Efficacy and mechanism of angiotensin II receptor blocker treatment in experimental abdominal aortic aneurysms

Background

Despite the importance of the renin-angiotensin (Ang) system in abdominal aortic aneurysm (AAA) pathogenesis, strategies targeting this system to prevent clinical aneurysm progression remain controversial and unproven. We compared the relative efficacy of two Ang II type 1 receptor blockers, telmisartan and irbesartan, in limiting experimental AAAs in distinct mouse models of aneurysm disease.

Methodology/Principal Findings

AAAs were induced using either 1) Ang II subcutaneous infusion (1000 ng/kg/min) for 28 days in male ApoE^−/− mice, or 2) transient intra-aortic porcine pancreatic elastase infusion in male C57BL/6 mice. One week prior to AAA creation, mice started to daily receive irbesartan (50 mg/kg), telmisartan (10 mg/kg), fluvastatin (40 mg/kg), bosentan (100 mg/kg), doxycycline (100 mg/kg) or vehicle alone. Efficacy was determined via serial in vivo aortic diameter measurements, histopathology and gene expression analysis at sacrifice. Aortic aneurysms developed in 67% of Ang II-infused ApoE^−/− mice fed with standard chow and water alone (n = 15), and 40% died of rupture. Strikingly, no telmisartan-treated mouse developed an AAA (n = 14). Both telmisartan and irbesartan limited aneurysm enlargement, medial elastolysis, smooth muscle attenuation, macrophage infiltration, adventitial neocapillary formation, and the expression of proteinases and proinflammatory mediators. Doxycycline, fluvastatin and bosentan did not influence aneurysm progression. Telmisartan was also highly effective in intra-aortic porcine pancreatic elastase infusion-induced AAAs, a second AAA model that did not require exogenous Ang II infusion.

Conclusion/Significance

Telmisartan suppresses experimental aneurysms in a model-independent manner and may prove valuable in limiting clinical disease progression.

A novel bipolar electric fence for excluding white-tailed deer from stored livestock feed

Where cattle (Bos taurus) and free-ranging white-tailed deer (Odocoileus virginianus) coexist, they frequently share space and resources, potentially resulting in damage to stores of livestock feed and risk of interspecies disease transmission. Preventing use of stored feed by deer can be an important objective in farm management, depending on amount of damage experienced and perceived risk of disease transmission. Woven wire fences (2.4 to 3.0 m high) are generally considered to be the most effective means for excluding deer. However, rapidly deployable temporary means of excluding deer could be useful, especially during late winter when deer are most physiologically stressed and motivated to consume feed meant for cattle. Thus, the objective of this study was to evaluate a novel 1.2-m-tall electric fence consisting of 4 strands of bipolar tape (not requiring separate ground wires or animal contact with ground) for excluding deer from artificially established feed piles during late winter 2008 in northwestern Minnesota. To induce deer to pause, investigate the fence, and receive negative stimuli before attempting to jump the fence, the bipolar tape was baited with a viscous fluid attractive to deer. The fence was estimated to be >80% effective at reducing deer presence at feed piles (10 treatment sites and 11 control sites) given the late winter to early spring conditions. Despite the efficacy, using the fence as a primary means of protecting stored feed from deer in areas with known disease transmission risk (e.g., presence of bovine tuberculosis) is not recommended because risk could remain unacceptably high if even low numbers of deer access stored feed. Yet, the fence could be effective as immediate protection of stored feed in winter before a more permanent and effective deterrence strategy, such as woven-wire fencing, could be installed during the subsequent summer. The fence would also be effective for reducing deer depredation of stored feed, as well as gardens, small orchards, or other localized or seasonal resources.

No increased mortality with early aortic aneurysm disease

OBJECTIVE

In addition to increased risks for aneurysm-related death, previous studies have determined that all-cause mortality in abdominal aortic aneurysm (AAA) patients is excessive and equivalent to that associated with coronary heart disease. These studies largely preceded the current era of coronary heart disease risk factor management, however, and no recent study has examined contemporary mortality associated with early AAA disease (aneurysm diameter between 3 and 5 cm). As part of an ongoing natural history study of AAA, we report the mortality risk associated with presence of early disease.

