User experience with a parenting chatbot micro intervention

Background

The use of chatbots to address mental health conditions have become increasingly popular in recent years. However, few studies aimed to teach parenting skills through chatbots, and there are no reports on parental user experience. Aim: This study aimed to assess the user experience of a parenting chatbot micro intervention to teach how to praise children in a Spanish-speaking country.

Methods

A sample of 89 parents were assigned to the chatbot micro intervention as part of a randomized controlled trial study. Completion rates, engagement, satisfaction, net promoter score, and acceptability were analyzed.

Results

66.3% of the participants completed the intervention. Participants exchanged an average of 49.8 messages (SD = 1.53), provided an average satisfaction score of 4.19 (SD = .79), and reported that they would recommend the chatbot to other parents (net promoter score = 4.63/5; SD = .66). Acceptability level was high (ease of use = 4.66 [SD = .73]; comfortability = 4.76 [SD = .46]; lack of technical problems = 4.69 [SD = .59]; interactivity = 4.51 [SD = .77]; usefulness for everyday life = 4.75 [SD = .54]).

Conclusions

Overall, users completed the intervention at a high rate, engaged with the chatbot, were satisfied, would recommend it to others, and reported a high level of acceptability. Chatbots have the potential to teach parenting skills however research on the efficacy of parenting chatbot interventions is needed.

Physical interactions between mast cells and eosinophils: a novel mechanism enhancing eosinophil survival in vitro

BACKGROUND

Mast cells (MCs) and eosinophils (Eos) are the key effector cells of the allergic reaction. Although classically associated with different stages of the response, the cells co-exist in the inflamed tissue in the late and chronic phases in high numbers and are likely to cross-talk. While some mediators of MCs are known to affect Eos biology and vice versa, paracrine and physical interplay between the two cells has not been described yet. We aimed to investigate whether intercellular MC-Eos communication could take place in the allergic response and exert functional bidirectional changes on the cells.

METHODS

Tissue sections from various allergic disorders were specifically stained for both cells. Human cord blood-derived MCs and peripheral blood Eos, co-cultured under different conditions, were studied by advanced microscopy and flow cytometry.

RESULTS

Several co-localized MC-Eos pairs were detected in human nasal polyps and asthmatic bronchi, as well in mouse atopic dermatitis. In vitro, MCs and Eos formed stable conjugates at high rates, with clear membrane contact. In the presence of MCs, Eos were significantly more viable under several co-culture conditions and at both IgE-activated and steroid-inhibited settings. MC regulation of Eos survival required communication through soluble mediators but was even more dependent on physical cell-cell contact.

CONCLUSIONS

Our findings provide the first evidence for a complex network of paracrine and membrane interactions between MCs and Eos. The prosurvival phenotype induced by this MC-Eos interplay may be critical for sustaining chronic allergic inflammation.

Manipulation of NK cytotoxicity by the IAP family member Livin

Natural killer (NK) cells are part of the innate immune system, capable of killing tumor and virally infected cells. NK cells induce apoptosis in the target cell by either granule- or receptor-mediated pathways. A set of inhibitory and activation ligands governs NK cell activation. As transformed cells often attempt to evade NK cell killing, up-regulation of a potential anti-apoptotic factor should provide a survival advantage. The inhibitor of apoptosis protein (IAP) family can inhibit apoptosis induced by a variety of stimuli. We have previously described a new IAP family member, termed Livin, which has two splice variants (alpha and beta) with differential anti-apoptotic activities. In this study, we explore the ability of Livin to inhibit NK cell-induced killing. We demonstrate that Livin beta moderately protects against NK cell killing whereas Livin alpha augments killing. We show that Livin beta inhibition in Jurkat cells is apparent upon concomitant activation of an inhibitory signal, suggesting that Livin augments an extrinsic inhibitory signal rather than functioning as an independent inhibitory mechanism. Finally, we demonstrate that detection of both Livin isoforms in melanoma cells correlates with a low killing rate. To date, this is the first evidence that directly demonstrates the ability of IAP to protect against NK cell-induced apoptosis.

CD100 on NK cells enhance IFNgamma secretion and killing of target cells expressing CD72

Background

NK cells are able to kill tumor and virus-infected cells without the need of prior antigen stimulation. The killing of these target cells is regulated by inhibitory, lysis and co-stimulatory receptors that are expressed on the surface of NK cells.

