Decision Making by Young Transplant Surgeons Regarding Expanded-Criteria Donors With Acute Kidney Injury or Allocation Failure

BACKGROUND

The utilization of expanded-criteria donors (ECDs) has increased to overcome donor shortages. Unfortunately, the discard rate has also increased, especially in ECDs with acute kidney injury (AKI). We evaluated the outcomes of kidney transplantation in ECDs and standard-criteria donors (SCDs) with and without AKI.

METHODS

We reviewed the medical records of patients who underwent kidney transplantation. We used the AKI definition published by the Kidney Disease: Improving Global Outcomes group and reviewed the demographic characteristics of donors and recipients. We analyzed transplantation outcomes.

RESULTS

Twenty-seven patients underwent kidney transplantation from ECDs with AKI (n = 6) or without AKI (n = 5) and SCDs with AKI (n = 6) or without AKI (n = 10). Initial creatinine and estimated glomerular filtration rate (eGFR) were not significantly different between the groups. The incidence of delayed graft function was highest in ECDs with AKI (n = 3; 36.4%), but this was not a significantly difference. There was no difference in the last creatinine and eGFR in ECDs with AKI (1.32 mg/dL, 58.7 mL/min/1.73 m(2)), ECDs without AKI (1.67 mg/dL, 44.2 mL/min/1.73 m(2)), SCDs with AKI (0.94 mg/dL, 81.5 mL/min/1.73 m(2)) and SCDs without AKI (0.97 mg/dL, 81.8 mL/min/1.73 m(2)).

CONCLUSIONS

As the donor pool is extended to ECDs, young transplant surgeons may increasingly face decisions regarding ECDs with AKI or allocation failure. There is no consensus regarding discard criteria. However, if the donor showed initially normal creatinine levels or if dual-kidney transplantation can be performed, young transplant surgeons should not hesitate to use ECDs with AKI or allocation failure.

Restoration of electric footshock-induced immunosuppression in mice by Gynostemma pentaphyllum components

The immunomodulatory effects of the ethanol extract of Gynostemma pentaphyllum (GP-EX) were examined in electric footshock (EFS)-stressed mice. The mice were orally administered various doses of GP-EX for 7 days before exposure to EFS (duration: 3 min, interval: 10 s, intensity: 2 mA) once a day from day 8 for 14 days with continuous daily feeding of GP-EX. Oral administration of GP-EX to mice prevented EFS stress-induced immunosuppression as determined by the lymphoid organ (thymus and spleen) weight and cellularity. In addition, oral administration of GP-EX restored EFS-suppressed functional properties of mature lymphocytes in terms of concanavalin A-induced proliferation of splenocytes and lipopolysaccharide-induced cytokine production (TNF-α, IL-1β). Furthermore, we found that mice that were orally administered with GP-EX generated much more potent ovalbumin-specific cytotoxic T lymphocyte responses upon intravenous ovalbumin injection compared to the untreated controls. These results demonstrate that oral administration of the ethanol extract of Gynostemma pentaphyllum could increase host defense in immunocompromised situations such as stress-induced immunosuppression.

Effects of a cGMP-specific phosphodiesterase inhibitor on expression of endothelial nitric oxide synthase and vascular endothelial growth factor in rats with cyclosporine-induced nephrotoxicity

BACKGROUND

The mechanism of cyclosporine (CsA)-induced nephrotoxicity has been suggested to be vasoconstriction due to reduced nitric oxide (NO), providing tissue fibrosis by elevation of transforming growth factor beta and vascular endothelial growth factor (VEGF). In this study using a rat model of CsA-induced nephrotoxicity, we administered a phosphodiesterase-5 inhibitor to ameliorate the renal injury and alter the expression of endothelial No synthase (eNOS) and VEGF.

METHODS

A right nephrectomy was performed in Sprague-Dawley rats (n = 30; 200-250 g, all male). The Ischemia group (n = 6) underwent ligation of the left renal artery for 45 minutes (IR) before observation for 28 days. After IR, the udenafil group (n = 6) was treated with 10 mg/kg drug orally, the CsA group (n = 6) received 15 mg/kg CsA injected subcutaneously and the CsA plus udenafil group (n = 6) received 15 mg/kg CsA injected subcutaneously together with the oral administration of 10 mg/kg udenafil.

RESULTS

Administration of udenafil significantly decreased serum creatinine either alone (0.21 ± 0.04 mg/dL) or in combination with CsA (1.86 ± 0.35 mg/dL) versus the ischemia (0.85 ± 0.22 mg/dL) and the CsA alone (3. 10 ± 0.77 mg/dL) group. (P = .002; P = .002). Comparing the Hematoxylin-eosin staining of the ischemia (0.41 ± 0.09) and CsA (0.44 ± 0.08) groups showed a significantly decreased loss of nuclei in proximal tubules after the administration of udenafil (0.27 ± 0.05 [P = .004] and 0.26 ± 0.02 [P = .002] respectively). Immunohistochemical staining showed strong eNOS staining in the udenafil and CsA plus udenafil groups. Western blots for eNOS showed decreased expression in the CsA group and increased expression in the udenafil group. Western blots for VEGF revealed reduced expression only in the CsA plus udenafil group. eNOS mRNA was decreased in the CsA (0.017 ± 0.010) compared with the ischemia group (0.048 ± 0.015; P = .000). VEGF mRNA which was decreased in the CsA group (2.026 ± 1.109), showed greater tendency after administration of udenafil (0.440 ± 0.449) (P = .003).