METHODS

Participants were recruited from three distinct health care systems in Northern California between 2006 and 2011. Aneurysm diameter, demographic information, comorbidities, medication history, and plasma for biomarker analysis were collected at study entry. Survival status was determined at follow-up. Data were analyzed with t-tests or χ(2) tests where appropriate. Freedom from death was calculated via Cox proportional hazards modeling; the relevance of individual predictors on mortality was determined by log-rank test.

RESULTS

The study enrolled 634 AAA patients; age 76.4 ± 8.0 years, aortic diameter 3.86 ± 0.7 cm. Participants were mostly male (88.8%), not current smokers (81.6%), and taking statins (76.7%). Mean follow-up was 2.1 ± 1.0 years. Estimated 1- and 3-year survival was 98.2% and 90.9%, respectively. Factors independently associated with mortality included larger aneurysm size (hazard ratio, 2.12; 95% confidence interval, 1.26-3.57 for diameter >4.0 cm) and diabetes (hazard ratio, 2.24; 95% confidence interval, 1.12-4.47). After adjusting for patient-level factors, health care system independently predicted mortality.

CONCLUSIONS

Contemporary all-cause mortality for patients with early AAA disease is lower than that previously reported. Further research is warranted to determine important factors that contribute to improved survival in early AAA disease.

Gaining new insights into early abdominal aortic aneurysm disease

Abdominal aortic aneurysm (AAA) disease is a prevalent and highly morbid condition among older people in the US. There are currently no proven methods for reducing or eliminating enlargement in smaller preclinical aneurysms. Given their relatively slow increase in diameter (typically <0.4 cm/year), these smaller aneurysms offer a valuable window into the underlying pathophysiology of AAA disease. Through a Vascular Remodeling Specialized Center of Clinically Oriented Research program funded by the National Institutes of Health, we have established, in conjunction with Northern California Kaiser Permanente, a multidisciplinary research effort to efficiently identify and handicap suppressive therapeutic strategies for early AAA disease.

A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial

BACKGROUND AND STUDY AIMS

Reliable closure of the transluminal incision is the crucial step for natural orifice transluminal endoscopic surgery (NOTES) procedures. The aim of this study was to evaluate the feasibility and effectiveness of transgastric access closure with a flexible stapling device in a porcine survival model.

PATIENTS AND METHODS

We carried out four experiments (two sterile and two nonsterile) on 50 kg pigs. The endoscope was passed through a gastrotomy made with a needle knife and an 18-mm controlled radial expansion dilating balloon. After peritoneoscopy, a flexible linear stapling device (NOLC60, Power Medical Interventions, Langhorne, Pennsylvania, USA) was perorally advanced over a guide wire into the stomach, positioned under endoscopic guidance, and opened to include the site of gastrotomy between its two arms; four rows of staples were fired. One animal was sacrificed 24 hours after the procedure (progression of pre-existing pneumonia). The remaining animals were survived for 1 week and then underwent repeat endoscopy and postmortem examination.

RESULTS

Peroral delivery and positioning of the stapling device involved some technical difficulties, mostly due to the short length (60 cm) of the stapling device. The stapler provided complete leak-resistant gastric closure in all pigs. None of the surviving animals had any clinical signs of infection. Necropsy demonstrated an intact staple line with full-thickness healing of the gastrotomy in all animals. Histologic examination confirmed healing, but also revealed intramural micro-abscesses within the gastric wall after nonsterile procedure.

CONCLUSIONS

Gastrotomy closure with a perorally delivered flexible stapling device created a leak-resistant transmural line of staples followed by full-thickness healing of the gastric wall incision. Increasing the length of the instrument and adding device articulation will further facilitate its use for NOTES procedures.

