Homozygous XYLT2 variants as a cause of spondyloocular syndrome.

Spondyloocular syndrome (SOS) is a rare autosomal recessive, skeletal disorder. Two recent studies have shown that it is the result of biallelic sequence variants in the XYLT2 gene with pleiotropic effects in multiple organs, including retina, heart muscle, inner ear, cartilage, and bone. The XYLT2 gene encodes xylosyltransferase 2, which catalyzes the transfer of xylose (monosaccharide) to the core protein of proteoglycans (PGs) leading to initiating the process of PG assembly. SOS was originally characterized in 2 families A and B of Iraqi and Turkish origin, respectively. Using DNA from affected members of the same 2 families, we performed whole exome sequencing, which revealed 2 novel homozygous missense variants (c.1159C > T, p.Arg387Trp) and (c.2548G > C, p.Asp850His). Our findings extend the body of evidence that SOS is caused by homozygous variants in the XYLT2 gene. In addition, this report has extended the phenotypic description of SOS by adding follow-up data from 5 affected individuals in one of the two families, presented here.

Use of Transesophageal Echocardiography for Enhanced Safety During Bar Removal Procedures After Minimally Invasive Repair of Pectus Excavatum.

Background: Minimally invasive repair of pectus excavatum involves placement of retrosternal support (Nuss) bars. Hardware removal has been rarely associated with life-threatening hemorrhage from the heart, aorta, internal mammary arteries, and/or lung. There is no accepted standard intraoperative monitoring technique used during removal. We hypothesized that the use of transesophageal echocardiography (TEE) during Nuss bar removal would enhance safety of the procedure and be cost-effective. Methods: IRB-approved retrospective review of patients who underwent Nuss bar removal with intraoperative TEE monitoring over a 4-year period, from March 2013 to May 2017, was completed. Bar removal procedures were performed supine, under general anesthesia. TEE images were monitored and any distortion of the cardiac silhouette, new pericardial effusion, and/or cardiac arrhythmias would be considered evidence of possible bar adherence, triggering possible conversion to sternotomy or thoracotomy. Results: In total, 87 consecutive patients, mean age of 20 years, were identified. Bars had been in place for a mean of 30 months. Average procedure time was 67 minutes. No patients experienced arrhythmias, cardiac injury, or significant hemorrhage during removal. TEE gave excellent visualization of the cardiac silhouette and pericardium in all cases. No patient required insertion of an arterial line, a postoperative chest X-ray, or overnight hospitalization. Patients were discharged from the recovery room an average of 89 minutes postprocedure. Conclusion: TEE offers a minimally invasive safe way to visualize the pericardium and its contents during Nuss bar removal. Significant cardiac/mediastinal injuries should be immediately visible. The use of TEE is cost-effective and allows safe discharge the day of surgery.

Multiple output channels in the basal ganglia.

The neural circuits that link the basal ganglia with the cerebral cortex are critically involved in the generation and control of voluntary movement. Retrograde transneuronal transport of herpes simplex virus type 1 was used to examine the organization of connections in the cebus monkey between an output nucleus of the basal ganglia, the internal segment of the globus pallidus (GPi), and three cortical areas: the primary motor cortex, the supplementary motor ara, and the ventral premotor area. Spatially separate regions of the GPi were labeled after virus injections into each cortical area. The GPi projects to multiple cortical motor areas, and this pallidal output is organized into discrete channels. This information provides a new anatomical framework for examining the function of the basal ganglia in skeletomotor control.

Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes.

Introduction: The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Materials and Methods: Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). Results: A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. Conclusion: The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.

Morphine, opioids, and the feline pulmonary vascular bed.

