Eosinophils promote allergic disease of the lung by regulating CD4(+) Th2 lymphocyte function

Eosinophils are primarily thought of as terminal effectors of allergic responses and of parasite elimination. However, limited studies suggest a more discrete immunomodulatory role for this leukocyte during these inflammatory responses. In this investigation, we highlight the potential of eosinophils to act as APCs and thus modulators of allergic responses by influencing Th2 cell function. In response to Ag provocation of the allergic lung, eosinophils rapidly trafficked to sites of Ag deposition (airways lumen) and presentation (lung-associated lymph nodes and T cell-rich paracortical zones). Eosinophils from the allergic lung expressed class II MHC peptides, T cell costimulatory molecules (CD80 and CD86), and rapidly internalized and processed Ag that was sampled from within the airway lumen. Ag-loaded eosinophils promoted the production of IL-4, IL-5, and IL-13 in cocultures with in vitro-polarized Th2 cells and induced IL-5 production in a dose-dependent manner from Ag-specific CD4(+) T cells isolated from allergic mice. In addition, Ag-loaded eosinophils primed for Th2 cell-driven allergic disease of the lung when transferred to naive mice. Thus, eosinophils have the potential to not only activate Th2 cells to release disease-modulating cytokines but also to assist in priming the immune system for allergic responses. This investigation highlights the potential of eosinophils to not only act as terminal effector cells but also to actively modulate allergic inflammation by amplifying Th2 cell responses.

A polymorphic marker for the human cathepsin B gene

Human cathepsin B (CTSB) is a proteolytic enzyme implicated in tumor invasion and metastasis. We describe a PCR-based polymorphic marker for this gene comprising two amplimers differing in length by 19 consecutive nucleotides in intron 7, near the exon 8 splice acceptor site, identifying two gene alleles (A and B). Allele frequencies were 0.614 for A and 0.386 for the B allele, with an observed heterozygosity of 0.457 in a cohort of 70 non-related Australian blood donors. One additional nucleotide difference was also revealed through sequencing. The human CTSB gene is located on chromosome 8 and the alleles described here can potentially be used as markers in linkage and association studies of cancers and other diseases.

Complications of treatment of paediatric malignancies

Advances in surgical techniques, radiotherapy and chemotherapy have led to improved survival for children with solid tumours and leukaemia. However, the treatment has also resulted in increased side effects both in the short and long term. This article outlines the complications which may arise as a result of treatment under the headings of surgery; chemotherapy; radiotherapy; organ specific complications; infection and graft-v-host disease.

A case of Acro-renal-mandibular syndrome in an 18 week male fetus

An 18 week male fetus is described with Acro-renal-mandibular syndrome. This third reported case of the syndrome is the first known male case and extends the phenotypic spectrum that characterizes the condition.

Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography

AIMS

To address some of the issues in the ongoing debate over the optimal diagnostic imaging following childhood urinary tract infection (UTI), by determining the risk of missing renal cortical scarring which would be detected on a technetium-99m dimercaptosuccinic acid (DMSA) gold standard if ultrasound alone were used, factoring for clinical features (upper or lower tract), UTI recurrence, and age group (infants, preschool, or school age).

METHODS

Details of UTI clinical features and recurrence were recorded for 990 children with a proven UTI, and their DMSA and ultrasound results were compared for each kidney.

RESULTS

The risks of missing DMSA scarring varied between 0.4% (school age children with solitary lower tract UTI) and 11.1% (infants with recurrent upper tract UTI).

CONCLUSIONS

UTI clinical features are important in assessing the need for DMSA imaging. Current UK imaging guidelines are endorsed, although preschool children with solitary lower tract UTI remain a controversial group and more attention needs to focused on children with recurrent UTI.

99Tcm-HMPAO leucocyte labelling in orofacial granulomatosis and gastrointestinal Crohn's disease in childhood and early adulthood

Orofacial granulomatosis is a granulomatous inflammatory disorder, affecting the soft tissues of the face and mouth. The predominant feature is disfiguring lip swelling. Patients with this condition may be exhibiting a Type IV hypersensitivity reaction to dietary or environmental allergens, or these may be the orofacial manifestations of underlying gastrointestinal Crohn's disease. The results of 99Tcm-HMPAO leucocyte labelling of the gastrointestinal tract in 14 patients with orofacial granulomatosis and 15 patients with known gastrointestinal Crohn's disease are presented, indicating that this is a useful and non-invasive screening test for the identification of gastrointestinal Crohn's disease in paediatric and young adult patients presenting with orofacial granulomatosis.