Principal Findings

CD100 (Semaphorin 4D), a 150kD transmembrane protein, is expressed on the surface of activated NK cells as a homodimer, mediates the killing of target cells by binding to CD72. CD100 is not involved directly in the killing process but is rather increases NK cytotoxicity by enhancing the adhesion between NK cells and their targets. This increased adhesion leads to a more efficient killing and enhanced IFNγ secretion.

Significance

Since CD72 is expressed on antigen presenting cells (APC) and the CD100-CD72 interaction lead to the shading of CD100, we suggest that NK interacting with APC cells could be the early source of soluble CD100 which is crucial for the formation of antigen specific immune response. CD100-CD72 interaction can be the mechanism by which NK cell communicate with B cells.

A phenotypic and functional characterization of NK cells in adenoids

Adenoids are part of the MALT. In the present study, we analyzed cell surface markers and cytolytic activity of adenoidal NK (A-NK) cells and compared them with NK cells derived from blood of the same donors (B-NK). NK cells comprised 0.67% (0.4-1.2%) of the total lymphoid population isolated from adenoids. The majority (median=92%) of the A-NK cells was CD56(bright)CD16(-). A-NK cells were characterized by the increased expression of activation-induced receptors. NKp44 was detected on >60%, CD25 on >40%, and HLA-DR on >50% of freshly isolated A-NK cells. Functional assays indicated that the cytotoxic machinery of A-NK is intact, and sensitive target cells are killed via natural cytotoxicity receptors, such as NKG2D. Carcinoembryonic antigen-related cell adhesion molecule 1 (CEACAM1; CD66) expression was up-regulated in 23% (median) of the A-NK cells by IL-2 activation but unchanged in B-NK cells. CEACAM1 inhibited the A-NK killing of target cells. CXCR4 was expressed on more than 40% A-NK cells prior to activation. Its ligand, CXCL12, was found in endothelial cells of the capillaries within the adenoid and in cells of the epithelial lining. In addition, A-NK cells migrated in vitro toward a gradient of CXCL12 in a dose-responsive manner, suggesting a role for this chemokine in A-NK cell recruitment and trafficking. We conclude that the A-NK cells are unique in that they display an activated-like phenotype and are different from their CD16(-) B-NK cell counterparts. This phenotype presumably reflects the chronic interaction of A-NK cells with antigens penetrating the body through the nasal route.

Rectal bleeding and previous anticoagulant treatment in patients with colorectal cancer do not predict outcome

BACKGROUND

The aim of this study was to determine whether the outcome of patients with colorectal cancer who presented with bleeding and a history of anticoagulant treatment was different from those who did not have bleeding or previous anticoagulant treatment.

METHODS

This was a single institution, retrospective study of patients with colorectal cancer with and without a history of rectal bleeding and treatment with anticoagulants, assessed for age, gender, tumor site, stage, recurrence rate, and survival.

RESULTS

A total of 621 consecutive patients (309 men) with a mean age of 70 years (range, 36-94 years) diagnosed with colorectal cancer between 1998 and 2004 were studied. Of these, 149 patients (24%) were referred for symptoms of rectal bleeding and 161 patients (26%) had been previously treated with anticoagulants. A total of 592 patients (95%) underwent curative or palliative surgery; endoscopic polypectomy was performed in 3 cases only and in 26 patients (4%) surgery was not performed due to advanced disease or critical illness. Patients with bleeding and a history of anticoagulant treatment presented commonly with stage I cancer. In addition, tumor stage III was less common in patients with previous anticoagulant treatment irrespective of presenting signs. Disease-free and overall survival rates were similar in all groups, irrespective of bleeding at presentation or anticoagulant treatment.

CONCLUSIONS

Rectal bleeding and anticoagulant treatment do not affect the outcome of newly diagnosed patients with colorectal cancer.

Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery

BACKGROUND

Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations.

METHODS

A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery.

RESULTS

Laparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures.

CONCLUSION

Laparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.

