopeptidase for metabolism of proline-containing peptides.

Ret-proto-oncogene analysis in medullary thyroid carcinoma

INTRODUCTION

Medullary carcinoma of the thyroid (MTC) is a rare tumour which occurs in both sporadic and hereditary forms. Mutations of the RET proto-oncogene have been identified in hereditary forms. The aim of our study was to confirm or exclude familial disease by examining for germline mutations in the RET proto-oncogene in patients with medullary thyroid carcinoma.

METHODS

Nine patients with medullary thyroid carcinoma and 4 of their children were studied. Peripheral blood was used to examine for mutations in the RET proto-oncogene. When this was not available, archival thyroid tissue was used.

RESULTS

Seven patients had clinically sporadic tumours confirmed by mutational analysis of RET. Four children were at risk of being carriers of a mutated gene, as their fathers had histologically proven MTC and had tested positive for the mutation at codon 618 on exon 10 of the RET proto-oncogene. Three of these children carried the 618 mutation. To date, 2 have had a prophylactic thyroidectomy, the pathology of which revealed C-cell hyperplasia. One child had familial disease excluded by mutational analysis. One patient had a clinical diagnosis of MEN2B confirmed by detection of the 918 mutation on exon 16 of the RET proto-oncogene.

CONCLUSIONS

RET proto-oncogene analysis is a reliable method of differentiating familial from sporadic MTC. Mutational information determines which family members of affected kindreds are at risk of developing the disease and can be used to affect clinical management.

Pelvic distraction to improve exposure in radical surgery for pelvic tumours in children

We describe one patient who had pubic osteotomy and three who had symphysiotomy as an aid to radical tumour resections over the last 7 years. In each it was possible to distract the pelvis so improving access to the tumour. All four patients had pelvic rhabdomyosarcomata, three primarily in the prostate and lower bladder and one was a large tumour filling the pelvis, probably of bladder origin. No immediate or long-term complications of the procedure occurred, and in the two patients who died (2.5 years and 1 year post-surgery) or in the two survivors.

Regional lymphadenitis following BCG vaccination

A cluster of cases of lymphadenitis occurred in Dublin following vaccination with a newly introduced Copenhagen 1331 strain of Bacille Calmette-Guerin (BCG) vaccine during 1989. All cases of BCG lymphadenitis presenting to paediatric surgical clinics over an 11-year period were reviewed to determine the optimum treatment for this problem. Seventeen patients are included, 16 of whom received vaccine in the newborn period; 1 received BCG at 8 months. Nine were treated by initial operation, 6 with antituberculous drugs, and 2 were observed without specific therapy. All but 1 of the medically treated patients and both patients who received observation only required operation for failure to resolve or progression of disease. The best results were obtained with excision and primary closure. We conclude that although sponteneous resolution occurs in a majority of all cases of BCG lymphadenitis in infants, in those patients with more severe disease who require surgical referral, a short trial of anti-microbial therapy is indicated. Patients who fail to improve or develop complications are then best treated by surgical excision of the involved nodes.

The Dandy-Walker syndrome--a 10-year experience of its management and outcome

Hydroephalus of childhood may be associated with intracranial haemorrhage, infection, aqueductal stenosis, Arnold-Chiari malformation (spina bifida), tumours or more uncommonly with the Dandy-Walker syndrome (DWS). We present our experience with the management of this condition over a 10-year period. Twelve children with a definite diagnosis of DWS are reviewed with regard to the age at diagnosis, investigations, treatment, associated problems and overall outcome. Two patients died; there was a high incidence of mental retardation (65%) and associated problems. All but one child had ventriculo-peritoneal shunting and two had cysto-peritoneal shunts in addition to their V-P shunts. There were no familial cases; one child had a chromosomal abnormality. Although the long-term outcome is dismal in most cases, about 35% of the children have a reasonable outcome and hence the condition warrants energetic treatment.

Scarring following renal trauma in children

OBJECTIVE

To assess factors relating to renal scarring following kidney injury.

PATIENTS AND METHODS

A total of 25 children who had documented renal injury between 1981 and 1988 were included in the study and 19 were followed up for 1 month to 12 years (mean 5.5 years) and the development of hypertension and renal scars assessed using ultrasonography and radionuclide scans (dimercapto-succinic acid, DMSA).