BACKGROUND: Opioid-induced vasodepressor responses have been reported in a variety of species and laboratory models. The aim of this study was to ascertain the relative potencies of different clinically relevant opioids compared with traditional vasodepressor agents in the feline pulmonary vascular bed. A second aim was to study the effects of morphine and to identify the receptors involved in the mediation or the modulation of these effects. METHODS: This was a prospective vehicle-controlled study involving an intact chest preparation of adult mongrel cats. The effects of various opioids, morphine, fentanyl, remifentanil, sufentanil, and meperidine were compared with other vasodepressor agents. Additionally, the effects of L-N(5)-(1-iminoethyl) ornithine hydrochloride (L-NIO) (nitric oxide synthase inhibitor), nimesulide [selective cyclooxygenase (COX)-2 inhibitor], glibenclamide (ATP-sensitive K+ channel blocker), naloxone (non-selective opioid receptor antagonist), and diphenhydramine (histamine H(1)-receptor antagonist) were investigated on pulmonary arterial responses to morphine and other selected agonists in the feline pulmonary vascular bed. The systemic pressure and lobar arterial perfusion pressure were continuously monitored, electronically averaged, and recorded. RESULTS: In the cat pulmonary vascular bed of the isolated left lower lobe, morphine, remifentanil, fentanyl, sufentanil, and meperidine induced a dose-dependent moderate vasodepressor response and it appeared that sufentanil was the most potent on a nanomolar basis. The effects of morphine were not significantly altered after administration of L-NIO, nimesulide, and glibenclamide. However, the vascular responses to morphine were significantly attenuated following administration of naloxone and diphenhydramine. CONCLUSION: The results of the present study suggest that sufentanil appears to have slightly more potency and morphine the least of the five opioid agonists studied on a nanomolar basis. Morphine-induced vasodilatory responses appeared to be mediated or modulated by both opioid receptor and histamine-receptor-sensitive pathways.

Experimental infection of domestic cats (Felis domesticus) with Cytauxzoon manul from Pallas' cats (Otocolobus manul).

In a random, blind study, six domestic cats were assigned to two treatment groups that received either sterile water or dexamethasone by subcutaneous injection prior to intravenous inoculation with Pallas' cat (Otocolobus manul) blood infected with Cytauxzoon manul. A seventh domestic cat served as a control and was inoculated only with sterile water. Cats were monitored for clinical signs consistent with cytauxzoonosis, and periodically screened for hemoparasitemia. All domestic cats (6/6) that received Pallas' cat blood infected with C. manul developed a low but detectible parasitemia by 9 days post-inoculation, yet remained clinically healthy. All domestic cats (7/7) were subsequently challenged with Cytauxzoon felis and developed clinical signs typical of cytauxzoonosis within 5 days post-challenge. Affected animals were euthanized and cytauxzoonosis was confirmed by histopathology. While inoculation of domestic cats with Pallas' cat blood infected with C. manul induced a parasitemia, it did not cause disease or provide protection against challenge with C. felis. Further studies are warranted to determine the potential for interspecies transmission and disease with C. manul.

Does your patient really need testosterone replacement?

Or has he been made to think so by direct-to-consumer advertising? Here's how to properly screen patients and when to recommend treatment.

Increased P-selectin gene expression in the liver vasculature and its role in the pathophysiology of neutrophil-induced liver injury in murine endotoxin shock.

We studied the role of P-selectin, an adhesion molecule known to be important for neutrophil localization to sites of inflammation, in a model of inflammatory liver injury. Male C3Heb/FeJ (ET-sensitive) mice treated with 700 mg/kg galactosamine and 100 microg/kg Salmonella abortus equi endotoxin (Gal/ET), murine tumor necrosis factor alpha (TNF-alpha, 15 microg/kg), or interleukin-1 (IL-1, 13-23 microg/kg), showed increased P-selectin mRNA levels in the liver. In contrast, C3H/HeJ (ET-resistant) mice responded only to cytokines with P-selectin mRNA formation. Whereas no P-selectin expression was detectable in control livers, there was temporary staining of endothelium in large blood vessels but not in sinusoids between 3 and 5 h after ET, TNF-alpha, or IL-1 treatment. Severe liver injury induced by Gal/ET at 7 h was not inhibited by an anti-P-selectin antibody in C3Heb/FeJ mice or in P-selectin-deficient animals. Sequestration of neutrophils in sinusoids, i.e. those neutrophils that have been identified as critical for the injury, was not affected by the antibody or in P-selectin-deficient mice. However, the temporary margination in portal and post-sinusoidal venules was reduced by 75% in anti-P-selectin antibody-treated animals and by 51% in P-selectin-deficient mice. We conclude that hepatic P-selectin gene transcription in vivo involves cytokines. However, blocking P-selectin neither attenuated sinusoidal neutrophil sequestration nor prevented neutrophil-induced liver injury during endotoxin shock but attenuated neutrophil margination in larger vessels. Thus, our data demonstrate similarities and fundamental differences in the requirement for adhesion molecules to localize neutrophils in the liver vasculature compared to other organs during an inflammatory response.