CONCLUSION

The phosphodiesterase inhibitor ameliorated renal injury in a rat model of CsA-induced nephrotoxicity, possibly related to increased eNOS and reduced VEGF expression.

Development of an LC-MS method for measuring TNF in human vaginal tissue

A sensitive, accurate, and precise liquid chromatography-mass spectrometry assay for the determination of tenofovir (TNF) in human vaginal tissue was developed and validated. After homogenization of the tissue, solid-phase extraction on Varian Bond Elut-C(18) column was used for sample clean up. Chromatographic separation of TNF and the internal standard (tolbutamide) was achieved with a Varian Polaris 3C(18)-A reversed-phase analytical column (150 mm x 2 mm). A gradient method using 0.1% formic acid in water and 0.1% formic acid in acetonitrile was employed. Detection of TNF and tolbutamide was achieved by electrospray ionization mass spectrometry in the positive ion mode using 288.05 and 271.00 m/z, respectively. Linear TNF calibration curves were obtained between 1-1,000 ng/mL with a correlation coefficient (r(2)) greater than 0.999. Intra- and inter-day accuracy for TNF ranged from 89.7% and 109.4% and from 97.3% and 104.9%, and precision ranged from 1.3% and 10.9% and 2.6% and 9.0%, respectively. This is the first validated method developed to quantitate TNF in human tissues.

A phenotype-genotype approach to predicting CYP450 and P-glycoprotein drug interactions with the mixed inhibitor/inducer tipranavir/ritonavir

The effects of tipranavir/ritonavir (TPV/r) on hepatic and intestinal P-glycoprotein (P-gp) and cytochrome P450 (CYP) enzyme activity were evaluated in 23 volunteers. The subjects received oral (p.o.) caffeine, warfarin + vitamin K, omeprazole, dextromethorphan, and midazolam and digoxin (p.o. and intravenous (i.v.)) at baseline, during the first three doses of TPV/r (500 mg/200 mg b.i.d.), and at steady state. Plasma area under the curve (AUC)(0-infinity) and urinary metabolite ratios were used for quantification of protein activities. A single dose of TPV/r had no effect on the activity of CYP1A2 and CYP2C9; it weakly inhibited CYP2C19 and P-gp; and it potently inhibited CYP2D6 and CYP3A. Multiple dosing produced weak induction of CYP1A2, moderate induction of CYP2C19, potent induction of intestinal P-gp, and potent inhibition of CYP2D6 and CYP3A, with no significant effects on CYP2C9 and hepatic P-gp. Several P450/transporter single-nucleotide polymorphisms correlated with the baseline phenotype but not with the extent of inhibition or induction. Although mixed induction and inhibition are present, this approach offers an understanding of drug interaction mechanisms and ultimately assists in optimizing the clinical use of TPV/r.

Technical innovation for noninvasive and early diagnosis of biliary atresia: the ultrasonographic "triangular cord" sign

In this article, we introduce our experience regarding a new and noninvasive diagnostic tool, using ultrasonography, for the early and definite diagnosis of biliary atresia. We have focussed on the ultrasonographic image of the cone-shaped periportal fibrous mass in infants with biliary atresia since 1992, and have finally identified a triangular or band-like periportal echogenicity ("triangular cord" sign), mainly cranial to the portal vein. Based on our experience and other reports from Japan and Singapore, the ultrasonographic triangular cord sign is a simple, time-saving, highly reliable, and definite tool in the diagnosis of biliary atresia from infantile intrahepatic cholestasis, representing a positive predictive value greater than 95%. We have proposed a new diagnostic strategy in the evaluation of infantile cholestasis, with emphasis on the ultrasonographic triangular cord sign.

Technical innovation for noninvasive and early diagnosis of biliary atresia: the ultrasonographic "triangular cord" sign

In this article, we introduce our experience regarding a new and noninvasive diagnostic tool, using ultrasonography, for the early and definite diagnosis of biliary atresia. We have focussed on the ultrasonographic image of the cone-shaped periportal fibrous mass in infants with biliary atresia since 1992, and have finally identified a triangular or band-like periportal echogenicity ("triangular cord" sign), mainly cranial to the portal vein. Based on our experience and other reports from Japan and Singapore, the ultrasonographic triangular cord sign is a simple, time-saving, highly reliable, and definite tool in the diagnosis of biliary atresia from infantile intrahepatic cholestasis, representing a positive predictive value greater than 95%. We have proposed a new diagnostic strategy in the evaluation of infantile cholestasis, with emphasis on the ultrasonographic triangular cord sign.

Choroidal tuberculoma with membranous glomerulonephritis

We report treatment of a 24-year-old man with membranous glomerulonephritis (MGN) who developed a solitary choroidal tuberculoma in association with miliary tuberculosis during steroid therapy. In June 1995, the patient had developed nephrotic syndrome. He had refused renal biopsy at that time. So we treated him with corticosteroids having assumed a diagnosis of minimal change nephrotic syndrome. After initial corticosteroids and diuretics therapy for 5 months, his generalized edema resolved but proteinuria (3 positive) continued, suggesting the presence of other forms of glomerulonephritis. Renal biopsy performed in January 1996. The patient was diagnosed as having MGN. The patient was closely observed over a period of 34 months and remained stable without steroid therapy. However at 34 months, generalized edema was again noted and steroid therapy at high dosage was initiated. After 5 months of steroid therapy, he developed miliary tuberculosis and a solitary choroidal mass. An antituberculosis chemotherapeutic regimen was started and after a further 5 months, all clinical symptoms and signs of the pulmonary lesion were resolved and a measurable shrinking of the choroidal mass was recorded.

