Nineteenth century mortality at the Royal Hospital for Sick Children, Glasgow.

BACKGROUND AND AIMS: Since Glasgow's Royal Hospital for Sick Children opened in 1882, significant advances have been made in child health. Our aim was to investigate the hospital mortality that occurred in the last decade of the 19th century at Royal Hospital for Sick Children. METHODS AND RESULTS: Hospital mortality records for the decades, 1890-1899, were collected from the Archives of the Royal Hospital for Sick Children. Data were extracted from the hospital inpatient records and the pathology records. In the decade 1890-1899, there were 731 hospital deaths. The main cause of death at that time in the 19th Century was infection, particularly of the respiratory tract. The age at which death occurred was analysed and the recorded cause were analysed as was the distance patients travelled to the hospital. The ratio of boys to girls and length of inpatient stay was similar to that seen in the hospital currently. CONCLUSION: This study records the mortality in a children's hospital in a large developing industrial city in the 19th century as experienced in a children's hospital.

A stain for demonstrating Helicobacter pylori in gastric biopsies.

Helicobacter pylori continues to be a significant health care problem. It is associated with a variety of stomach disorders such as gastritis, gastric ulcer disease, gastric carcinoma and B-cell gastric lymphoma. One common method diagnosing an infection by this bacterium is microscopic examination of routine processed gastric or duodenal biopsies. With this type of specimen, it is necessary to demonstrate visually the presence of H. pylori using an appropriate staining technique. This paper presents a simple staining technique for demonstrating H. pylori in gastric biopsy specimens using carbol fuchsin staining against a contrasting background of light green.

Preliminary studies on the effect of dehydroepiandrosterone (DHEA) on both constitutive and phytohaemagglutinin (PHA)-inducible IL-6 and IL-2 mRNA expression and cytokine production in human spleen mononuclear cell suspensions in vitro.

In order to gain further insight into the potential immunological benefits of oral administration of DHEA we have examined its effects on the constitutive and PHA-inducible expression by human spleen cell suspensions in vitro of IL-6 and IL-2. This was studied at both the mRNA and protein levels. The quantification of specific mRNA was undertaken using commercially available quantitative polymerase chain reaction kits. These studies, which were performed on suspensions from six individual spleens, revealed that 10(-5) M DHEA did not impair the expression of IL-6 at either the mRNA or protein level, but may have slightly enhanced the latter. In contrast, IL-2 mRNA levels were increased on most occasions, whilst IL-2 secretion was decreased, albeit slightly. Additional studies revealed that cyclosporin (approx. 10(-5) M) and dexamethasone (10(-7) M) readily inhibited these responses and the production of other cytokines, including interferon-gamma and tumour necrosis factor-alpha. These preliminary studies suggest that high doses of DHEA do not readily inhibit the production of IL-6, and indeed other cytokines, by PHA-stimulated secondary human lymphoid tissue suspensions in vitro. They may also partially explain the meagre immunomodulatory effects noted in some DHEA replacement studies in humans.

Transorbital optic nerve sheath ultrasonography in normal children.

AIM: Early diagnosis of acute intracranial hypertension is essential to enable prompt, optimal treatment. The optic nerve sheath diameter (ONSD) is increased in raised ICP and there has been recent interest in the use of ultrasound to diagnose and indirectly monitor raised ICP by ONSD measurement. The advantages of the technique include its non-invasiveness, wide availability, portability, low cost and the absence of ionizing radiation. This prospective study was designed to establish the range of normal values for ONSD in infants and children up to 15 years of age. PATIENTS AND METHODS: One hundred and two children attending the hospital for other reasons were recruited to the study. Three measurements of the ONSD were taken for each eye, 3 mm behind the optic nerve head using a 7 MHz sector probe. RESULTS: The range for ONSD was 2.1-4.3 mm, mean 3.08 (SD 0.36). There were no significant differences on ONSD measurement between boys and girls (P = 0.59) or between right and left eyes (P=0.66). When the data were grouped and analysed, a correlation between increasing age and increasing ONSD was seen (r2=0.48), with the greatest increase occurring in the first 2 months of life. CONCLUSION: Using the technique described here, our results suggest that an ONSD of greater than 4 mm in infants less than 1 year, and 45 mm or greater in older children, should be regarded as abnormal.

The influence of age and gender on serum dehydroepiandrosterone sulphate (DHEA-S), IL-6, IL-6 soluble receptor (IL-6 sR) and transforming growth factor beta 1 (TGF-beta1) levels in normal healthy blood donors.