The involvement of NK cells in ankylosing spondylitis

A role for NK cells in the regulation of autoimmunity has been demonstrated. Since there is a strong association between Ankylosing Spondylitis (AS) and HLA-B27, which is specifically recognized by the NK-inhibitory receptor KIR3DL1, this study evaluated the potential involvement of NK cells in AS. We studied 19 AS patients and 22 healthy volunteer donors and assessed the percentage, activity and receptor expression of peripheral blood NK cells. We also evaluated candidate-inflammatory mediators in sera. We found that AS patients have significantly higher percentages of NK cells. However, we found no differences between the ability of NK cells derived from AS and healthy controls to recognize target cells expressing HLA-B27. Remarkably, we observed that the NK-inhibitory receptor CEACAM1 (carcino-embryonic antigen-cell adhesion molecule) is highly expressed among AS-derived NK cells. Furthermore, engagement of CEACAM1 inhibited NK activity in these patients. Finally, we demonstrated that CEACAM1 expression is induced by IL-8 and SDF-1 (stromal cell derived factor), both of which are present in high levels in the sera of AS patients. These results may indicate that NK cells and CEACAM1 play a role in AS pathogenesis and implicate chemokines in the mechanism of CEACAM1 expression.

Laparoscopic management of acute small bowel obstruction

BACKGROUND

As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).

METHODS

From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.

RESULTS

Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.

CONCLUSIONS

Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.

Does supplemental perioperative oxygen administration reduce the incidence of wound infection in elective colorectal surgery?

AIM

An association has been proposed between perioperative administration of 80% oxygen and a lower incidence of wound infection after colorectal surgery. The present study was conducted to assess this hypothesis.

METHODS

Thirty-eight patients (ASA classification 1 and 2) undergoing elective colorectal cancer surgery were allocated at random to 2 groups. Group 1 consisted of 19 patients who received an admixture of 80% oxygen and 20% nitrogen during anesthesia through an orotracheal tube and during the 2 first hours in the recovery room through a tight facemask with reservoir. Group 2 consisted of 19 patients who received an admixture of 70% nitrous oxide and 30% oxygen during anesthesia, followed by administration of 30% oxygen delivered by a blender through a tight facemask with reservoir in the same manner than group 1, during the first 2 hours in the recovery room. Wound infection was evaluated daily during hospital stay and after 7 days, 2 weeks, and 1 month.

RESULTS

The incidence of wound infection was 12.5% in group 1 and 17.6% in group 2 (p=0.53).

CONCLUSIONS

The results of this study showed no reduction in the incidence of wound infection following elective colorectal surgery in patients receiving 80% oxygen during the perioperative period.

Biological function of the soluble CEACAM1 protein and implications in TAP2-deficient patients

Interactions of natural killer (NK) cells with MHC class I proteins provide the main inhibitory signals controlling NK killing activity. It is therefore surprising to learn that TAP2-deficient patients suffer from autoimmune manifestations only occasionally in later stages of life. We have previously described that the CEACAM1-mediated inhibitory mechanism of NK cytotoxicity plays a major role in controlling NK autoreactivity in three newly identified TAP2-deficient siblings. This novel mechanism probably compensates for the lack of MHC class I-mediated inhibition. The CEACAM1 protein can also be present in a soluble form and the biological function of the soluble form of CEACAM1 with regard to NK cells has not been investigated. Here we show that the homophilic CEACAM1 interactions are abrogated in the presence of soluble CEACAM1 protein in a dose-dependent manner. Importantly, the amounts of soluble CEACAM1 protein detected in sera derived from the TAP2-deficient patients were dramatically reduced as compared to healthy controls. This dramatic reduction does not depend on the membrane-bound metalloproteinase activity. Thus, the expression of CEACAM1 and the absence of soluble CEACAM1 observed in the TAP2-deficient patients practically maximize the inhibitory effect and probably help to minimize autoimmunity in these patients.

Recognition ofMycoplasma hyorhinis by CD99-Fc molecule

The human CD99 protein is expressed on many cell types and is mostly abundant on lymphocytes and on several tumors. Different functions were attributed to the CD99 receptor, including adhesion, apoptosis and activation. However, until now the only ligand suggested to be recognized by CD99 was CD99 itself. In order to identify possible new CD99 ligands we constructed a CD99 protein fused to human IgG1. Surprisingly, a pronounced specific staining of melanoma cell lines that were infected with mycoplasmas was observed whereas clean cells were not recognized. Staining was specific, as other fusion proteins did not recognize the mycoplasma-infected cells. Sequencing of the 23s-16s region revealed that the contaminating agent is Mycoplasma hyorhinis. The CD99 interaction with M. hyorhinis was direct since it was blocked by anti-CD99 monoclonal antibody and by M. hyorhinis. It was also strain-specific as other mycoplasmas were not recognized. Our results show that CD99 interacts with a novel ligand of M. hyorhinis.

