Parenteral nutrition-induced anaphylaxis

A case report of a 4-yr-old child who developed an anaphylactic reaction to parenteral nutrition is presented. Dermal allergy tests demonstrated a sensitivity to Travasol solution and Armour multivitamin 2 solution. This is the first reported case known to us of such a response to elemental parenteral nutrition.

Intracellular calcium and sodium in hypertensive patients

Untreated subjects with mild to moderate hypertension were compared with normotensive controls recruited from the same ambulatory screening clinic. All subjects were black. Resting levels of cytosolic free calcium were estimated in washed platelets with the fluorescent intracellular probe fura 2, and sodium and potassium were measured in red blood cells. Calcium levels were 21% higher in the hypertensive subjects (p = 0.02), and a 9% increase in sodium was observed in an expanded sample (p = 0.04). Neither intracellular calcium nor intracellular sodium had a significant linear correlation with blood pressure when hypertensive subjects and controls were examined separately or when the two groups were combined. Potassium was slightly but not significantly increased in hypertensive subjects. Among the participants for whom both calcium and sodium measurements were available, a weak, nonsignificant correlation between these ions was noted (r = 0.2; n = 48). This correlation was significant among participants in the control group examined separately (r = 0.3; n = 33; p = 0.05). Although the measurements were performed in different cell lines, these findings demonstrate increases in both intracellular calcium and sodium in hypertensive humans.

Surgical treatment of infants with esophageal atresia and VATER association

Our surgical experience in 10 infants with esophageal atresia and the VATER association of multiple congenital anomalies is reviewed. Early recognition and evaluation of the various lesions enabled the planning of a staged surgical approach with a satisfactory outcome. Seven of the patients survived. There were no immediate postoperative deaths. Development and growth curves of the surviving patients are satisfactory. Despite multiple operative procedures infants with VATER association may lead a reasonably normal life.

Intussusception in a premature infant simulating necrotising enterocolitis

Intussusception in older infants is manifested by bloody stools, colicky abdominal pain and a palpable abdominal mass. In neonates the symptoms are often restricted to vomiting, guaiac positive stools and abdominal distension. These symptoms closely mimic necrotising enterocolitis. Surgical treatment of necrotising enterocolitis should be postponed until perforation of the gastrointestinal tract has occurred, whereas, prompt surgical treatment is recommended for intussusception. We report a case of intussusception that simulated necrotising enterocolitis in a 740 grammes premature infant in the second week of life. The clinical and radiographic features are described and the difficulty in distinction between the two conditions is emphasised. Neonatologists and paediatric surgeons should always include intussusception in the differential diagnosis of abdominal distension and guaiac positive stools in small premature infants.

Non-operative management of traumatized spleen in children: the role of open abdominal tap

Experience with non-operative management of paediatric splenic trauma in 12 children, and current treatment protocol are presented. Splenic injury was confirmed in all instances by scintiscan. Under close observation no evidence of rebleeding was found. In one patient with persistent fever, peritoneal irritation and leukocytosis open abdominal tap was performed in order to eliminate other intra-abdominal injury and conservative treatment continued. Average stay in hospital was 11 days. Patients recovered fully by six weeks and repeat scintiscan at three months were normal in 9 patients and greatly improved in the other three. Most children sustaining splenic injury may be non-operatively managed. In a special subgroup of moderate bleeders open abdominal tap may increase the safety of this approach and reduce the number of superfluous laparotomies to a minimum.

Intracellular free calcium levels in mononuclear cells of patients with cystic fibrosis and normal controls

The time course of resting free intracellular calcium concentrations in isolated mononuclear blood cells following a one hour incubation period with the fluorescent dye quin2 was evaluated. Under equal experimental conditions, a slow time-dependent increase of intracellular free calcium in patients with cystic fibrosis and normal healthy controls was noted. Using regression analysis, cystic fibrosis patients were seen to exhibit significantly higher free intracellular calcium concentrations than the controls over the time span covered. At an arbitrarily selected time (60 minutes) the free calcium level was 143.7 +/- 4.3 nM (SEM) in the patients, and 125.5 +/- 2.6 nM in controls. From these data it is concluded that neglecting the time-dependent (Ca2+)i changes following quin2 incubation leads to over- and/or underestimation of the unstimulated resting, basic free calcium levels and prevents the detection of differences between normals and cystic fibrosis patients.