Assessment of dilation methods in achalasia: large diameter mercury bougienage followed by pneumatic dilation as needed

In a retrospective study, 33 achalasia patients were treated with dilation therapy using large diameter mercury bougienage (mean, 56 French) and/or pneumatic balloon dilation. Mean follow-up time was 35 months. Mercury bougienage, performed in 20 patients, was successful in 10 (50%) with no complications. Pneumatic dilation was performed as initial therapy or in those having failed previous pharmacologic therapy and/or bougienage. A successful response was achieved in 19 of 23 patients (83%), with a 3.2% complication rate. In addition, in four patients with eventual recurrence of symptoms after initial pneumatic dilation, bougienage was used as a successful alternative to repeat pneumatic treatment. The combined efficacy of both forms of dilation was 88% with a complication rate of 1.4%. These data indicate that mercury bougienage should be considered initial therapy for achalasia in view of its simplicity, safety, and acceptable efficacy, followed by pneumatic dilation if bougienage is unsuccessful. Bougienage also may be considered if eventual recurrent symptoms develop after initially successful pneumatic dilation. Surgery should be utilized only if dilation therapy fails to achieve a satisfactory response.

Late sequelae of septic arthritis of the hip in infancy and childhood

We report a multicenter long-term follow-up study of patients with septic arthritis of the hip during infancy or childhood. Group I ("infantile") consisted of patients with onset before age 3 months, and Group II ("childhood") consisted of patients in whom onset occurred after age 3 months. Patients were specifically examined for this review. Generally, patients at follow-up had poor anatomic appearance radiographically and scored poorly on the Harris rating system. However, pain and activity restriction were minimal. Patients who were not treated operatively tended to function better than patients who underwent operative reconstruction.

Celiac disease presenting as entero-enteral intussusception

Cramping abdominal pain with intermittent intestinal obstruction finally prompted investigation in a 4 1/2-year-old boy with severe failure to thrive (FTT). An entero-enteric intussusception was corrected, and celiac disease was identified as the cause of his inanition. Concomitant FTT and cramping abdominal pain should prompt investigation for celiac disease and small-bowel intussusception.

Investigation of human low-density lipoprotein by (1)H nuclear magnetic resonance spectroscopy: mobility of phosphatidylcholine and sphingomyelin headgroups characterizes the surface layer

The resolution of the trimethyl headgroup resonance of phosphatidylcholine (PC) and sphingomyelin (SM) in the intact human low-density lipoprotein (LDL) (1)H NMR spectrum at 600 MHz enabled the investigation of LDL surface structure and phospholipid-apoB interactions. We have previously shown that a higher proportion of PC headgroups (25-35% of total PC in LDL) compared to SM were tightly bound to apoB and therefore NMR-invisible [Murphy, H. C., et al. (1997) Biochem. Biophys. Res. Commun. 234 (3), 733-737]. In the present study, we have investigated the mobility of phospholipid (PL) headgroups, using (1)H NMR spin-spin (T(2)) relaxation measurements, in LDL isolated from nine volunteers. We show that both PC and SM exist in two additional and distinct environments indicated by the biexponential behavior of the relaxation decays in each case. The data showed that 36% of PC headgroups had a short T(2) component, mean T(2) of 31 ms, and 64% had a longer T(2) component of 54 ms. Approximately 15% of SM headgroups had a short T(2) component (mean T(2) of 27 ms) and 85% had a longer T(2) component of 78 ms. Therefore the majority of SM headgroups (85%) were more mobile than PC (P < 0.001) and since PC headgroups in organic media were more mobile than SM, we conclude that the characteristic high mobility of LDL SM is not an intrinsic property but arises from a high degree of order in molecular packing of the surface PL of human LDL. We suggest that because PC and SM interact differentially with cholesterol and possibly with neighboring phospholipids, this results in the formation of relatively long-lived microdomains of PL in vivo.