RESULTS

Of the 19 children 13 had renal contusions, four had renal lacerations and two sustained severe renal injury, one of whom had pelvi-ureteric disruption. Eighteen patients presented with macroscopic or microscopic haematuria except the patient with pelvi-ureteric junction disruption who presented 3 weeks later with abdominal distension, vomiting and hypertension. All the patients were managed without an operation except the latter patient who required nephrectomy. Renal scarring was demonstrated in four children at a mean follow-up of 3.5 years, one following renal contusion (5% scarring), two after renal laceration (50% scarring) and one after rupture of the kidney (100% scarring). In one patient intravenous pyelography did not reveal a renal scar but a radionuclide scan performed 5 years later demonstrated a scar. Transient hypertension was noted in only two patients but peripheral plasma renin levels were normal.

CONCLUSION

Renal scars developed in four of 19 patients with renal trauma and more than half of the patients with severe renal injury. Long-term follow-up including a radionuclide scan is therefore necessary in patients with renal injury. Although no sustained hypertension was noted in any patients in this study, long-term blood pressure assessments would seem prudent.

Varicocele and the horizontal testis: a change in position?

Horizontal lie of the testis has recently been observed in association with varicoceles in a pediatric population. Six children with a varicocele presented to the surgical department during a 6-month period. All had an associated horizontal lie of the testis. In two of these cases, high ligation of internal spermatic veins was performed, after which one reverted to a vertical position with resolution of the varicocele. Seven children who underwent high ligation of a varicocoele over a 5-year period were examined. All were found to have no evidence of the varicocele at follow-up. All but one had a vertical lie. Horizontal lie of the testis in children is a new clinical sign that should alert the examiner to the possibility of an underlying varicocele.

A microbiological study of recurrent dentinal caries

A cross-sectional microbiological study of recurrent (secondary) dentinal caries was conducted. Freshly extracted human teeth containing amalgam restorations judged to be clinically intact were scrubbed with chlorhexidine soap and soaked in povidone-iodine solution. The teeth were then split to remove the fillings and examined for dentinal caries. Of 54 teeth examined, 22 (40%) were free of dentinal caries in the restored site. The remainder were assigned to arbitrary groups of questionable (15), initial (8) and active caries (9), based on the amount of dentinal decay observed. Comparison of pre-extraction bite-wing radiographs with the in situ findings revealed the sensitivity for secondary caries detection to be only about 50%. In contrast, the specificity for absence of caries was 73%. There was considerable variation in the numbers and types of micro-organisms found in dentine samples from lesions of comparable severity. Facultatively, anaerobic streptococci were the most numerous and most prevalent micro-organisms in the affected dentine, but no single species was significantly associated with recurrent caries. Mutans streptococci were found in 40% of sites with any degree of caries and in only 3 of the 9 sites with the most caries. Homofermentative lactobacilli were present in 18 of the 54 dentine samples, including 4 from caries-free sites. While the prevalence and numbers of lactobacilli increased with the degree of caries, they occurred in less than half of the affected dentine samples. Actinomyces occurred in 15 of 32 affected sites but only in 2 of the 9 most active sites. Their numbers never exceeded 3 x 10(3) CFU/mg.(ABSTRACT TRUNCATED AT 250 WORDS)

Laryngo-tracheo-oesophageal cleft: a plea for early diagnosis

Congenital laryngeal clefts are rare. This paper reports on the management of 3 patients with Type 2 laryngo-tracheo-oesophageal cleft. One patient died following tracheopexy after successful cleft closure. Prognosis is related to the presence of other major anomalies, the early diagnosis of the lesion and institution of appropriate respiratory and nutritional care prior to correction of the defect. A greater awareness of the condition combined with aggressive diagnostic endoscopy should result in early diagnosis and improved survival.