The use of patch angioplasty to alter the incidence of carotid restenosis following thromboendarterectomy

Eighty-nine consecutive patients were followed for twelve to twenty-four months after carotid thromboendarterectomy. Forty-seven underwent operations using a standard carotid closure; a second group of forty-two patients had a saphenous vein patch graft applied in closure. The patients were evaluated with carotid duplex scans at regular intervals to evaluate the incidence of early restenosis. Patients with positive duplex scans underwent arterial angiography or digital subtraction angiography. Operative mortality was zero. Twelve late deaths occurred; eleven due to cardiac disease. In the unpatched group, 19.1% of the patients developed significant restenosis (a luminal narrowing of greater than 50%) with only a 2.4% incidence occurring in the patched group, a statistically significant difference (p less that 0.05). There was a higher incidence of symptomatic restenosis in the unpatched group, though the results were not considered significant. Venous patch rupture was seen in three patients who have not been included in the study group. All of these had venous patches harvested from a distal greater saphenous vein site at the ankle. The authors recommend venous patch closure with a thicker patch taken from the proximal saphenous vein at the groin to reduce the incidence of early restenosis and to avoid venous patch rupture. Regular non-invasive evaluation is recommended to detect restenosis with careful clinical follow-up to evaluate neurologic complications.

The hierarchical relationship between activities of daily living and instrumental activities of daily living

A three-level hierarchical scale including IADL (shopping and transportation) and ADL (bathing, dressing, transferring, and feeding) was tested and validated based on secondary analysis of three studies of elders in the community: a population-based sample, the Cleveland-GAO, and two service-based samples, the Alternative Health Services Project, a study of Medicaid-eligible elders in Georgia, and the Section 222 Homemaker-Day Care study, a sample of Medicare-eligible elders. Scalability analysis included evaluation of Kronbach's alpha, Guttman analysis, and analysis of the pairwise association of individual items using phi/phi max. Validation included discriminant validity and predictive validity. With respect to discriminant validity, the negative association between functional ability (as measured by the scale) and age was observed. With respect to predictive validity, the negative relationship between functional ability (as measured by the scale) and risk of decline to ADL, death, and hospitalization in a year was observed. A six-level scale similar in structure and detail to the Katz Index of ADL was examined with the three studies. This scale can be used to described a broader range of needs of elders in the community and will be particularly useful to health services planners, practitioners, and researchers.

Varicocele in children: "to treat or not to treat"--venographic and manometric studies

The management of varicocele is still controversial in spite of its high incidence (15%) in prepubertal boys and young adults and although it is believed to represent a major contributing factor to male subfertility. Fifty boys between 6 and 14 years of age were operated on for left varicocele, and a long segment of the left internal spermatic vein was excised. Thirty-four of them underwent preoperative retrograde left renal venography and pressure readings in both renal veins and inferior vena cava. In all 50 patients, intraoperative antegrade (via internal spermatic vein) left renal venography was performed. This examination revealed impaired renal venous drainage in 38 patients (group A) and normal venous return through the left renal vein in 12 patients (group B). In all 34 patients (from both groups) on whom retrograde venography was performed, there was marked renospermatic reflux. The pressure readings in the left renal vein were significantly increased in group A only. Our data strongly suggest that left varicocele is caused by renospermatic venous reflux and that this condition is probably irreversible. The reflux in group A is explained by the impaired venous drainage through the left renal vein. In group B, it is our impression that the reflux is a result of a congenitally valveless left internal spermatic vein. If varicocele is indeed a major cause for infertility, then our data logically point toward surgery.

Non-iatrogenic deep vein thrombosis of lower extremities in children

Non-iatrogenic ileo-femoral vein thrombosis is rarely encountered in childhood. Six children with postphlebitic leg following venous thrombosis are presented. Venous thrombosis occurred following peritonitis, osteomyelitis and scarlet fever. None of the patients had history of trauma or intravenous treatment. Based on world literature and our experience, the main clinical and radiological manifestations of this rare entity are summarised. Early detection and aggressive anti-coagulant therapy of deep vein thrombosis may probably prevent post-thrombotic syndrome--a major disabling condition in children.