Cystic rectal duplication: a rare cause of neonatal bladder-outlet obstruction and hydronephrosis

A case of cystic rectal duplication (RD) is presented. A 7-day-old female was admitted with acute urinary retention, voiding difficulty, and abdominal distention since she was 4 days of age. Ultrasound and abdominal computed tomography (CT) demonstrated a huge, cystic mass in the pelvis and abdomen that resulted in acute urinary retention and bilateral hydronephrosis. CT-guided drainage of the lesion followed by transabdominal surgical excision resulted in a cure. Pathologic examination demonstrated a RD lined by respiratory epithelium.

Identification of active-site residues in Bradyrhizobium japonicum malonamidase E2

Malonamidase (MA) E2 was previously purified and characterized from Bradyrhizobium japonicum USDA 110. The gene encoding this enzyme has been cloned, sequenced and expressed in Escherichia coli. The recombinant MAE2 was purified to homogeneity from the transformed E. coli. The biochemical properties of the recombinant enzyme are essentially identical to those from wild-type B. japonicum. A database search showed that the MAE2 protein has a high sequence similarity with the common signature sequences of the amidase family. The only exception is that the aspartic residue in these signature sequences is replaced by a glutamine residue. In order to identify amino acid residues essential for enzyme activity, a series of site-directed mutagenesis studies and steady-state kinetic experiments were performed. Gln(195), Ser(199), Cys(207) and Lys(213) of the common signature sequences were selected for site-directed mutagenesis. Among the mutants, Q195D, Q195E and S199C showed less than 0.02% of the k(cat) value of the wild-type enzyme, and S199A, Q195L and Q195N exhibited no detectable catalytic activities. Mutants (K213L, K213R and K213H) obtained by replacement of the only conserved basic residue, Lys(213), in the signature sequences, also displayed significant reductions (approx. 380-fold) in k(cat) value, whereas C207A kept full activity. These results suggest that MAE2 may catalyse hydrolysis of malonamate by a novel catalytic mechanism, in which Gln(195), Ser(199) and Lys(213) are involved.

Stereoselective determination of cetirizine and studies on pharmacokinetics in rat plasma

Enantiomers may confer benefits over racemates in therapeutic uses and we developed a chiral separation method of cetirizine enantiomers, a second generation H1 histamine receptor antagonist, in rat plasma. alpha1-Acidglycoprotein based chiral stationary phase(AGP-CSP), monitored with UV at 230 nm was used to separate the enantiomers. Observed enantioselectivity (alpha) was 2.0. The AGP-CSP was also used at a preparative scale to isolate the enantiomers with an optical purity of greater than ee 99%. In addition, an analysis was carried out for the cetirizine enantiomers in rat plasma to study the differences of enantiomers in pharmacokinetics. Both (+)- and (-)-cetirizine were separated using a reversed-phase column of AGP, and were detected at the range of 2.5-200 microg ml(-1) in plasma. Although there was no recognizable differences in pharmacokinetics between the enantiomers in rat, the method appears to be useful for their pharmacokinetic studies.

A case of membranoproliferative glomerulonephritis associated with a hydatidiform mole

We treated a 54-year-old woman who was suffering from membranoproliferative glomerulonephritis associated with a complete type of hydatidiform mole. The renal manifestations were proteinuria and hematuria. A renal biopsy, performed before gynecologic management, disclosed focal and segmental subendothelial deposits with a proliferation of the mesangial cell and showed irregularly thickened capillary loops by light and electronmicroscoy. Genralized edema, proteinuria and hematuria were completely recovered by suction and curettage of the hydatidiform mole with prophylactic chemotherapy. The clinical manifestation of earlier presented 3 cases have been the nephrotic syndrome. The common feature of them was a complete remission of the nephropathy after the removal of the hydatidiform mole. The relationship between the hydatidiform mole and glomerulonephritis remains unresolved at present. But we concluded that the hydatidiform mole might be a cause of glomerulonephritis in this case.

Do dialysis patients need extra folate supplementation?

To assess folate status and to evaluate the need for conventional folate supplementation in patients on dialysis, we measured serum folate, vitamin B12, and red cell folate concentrations by radioimmunoassay. Thirty-four continuous ambulatory peritoneal dialysis (CAPD) patients and 60 hemodialysis (HD) patients who had not been supplemented with folate were enrolled. Serum folate levels (5.8 +/- 3.6 ng/mL vs 2.0 +/- 1.1 ng/mL, p < 0.001) and vitamin B12 levels (831.4 +/- 416.9 pg/mL vs 513.9 +/- 213.3 pg/mL, p < 0.001) were significantly higher in CAPD patients than HD patients. The red cell folate levels (849.7 +/- 489.4 ng/mL vs 491.0 +/- 253.2 ng/mL, p < 0.001) were also significantly higher in CAPD patients. The incidences of folate deficiency in CAPD and HD patients were overestimated using the cut-off value for serum folate concentration (3.0% vs 71.7%, respectively), but the incidence of true folate deficiency was lower using the cut-off value for red cell folate level (0.0% vs 10.0%, respectively). In conclusion, the true incidence of folate deficiency in stable CAPD and HD patients is surprisingly low, even in patients who may not be taking folate supplements. The need for conventional folate supplementation in patients with end-stage renal disease on dialysis must therefore be re-evaluated. Before the decision is made to use folate supplementation, measurement of red cell folate is essential to assess of folate reserves of the patients on dialysis.