Biochemical properties of Streptococcus sobrinus reisolates from the gastrointestinal tract of a gnotobiotic rat

Streptococcus sobrinus strain 6715-13-201 was inoculated into the oral cavity of a gnotobiotic rat and then reisolated from different portions of the gastrointestinal tract. Fourteen isolates, selected on the basis of their colonial morphology, were then screened for their ability to adhere to saliva-coated hydroxyapatite (SHA) in vitro, and their ability to produce extracellular polysaccharide from sucrose, and low pH in glucose broth. Certain isolates were also tested for their cariogenic potential as monoinfectants in gnotobiotic rats. All isolates differed in their abilities to adhere to SHA, with most showing an increased level of adhesion in the presence of sucrose, but this did not correlate with their ability to be aggregated by dextran. Most isolates were capable of producing glucosyltransferases (with only one exception) and dextranases (also one exception). There was more variability in the production of dextranase inhibitor. No isolate was capable of producing dextranase inhibitor in the absence of dextranase production. There were no correlations between the ability of isolates to adhere in vitro or produce/utilize polysaccharides and their ability to produce caries in vivo. Due to the differences between strains in their abilities to adhere, produce polysaccharides, utilize polysaccharides or produce a low pH and the lack of correlation between any of these parameters and cariogenicity, the results suggest that the ability of strains to colonize and produce caries depends on a number of different characteristics, no one of which is essential.

Extrarenal Wilms' tumor

Extrarenal nephroblastoma (Wilms' tumor) is very rare with to date just 34 cases described. Two such cases out of a total of 61 patients with WT presenting to a single institution over a 10-year period are presented. Both children, a boy aged three years and a girl aged four years, both presented with an abdominal mass which had crossed the midline. Ultrasonography and contrast studies in the two patients revealed retroperitoneal tumors distinct from kidneys, but unilateral hydronephrosis was noted in both patients. Primary surgical excision was performed and both patients grouped as stage III favorable histology. Postoperative treatment included chemotherapy and radiotherapy as per UKCCSG protocols. The patients are clinically well with no evidence of disease 7 years and 20 months respectively from diagnosis. An individualized approach to treatment of extrarenal WT is advocated.

Heterotopic gastric cyst of the tongue in a newborn

Gastrointestinal heterotopia in the tongue is a rare condition. A male newborn was noted to have a cystic swelling in the anterior part of the dorsum of the tongue. This was surgically excised. Histology revealed it to be a heterotopic gastrointestinal cyst. A literature review was undertaken because of the rarity of this lesion. As most of these cysts are present from birth, they are likely to be developmental in origin.

Gastrointestinal manifestations of neurofibromatosis in childhood

Von Recklinghausen's neurofibromatosis (VRN) is a familial disorder characterised by a generalized neuroectodermal dysplasia--symptomatic involvement of the gastrointestinal tract is rare. We report on our experience with two children who had proven gastrointestinal neurofibromas and highlight the need for careful assessment in children with VRN who develop abdominal pain.

Neuroblastoma--a surgical perspective

The role of an aggressive surgical policy in the management of neuroblastoma (NBL) was examined in a retrospective study from a total of 57 patients presenting to a single institution between 1979 and 1989. Surgery consisted of either primary excision of tumour or elective resection following intensive chemotherapy. Two year disease-free survival (DFS) for the entire group was 100% for Stage I patients (n = 2), 86% for Stage II (n = 7), 55% for Stage III (n = 11), 12% for stage IV (n = 33) and 50% for stage IVs (n = 4). In all long-term survivors, surgical excision of primary tumour had been achieved. Elective surgery of primary tumour was not performed in six patients with Stage IV disease; median survival for these patients was eight months compared with 19 months for those other patients with Stage IV disease who did have surgery +/- high dose melphalan and autologous bone marrow rescue. Postoperative complications were documented in 13 of 48 operated patients (27%), emphasising the technical challenges encountered in resection of NBL. Age at presentation and site of primary tumour were major factors affecting prognosis: patients who presented < 1 years of age (n = 15) achieved 80% DFS, > 1 year and < 2 years (n = 12), 33%, and > 2 years (n = 30) 13%; 10 of 11 patients (91%) with primary supradiaphragmatic disease are alive and well compared with 10 out of 46 (22%) with infradiaphragmatic disease (P = 0.01). Based on the experience from this centre, it would appear that surgery can be curative for patients with Stage I, II and III disease but can only, at best, prolong DFS for Stage IV patients. Alternative therapeutic strategies are indicated for this latter group of patients.