Sodium sensitivity, growth and family history of hypertension in young blacks

The response to chronic oral sodium loading was studied in young adult (18-23 years) blacks. A representative sample of participants (n=40) from previous longitudinal studies had growth measures at age 6-7 years and 11-16 years. Blood pressure, weight and stress-induced reactivity were measured before and after 14 days of 10 g NaCl daily added to the usual diet. A sodium-sensitive response (SS) was an increase in mean arterial pressure (MAP) greater than or equal to 5 mmHg. A sodium-insensitive response (S) was an increase in MAP less than or equal to 5 mmHg. Family history of hypertension (FH+) was determined by self-report. Fifty-three per cent were SS. There were no difference in age-related BP, weight or height between SS and SI in childhood or adolescence. Those with a family history of hypertension had a greater BP response to stress and greater weight change with sodium load. The group which was both SS and FH+ had the highest weight and MAP stress response after sodium load. These results indicate that sodium sensitivity is high among blacks, but does not correlate with childhood growth variables. Sodium sensitivity and FH+ combined produce the greatest stress-induced BP response.

Investigation of (Ca2+ + Mg2+)-ATPase phosphoprotein formation in erythrocyte membranes of patients with cystic fibrosis

The (Ca2+ + Mg2+)-ATPase present per mg of protein in erythrocyte membranes of controls and patients with cystic fibrosis (CF) was determined by estimation of the levels of its phosphoprotein. In the presence of 10 mM free Ca2+, which inhibits phosphoprotein decomposition, significantly less phosphoprotein intermediate, ECaP, was found in erythrocyte membranes from CF patients than in age- and sex-matched controls; this correlated with a significant decrease in (Ca2+ + Mg2+)-ATPase activity. These observations indicate a decrease in the number of functional (Ca2+ + Mg2+)-ATPase molecules in erythrocyte membranes from CF patients or an alteration in either the structure of the pump protein or the composition of its environment.

Na-K-C1 cotransport and Na pump in red cells of young blacks and blood pressure response to salt loading

The functional operation of Na and K fluxes, mediated by the furosemide-sensitive (FS) Na-K-C1 cotransport and the ouabain-sensitive Na pump, was studied in a representative young (18-22 years) black population. Cation fluxes (mumol/L cell X hour = FU) were studied prior to salt loading; results were compared with the blood pressure response to chronic oral salt loading. All subjects (n = 26) took 10 g/day NaC1 plus their usual diets for 14 days. A mean arterial blood pressure increase higher than 5 mmHg was considered a sodium-sensitive (SS) response; a response lower than 5 mmHg was considered sodium-insensitive (SI). The Km for Nac to stimulate FS Na efflux was significantly greater in SS (SS = 13.8 +/- 1.39 mmol/L cells, n = 15; SI = 8.5 +/- 0.8 mmol/L cells, n = 11; p less than 0.001). Inward cotransport of Na and K was also studied at constant Nac (13 mmol/L cells) and incubation of 140 mM Na and 4 mM K. No significant differences were found in the Vmax of outward FS Na and K efflux, FS86 Rb, Na influx, net Na movement (efflux minus influx), and the Na/K ratio of inward cotransport. Several parameters of the ouabain-sensitive Na pump (Vmax of the Na efflux, Rb influx, Na/K coupling ratio (2.2), and fresh Nac) were found to be similar in both groups. The results indicate that in young blacks, the Na sensitivity of the blood pressure may be associated with lower affinity for internal Na of the outward Na-K-C1 cotransport system.

Fluorometric determination of nanogram quantities of protein in small samples: application to calcium-transport adenosine triphosphatase

A fluorometric micro protein assay based on fluorescamine-labelling of homogeneous proteins in solution has been developed which is capable of accurately quantitating as little as 25 ng protein at a concentration of 1.25 micrograms/ml. This micro assay uses a flow-through HPLC fluorescence detector. Typical micro assays measuring bovine serum albumin standards (0-25 mg/l) yielded linear regression coefficients of r = 0.999. Assays of purified Ca2+-ATPase solutions determined by the micro fluorescamine procedure correlated well with measurements made using the deoxycholate-TCA-precipitation modification of the Lowry assay: 1.0 microgram ATPase by Lowry method = 1.1 microgram protein by fluorescamine microassay (when both procedures were standardized with bovine serum albumin) (r = 0.995). The assay proposed offers a 100-fold increase in sensitivity, compared to the Lowry procedure.