Enantioselective determination of cetirizine in human urine by HPLC

In order to study the simultaneous determination of (+)- and (-)-cetirizine in human urine we have developed a chiral separation method by HPLC. A chiral stationary phase of alpha1-acidglycoprotein, the AGP-CSP, was used to separate the enantiomers. The pH of the phosphate buffer, as well as the content of the organic modifier in the mobile phase, markedly affected the chromatographic separation of (+)- and (-)-cetirizine. A mobile phase of 10 mmol/l phosphate buffer (pH 7.0)-acetonitrile (95: 5, v/v) was used for the urine assays. Ultraviolet absorption was monitored at 230 nm and roxatidine was employed as the internal standard for quantification. (+)-Cetirizine, (-)-cetirizine and the internal standard were eluted at retention times of 12, 16, and 32 mins, respectively. The detection limit for cetirizine enantiomers was 400 ng/ml of urine. A pharmacokinetic study was conducted with the help of 5 healthy female volunteers who were administered with a single oral dose of racemic cetirizine (20 mg). The peak area ratios provided by the cetirizine enantiomers were linear (r>0.997) over a concentration range of 2.5-200 microg/ml. The peak of the excreted cetirizine enantiomers appeared in the urine sample during the period of 1-2 hrs following the administration of the oral dose. The excreted level of (+)-cetirizine was slightly higher than (-)-cetirizine but the difference was not statistically significant. However, this method appears to have applications for enantioselective pharmacokinetic studies of racemic drugs.

The ultrasonographic 'triangular cord' coupled with gallbladder images in the diagnostic prediction of biliary atresia from infantile intrahepatic cholestasis

PURPOSE

The aim of this study was to evaluate the importance of the ultrasonographic "triangular cord" (TC) coupled with gallbladder images in the diagnostic prediction of biliary atresia (BA) from infantile intrahepatic cholestasis.

METHODS

Seventy-nine infants with cholestatic jaundice underwent ultrasound examinations, focusing on the TC and gallbladder images. The TC was defined as visualization of a triangular or bandlike periportal echogenicity (3 mm or greater in thickness), which represents a cone-shaped fibrotic mass cranial to the portal vein in infants with BA. An abnormal gallbladder (nonvisualized or small) was thought to be more suggestive of BA than infantile intrahepatic cholestasis.

RESULTS

Among 25 infants with BA, 21 showed TC, whereas 4 had no TC. Fifty-three of 54 infants with infantile intrahepatic cholestasis had no TC, showing a diagnostic accuracy of 94% with 84% sensitivity and 98% specificity. As for positive predictive value in the diagnosis of BA by the TC coupled with gallbladder images, it was 100% when a positive TC was coupled with an abnormal gallbladder and 88% when a positive TC was coupled with a normal gallbladder. It decreased to 25% when a negative TC was coupled with an abnormal gallbladder.

CONCLUSIONS

The TC appears to be a very specific and definite ultrasonographic finding in the early diagnosis of BA. Positive TC regardless of gallbladder images is highly suggestive of BA, showing a 95% positive predictive value, but BA cannot be ruled out when negative TC is coupled with an abnormal gallbladder, requiring further diagnostic modalities such as liver needle biopsy or hepatobiliary scintigraphy.

Immunoglobulin A nephropathy in patients with non-insulin dependent diabetes mellitus

The occurrence of immunoglobulin A nephropathy (IgAN) in patients with noninsulin dependent diabetes mellitus (NIDDM) is a rare event and of pathogenetic interest. It is not clear whether this is merely coincidence. We report here five patients with IgAN in NIDDM associated with or without diabetic glomerulosclerosis. All of the patients were Korean males. In three patients, diabetes mellitus was diagnosed at the same time with diagnosis of IgAN, and the known duration of the diabetes in the other two patients were three and seven years, respectively. There was no evidence of diabetic retinopathy in four patients, but it was found in one patient. In all cases, the diagnosis of IgAN was made by immunohistology.

Non-diabetic renal disease in patients with non-insulin dependent diabetes mellitus

The diagnosis of diabetic nephropathy (DN) is almost always based on clinical grounds. The diagnosis is supported by a long history of diabetes, evidence of target organ damage and proteinuria preceding azotemia. The validity of this clinical approach is well established in insulin dependent diabetes mellitus but not in non-insulin dependent diabetes mellitus (NIDDM). It is thus important to determine which patients with NIDDM accompanied by non-diabetic renal disease (NDRD) should have a biopsy. However, factors clinically associated with NDRD in patients with NIDDM remain unclear. Therefore we reviewed clinical data, laboratory data and renal biopsies from 22 NIDDM patients who underwent renal biopsy between 1992 and 1998 in Wonju Christian Hospital. From this data, we identified important features that would discriminate between DN and NDRD. There were 8 women and 14 men. Age ranged from 33 to 68 (51.2 +/- 10.7) years. The duration of diabetes at biopsy ranged from 0 to 13 (4.2 +/- 4.2) years. Nephrotic syndrome was present in 13 patients. The patients with NDRD (n = 14) and DN (n = 8) had comparable 24-hour proteinuria, 24-hour albuminuria, creatinine clearance, serum creatinine, albumin, as well as incidences of neuropathy and hypertension. The significant factors that predict the NDRD included a short duration of the diabetes mellitus, the presence of dysmorphic red blood cells in urine, the absence of retinopathy and HbA1c below 9% (p < 0.05, respectively). NDRD included IgA nephropathy (n = 6), minimal change disease (n = 3), membranous nephropathy (n = 3), membranous lupus nephritis (n = 1) and acute interstitial nephritis (n = 1). Multiple logistic regression analysis revealed that the short duration of DM and the absence of retinopathy were factors significantly associated with NDRD. In summary, when there is a short duration of diabetes mellitus, or an absence of retinopathy seen in patients with NIDDM, then renal biopsy in diabetic patients aids in the detection of NDRD.