The use of a long split rectal tube to aid in pull-through procedures for imperforate anus

Problems with loss of correct orientation of the pull-through rectal pouch during posterior sagittal anorectoplasty (PSARP) for high imperforate anus can occur during laparotomy after perineal closure is complete. A simple modification of the de Vries-Peña technique is described that facilitates preservation of orientation and precise anatomical neomuscle construction. A slotted rubber tube preserves correct anatomical orientation of the neorectal pouch and allows accurate construction of the muscle complex around the tube.

Tumours of heterotopic salivary tissue in the upper cervical region in children

Heterotopic salivary tumours in the upper neck are rare. Three children, one with mucoepidermoid carcinoma and two with pleomorphic adenoma in ectopic cervical sites are presented. Local complete excision was successful in the patients with pleomorphic adenoma. More extensive surgery was undertaken for the mucoepidermoid carcinoma. All three patients remain disease free at 3-6 years follow-up. Oncogenesis of heterotopic salivary tissue entrapped in an upper cervical lymph node during embryogenesis is a possible etiological mechanism. In a patient with a cervical malignant salivary tumour, a careful search should be made to find a primary tumour. In the event of a negative search, this should be considered the primary tumour and treated appropriately.

Delayed primary anastomosis for esophageal atresia: 18 months' to 11 years' follow-up

In 1977 we started treating babies with isolated esophageal atresia by delayed primary anastomosis and in 1981 reported our early experience in five cases treated between 1977 and 1979. Since 1979, 11 further consecutive cases have been managed by initial gastrostomy followed by delayed primary esophageal anastomosis. Their mean gestation was 35 weeks (range, 28 to 40 weeks) and mean birth weight was 2,040 g (range, 1,140 to 2,720 g). The esophageal gap between the two ends when assessed initially at fluoroscopy ranged from 2.2 to 4.5 cm (mean, 3.2 cm). Age at delayed primary anastomosis ranged from 6 to 20 weeks. Anastomotic leak occurred in three babies in the immediate postoperative period and all were successfully managed conservatively. Eight of the 11 patients developed anastomotic strictures; seven cases required 1 to 5 esophageal dilatations. One patient who did not respond to multiple esophageal dilatations required resection of an esophageal stricture. One patient died at 15 months of age of unrelated causes. The 10 surviving patients have been followed-up from 18 months to 11 years. At follow-up, seven patients were eating normally. Three patients had swallowing difficulties and all three were found to have esophageal strictures on barium swallow, two of them also had gross esophageal reflux and hiatus hernia. The height and weight in the 10 patients varied from 3rd centile to 75th centile. Delayed primary anastomosis is feasible in cases of isolated esophageal atresia and the patient's own esophagus is the best. A more aggressive approach should be applied to gastroesophageal reflux in these patients.

Primary hepatic tumours in children: a 26-year review

Twenty-one children were admitted to a single paediatric institution between 1964-1990 with histologically proven primary liver tumours. The diagnosis was hepatoblastoma (HBL) in 15 patients, hepatocellular carcinoma (HCA) in 2, rhabdomyosarcoma (RMS) in 2, non-Hodgkin's lymphoma (NHL) in 1, and haemangioendothelioma (HE) in 1. The common presenting clinical features were anaemia, abdominal mass, and abdominal pain. Serum alpha-foetoprotein was useful in establishing a diagnosis in HBL and in monitoring disease activity. Computed tomographic (CT) scan, ultrasound, and angiography were useful preoperative investigations for assessing site and resectability of tumour. There were no survivors in patients with malignant hepatic tumours (n = 10) who had surgery alone prior to 1981. Of 7 patients with HBL diagnosed after 1981 who had adequate surgical resection and chemotherapy, 5(72%) are currently alive and disease free between 15 months and 8 years from diagnosis. We conclude that adequate surgical resection and adjuvant chemotherapy can improve disease free survival for children with HBL. Optimal treatment has yet to be devised for other malignant hepatic tumours.