Evidence for distinct behaviour of phosphatidylcholine and sphingomyelin at the low density lipoprotein surface

This study demonstrates that the use of high field 1H NMR spectroscopy permits individual detection of phosphatidylcholine and sphingomyelin molecules at the surface of native low density lipoprotein (LDL) particles. Distinct behaviour was observed for the choline head group -N(CH3)3 resonances of these different phospholipids revealing preferential immobilisation for phosphatidylcholine. This suggests the existence of reversible and irreversible phosphatidylcholine-apolipoprotein B interactions and is consistent with microdomain formation at the surface monolayer of LDL. The novel resonance assignment and results show that 1H NMR can provide efficient and practical means for future studies on the structure and dynamics at the LDL surface.

Cancer incidence and mortality trends in Northeastern Ontario

Over 629,000 people reside in the catchment area for the Northeastern Ontario Regional Cancer Centre. Historically, the area was renowned for employment in mining, forestry and lumbering, agriculture, the railway, and pulp and paper. At present, it is known for mining; community, business, and personal services; trade; manufacturing; and construction. Comparison of cancer incidence and mortality trends for two decades (1971-1980 and 1981-1990) with those of Ontario has revealed statistically significant excesses, at the 5% level or better, of trachea, bronchus, and lung cancer cases (SIR = 123 for 1971-1980 and 125 for 1981-1990) and deaths in men (SMR = 116 and 125, respectively); for women, excesses were observed for trachea, bronchus and lung cancer case (SIR = 114 and 118), and cervical cancer cases (SIR = 142 and 115) and deaths (SMR = 133 and 128). Enhanced recruitment strategies and early educational interventions are identified as priorities.

Innovative sensory input for the comatose brain-injured patient

Coma following brain injury may last days or months and is associated with decreased quality of life for survivors and families. One intervention postulated to improve coma recovery is sensory stimulation. This article critically examines current theoretical perspectives and empirical data related to sensory stimulation, discusses the usefulness of sensory stimulation programs (SSP) in critical care settings, and poses strategies for implementation of an SSP. Future directions for nursing practice and research also are addressed.

AIDS prevention struggles in ethnocultural neighborhoods: why research partnerships with community based organizations can't wait

Community based AIDS prevention programming and research in minority neighborhoods are growing. The AIDS epidemic has demoralized many minority communities and has added to enormously stressing social conditions. Obstacles to effective AIDS prevention programming must be removed before stable, accessible, and culturally relevant services can be provided. A pilot study was conducted to identify the obstacles to AIDS research or intervention in ethnic minority neighborhoods. Twenty-nine administrators and counselors from Community Based Organizations completed questionnaires concerning reasons for entering the field of AIDS prevention, enjoyment of work, hopefulness towards AIDS efforts, priority of AIDS funding, and opinions about most and least helpful prevention efforts in minority communities. Barriers identified as most problematic include insufficient funds, lack of culturally relevant materials, denial of the epidemic in minority communities, distrust of majority culture institutions, and myths/beliefs regarding AIDS contraction, transmission, and origin. Future research ideas are identified to improve culturally relevant AIDS prevention interventions in ethnocultural neighborhoods.

Central line occlusion with three-in-one nutrition admixtures administered at home

The use of single-container parenteral nutrition admixtures can be cost effective and can simplify home administration. Three-in-one admixtures (dextrose, amino acids, lipid emulsion, and other additives in a single bag) were in use when a marked increase in catheter occlusions was seen in the pediatric home parenteral nutrition population. Insoluble laminar deposits were found in the removed catheters. In all subsequently placed catheters, separate (SPLIT) infusions of lipid and parenteral nutrition solution were used rather than three-in-one admixtures. This was associated with an obvious decrease in catheter occlusions. Catheter life-span was retrospectively determined for 15 catheters of identical size and style that were used in eight patients who had received either infusions of three-in-one admixtures or SPLIT infusions. Life table survival analysis revealed a median survival time of 70 days for the three-in-one group (n = 8) and 290 days for the SPLIT group (n = 7). Survival distributions for the two groups were significantly different (p = .025). During the period of clustered catheter occlusion, the use of three-in-one admixtures that were stored in the home for up to 7 days was associated with a shortened catheter life-span. Occlusion or deposit development was not seen in catheters used for inpatient parenteral nutrition support when admixtures were prepared and infused within 28 hours. Catheter deposits were implicated as sanctuary sites for pathogenic bacteria in two patients. Failure to retrieve and inspect occluded catheters delayed the identification of the deposits.(ABSTRACT TRUNCATED AT 250 WORDS)