Environmental controls in reducing house dust mites and nasal symptoms in patients with allergic rhinitis

A randomized comparison group pretest-posttest experimental design was used to quantitatively determine the effects of environmental control measures on patients with allergic rhinitis. Environmental controls included wrapping the mattress with a vinyl cover, washing the top bedding cover with 55 degrees C hot water every two weeks, removal of soft furniture, and wet cleaning of the bedroom floor every day. Thirty subjects were randomly assigned to experimental and control groups. The amount of house dust mites in dust samples collected from the bedroom floor, bedding and mattress, as well as the nasal symptoms of patients, were measured twice at one-month intervals. A significant decrease in house dust mites in dust samples and relief in patients' nasal symptoms were observed in the experimental group who had environmental controls.

Ultrasonographic "triangular cord": the most definitive finding for noninvasive diagnosis of extrahepatic biliary atresia

Early diagnosis of extrahepatic biliary atresia (EHBA) is very important for a successful bile drainage procedure. An urgent and extensive investigation is warranted to make a differential diagnosis of EHBA from other cholestatic disease, especially neonatal hepatitis (NH). The diagnosis may be made by laparotomy with cholangiogram and liver biopsy but these procedure are invasive. Because a cone-shaped fibrous tissue was always found at the porta hepatis during Kasai's procedure and that type of fibrous tissue has never been seen in other types of cholestatic jaundice, the authors have used ultrasonography (US) to detect fibrous remnants at the porta hepatis in infants clinically suspected of having EHBA and identified a triangular- or tubular-shaped echogenic density in the bifurcation of the portal vein at the porta hepatis in EHBA and called it an ultrasonographic "triangular cord (TC)". The authors determined that the presence of TC denoted the EHBA. On the other hand, nonvisualization of TC was interpreted as consistent with NH. In the present study, the authors reviewed ultrasonographic examination and hepatobiliary scintigraphy in a series of 41 infants suspected of having EHBA or NH. The TC was identified in thirteen infants. In twelve of thirteen infants with TC found by US, the diagnosis of EHBA was confirmed at the time of Kasai's Roux-en-Y hepatoportojejunostomy operation. The remaining one died at 15 months of age without having treatment. TC was not visualized in 28 infants. Twenty-seven of 28 infants with absent TC improved clinically through medical treatment for NH. The other, diagnosed to have NH by needle and wedge liver biopsies, eventually showed a TC on follow-up US examination performed 40 days after the initial examinations. Moreover, follow-up percutaneous liver biopsy specimen showed typical findings of biliary atresia with bile duct proliferation and portal fibrosis. The patient underwent a Kasai hepatoportoenterostomy. On review of the hepatobiliary scintigraphy, all 13 infants with TC had no intestinal excretion of isotope. Thirteen of 28 infants (46%) without TC also had no intestinal excretion of isotope in the 24hour follow-up but all of them were confirmed to have NH by percutaneous liver biopsy and their subsequent clinical course confirmed NH with the detection of bile in their stool except one. On the basis of these results, the authors conclude that ultrasonographic TC is a very specific finding representing the fibrous cone at the porta hepatis and is a quick, simple, and definitive tool in the noninvasive diagnosis of EHBA. If TC is visualized, no further studies are necessary and exploratory-laparotomy can be done. If TC is not visualized, hepatobiliary scintigraphy is recommended to demonstrate bile duct patency. Percutaneous liver biopsy is only required if neither TC nor intestinal excretion of isotope is seen. However, early exploration or close US follow-up study is recommended in any patient suspected of having EHBA clinically, even if liver biopsy confirms the presence of NH.

A new diagnostic approach to biliary atresia with emphasis on the ultrasonographic triangular cord sign: comparison of ultrasonography, hepatobiliary scintigraphy, and liver needle biopsy in the evaluation of infantile cholestasis

BACKGROUND/PURPOSE

The authors evaluated prospectively the utility of ultrasonography, Tc-99m-DISIDA hepatobiliary scintigraphy, and liver needle biopsy in differentiating biliary atresia (BA) from intrahepatic cholestasis in 73 consecutive infants who had cholestasis.

METHODS

Sixty three ultrasonographic examinations of 61 infants with 7.0-MHz transducer were carried out, focusing on the fibrous tissue at the porta hepatis. The authors defined the triangular cord (TC) as visualization of a triangular or tubular shaped echogenic density just cranial to the portal vein bifurcation on a transverse or longitudinal scan.