Regulation of adaptive immune responses by innate cells expressing NK markers and antigen-transporting macrophages.

A continuing theme of work done in our laboratory involves regulation of adaptive immune response by innate cells, in general, and immuneregulation by natural killer (NK) and NKT cells, in particular. Studies include work with the lung and the eye. In addition to immune surveillance of tumor cells, the NK cell is often associated with secreting cytokines that contribute to the creation of microenvironments conducive to Th1 responses and with defense mechanisms that lessen the initial infecting viral load. Reported studies show that the NKT cells support both T helper cell responses (type 1 and 2), as well as their being absolutely central to the development of antigen-specific T-regulatory cells involved in peripheral tolerance. Because of the multifunctional capabilities of the NKT cell, we propose that yet another cell, such as the antigen-presenting cell (APC), may influence the effector pathway of the NKT cell. We postulate that the APC that transports the antigen from the entry environment provides both trafficking and activation signals for innate cells in the secondary lymphoid organs. Evidence is presented that macrophage-derived signals selectively recruit NKT cells and bias their cytokine synthesis. Data imply that, just as occurs in immune inflammation, a collection of innate and adaptive immune cells interact within the secondary lymphoid tissue to generate antigen-specific tolerance in the periphery.

Oral contraceptive and postmenopausal estrogen effects on lipoprotein triglyceride and cholesterol in an adult female population: relationships to estrogen and progestin potency.

PIP: A study of the prevalence of hyperlipidemia has been conducted among female telephone company employees using oral contraceptives (OCs) or estrogenic hormones. This paper relates hormone formulation and estrogen/progestin potency to striglyceride and cholesterol concentrations in total plasma and lipoprotein fractions and relative lipid composition. Changes in these lipid parameters are of interest because they may predict atherosclerosis risk. Results in 148 hormone users are compared with those in 306 nonhormone users. All data are adjusted for the effects of age, relative body weight, cigarette smoking, and alcohol intake. Triglyceride concentrations in whole plasma, very low density lipoprotein (VLDL), and high density lipoprotein (HDL) are elevated 1.5-2.5 fold with increasing estrogen potency. Low density lipoprotein (LDL) triglyceride concentration is elevated to a similar degree among OC users regardless of estrogen potency, but there is no significant effect of postmenopausal estrogen use on LDL triglyceride concentrations. The LDL cholesterol concentration shows an increasing trend with increasing estrogen potency in a random sample of OC-treated women, but is slightly lower than control in postmenopausal women treated with estrogen alone. The HDL cholesterol concentration in plasma is highest with hormones having the greatest estrogen potency and lowest with those having the greatest progestin potency. The VLDL cholesterol to triglyceride ratio adjusted for triglyceride concentration is significantly increased with the use of Ovral, a progestin-predominant contraceptive preparation. The LDL cholesterol to triglyceride ratio is reduced with the use of all OCs examined, except for Ovral, where the ratio is above average. The HDL cholesterol to triglyceride ratio is reduced for all combination OCs examined. The use of a sequential OC or postmenopausal estrogens is not associated with a significant alteration in the cholesterol to triglyceride ratio in any lipoprotein fraction. Knowledge of estrogen and progestin potency and kind of progestin are important in predicting the effect of OCs on plasma and lipoprotein lipids. On the basis of observed differences in lipoprotein lipid concentrations and relationships, the potential arteriosclerotic risk from sex hormones may vary among OC formulations.^ieng

How blind was the patient blind in AMIS?