Dysregulation of IL-6 synthesis is thought to play a role in the development of a number of age-related conditions, such as rheumatoid arthritis, osteoporosis, atherosclerosis, Alzheimer's disease and B cell malignancies. Recently it has been suggested that the production of IL-6 is influenced by the adrenal hormone dehydroepiandrosterone (DHEA) and its sulphated derivative DHEA-S. In humans we investigated the relationship between DHEA-S, IL-6, IL-6 sR and TGF-beta1 in the serum of normal healthy male and female blood donors. Using immunoassay techniques we found that the serum levels of DHEA-S significantly (P = 0.0001) decreased with age in both males and females. Furthermore, mean DHEA-S levels in all age groups were significantly (P = 0.0001) higher in males. Such correlations were not apparent for IL-6 using a standard assay, but a high sensitivity assay revealed that serum IL-6 was significantly (P = 0.0018) positively correlated with age in males only. In addition, serum levels of DHEA-S were significantly (P = 0.048) negatively correlated with serum IL-6, again in male subjects only. In contrast, serum IL-6 sR and TGF-beta1 levels were not correlated with age in either males or females and were not significantly different between the sexes. However, a significant (P = 0.024) negative correlation between DHEA-S and IL-6 sR was found in males. These studies clearly highlight the complex nature of the relationship between these molecules in the ageing process in normal healthy blood donors and demonstrate the need to use high sensitivity assays when measuring IL-6 in apparently healthy individuals under the age of 70 years.

The Mason Brown Lecture. Scots and paediatric surgery.

Scotland and Scots paediatric surgeons have been in the forefront of the development of surgical services for children. Development has occurred at different rates in sections of society. Progress or obstruction has seldom been for 'scientific' reasons but much more according to the personal interests or drive of individuals. The Scots can justifiably claim some influence in the overall evolution of paediatric surgery. It is no wonder that Henley wrote after his visit to Walter Scott in Edinburgh, "The conceit of these bloody Scotsmen is atrocious".

Evidence of cognitive visual problems in children with hydrocephalus: a structured clinical history-taking strategy.

Damage to the occipital cortex in children can result in many complex disorders of cognitive visual function. A series of clinical questions, developed from the specific problems of a cohort of children with cortical visual impairment, was asked of the parents of 200 children with no history of cerebral pathology, aged 5 to 12 years. One hundred and ninety-two parents gave reliable consistent responses. The results show a progressive improvement in performance with age, culminating in few 11- and 12-year olds having frequent problems, apart from 8% having frequent difficulty with orientation in new surroundings and 2% having problems with simultaneous perception tasks. The parents of 52 children (aged 5 to 17 years) with shunted hydrocephalus were then asked the same set of questions. Evidence of cognitive visual problems was identified in 27 of these children of whom 16 manifested multiple difficulties. The disabilities identified by our study comprised problems with: shape recognition, simultaneous perception, perception of movement, colour perception, orientation, object recognition, and face recognition. The range, nature, and combinations of these disorders are presented in this paper.

Enhancing the immunotherapeutic potential of mycobacteria by transfection with tumour necrosis factor-alpha.

In an attempt to enhance the anti-tumour properties of mycobacteria we have developed recombinant forms of Mycobacterium smegmatis which express and secrete biologically active human tumour necrosis factor-alpha (TNF-alpha). This was achieved by transfecting M. smegmatis using shuttle plasmids incorporating the cDNA sequence for the human TNF-alpha mature peptide. In vitro experiments on a panel of human bladder tumour cell lines (EJ18, MGH-U1, RT4, RT112) indicate that our genetically modified mycobacteria are more effective than wild-type at inducing or up-regulating the expression of intracellular adhesion molecule-1 and the secretion of an array of proinflammatory cytokines [interleukin-1 (IL-1), IL-6, IL-8, granulocyte-macrophage colony-stimulating factor]. We have also demonstrated increased adhesion molecule and cytokine expression in response to mycobacteria transfected with vector containing no gene insert. However, this was not as pronounced as that observed following tumour cell stimulation by the TNF-alpha-transfected strain. In contrast, in three out of four tumour cell lines all M. smegmatis strains were found to down-regulate the secretion of the anti-inflammatory cytokine transforming growth factor-beta1. Our studies have also confirmed that M. smegmatis is a powerful inhibitor of bladder tumour cell growth and revealed that its antiproliferative potency is enhanced by transfecting with human TNF-alpha and, to a lesser extent, with vector alone. All M. smegmatis strains were effective in the activation of peripheral blood leucocyte cultures. However, no differences were observed in the ability of the TNF-alpha-transfected, mock-transfected and wild-type mycobacteria to induce tumour cell killing activity. These results suggest that the immunomodulatory effects of M. smegmatis can be enhanced by transfection with vectors which allow the secretion of human TNF-alpha, thus increasing mycobacterial immunotherapeutic potential.