RESULTS

Although 17 of 20 ultrasonographic examinations from infants who had BA denoted TC, 43 ultrasonographic examinations from infants with either neonatal hepatitis (NH) or other causes of cholestasis denoted no TC, showing a diagnostic accuracy of 95% with 85% sensitivity and 100% specificity. Investigation with Tc-99m-DISIDA hepatobiliary scintigraphy showed that 24 of 25 infants who had BA had no gut excretion, and 16 of 46 infants who had either NH or other causes of cholestasis had gut excretion, showing a diagnostic accuracy of 56% with 96% sensitivity and 35% specificity. Therefore, gut excretion of tracer excluded BA, but no gut excretion of tracer needed further investigations as liver needle biopsy. Forty-four liver needle biopsies were carried out in 19 infants who had BA and 24 infants who had either NH or other causes of cholestasis. Although 18 of 20 biopsy findings in infants who had BA were correctly interpreted as having BA, 23 of 24 biopsy results in infants who had either NH or other causes of cholestasis were correctly diagnosed, showing a diagnostic accuracy of 93% with 90% sensitivity and 96% specificity.

CONCLUSIONS

Since the introduction of ultrasonographic TC sign in the diagnosis of BA by our institution, we have found that it seemed to be a simple, time-saving, highly reliable, and non-invasive tool in the diagnosis of BA from other causes of cholestasis. The authors propose a new diagnostic strategy in the evaluation of infantile cholestasis with emphasis on ultrasonographic TC sign as first priority of investigations. When the TC is visualized, prompt exploratory laparotomy is mandatory without further investigations. When the TC is not visualized, hepatobiliary scintigraphy is the next step. Excretion of tracer into the small bowel actually rules out BA. Liver needle biopsy is reserved only for the infants with no excretion of tracer. The authors believe that a correct decision regarding the need for surgery can be made in almost all cases with infantile cholestasis by this multidisciplinary approach.

Electron microscopic study of the liver with biliary atresia and neonatal hepatitis

Eleven cases of biliary atresia (BA) and eight of neonatal hepatitis (NH) were studied, using transmission electron microscopy, to document their different ultrastructural characteristics and to elucidate the possible pathogenesis of biliary atresia. Among 30 consecutive liver biopsies obtained from 19 infants with BA or NH, 21 specimens composed (13 BA, 8 NH) were examined ultrastructurally. The electron microscopic features of NH (patients' age range, 35 to 60 days) were (1) giant hepatocytic transformation with scattered areas of dilated endoplasmic reticulum, indicative of intracytoplasmic degeneration, (2) frequent cytoplasmic biliary necrosis, and (3) relatively intact microvilli in most bile canaliculi, which contained some hepatocytic cytoplasmic fragments. These features strongly suggest that the main pathological process in NH is hepatocellular injury rather than bile duct damage. In contrast, all cases with BA (age range, 27 to 130 days) demonstrated (1) marked hepatocellular cholestasis associated with many lysosomes and myelin figures, (2) marked loss of bile canalicular microvilli, (3) degenerated bile ductular cells containing bile pigments, and (4) periductal inflammatory fibrosis. These features suggest that the main pathological process in BA involves the biliary system. A few viral inclusions were observed in two cases with BA, which suggests that viral infection is a potential cause. In two BA cases (aged 40 and 43 days at the time of first biopsy), the ultrastructural findings essentially were the same as those of NH, and follow-up biopsy specimens (at 48 and 94 days) showed findings consistent with BA. Such results support Landing's hypothesis that BA and NH are different manifestations of a single pathological process.

'Triangular cord': a sonographic finding applicable in the diagnosis of biliary atresia

Biliary atresia (BA) is characterized by luminal obstruction of the extrahepatic bile duct with fibrous remnants. The authors reviewed ultrasonographic examinations of the fibrous tissue in the bifurcation of the portal vein at the porta hepatis and identified the triangular- or tubular-shaped echogenic density, the so-called "triangular cord" (TC), in the vicinity of the portal vein on a transverse or longitudinal scan. In this prospective study, the authors investigated whether TC was useful in the noninvasive diagnosis of biliary atresia in 18 infants who had persistent neonatal jaundice. This was done by comparing the ultrasonographic examination with the histopathologic examination (HPE) of liver specimens obtained from a needle biopsy. The TC was identified in nine patients, all of whom were confirmed to have BA by HPE. The TC was not observed in the other nine patients, who had neonatal hepatitis (NH). The mean size of the TC was 13 mm (wide) x 6 mm (thick) (width range, 5 to 21 mm; thickness range, 4 to 12 mm). The diagnosis of BA was confirmed at the time of Kasai hepatoportojejunostomy in eight of the nine patients whose TC was noted by ultrasonography (US). The other patient was discharged because his parents refused the operation; he died of liver failure at 15 months of age. The nine patients with absent TC were treated medically for NH. Eight of them improved clinically. The other, diagnosed to have NH by needle and wedge liver biopsies, was reexamined 40 days after the initial examination because of worsening jaundice. A 18 x 12-mm TC was visualized ultrasonographically. Additionally, a percutaneous liver biopsy specimen showed BA with severe portal fibrosis and ductal proliferation. The patient underwent a Kasai hepatoportoenterostomy. On the basis of these results, the authors conclude that TC is a very specific ultrasonographic finding, representing the fibrous cone at the porta hepatis, and is a useful tool in the noninvasive diagnosis of BA. However, early exploration or close US follow-up is recommended for any patient suspected of having BA clinically, even if a liver biopsy confirms the NH.