The Aspirin Myocardial Infarction Study (AMIS) was a double-blind placebo-controlled trial to test the effect of aspirin on the survival of 4524 people who had experienced a prior heart attack. Shortly before their closeout visits, 400 of the participants were randomly selected to be interviewed concerning their perceptions of their treatment assignments; 380 were actually interviewed. A bare majority (52)% correctly identified their study therapy, 28% mistakenly named the alternative treatment, 13% declined to guess, and 7% specified extraneous substances. According to the proposed formula for evaluating the patient blind, only 24% of the sample made "informed" guesses regarding their therapy, while the remainder guessed in an uninformed way or not at all. Those who tested their capsules (usually be taste) showed proportionately more correct responses than the nontesters. Correctness also varied with the reasons for the subjects' guesses (e.g., side effects). Among the sample as a whole, most people were only moderately or less than moderately certain their guess was correct. Even among those who were in fact correct, only 18% were absolutely certain of their choice.

Morphological relationships among extensor digitorum longus, tibialis anterior, and semitendinosus motor nuclei of the cat: an investigation employing the retrograde transport of multiple fluorescent tracers.

To determine the morphological relationships among extensor digitorum longus (EDL), tibialis anterior (TA), and semitendinosus (St) motor nuclei in the spinal cord of the cat, these nuclei were retrogradely labeled with three different fluorescent tracers. The fluorochromes--bisbenzimide, nuclear yellow, and propidium iodide--were applied by intramuscular injection or soaking the muscle nerve. The positions of the labeled motor nuclei were bilaterally symmetrical. The EDL and TA motoneurons were located in close proximity to one another, in the lateral regions of lamina IX in spinal segments L6 and L7. Although the boundaries of each nucleus were tightly opposed, the EDL and TA motor nuclei overlapped minimally, with the somata of EDL motoneurons positioned dorsal to those of TA. The St motor nucleus was located ventromedial to that of EDL and extended from the caudal portion of L6 through S1. Supplemental studies of the reflex effects evoked in EDL, TA, and St muscles by cutaneous nerve stimulation provided physiological observations that may be related to these anatomical results.

Overlapping corticostriatal projections from the rodent vibrissal representations in primary and secondary somatosensory cortex.

To determine whether the neostriatum receives overlapping projections from two somatosensory cortical areas, the anterograde tracers biotinylated dextran amine (BDA) and fluoro-ruby (FR) were injected into the whisker representations of primary (SI) and secondary (SII) somatosensory cortex. Reconstructions of labeled terminals and their beaded varicosities in the neostriatum and thalamus were analyzed quantitatively to compare the extent of overlapping projections to both subcortical structures. Corticostriatal projections from focal sites in both somatosensory areas exhibited substantial amounts of divergence within the dorsolateral neostriatum. Most of the labeled terminals were concentrated in densely packed arborizations that occupied lamellar-shaped regions along the dorsolateral edge of the neostriatum. Tracer injections in both cortical areas also produced dense anterograde and retrograde labeling in the thalamus, especially in the ventrobasal complex (VB) and in the medial part of the posterior (POm) nucleus. Because these thalamic regions are topographically organized and have reciprocal connections with corresponding representations in both SI and SII, the amount of labeled overlap in the thalamus was used to indicate the degree of somatotopic correspondence at the SI and SII injection sites. We found that the proportion of overlapping projections to the neostriatum was moderately correlated with the amount of overlap observed in the thalamus. This result strongly indicates that specific sites in the dorsolateral neostriatum receive convergent projections from corresponding somatotopic representations in SI and SII, but also suggests that some of the corticostriatal divergence may reflect neostriatal integration of somatosensory information from noncorresponding representations in SI and SII.

Overlapping corticostriatal projections from the rodent vibrissal representations in primary and secondary somatosensory cortex.