The changing role of surgery in the management of rhabdomyosarcoma

A retrospective analysis was performed of 56 patients presenting to Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland, over a 25 year period with a diagnosis of rhabdomyosarcoma, in an effort to assess the changing role of surgery in the management of this disease. There were 38 males and 18 females; the age range at presentation was from birth to 13 years with a median of three years. Head and neck tumors occurred most frequently (23) followed by pelvic (14), paratesticular (6), extremities (6), gastrointestinal (4) and thoracic (3). Prior to 1971 there were no survivors while a doubling of survival has been observed within the past decade (31% to 63%). The minimum period of follow-up was four years. Surgical intervention ranged from total primary excision (20) to biopsy only (21) with total or subtotal resection performed electively in 15. Surgical evaluations, including examinations under anesthesia, staging laparotomy and second look laparotomy were also invaluable in assessing disease status. The incorporation of multiagent chemotherapy together with more selective use of radiotherapy has enabled a more conservative role to be adopted by the surgical oncologist thereby minimizing longterm sequelae.

Are the selection criteria for the conservative management in spina bifida still applicable?

Management of spina bifida is still controversial. At one extreme is the policy of total care in all cases while some form of selection is practised in many centres. We reviewed 104 patients treated over the last five years. Forty-nine patients, who had one or more adverse criteria, were managed conservatively. Twenty-four of these 49 patients required VP shunt insertions subsequently. Four patients had delayed closure of back lesions, three of them were followed by shunts. There was an overall increased (57%) incidence of surgical intervention in conservatively managed patients over the last five years as compared with 34% from our previous report. We found no difference in the timing of insertion of shunts in actively and conservatively managed patients in this study. The mortality in the actively and conservatively managed patients was 7% and 47% respectively. Eighty-five per cent of the patients who had no surgery died at an average age of 23 days. Patients who died without surgical intervention did not survive long enough to warrant surgery, while the mortality was 20% and had among those who survived surgical intervention. Paraplegia alone was not a predictor of high mortality but the presence of two or more adverse criteria were more accurate indicators of poor prognosis. As 78% of all the deaths in conservatively managed patients occurred within three months, reappraisal of management policy is necessary in the infants surviving beyond three months of age as death is less likely after this time.

Ultrasonography to diagnose and exclude intussusception in Henoch-Schönlein purpura

Abdominal pain is a frequent symptom in the child with Henoch-Schönlein purpura and raises the suspicion of intussusception or perforation. One hundred and fifty two children with a diagnosis of Henoch-Schönlein purpura over 11 years were reviewed. Of these 60 had abdominal pain, 19 gastrointestinal bleeding, and nine were suspected intussusception. Intussusception was confirmed in two of these cases with ultrasonography. Ultrasound is an important tool in the early diagnosis of intussusception complicating Henoch-Schönlein purpura. Where the intussusception appears loose an expectant policy, with careful monitoring, may allow spontaneous reduction. It may also be used in monitoring patients for postoperative recurrence of intussusception, mural haematoma, and uncomplicated intestinal vasculitis with oedema.

Evaluation of conservative therapy for exomphalos

Two management patterns were identified in 36 patients with exomphalos--primary surgical closure and initial topical therapy with delayed surgical closure. Primary surgical closure of minor exomphalos was well tolerated in 15 patients, but was associated with a high local and systemic morbidity rate in 14 patients with major defects. In contrast, initial topical therapy with silver sulphadiazine and delayed closure in seven matched patients with a major defect were well tolerated and did not prolong duration of hospitalization. Enteral feeding was more readily established and subsequent fascial closure facilitated in the conservatively treated group. It was suggested that this method should be more often considered in the management of all instances of major exomphalos.

Renal function following extracorporeal lithotripsy in children

Although extracorporeal shockwave lithotripsy (ESWL) has revolutionised the management of urinary calculous disease, the long-term effects of ESWL on renal function are not known. This study of 18 children demonstrated a mild, statistically insignificant decrease of 15% in DTPA measured glomerular filtration rate following ESWL. In view of this, we recommend that pretherapy and posttherapy estimates of renal function be obtained in all patients undergoing ESWL. Long-term follow-up is necessary to further quantify the effects of ESWL on the developing kidney.