Preduodenal portal vein: a cause of prenatally diagnosed duodenal obstruction

Preduodenal portal vein is a rare congenital anomaly that causes high intestinal obstruction. The authors report on a newborn who was diagnosed as having duodenal obstruction at 30 weeks' gestation. During surgery the patient was found to have duodenal obstruction caused by a preduodenal portal vein. Malrotation was an associated finding. Treatment consisted of Ladd's procedure and a diamond-shaped duodenoduodenostomy performed anterior to the portal vein.

On the psychophysics of arm-positioning movements

The basis for the relationship between physical stimulus and magnitude of psychological response in angular movements of the upper limbs was investigated. Participants compared movements to a standard location with movements to comparison locations and movements of a standard distance with movements of comparison distances. The results add to the controversy surrounding the explanations for the differences in psychological response magnitude of movements to locations and movements across distances. Data obtained from movements to locations and movements across distances indicated similar Weber ratios but different patterns for the just noticeable differences. The data of this and previous research suggest that the application of a prothetic continuum to arm movements is inappropriate. An alternative explanation of the differences in the perception of movements to locations and movements across distances is offered.

A case of Henoch-Schönlein purpura in disseminated tuberculosis

Tuberculosis is still a common disease, even in some parts of developing countries. Although its major impact is pulmonary, the tuberculosis is actually a disseminated disease. An unusual form of renal involvement of tuberculosis is glomerulonephritis, as a part of systemic vasculitis, Henoch-Schoenlein Purpura (HSP). A 41-year-old man, being treated with antituberculous agents for pulmonary tuberculosis, was transferred to our hospital because of newly developed generalized purpura and pretibial edema. Renal manifestations were proteinuria and hematuria. Renal biopsy disclosed interstitial chronic granulomatous inflammation with caseous necrosis and strong nodular mesangial Ig A deposit, along with trace granular Ig G deposition and perivascular C3 deposit. Skin lesions were non-thrombocytopenic palpable purpurae, proved leukocytoclastic vasculitis by skin biopsy. All clinical symptoms and signs were relieved by antituberculous medication. We concluded that disseminated tuberculosis might be a cause of HSP, an immune complex mediated disease.

Ultrasound-guided water enema: an alternative method of nonoperative treatment for childhood intussusception

Ultrasound-guided water enema (USWE) reduction was performed in 115 patients with intussusception, which was diagnosed by ultrasound between April 1988 and August 1992 at Keimyung University Dongsan Medical Center. The overall rate of successful reduction was 80.9%. The rate was 91.0% for patients with symptoms of < or = 24 hours' duration, and 61.1% for patients with symptoms of more than 24 hours' duration (P < .001). Six patients had recurrence during the study period (recurrence rate, 5.2%). There was no perforation or other complications during and after the water enema reduction. The authors conclude that (1) USWE reduction for childhood intussusception has a higher rate of successful reduction and a lower rate of recurrence than does barium enema and (2) USWE is safe and may be an alternative method in the nonoperative treatment of intussusception.

Enteric duplications in children--an analysis of 6 cases

This is an analysis of 6 patients with enteric duplications seen over an 8 year period at the Department of Pediatric Surgery, Dongsan Medical Center. They were all males but one. All duplications were cystic, and single except one. Locations of duplications were in the duodenum in one patient, in the jejunum in one, and in the terminal ileum in four. Five of the 6 patients were seen within 1 year of life. Three were newborn infants who had symptoms of intestinal obstruction with palpable mass since birth. Duplication cyst acted as a leading point of intussusception in 4 month and 8 month old infants respectively. One jejunal duplication was found in an 11-year-old boy who had malrotation of the midgut with Ladd's bands. Clinical presentation, embryogenesis of duplication, and management are discussed.

Prepubic dermoid sinus: possible variant of dorsal urethral duplication (Stephens type 3)

The authors present the case of 4-month-old girl with a midline prepubic sinus extending from the skin overlying the pubis to the superior surface of the bladder, and continuing to the umbilicus via the median umbilical ligament. The distal portion of the exicised sinus was surrounded by concentric bundles of collagen and smooth muscle with minimal inflammatory infiltrates, which suggests a developmental origin. According to Stephens' classification, the sinus appears to be a variant of dorsal urethral duplication of Stephens type 3.

Detection of chromosome aberrations in interphase nuclei using fluorescence in situ hybridization technique

We report here several experiences of interphase cytogenetics, using fluorescence in situ hybridization (FISH) technique, for the detection of chromosome aberrations. FISH, using alpha satellite specific probes of 18, X, Y chromosomes, was done in interphase nuclei from peripheral blood of patients with Edwards' syndrome, Klinefelter's syndrome and Turner's syndrome with healthy male and female controls, respectively. The distributions of fluorescent signals in 100 interphase nuclei were well correlated with metaphase findings. Nowadays FISH plays an increasingly important role in a variety of research areas, including cytogenetics, prenatal diagnosis, tumor biology, gene amplification and gene mapping.