Special organization of the HLA-G protein on the cell surface

The human leukocyte antigen G (HLA-G) molecule possesses unique properties such as low polymorphism and restricted distribution mainly to the extravillous cytotrophoblast (EVT) cells. The EVT cells vigorously penetrate into the maternal decidual tissues and are found in contact with maternal lymphocytes, mainly with natural killer (NK) cells. The HLA-G molecule inhibits the effector function of maternal NK cells via interaction with the KIR2DL4 and the ILT-2 inhibitory NK receptors. Previously, we have demonstrated that complexes of the HLA-G protein are expressed on the cell surface. We reported that these complexes are formed due to the presence of two unique cysteine residues located at positions 42 and 147. Finally, we demonstrated that efficient binding and function of ILT-2 is dependent on the presence of HLA-G complexes on the cell surface. Here we expand the significance of these observations by revealing that complexes of HLA-G are present on the cell surface using different assays and cell lines and further demonstrate that complexes of HLA-G might be present in a soluble form after interaction with ILT-2. Therefore, the HLA-G molecule has developed a special mechanism to increase the avidity of NK receptors to the HLA-G molecule, which provides better protection for the fetus from maternal NK rejection.

Complexes of HLA-G protein on the cell surface are important for leukocyte Ig-like receptor-1 function

The nonclassical class I MHC molecule HLA-G is selectively expressed on extravillous cytotrophoblast cells at the maternal-fetal interface during pregnancy. HLA-G can inhibit the killing mediated by NK cells via interaction with the inhibitory NK cell receptor, leukocyte Ig-like receptor-1 (LIR-1). Comparison of the sequence of the HLA-G molecule to other class I MHC proteins revealed two unique cysteine residues located in positions 42 and 147. Mutating these cysteine residues resulted in a dramatic decrease in LIR-1 Ig binding. Accordingly, the mutated HLA-G transfectants were less effective in the inhibition of NK killing and RBL/LIR-1 induced serotonin release. Immunoprecipitation experiments demonstrated the involvement of the cysteine residues in the formation of HLA-G protein oligomers on the cell surface. The cysteine residue located at position 42 is shown to be critical for the expression of such complexes. These oligomers, unique among the class I MHC proteins, probably bind to LIR-1 with increased avidity, resulting in an enhanced inhibitory function of LIR-1 and an impaired killing function of NK cells.

The use of laparoscopy in abdominal emergencies

BACKGROUND

The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions.

METHODS

Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%).

RESULTS

Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed.

CONCLUSIONS

For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

Laparoscopic repair of large incisional hernias

BACKGROUND

Traditional approaches to incisional hernias (IH)--particularly in cases with large fascial defects--are plagued by a significant recurrence rate as well as frequent wound infections. The laparoscopic repair of incisional hernias was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. Several years ago, we adopted the laparoscopic technique in our department and set out to appraise its touted advantages.

METHODS

During the years 1997-2000, 103 patients underwent laparoscopic IH repair with implanted Dual Gore-tex mesh. Forty percent of them were obese, and 41% had undergone more than one previous attempt at conventional repair. All patients were discharged home within 24-72 hs.

RESULTS

In three patients, the operation was converted to open surgery due to severe adhesions and technical difficulties. In two cases, inadvertent enterotomies were repaired laparoscopically, and since there was no major spillage, the repair was continued as planned, with no adverse consequences. Twelve patients underwent additional laparoscopic procedures at the initial operation. Two graft infections and four recurrences were observed during the 1-49 month follow-up period.

CONCLUSIONS

Laparoscopic IH repair is technically feasible and safe in patients with large fascial defects as well as in obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence.