Elective cesarean section improves outcomes of neonates with gastroschisis

OBJECTIVE

Our objective was to compare neonatal postoperative morbidity for the neonate with prenatally diagnosed gastroschisis delivered vaginally with that for the perinate undergoing elective cesarean at or before the onset of labor.

STUDY DESIGN

Retrospective maternal and neonatal data were obtained by chart review on 22 neonates prenatally diagnosed with gastroschisis who underwent operative closure of the ventral wall defect between 1987 and 1991 at Loma Linda University Medical Center. Perioperative data and postoperative courses were compared between 12 infants who underwent labor with vaginal delivery and 10 infants who were delivered by elective cesarean section at or before the onset of labor.

RESULTS

Neonatal transports and significant bowel edema were more likely (p < 0.05) in the vaginal delivery group. The elective cesarean section infants had less sepsis (p < 0.05), fewer hospital days (p < 0.01) and parenteral nutrition days (p < 0.01), and shorter time to enteral feedings (p < 0.01).

CONCLUSIONS

Elective cesarean section at or before the onset of labor may benefit the fetus with gastroschisis, compared with undergoing labor and vaginal delivery.

Gastroschisis in successive siblings: further evidence of an acquired etiology

In recent years, we have treated two families that had successive siblings with gastroschisis. In the first family, the delivery of their second child, a boy with gastroschisis, was followed 11 months later by the delivery of a girl also with gastroschisis. The mother admitted to use of tobacco, alcohol, and marijuana during both pregnancies; the father was the same for both children. In the other family, the second child was a boy with gastroschisis, and the third, born 6 years later, was also a boy with gastroschisis. The mother denied any use of tobacco, alcohol, or recreational drugs; these two boys had different fathers. Gastroschisis in siblings has been reported only rarely, and has been noted in both identical and dizygotic twins. Our second set of siblings is the first documented case involving paternity by different fathers. Although a genetic factor cannot be excluded completely, teratogenic factors operative through the mother seem most probable. In conjunction with other reports of "epidemics" of gastroschisis, these two families amid our own recent outbreak of gastroschisis strongly suggest that the teratogenic factors may be environmental.

Comparison of MRI and discography in the diagnosis of lumbar degenerative disc disease

Recent reports have attempted to compare the relative value of discography and MRI in the evaluation of lumbar degenerative disc disease. None has compared the accuracy of the two techniques in regard to the detection of disc herniation specifically, and none has offered surgical correlation. In this prospective study, both techniques were used to evaluate 264 disc levels in 90 patients with incapacitating low back pain or radicular pain. The results showed an 86% agreement level both between tests and between the orthopaedist and radiologist on each test. Surgical findings agreed with diagnostic studies at 63 of 76 levels in 57 patients who underwent operative treatment. An analysis of the relative sensitivity and specificity of each test in the diagnosis of degeneration and herniation revealed that the greater sensitivity of MRI in the detection of herniation was the only statistically significant difference (p < 0.05).

A critical analysis of blood transfusion requirements in children with blunt abdominal trauma