Acetylcholinesterase histochemistry of rectal suction biopsies in the diagnosis of Hirschsprung's disease

Rectal suction biopsy with acetylcholinesterase (AChE) histochemistry has gained increased acceptance as the means of definitely diagnosing Hirschsprung's disease (HD) as well as of excluding this diagnosis when evaluating children with low intestinal obstruction or chronic constipation since the report of Meier-Ruge et al. in 1972. But this AChE histochemical study has not been reported yet in Korea. During the 14-month period from April, 1991 through June, 1992, 37 children, aged 3 days to 17 years had rectal suction biopsies for the diagnosis or exclusion of HD. In this study, AChE histochemistry (N = 37) was compared with hematoxylin & eosin (H&E) staining of same suction biopsy specimens (N = 35) for diagnostic accuracy. The histochemical criterion used for the diagnosis of Hirschsprung's disease was that of Chow et al. (1977), i.e., the presence of many coarse discrete cholinergic fibers in the muscularis mucosae and in the immediately subjacent submucosa regardless of an infiltration of cholinergic fibers in the lamina propria. Of 13 biopsies from the patients with Hirschsprung's disease (N = 13), there were 12 positive reactions, and one false negative reaction in a neonate with total colonic aganglionosis. All biopsies from 24 unaffected children demonstrated negative reactions with no false positive reaction. In comparison, of the 35 specimens examined by H&E staining, ganglion cells were present in the submucosal Meissner's plexus only in 15 of these 24 unaffected children. In conclusion, a 97% diagnostic accuracy was achieved with AChE histochemistry compared with a 74% accuracy with H&E staining (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric gastric volvulus--experience with 7 cases

Gastric volvulus, organoaxial or mesenterioaxial, is a rare condition in infancy and childhood. We experienced 7 cases of pediatric gastric volvulus, consisting of 3 cases of secondary gastric volvulus due to left diaphragmatic eventration or paraesophageal hernia and 4 cases of idiopathic gastric volvulus. Of 7 cases, five were organoaxial in type and two were mesenterioaxial. The main symptoms of secondary gastric volvulus were vomiting and respiratory difficulty whereas those of idiopathic gastric volvulus were abdominal distension and weight loss with or without failure to thrive. It may be suspected on plain abdominal radiographs and usually confirmed by upper gastrointestinal series. Upper gastrointestinal series in organaxial volvulus demonstrated characteristic findings such as reversal of the greater and lesser curvatures and two air-fluid levels. In mesenterioaxial volvulus, the stomach was rotated into inverted position with pyloroantral obstruction showing a beak appearance. The three patients with secondary volvulus underwent repair of associated defect with or without gastropexy and the 3 patients with idiopathic volvulus underwent anterior gastropexy or gastrostomy. In those with idiopathic gastric volvulus, there was no obvious cause such as laxity of the perigastric ligaments. The operative results were satisfactory except for the three patients with idiopathic gastric volvulus whose abdomen remained distended regardless of weight gain.

Childhood intussusception: US-guided hydrostatic reduction

Over a 30-month period, real-time ultrasound (US) was performed in 116 children with suspected intussusception. US findings were positive in all 75 cases of intussusception. Except in one case of transient small-bowel intussusception, the authors immediately attempted US-guided hydrostatic reduction in all cases. Reduction was successful in 63 cases (85%), as demonstrated with US and resolution of signs and symptoms of intussusception. Negative sonograms were confirmed with clinical follow-up. Among 11 failed cases, reduction with barium enema was attempted in six, but all attempts failed. No complications have occurred to date. The authors conclude that US is a reliable diagnostic screening modality in cases of suspected intussusception and that US-guided hydrostatic reduction is a promising technique in nonoperative treatment.

Appendicoumbilical fistula as a sequela of perforated appendicitis

This is the first report, we believe, of a 5-year-old boy who developed appendicoumbilical fistula as a sequela of perforated appendicitis. We discuss a proposed explanation of the mechanism in its formation.

High jejunal obstruction as a sequela of necrotizing enterocolitis

A case of high jejunal obstruction due to stricture is reported. It is a rare form of late sequelae of neonatal necrotizing enterocolitis(NEC). Barium contrast study of the small bowel is recommended for earlier diagnosis and treatment before discharge from the hospital, even is an asympto-matic patient.

Ectopic umbilical liver in conjunction with biliary atresia: uncommon association

The case of a neonate with an ectopic liver in the umbilicus in conjunction with biliary atresia in the liver proper and an ectopic pancreas in the jejunum is reported. Following excision of the ectopic umbilical liver and Kasai type 1 hepatic portoenterostomy, bile fistula originating in the anterior inferior area of the right lobe of the liver was a complication, and it was successfully treated by construction of hepaticojejunostomy. No similar case has been reported in English language literature. It is of particular interest that the pathological features of the ectopic liver and the liver proper are quite similar.

Purulent umbilical drainage from infection of left umbilical artery associated with open umbilicoperitoneal communication

This is a case report of a 20-day-old girl with persistent umbilical drainage due to infection of the left umbilical artery that ruptured at the base of the umbilicus and formed an open umbilicoperitoneal communication.

Gastrointestinal phytobezoars in childhood

We reviewed 33 children under the age of 15 with gastrointestinal phytobezoars. Twenty were boys and 13 were girls. Nearly all patients were observed in late fall and winter. In 22 patients, symptoms developed following ingestion of several ripe or dried persimmons with seeds but none had a history of unripe persimmon ingestion. All patients but three underwent enterotomy, gastrotomy, or enterotomy combined with gastrotomy for bezoar removal. The remaining three had small bowel resection due to strangulation. There was a single location of the bezoar in 85% and multiple locations in 15% at operation. Emergency laparotomy was performed on 25 patients who had typical mechanical intestinal obstruction revealed the plain abdominal films. It is not surprising that persimmon is the most common cause of bezoar formation in Korea, because it is a favorite fruit among Koreans, either in hard, soft, or dried variety.