Recognition of HLA-Cw4 but not HLA-Cw6 by the NK cell receptor killer cell Ig-like receptor two-domain short tail number 4

NK cells are cytotoxic to virus-infected and tumor cells that have lost surface expression of class I MHC proteins. Target cell expression of class I MHC proteins inhibits NK cytotoxicity through binding to inhibitory NK receptors. In contrast, a similar family of activating NK receptors, characterized by the presence of a charged residue in their transmembrane portion and a truncated cytoplasmic tail, augment lysis by NK cells when ligated by an appropriate class I MHC protein. However, the class I MHC specificity of many of these activating NK receptors is still unknown. Here, we show enhanced lysis of HLA-Cw4 but not HLA-Cw6-expressing cells, by a subset of NK clones. This subset may express killer cell Ig-like receptor two-domain short tail number 4 (KIR2DS4), as suggested by staining with various mAb. It is still possible, however, that these clones may express receptors other than KIR2DS4 that might recognize HLA-Cw4. Binding of KIR2DS4-Ig fusion protein to cells expressing HLA-Cw4 but not to those expressing HLA-Cw6 was also observed. The binding of KIR2DS4-Ig to HLA-Cw4 is weaker than that of killer cell Ig-like receptor two-domain long tail number 1 (KIR2DL1)-Ig fusion protein; however, such weak recognition is capable of inhibiting lysis by an NK transfectant expressing a chimeric molecule of KIR2DS4 fused to the transmembrane and cytoplasmic portion of KIR2DL1. Residue alpha14 is shown to be important in the KIR2DS4 binding to HLA-Cw4. Implications of the role of the activating NK receptors in immunosurveillance are discussed.

[Selective embolization of hepatic arteries--an additional precaution to control hemorrhage in the management of severe liver trauma]

Two cases of severe hepatic injury in which selective hepatic artery embolization was used to control hemorrhage are presented. The first case is that of a 35 year old patient who sustained a severe liver injury after a car accident. A CAT scan of the abdomen revealed an AAST grade 5 liver injury, pooling of contrast material within the liver parenchyma, and blood within the peritoneal cavity. The patient was given fluid resuscitation and taken to angiography where bleeding from branches of the right hepatic artery was demonstrated. While angiography was being undertaken the hemodynamic status of the patient deteriorated, blood transfusion was started, and a selective embolization of the right hepatic artery was performed. The bleeding stopped promptly and hemodynamic stability was regained. The second case is that of a 40 year old pedestrian run over by a car. Abdominal ultrasound revealed free fluid in the peritoneal cavity and the patient was rushed to the O.R. Crushed right lobe of the liver, and inferior vena cava and bowel tears were found. After perihepatic packing and resection of the right and sigmoid colons retrohepatic vena cava tear was repaired and perihepatic packing restored. The abdominal cavity was closed and the patient was taken to the ICU for the correction of hypothermia, metabolic acidosis, and coagulopathy that had developed during the surgery. After 8 hours in the ICU the patient was transferred for angiography and a selective embolization of branches of the right hepatic artery was performed. The clinical course of the patients after angiographic embolization of the hepatic arteries is described and the literature that discusses the use of angiography and embolization of hepatic arteries after traumatic hepatic bleeding is reviewed.

Extension of the organ pool in kidney transplantation: first year experience of the Israel Transplant Center

BACKGROUND

Over a 12 month period, the Israel Transplant Center doubled the number of donors by assigning a nurse coordinator to each of 22 hospitals around the country and by using kidneys from elderly donors.

OBJECTIVE

To evaluate the impact of our "marginal donors" policy on the results immediately following transplantation.

METHODS

Between October 1997 and September 1998, 140 cadaveric kidney transplantations from 72 donors were performed in Israel. We defined two groups of recipients: patients with immediate graft function and patients with either delayed graft function requiring > 1 week of dialysis post-transplant or with primary graft non-function. We compared the following parameters between groups: donor and recipient age and gender, cause of donor's death, length of stay in the intensive care unit, vasopressor dosage and creatinine levels before harvesting, cold ischemic time, and the number of recipient grafts.

RESULTS

There were 102 recipients (72.8%) with immediate graft function and 38 with either PNF (n = 13, 9.3%) or DGF (n = 25, 17.9%). On regression analysis, donor age > 50 year and retransplantation were significant risk factors for PNF or DGF (odds ratio 4.4 and 2.8, respectively). Of the 56 kidneys from donors > 50 years old, 21 (37.5%) developed either PNF (n = 9) or DGF (n = 12).

CONCLUSIONS

We conclude that kidneys from donors over age 50 are at increased risk for graft non-function or delayed function. Better assessment of functional capacity of kidneys from "aged" donors may help to choose appropriate donors from that pool.