The role of nuclear medicine in children

Nuclear medicine studies have an important role to play in the diagnosis, treatment and follow-up of several paediatric conditions. This article highlights this role and indicates areas of potential growth.

An unusual hernia: congenital pericardial effusion associated with liver herniation into the pericardial sac

To our knowledge there have been only two previous cases of diaphragmatic hernia into the pericardium diagnosed antenatally. We describe our pre- and post-natal radiological findings in such a case, although the final diagnosis eluded us until after delivery.

A review of renal scarring in children

It is now widely accepted that children with a proven urinary tract infection should undergo some form of diagnostic imaging to assess the presence of, or the potential to develop, renal scarring. The type of investigation which should be performed is controversial. Some centres still perform intravenous urography, others rely on ultrasound alone, while others believe that a 99Tc(m)-dimercaptosuccinic acid (99Tc(m)-DMSA) scan is essential. This review discusses the advantages and disadvantages of these techniques by drawing from the extensive literature currently available. The consensus view is that a DMSA scan is the most sensitive method of detecting renal scarring and of highlighting the kidney at risk of developing scarring. It is hoped that wider early use of DMSA scintigraphy will lead to a fall in the number of children who develop end-stage renal disease.

Total hip replacement for coxarthrosis secondary to congenital dysplasia and dislocation of the hip. Long-term results

Between 1970 and 1982, sixty-six total hip replacements were performed with cement, without bone-grafting, in fifty-three patients who had congenital dysplasia and dislocation of the hip. Preoperatively, the patients had had Crowe type-II, III, or IV subluxation. Current information was available for fifty-nine hips in forty-six patients after an average duration of follow-up of sixteen years (range, ten to twenty-one years). The average age of the patients at the time of the operation was fifty-three years (range, twenty-three to seventy-three years). The average Harris hip score at the most recent examination was 92 points (range, 61 to 100 points). Eight hips were revised. The reason for the revision was infection in two hips, fracture of the femoral stem in two, and loosening of the acetabular component in four. The rate of revision for aseptic loosening, therefore, was 10 per cent (six hips). In the unrevised hips for which radiographs were available, the rate of radiographic loosening of the femoral component was 5 per cent (two hips) and that of the acetabular component was 32 per cent (twelve hips). We did not find a relationship between the amount of horizontal or vertical displacement of the center of the femoral head and the rate of loosening. Kaplan-Meier survivorship analysis with revision as the end point predicted a rate of survival of 85 per cent (95 per cent confidence interval, 75 to 95 per cent) at fifteen years. With radiographic loosening as the end point, the predicted rate of survival was 68 per cent (95 per cent confidence interval, 54 to 81 per cent) at fifteen years. We concluded that, for patients who have Crowe type-II, III, or IV congenital dysplasia of the hip, good long-term results can be obtained with insertion of a femoral stem with cement. The high rate of loosening of cemented acetabular components is a concern.

Symptomatic cortical irregularities of the distal femur simulating malignancy

We reviewed the records and radiographs of seven children who presented with knee pain, local tenderness over the medial femoral condyle, and radiological irregularity of the distal medial metaphysis of the femur suggestive of malignancy. In the five patients who had biopsies, histological changes were consistent with musculotendinous avulsion, and the dissection of ten cadavers confirmed the site to be the insertion of part of the adductor magnus. The recognition of this lesion and knowledge of its benign nature may avoid unnecessary anxiety and needless biopsy.

The value of ultrasound in the child with an acute urinary tract infection

OBJECTIVE

To assess the value of an ultrasound examination in children with a proven urinary tract infection.

PATIENTS AND METHODS

The results of renal ultrasound and 99mTc-dimercapto-succinic acid (DMSA) studies were compared in 112 children with a first documented symptomatic Escherichia coli urinary tract infection.

RESULTS

Ultrasound was particularly effective in detecting the presence of obstruction, renal swelling and parenchymal change consistent with acute pyelonephritis. However, ultrasound failed to detect half of the kidneys with photon deficient areas on 99mTc DMSA scan and was unreliable in detecting the presence of scarring.

CONCLUSION

An ultrasound examination alone should not be relied on in the child with an acute urinary tract infection.