To determine whether the neostriatum receives overlapping projections from two somatosensory cortical areas, the anterograde tracers biotinylated dextran amine (BDA) and fluoro-ruby (FR) were injected into the whisker representations of primary (SI) and secondary (SII) somatosensory cortex. Reconstructions of labeled terminals and their beaded varicosities in the neostriatum and thalamus were analyzed quantitatively to compare the extent of overlapping projections to both subcortical structures. Corticostriatal projections from focal sites in both somatosensory areas exhibited substantial amounts of divergence within the dorsolateral neostriatum. Most of the labeled terminals were concentrated in densely packed arborizations that occupied lamellar-shaped regions along the dorsolateral edge of the neostriatum. Tracer injections in both cortical areas also produced dense anterograde and retrograde labeling in the thalamus, especially in the ventrobasal complex (VB) and in the medial part of the posterior (POm) nucleus. Because these thalamic regions are topographically organized and have reciprocal connections with corresponding representations in both SI and SII, the amount of labeled overlap in the thalamus was used to indicate the degree of somatotopic correspondence at the SI and SII injection sites. We found that the proportion of overlapping projections to the neostriatum was moderately correlated with the amount of overlap observed in the thalamus. This result strongly indicates that specific sites in the dorsolateral neostriatum receive convergent projections from corresponding somatotopic representations in SI and SII, but also suggests that some of the corticostriatal divergence may reflect neostriatal integration of somatosensory information from noncorresponding representations in SI and SII.

Alterations of plasma lipid and lipoprotein levels associated with benzodiazepine use--the LRC Program Prevalence Study.

In a study of white adults from 10 North American Lipid Research Clinics populations, plasma lipid and lipoprotein levels in benzodiazepine (diazepam, chlordiazepoxide, flurazepam) users were compared to both the entire population of non-users and matched control non-users. Significantly higher plasma triglyceride and very low density lipoprotein cholesterol levels and by one method of analysis, lower high density lipoprotein cholesterol levels were noted in male benzodiazepine users. No significant differences were noted in total plasma cholesterol or low density lipoprotein cholesterol levels.

Distribution of lipoproteins triglyceride and lipoprotein cholesterol in an adult population by age, sex, and hormone use- The Pacific Northwest Bell Telephone Company health survey.

This report describes the distribution of lipoprotein triglyceride and lipoprotein cholesterol in employees of the Pacific Northwest Bell Telephone Company. Means, medians, and selected percentiles are presented for very low, low, and high density lipoproteins (VLDL, LDL, and HDL, respectively) in 606 randomly selected white subjects aged 20-59. Results are specific for age decade, sex, and female sex hormone usage. Women who use sex hormones have significantly higher concentrations of triglycerides in all of the fractions across all age decades from 20 to 59 than do women not taking hormones. The average VLDL, LDL, and HDL triglyceride levels in women taking hormones are 69, 25 and 18 mg/dl which are considerably higher than the corresponding averages of 44, 17 and 12 mg/dl noted in women not taking hormones. Men have the highest average VLDL triglyceride value (85 mg/dl) but their average triglyceride concentrations in the LDL and HDL fractions (18 and 12 mg/dl) approximate those of women not taking hormones. This study in a well-defined population provides references standards for lipoprotein triglyceride concentrations. These results can be used to evaluate the effect of sex hormone treatment on the lipoprotein triglyceride content in VLDL, LDL and HDL, and to assess triglyceride content as a potential risk factor in men and older women.

PIP: A study of lipoprotein triglyceride and lipoprotein cholesterol distribution was done between 1973-76 on a randomly selected group of 606 white male and female employees, aged 20-59, of the Pacific Northwest Bell Telephone Company. Data obtained were used to ascertain whether triglyceride content of lipoprotein differs in men and women by observing mean, standard and percentile distribution of VLDL, LDL, and HDL (very low, low, and high density lipoprotein). A high proportion of women, i.e. 50% in the age group 20-29, and 50-59, reported current use of some form of exogenous sex hormone preparation. The average VLDL, LDL, and HDL triglyceride level in women taking hormones were 69, 25, and 18 mg/dl, considerably higher than the corresponding averages of 44, 17, and 12 mg/dl observed in women not taking hormones. For VLDL triglyceride, the youngest and oldest male groups had lower average levels than females in the same age taking hormones; in the middle-age group the levels were the same among men and women. For VLDL cholesterol, the 20-29 year old male and female hormone users had similar concentration levels, but male values were higher in each of the remaining age strata. These data confirm the fact that lipoprotein triglyceride rise is associated with the type of oral contraceptives used in the U.S., and with postmenopausal treatment as well.