Over the past 2 years, 178 children with blunt abdominal trauma were admitted for observation. Fifty-five patients (31.5%) had intra-abdominal injury confirmed by computerized tomography (CT) scan, laparotomy, or postmortem examination. Forty-four children (80%) were managed with observation only; nine had other operations. Eleven patients (20%) required an operation for their intra-abdominal injuries. Thirteen patients died, ten from head or spinal injuries and three from intra-abdominal injuries (5.5%). Of 35 children with intra-abdominal injuries observed without any type of operation, 27 (77%) were not transfused (mean Pediatric Trauma Score [PTS] 8, Injury Severity Score [ISS] 19.3, average low hemoglobin [ALH] 10.1). The other eight were transfused an average of 49 cc/kg (mean PTS 4.5, ISS 26.5 ALH 6.1). Twenty children had operations. Eleven 11 (20%) of these were laparotomies; nine were transfused an average of 200.6 cc/kg (mean PTS 6, ISS 33, ALH 9). Nine had neurosurgical/orthopedic procedures (mean PTS 6.2, ISS 27.7), with six transfusions averaging 84.9 cc/kg (ALH 8.9). There were no significant complications. Blood transfusion was necessary only for 33 per cent of the observed cases, usually with multiple injuries. Blood should be transfused only to maintain hemodynamic stability (normal vital signs and tissue perfusion). Hemoglobin levels as low as 7 gm% do not mandate transfusion in children who are hemodynamically stable.

The splenic snood: an improved approach for the management of the wandering spleen

A wandering spleen is in constant danger of torsion and infarction. Splenectomy, the traditional treatment, leaves children in danger of postsplenectomy sepsis. Three children with wandering spleens were treated by a new splenopexy technique, the splenic snood. After detorsion, the spleens were wrapped in polyglycolic mesh and anchored by the mesh subdiaphragmatically in the left upper quadrant. All have retained their spleens which have remained where anchored up to a 4-year follow-up. The simplicity and technical ease of the splenic snood operation recommend it as an improved method to avoid splenectomy and safely normalize intraabdominal anatomy in the management of the wandering spleen.

Decortication for childhood empyema. The primary provider's peccadillo

Of the 31 children treated for empyema thoracis secondary to pneumonitis at the Loma Linda University Medical Center, Loma Linda, Calif, from 1980 to 1990, 23 responded to prompt directed antibiotic therapy coupled with drainage, usually tube thoracostomy. All patients were cured clinically; some demonstrated residual pleural reaction with chest roentgenography or computed tomography that resolved over time. Decortication was necessary in eight severely ill children; three required concurrent lung resection for abscess. Distinct from the nonoperated group, there was a pattern of initial antibiotic trials in these patients averaging 6.5 different drugs plus delayed drainage of effusions. Delay in the initiation of antibiotic therapy was six times longer for the operated vs the nonoperated group. Delay to tube thoracostomy was 18 days for the decorticated children compared with 5.4 days for the nondecorticated children. All eight children responded completely and rapidly to their decortications. Roentgenographic changes lagged considerably behind the clinical course of the child, and computed tomographic scans provided better identification of chest tube placement but little information predictive of the need for decortication. Decortication for empyema seldom is necessary when a child is treated promptly with appropriate antibiotics directed by thoracentesis findings, and drainage, usually tube thoracostomy. The criterion for decortication is persistent sepsis, not the roentgenographic appearance of the chest.

Assignment of the human prohibitin gene (PHB) to chromosome 17 and identification of a DNA polymorphism

Prohibition is a recently identified antiproliferative protein whose exact role in the cell is under investigation. To determine the human chromosomal location of the prohibition gene (PHB) and whether this site corresponds to that of any suspected tumor suppressor gene, we have analyzed DNA from three sources by hybridization analysis: mouse--human hybrid cell lines, hybrid cell lines containing portions of human chromosomes, and human metaphase chromosomes in situ. All three techniques confirm a location in the region 17q21-q22, a region genetically linked to early-onset human breast cancer. Further analysis will be required to establish the significance of this relationship; Southern hybridizations show a polymorphic EcoRI site that may be useful for this purpose.

DNA alterations in prostatic adenocarcinoma and benign prostatic hyperplasia: detection by DNA fingerprint analyses

DNA fingerprinting can be utilized to examine a large number of autosomal loci throughout the human genome. Alterations in banding patterns observed on DNA fingerprint analyses reflect DNA alterations ranging from single base changes to complex chromosomal rearrangements. In this report, we describe the application of this technique to prostatic adenocarcinoma (CAP) and benign prostatic hyperplasia (BPH). The majority of CAP cases (12 of 14) displayed alterations in at least 1 of the approximately 30 resolvable bands obtained by fingerprint analyses when compared with DNA obtained from peripheral white blood cells. Unexpectedly, 5 of the 12 cases of BPH examined revealed at least 1 identifiable band alteration in the prostatic tissue. These findings demonstrate the usefulness of fingerprint analyses in the examination of cancer-associated genetic alterations. They also suggest the presence of observable genetic alterations in BPH.