A personal audit of pediatric surgical training before implementation of the Calman guidelines.

PURPOSE: The purpose of this study was to audit the surgical training experience of a Higher Surgical Trainee in the United Kingdom during the tenure of the posts of Career Registrar, Research Fellow, and Senior Registrar from August 1992 to July 1997. Although the Report of the Working Party on the UK Specialist Medical Training (the Calman report) was published during this study, the training remained the same because the author elected not to transfer to the new grade. METHODS: A 39-field database was designed, and the surgical experience was entered prospectively. The data were analyzed chronologically according to age of patient, condition, level of supervision, and nature of admission (emergency, elective). RESULTS: Two thousand two hundred ninety patients or operations are presented. Only a small number of patients underwent surgery during the research year (1994). The pattern of operating changed from one of large numbers of supervised to one of more major procedures. The numbers of neonates and younger infants who underwent surgery increased significantly, and the level of supervision changed allowing more autonomy toward the end of the training period. This trend was reversed partially during the period of overseas secondment. The results are compared with those in a recently published USA/Canadian study. CONCLUSION: The volume of work undertaken by the trainee ensures adequate exposure to a wide range of procedures to achieve a satisfactory level of competence. Changes that may affect this are discussed.

Ectomesenchymoma: one or two tumors? Case report and review of the literature.

Ectomesenchymoma has not previously been reported in a patient with the cutaneous nevus syndrome. A case of perineal ectomesenchymoma is presented with unusual cytogenetic findings. The significance of these is discussed and the world literature reviewed. This is the first such case reported.

Fiberoptic localization of the upper pouch in esophageal atresia.

This report describes a technique that the authors developed as a simple, quick means of identifying the proximal pouch in neonates with esophageal atresia by fiberoptic instrumentation.

Collagen-coated Vicryl mesh is not a suitable material for repair of diaphragmatic defects.

Encouraged by the results in abdominal wall defects, the authors used the collagen-coated Vicryl mesh (CCVM) in repair of diaphragmatic defects in two patients. In a patient with recurrent diaphragmatic hernia, CCVM was used to reinforce the anterior abdominal muscle flap. The hernia recurred after 8 months. In another patient, it was used to repair a large diaphragmatic defect. This patient had a recurrence of the hernia in 10 weeks. The results suggestthat CCVM is not a good material for repairing the diaphragmatic defect. However, it can be used to reinforce other types of repairs.

Male pseudohermaphroditism secondary to panhypopituitarism.

An infant with a 46XY karyotype was born with ambiguous genitalia, including microphallus and perineal hypospadias. A female gender was assigned due to extreme failure of development of the external genitalia. Subsequent investigations demonstrated panhypopituitarism, and it is believed that severe gonadotrophin deficiency was responsible for the intersex state. This case illustrates the need to evaluate the hypothalamic-pituitary axis in selected cases of intersex, and also questions the prevailing assumption that testosterone secretion during embryogenesis is largely pituitary gonadotrophin independent, under the control of human chorionic gonadotrophin.

Trypanosome transmission by Corethrella wirthi (Diptera: Chaoboridae) to the green treefrog, Hyla cinerea (Anura: Hylidae).

Seventy-two percent of 215 male green tree frog, Hyla cinerea (Schneider), captured in Alachua and Levy counties, FL, between April and mid-September 1978 and 1979 were infected with an undescribed Trypanosoma sp. None of the 31 female frogs captured concurrently was infected. Periodic sampling of the peripheral blood from the infected male frogs showed that the trypanosomes were present in high numbers only at night. Conspecific trypanosomes also were found in the mid and hind guts of female Corethrella wirthi Stone flies collected on or near male frogs in the field. Transmission of the parasite to uninfected frogs was demonstrated by exposure of male and female frogs to naturally infected flies and to parasites injected subdermally. This is the first report of parasite transmission by a species of Corethrella.

Ecology of phlebotomine sand flies (Diptera: Psychodidae) in a focus of Leishmania (Viannia) braziliensis in northeastern Colombia.

The phlebotomine sand fly fauna of two coffee plantations in a Leishmania-endemic area of Norte de Santander, Colombia was studied. Regular insect collections using a variety of methods were made for three and a half years. Information was obtained on diurnal resting sites, host range and seasonal abundance for 17 species, of which five (Lutzomyia spinicrassa, Lu. serrana, Lu. shannoni, Lu. ovallesi and Lu. gomezi) were far more numerous than the others, anthropophilic and present throughout the year. The behaviour of these and the remaining 12 species is discussed in relation to their potential role in transmission of Leishmania (Viannia) braziliensis in the area.