Total hip arthroplasty with cement in patients who are less than fifty years old. A sixteen to twenty-two-year follow-up study

Eighty-nine Charnley total hip arthroplasties were performed with cement, by a single surgeon, in sixty-seven patients who were less than fifty years old at the time of the procedure. The follow-up period ranged from sixteen to twenty-two years (average, eighteen years). The most recent evaluation consisted of a clinical and a radiographic examination for forty-six patients (fifty-eight hips), a telephone interview and a review of the most recent radiographs for eleven patients (sixteen hips), and a telephone interview only for six patients (ten hips). Four patients (five hips) were lost to follow-up. Eleven (13 per cent) of the eighty-four hips that were followed were revised because of aseptic loosening of the acetabular implant, and two hips (2 per cent) were revised because of aseptic failure (loosening or fracture) of the femoral component. When the number of hips that were revised was combined with the number of hips in which there was radiographic evidence of failure, the rate of loosening of the acetabular component was 50 per cent (forty-two hips) and the rate of failure of the femoral component was 8 per cent (seven hips). Three hips had recurrent dislocations after the operation; none of the three was revised. One patient (two hips) had Grade-III heterotopic ossification according to the system of Brooker et al.; no other patient had more than Grade-II heterotopic ossification. Nine hips had a trochanteric non-union without migration of the trochanter.(ABSTRACT TRUNCATED AT 250 WORDS)

Areas of contact and extent of gaps with implantation of oversized acetabular components in total hip arthroplasty

Contact between porous surfaces and bone and initial stable fixation of the implant to bone are required to achieve bone ingrowth into prosthetic devices. To avoid the potential problems associated with screws that are often used to obtain initial stability of uncemented acetabular components, oversizing of the component has been recommended. This study investigated the shape of the reamed surface compared with the acetabular reamers used, the areas of bone implant contact obtained with oversizing, and the extent of polar area gaps created by this surgical technique. In embalmed hemipelvises, using surface fitting algorithms, the average departure from sphericity, of the reamed acetabular surface, was 0.56 mm. Using Pressensor film, extensive peripheral cup contact but minimal polar area contact was demonstrated when oversizing the components. In addition, large polar area gaps were demonstrated using polyvinylsiloxane epoxy molds. This study confirms the potential concerns associated with oversizing the acetabular component in relation to the reamed acetabular surface. Although excellent peripheral contact was obtained using this technique, polar area contact was demonstrated to be minimal or nonexistent, and large polar area gaps were observed. In addition, this study demonstrates that a precisely reamed surface can be obtained in the acetabulum when accurately sized reamers are used.

The prevalence of peripheral neuropathy in patients with anorexia nervosa

A prospective, controlled study was conducted to determine the prevalence of peripheral neuropathy (PN) in patients with anorexia nervosa (AN). Fifty-one patients (49 females, 2 males) between the ages of 12 and 47 (means = 22.5) who met the criteria for AN of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, were randomly selected from an inpatient eating disorders unit during 15 months. Fifty healthy volunteers (41 females, 9 males) between the ages of 17 and 50 (means = 26.5) served as controls. After a neurologic history, all patients were evaluated by physical examination and standardized electrodiagnostic testing. Chi-square contingency testing was used to assess data. Four study group patients (8%) had electrodiagnostic evidence of a sensorimotor PN compared with none in the control group. This is approaching statistical significance (p = 0.13). Three of four patients with AN for at least ten years were among those with PN. The prevalence of subjective symptoms among the study group (65%) as compared to the control group (4%) was of marked significance (p = 5.62 x 10(-10]. In addition, three anorexic patients were found to have an isolated peroneal nerve palsy. We conclude that PN is a notable complication of AN, particularly in long-standing cases. The PN is most likely a product of chronic malnutrition rather than a specific nutrient deficiency. Patients with AN also appear to be at increased risk for developing localized compression neuropathies secondary to subcutaneous tissue loss.

A prospective study of children with first acute symptomatic E. coli urinary tract infection. Early 99mtechnetium dimercaptosuccinic acid scan appearances

Between 1985 and 1987 102 children, age 0-14 years, presented with a first acute symptomatic E. coli urinary tract infection. Investigations included early 99mtechnetium dimercaptosuccinic acid (DMSA) scan (which was performed at a median of 27 days), ultrasonography, micturating cysto-urethrography and indirect voiding radionuclide cystography using 99mTc DTPA. Follow-up DMSA scan was carried out after 6 months. Twenty-one of 102 of initial DMSA studies showed diminished uptake of radionuclide and 12 showed cortical scarring. Twenty-nine patients had significant vesicoureteral reflux (VUR). The finding of diminished uptake on the initial scan was significantly associated with fever, systemic upset, length of symptoms and a peripheral blood leucocytosis, (p less than 0.05). In addition the finding was associated with fever and loin pain in the older child. Both diminished uptake and scarring were more common in refluxing kidney units. We propose that, in children with UTI, diminished uptake on early DMSA scan localises infection in the renal parenchyma.