Eicosanoid regulation of acute intestinal vascular permeability induced by intravenous peptidoglycan-polysaccharide polymers

A model of rapidly developing, self-limited acute vascular permeability changes localized to the gut-associated lymphoid tissue (GALT) of the rat was used to study the role of prostaglandins (PGs), thromboxanes (Txs), and leukotrienes (LTs) in the in vivo regulation of early intestinal inflammatory events. Sprague-Dawley rats were pretreated with metabolites, enzyme inhibitors, or receptor antagonists of the arachidonic acid pathway before intravenous injection of sonicated peptidoglycan-polysaccharide polymers derived from group A streptococci (PG-APS, 5 micrograms rhamnose/g body weight). Rats were killed five minutes after PG-APS injection and were evaluated grossly for petechiae of the intestinal parenchyma and lymphoid aggregates. Indomethacin or dexamethasone increased intestinal injury by PG-APS by inducing mid-small bowel and cecal parenchymal hemorrhage. Indomethacin significantly diminished colonic lymphoid aggregate hemorrhage. PGE1, PGE2, and prostacyclin dramatically inhibited GALT hemorrhage; prostacyclin was the most potent with an effective dose of 0.1 microgram/kg. Dazmegrel, a specific Tx synthetase antagonist, significantly inhibited PG-APS-induced vascular permeability. Dazmegrel continued to diminish colonic lymphoid aggregated hemorrhage during concurrent treatment with indomethacin, which removed potential endogenous prostaglandin protection. Diethylcarbamazine, a lipoxygenase inhibitor, and FPL-55712, a LT receptor antagonist, inhibited the PG-APS-induced lesions, with FPL-55712 being more potent. LT blockade had a predominant effect on the intestinal parenchymal hemorrhage. We postulate that the normal homeostatic suppression of inflammation induced by phlogistic bacterial cell wall polymers is PG mediated, and that pathological responses are Tx and LT dependent.

Ectopic gastric-like duplication of the pancreas

A 4-month-old girl presented with intermittent left upper quadrant abdominal pain and was found to have an ectopic cystic gastric-like duplication attached to the tail of the pancreas. The literature, pathology, clinical features, diagnosis, and treatment are discussed.

Long-term follow-up of infantile hip sepsis

Nine hips in eight patients were available at a mean follow-up of 31.5 years for participation in a retrospective functional and radiographic analysis for the purpose of examining the late effects of infantile septic hip arthritis in a group untouched by reconstructive hip surgery. Results suggest that reconstructive efforts following hip joint sepsis designed for relocation of an inadequate femoral head for persistent dislocation or for transference of the greater trochanteric epiphysis into the acetabulum may not yield results comparable to nonoperative treatment.

Effects of morphine on rat kidney glomerular podocytes: a scanning electron microscopic study

Degenerative kidney changes are associated with heroin use in human addicts, but it is not known whether these changes result from exposure to the opioid or from contaminants in street heroin. In the present study, 4-6-month-old rats each received 1 subcutaneous pellet containing 75 mg of morphine or placebo, followed 3 days later by implantation of 2 additional morphine or placebo pellets. Seven days after implantation of the first pellet, the rats were killed by aldehyde perfusion. The right kidney was excised, and coronal slices were prepared for scanning electron microscopy. Micrographs were taken at 5000X and were scored on the presence of short or long microprojections (a score of '1' indicating few and a score of '4' indicating many). Morphine significantly altered the frequencies of scores for long microprojections, suggesting that morphine treatment increased the number of microprojections on glomerular podocytes. No changes in filtration slits, pedicels, or blebbing (foval enlargements) were noted. The data support the view that kidney degeneration associated with opioid abuse reflects effects of opioids per se, and they are consistent with microprojection changes as a function of altered intracellular cyclic AMP levels.