Relationships of gender, sex hormone use, and age with lipoprotein cholesterol/triglyceride ratios in an adult population. The Pacific Northwest Bell Telephone Company health survey.

UNLABELLED: Effects of gender, sex hormone use, and age on lipoproteins composition have been evaluated in 603 Caucasian subjects, ages 20-59, randomly selected from employees participating in the Pacific Northwest Bell Telephone Company Health Survey. Lipoprotein composition in this analysis is defined as the cholesterol to triglyceride (C/TG) ratio in each lipoprotein fraction. The lipoprotein C/TG ratio is inversely related to the lipoprotein triglyceride concentrations in VLDL, LDL and HDL; the ratio falling in each instance as lipoprotein triglyceride concentration increases. Plots of this relationship are virtually superimposable among women hormone users and nonusers and men in VLDL and HDL and between men and nonhormone taking women in LDL. A consistently lower C/TG ratio is observed in LDL for hormone-treated women compared to the other 2 groups. Age in these analysis is without effect. CONCLUSIONS: We hypothesize that a lower LDL (C/TG) ratio is hormone-treated women may render the lipoprotein less crystalline or smectic and potentially less atherogenic. No such difference exists in the lipoprotein C/TG ratio between men and nonhormone-treated women and therefore cannot explain the observed difference in atherosclerosis sick. Nonetheless, the C/TG ratios may predict atherosclerosis if the ratio is high in VLDL or in LDL. However, the significance of the HLD (C/TG) ratio remains to be established.

Semisynthetic cephalosporins. Synthesis and structure-activity relationships of 7-sulfonylacetamido-3-cephem-4-carboxylic acids.

The synthesis and in vitro and in vivo activities of a series of 7-sulfonylacetamido-3-cephem-4-carboxylic acids with acetoxymethyl or heterocyclic thiomethyl substituents at the 3 position are described. Lengthening the alkyl chain attached to the sulfonyl group increased gram-positive activity but the effect on gram-negative activity was variable. Other structural changes on the 7-acyl side chain resulted in only minor changes in vitro activity. the protective effectiveness in infected mice generally paralleled the in vitro activity, except that the butylsulfonyl derivatives were less protective than predicted by in vitro activity. replacement of the 3-acetoxymethyl by a 3-heterocyclic thiomethyl group resulted in an overall improvement of activity both in vitro and in vivo.

Semisynthetic cephalosporins. Synthesis and structure-activity relationships of analogues with 7-acyl groups derived from 2-(cyanomethylthio)acetic acid or 2-[(2,2,2-trifluoroethyl)thio]acetic acid and their sulfoxides and sulfones.

The synthesis and in vitro and in vivo activities of a series of cephalosporins having side chains derived from 2-[(2,2,2-trifluoroethyl)thio]acetic acid or 2-(cyanomethylthio)acetic acid and with acetoxymethyl or 3-heterocyclic thiomethyl substituents at the 3 position are described. In both series, increasing the oxidation state of the side-chain sulfur atom from sulfide to sulfoxide/sulfone decreased the in vitro gram-positive activity, but the effect on gram-negative activity was variable and less pronounced. The protective effectiveness in mice infected with Escherichia coli increased as the oxidation level of the side-chain sulfur was raised from sulfied to sulfoxide/sulfone. Replacement of the 3-acetoxymethyl by a 3-heterocyclic thiomethyl group resulted in overall improvement of activity both in vitro and in vivo for all oxidation states.

Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series.

STUDY OBJECTIVES: Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema. DESIGN: We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema. RESULTS: Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy. CONCLUSIONS: Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.