Value of antenatal diagnosis of abnormalities of the urinary tract

OBJECTIVE

To assess the value of antenatal diagnosis of abnormalities of the urinary tract on ultrasonography.

DESIGN

Retrospective study.

SETTING

Two obstetric units in Glasgow.

SUBJECTS

62 Fetuses in which renal abnormalities were diagnosed on antenatal ultrasonography.

INTERVENTIONS

Six fetuses had their bladders aspirated to determine renal function. Fifteen pregnancies were terminated on the basis of the findings on antenatal ultrasonography, and if possible necropsy was performed on the fetuses. In babies who were born alive the final diagnosis was made by postnatal ultrasonography, intravenous urography, radionuclide scanning, cystography, and, in those who died in the early neonatal period, necropsy. Neonates who were referred with a known obstructed kidney had nephrostomy or pyeloplasty.

END POINT

Assessment of the value of antenatal diagnosis of renal abnormalities on ultrasonography for babies who had no clinical evidence of disease postnatally.

MAIN RESULTS

Eighteen fetuses did not survive birth; the antenatal diagnosis was accurate in all 18. Of the 44 babies born alive, five had normal urinary tracts, in two of whom antenatal ultrasonography had probably indicated a false positive diagnosis. Fourteen babies died during the early neonatal period. Twenty five babies with renal abnormalities were followed up; the antenatal diagnosis was inaccurate for 10 of them, the commonest misdiagnosis being hydronephrosis for multicystic kidney and vice versa, and there was one false positive diagnosis. The initial clinical findings in 14 babies would have led to the early detection of a urological abnormality. In the 30 babies with no clinical evidence of disease the antenatal diagnosis was of definite value in eight, probable value in 15, and marginal value in seven. Overall, an accurate antenatal diagnosis was made in 46 of the 62 cases (74%); in 12 cases renal disease was detected but its specific nature was not determined; and in four cases the diagnosis was misleading.

CONCLUSIONS

The overall value of antenatal diagnosis is that it indicates early termination of fetuses with fatal renal disease, prepares parents and medical staff for the likelihood of serious neonatal problems, and shows abnormalities of the urinary tract that may not be detected postnatally.

Intrarenal duplication

We report the anomaly of intrarenal duplication seen during the course of investigation of urinary tract infection in 6 children. The anomaly and its embryological basis are described.

Physeal widening in children with myelomeningocele

We report five examples of physeal widening in four children with myelomeningocele. In all cases there was rapid clinical resolution with the use of the patients' normal orthoses and minor limitation of activity, and there was no evidence of early epiphyseal closure or growth disturbance. We suggest that recognition of the pathological process before fracture occurred may explain the rapid return to normal.

Anatomic observations in carpal tunnel syndrome as they relate to the tethered median nerve stress test

The Tethered Median Nerve Stress Test (TMNST) has proved to be a reliable clinical tool in the diagnosis of chronic, low-grade carpal tunnel syndrome (CTS). The TMNST consists of hyperextending the index finger at the distal interphalangeal joint with the wrist maintained in a supinated position. Proximal volar forearm pain radiation is experienced by patients with chronic CTS during this maneuver. This investigation shows that significant distal excursion of the median nerve occurs with hyperextension of the index finger and to a greater degree than with hyperextension of the adjacent digits. Pain experienced during the TMNST appears to be vascular in origin and its severity is directly related to the duration of testing. This finding emphasizes the important role of ischemia in chronic entrapment neuropathies.

Renal scarring secondary to vesicoureteric reflux. Critical assessment and new grading

One hundred and fifty children with proven urinary tract infection who were assessed by renal ultrasound (U/S), intravenous urography (IVU) and dimercaptosuccinic acid (99mTc DMSA) scan, were studied to identify the sensitivity of each examination and the pick-up rate of renal scarring secondary to vesicoureteric reflux. Sixty-three of these children who had the examinations carried out within a 6-month period were assessed in detail. A DMSA scan is the most accurate method of detecting early renal scars in the young age group (0-2 and 2-5 years), followed by ultrasound. The examinations are equally sensitive over the age of 5. A new grading system of the severity of renal scarring is presented.