Early recognition and successful management of pelvic cellulitis following hemorrhoidal banding

Reports have focused attention on a rare but potentially serious complication following rubber band ligation of internal hemorrhoids: pelvic cellulitis with progression to shock and death. This report documents the successful treatment of pelvic cellulitis. The timely use of broad-spectrum antibiotics at an early stage is critical. Emphasis is placed on early recognition and treatment of this potentially fatal complication.

Correction of hypersplenism without splenectomy

Permanent interruption of splenic artery blood flow to the spleen was accomplished in a 4.5-yr-old girl with significant hypersplenism secondary to biliary cirrhosis. The splenic artery was successfully occluded by transfemoral catheterization and selective instillation of bucrylate tissue adhesive.

A simple objective system for early recognition of overwhelming neonatal respiratory distress

The early recognition of severe respiratory distress in the newborn allows for optimal care. The prompt identification of overwhelming respiratory failure may assist in the selection of candidates for new therapeutic techniques. We have evaluated, both retrospectively and prospectively, a simple scoring system for neonatal respiratory insufficiency. During the first 24 hr of life, serial inspired oxygen values (FiO2) are plotted with serial pH measurements against time on a graph. With pulmonary insufficiency, the lines cross. The severity of the insufficiency is quantified by integrating the area between the crossed lines. The 25 infants in our Regional Intensive Care Unit Nursery who died with respiratory distress syndrome (RDS) during 1976 were compared with surviving infants matched for gestational age, birth weight, and admission date; all patients received similar conventional management. The difference in the mean 24-hr cumulative scores between the two groups was significant (p < 0.01). Only 1 infant with a score over 40 U ultimately survived (96% specificity). From January 1978 through June 1979, data were graphed at the bedside on 100 neonates who required respiratory support, and analyzed without knowledge of the eventual outcome. Overall, the scoring system predicted the final outcome in 95% of the cases. False positive determinations were minimal, the system accurately selecting 86/87 ultimate survivors (98.8% specificity). These data suggest that this simple scoring system may prove useful in identifying infants with overwhelming respiratory distress. Such infants may be considered for specialized care or innovative yet unproven treatment modalities.

The natural history of bronchial atresia. Serial observations of a case from birth to operative correction

A 10-year-old child presented with a history of intermittent respiratory symptoms since birth. Progressive shift of the mediastinum away from a hyperexpanded left upper lobe to the right side was evident on serial chest films, since birth. Bronchograms demonstrated atresia of the bronchus to the hyperexpanded segment. Xenon washout demonstrated prolonged half-time in the left upper lobe resulting from collateral ventilatory channels. Resection of the apical posterior segment of the left upper lobe was performed without complication. Bronchial atresia with collateral ventilation caused "lobar emphysema" in this patient.

N-type anorectal malformations

Three cases of N-type anorectal malformations have been encountered. Two girls with anorectal-vestibular fistulas (one with a normal anus and the other with mild stenosis) were typical of 15 other such cases in the literature. A boy with an anorectal-urethral fistula and covered anus had a lesser variant than most of the other 8 males in the literature. The frequently accompanying esophageal, renal, and skeletal anomalies were not present, nor did he have anterior urethral hypoplasia. The constellation of other major associated anomalies in the boys, but not in the girls, follows the pattern of other types of anorectal malformations and suggests an earlier and/or more severe teratogenic insult in the boys. Anterior perineal resection of the fistula is appropriate for girls with N-type fistulas and for those boys with normal anterior urethras. An additional urethroplasty is necessary for boys with anterior urethral hypoplasia. Our experience and that from the literature suggest that N-type anorectal malformations constitute a rare but real entity, akin to N-type tracheoesophageal fistulas. A plea is made that they be included in classifications of anorectal anomalies.