Protocol Doppler color flow imaging immediately after kidney transplantation

Doppler color flow imaging has been used to identify obstruction, rejection, and nonfunctioning renal allografts. When done in the immediate posttransplant period on poorly functioning kidneys, it allows early and accurate detection of surgically correctable changes such as arterial or venous thrombosis or early obstruction by blood, urine, or lymph. Further, it determines changes in intrarenal flow patterns that may indicate early transplant dysfunction, such as acute tubular necrosis and/or acute rejection as well as obstruction. Additionally, baseline values can be obtained in uncomplicated cases for serial follow-up. Between July 1980 and February 1991, 20 transplant patients had Doppler color flow imaging in the immediate posttransplant period. The kidney contour, perirenal collections, vessel flow patterns, and resistive indexes were assessed. In two patients, immediate surgical intervention salvaged the allograft. In several other patients with primary nonfunctioning kidneys, the study distinguished between acute tubular necrosis and obstruction due to external compression. We concluded that protocol Doppler color flow imaging is valuable in the immediate posttransplant period for determining surgically correctable complications.

Modified vascular reconstruction for pancreaticoduodenal allograft

The simultaneous recovery of the cadaveric liver and pancreaticoduodenal allograft is well established. The current technique for procurement enables the retrieval of both organs in most multiorgan donor operations. Vascular complications may account for 45 percent of pancreatic graft failures, most of which are thromboses of the portal vein caused by low flow in the entire pancreatic vasculature, a twisted venous anastomosis or an acutely angled arterial reconstruction that can contribute to the thrombosis and, thereby, to graft failure. Because a diabetic recipient may have severely atherosclerotic vessels, an interposition autograft of the internal iliac artery of the recipient is not recommended. Our modified vascular reconstruction prevents compromised arterial blood supply when donor arterial grafts (iliac, carotid or femoral) are not available and when direct splenic to SMA reconstruction is not feasible.

Improved zipper closure of the abdominal wall in patients requiring multiple intra-abdominal operations

Optimal management of pancreatic abscess and septic complications of acute pancreatitis remains controversial. With the "open packing" approach, repeated closure of the midline fascia is complicated by loss of tissue integrity and suture strength. An improved zipper closure of the abdominal wall in six patients with pancreatic abscess is presented. Improvements included: (1) using a separating jacket-type zipper to allow maximal intraoperative exposure; (2) employing a removable tuck for expansion of the patch covering the wound; (3) substituting a nonmeshed polytetrafluoroethylene material for the polypropylene mesh to prevent adherence to the underlying viscera; and (4) creating a flap underneath the zipper teeth to protect the underlying tissue from injury. Satisfactory results were achieved with the improved zipper technique.

Liver transplantation in patients with situs inversus

Situs inversus has been considered an absolute contraindication to liver transplantation due to technical difficulties. Associated vascular malformation and distorted anatomy may make the procedure even more complicated or impossible. Only three cases of patients with abdominal situs inversus who underwent successful liver transplantation have been reported in the English literature. We describe two additional patients with situs inversus who suffered from biliary atresia and underwent successful liver transplantation. The preoperative evaluation and the operative procedure are presented, and technical difficulties are discussed. Since biliary atresia is associated with polysplenia syndrome, including vascular malformation and visceral malposition, we suggest that each case be extensively evaluated preoperatively to determine the size requirement for the donor liver and the feasibility of reconstruction.

Surgical approach and outcome in torsion of testis

A total of 31 patients with acute torsion treated over a fifteen-year period are reviewed. The peak incidence of the disease, its seasonal variations, predisposing factors, surgical procedure, and clinical outcome are analyzed. Most of the patients were operated upon via an inguinal incision and underwent detorsion and fixation or untwisting only of the involved testis. The contralateral one was never anchored. All patients were asked to complete a questionnaire, with 2 of 3 responding from one to fifteen years (mean, 6.7 years) after surgery. None underwent recurrent surgery on either testicle. We conclude that fixation of the testes, both detorsioned and normal is not necessary.

Foreign body removal through an appendicostomy

The removal of button cell batteries or small coins impacted in the terminal ileum or right colon through an appendicostomy is described. This technique was used effectively in three patients.

A baby with a cervical "braid"

Among the anomalies and curiosities of nature, a braid-like cervical protrusion is a rare anatomical finding. Most similar reported cases of tail-like appendages have been observed in the sacrococcygeal or lumbar region. Herein we describe a newborn with a high cervical malformation located along the vertebral column, and its histological features. To our knowledge, this congenital anomaly has never been reported in the English literature.