Serial quantitative 99mTc DTPA imaging in CMV-associated renal allograft dysfunction

Two cases of cytomegalovirus associated renal allograft dysfunction were monitored by serial 99mTc DTPA imaging and cytomegalovirus specific fluorescent antibody tests. One case of primary cytomegalovirus disease associated with pneumonitis, hepatitis and pyrexia occurred 25 days after transplantation. The second case, due to cytomegalovirus reactivation/reinfection had fewer symptoms and occurred 78 days following transplantation. 99mTc DTPA perfusion index at the height of the cytomegalovirus associated illness remained unaltered in both cases, and did not suggest the presence of acute rejection. This non-reactive response was associated with a rapid return of graft function. The combined use of these rapid diagnostic tests during suspected rejection episodes may be useful in indicating cytomegalovirus associated allograft dysfunction and preventing the addition of further potentially harmful immunosuppressants.

Positioning of umbilical arterial catheters with ultrasound

Fifty six infants were studied by ultrasound, 22 during the placement of the umbilical artery catheter. The descending aorta, bifurcation, common iliac arteries, and the intra-arterial catheter could be clearly seen. We recommend that the catheter tip be placed 5-10 mm above the aortic bifurcation thus avoiding the major branches of descending aorta.

Indications for aortography. Radiography after blunt chest trauma: a reassessment of the radiographic findings associated with traumatic rupture of the aorta

Indications for aortography in truncal trauma patients have expanded as reports of radiographic findings associated with traumatic rupture of the aorta (TRA) have proliferated. By studying to what extent these findings also occurred in trauma patients without TRA, we determined the utility of these findings in selecting patients for aortography. The detection of nine radiographic findings associated with TRA was tabulated in 173 patients undergoing arch aortography to rule out TRA from 1975 to 1980. Twenty-five of these had TRA. All patients with TRA under age 65 had a widened mediastinum (WM); this was the only finding that taken alone correlated significantly with TRA (P = 0.001). Only two of six patients with TRA over 65 had a WM. Other findings such as hemothorax, fracture of ribs 1 or 2, pulmonary contusion, or multiple rib fracture were more likely to be found in patients without TRA. Formal radiographic interpretation by staff radiologists detected more radiographic abnormalities than physicians caring for the patient emergencly, who had access to a junior radiology resident. However, these physicians were as successful as staff radiologists in detecting WM when it was associated with TRA. A widened mediastinum is the best single criterion for aortography in young trauma patients; all elderly persons with severe truncal trauma should probably have aortography even in the absence of mediastinal widening. Radiologic consultation is important for complete detection of thoracic pathology in trauma patients, but in this study late interpretation of more subtle findings did not detect additional patients with TRA.

Are ligand assay methods specific for cobalamin? A survey report

To determine whether or not laboratories participating in the ligand assay survey of the College of American Pathologists can measure cobalamin (vitamin B-12) in the presence of cobalamin analogues, either cobalamin or cobinamide (a model for the non-physiological analogues of cobalamin) was added to pooled human serum, and aliquots of the various samples were submitted to the participants. Nine hundred and nineteen results that represented 13 commercially available methods were analyzed. For a sample containing 412 pg/mL. of cobalamin, the mean interference produced by 400 pg/mL of cobinamide, expressed as the apparent increase in the cobalamin concentration, was 26.5 pg/mL with a range of 18 to 42 pg/mL. The mean recovery of added cobalamin was 104% of the expected value.

Leukocytosis in peritoneal lavage effluent after selected abdominal organ injury in an experimental model

Elevation of the corrected leukocyte count (Cwbc) in peritoneal lavage effluent has been reported by us in association with colon perforation. We have extended this study in order to investigate systematically the nature of the stimuli to, and the timing, magnitude, and consistency of this response in the presence of other occult abdominal injuries associated with trauma. This has been done by subjecting an anesthetized canine model to a variety of isolated intra-abdominal injuries and then measuring sequential peritoneal lavage leukocyte counts up to six hours after injury. A rising lavage leukocyte count gave Cwbc-positive lavages in 94% of animals with jejunal, ileal, and colonic wounds by six hours. In animals with isolated peritoneal penetration alone, or simple liver or spleen wounds, an elevated Cwbc count was unusual. In stomach, gallbladder, and urinary bladder perforation, a positive lavage was an inconsistent finding. Peritoneal lavage leukocyte counts corrected on the basis of red cell count can enhance the accuracy and utility of lavage for abdominal trauma, especially when gastrointestinal perforation is present as an isolated injury, by detecting an early peritoneal inflammatory response which appears independently from simple hemorrhage. [Mueller GL, Burney RE, MacKenzie JR: Leukocytosis in peritoneal lavage effluent after selected abdominal organ injury in an experimental model.