Ureaplasma urealyticum and chronic lung disease in very low birth weight infants during the exogenous surfactant era.

BACKGROUND: An association between recovery of Ureaplasma urealyticum from the respiratory tract of very low birth weight (VLBW) infants (< or =1500 g) and later chronic lung disease (CLD) was reported by several authors before the routine use of exogenous surfactant (SURF). We sought to assess whether this relation persists in the era of routine SURF. METHODS: We prospectively studied a cohort of 105 VLBW infants who required mechanical ventilation at < 12 h of age. Tracheal aspirates for U. urealyticum culture were obtained before administration of SURF or antibiotics. Clinicians were unaware of U. urealyticum status. Chest radiographs at 28 days were reviewed by a single pediatric radiologist, blinded to U. urealyticum status. Sample size was predetermined to detect a 30% increase in CLD among those with U. urealyticum recovery from tracheal culture (U. urealyticum-positive) with alpha <0.05 and beta <0.20. RESULTS: Of the study infants 22 were U. urealyticum-positive and 83 were U. urealyticum-negative. No differences were found between the groups for birth weight, gestational age, gender, inborn, antenatal or postnatal steroid use, SURF therapy, non-U. urealyticum infection, necrotizing enterocolitis, patent ductus arteriosus, intraventricular hemorrhage or cystic periventricular leukomalacia. At 28 days U. urealyticum-positive patients were significantly more likely to have CLD than U. urealyticum-negative [15 of 22 (68%) vs. 30 of 83 (36%); P < 0.02]. The U. urealyticum-positive patients also required significantly longer courses of supplemental oxygen and mechanical ventilation. No significant differences were found for CLD at 36 weeks postconception or duration of hospitalization, although type II error could not be excluded for these secondary endpoints. CONCLUSIONS: Respiratory U. urealyticum at or shortly after birth remains associated with CLD at 28 days despite routine use of SURF. Controlled trials of anti-Ureaplasma therapy in U. urealyticum-positive VLBWs as soon after birth as possible may determine whether CLD, duration of respiratory support and attendant costs can be decreased.

Intravenous cholangiography in different degrees of common bile duct obstruction. An experimental study in the dog.

A total of 83 cholangiograms was performed in three cholecystectomized dogs equipped with Thomas cannulas through which complete and different degrees of incomplete common bile duct obstruction were produced. With incomplete common bile duct obstruction, the iodine concentration in the bile necessary for radiographic visualization of the common duct was always obtained for all three tested iodipamide dosages of .3, .6, and 1.2 ml/kg, infused over 30 minutes. The largest dose resulted in the highest biliary iodine concentrations. With increasing obstruction, an increasing delay of the biliary iodipamide excretion was noted. With complete common bile duct obstruction the iodine concentration in the bile necessary for radiographic visualization of the common duct was never obtained, even with an iodipamide dose increased to 1.8 ml/kg and/or prolongation of the contrast material infusion time from 30 minutes to 2 and 6 hours. Nevertheless, the highest biliary iodine concentration in complete common bile duct obstruction resulted with the largest iodipamide dose (1.8 ml/kg) and the shortest infusion time (30 minutes).

Improved arterial portography in portal hypertension during reactive mesenteric hyperemia induced by preceding 2-minute balloon occlusion of the superior mesenteric artery.

The value of performing arterial portography during reactive hyperemia was investigated in four dogs with presinusoidal cirrhosis, stable portal hypertension in excess of 20 cm of water, and extensive porto-systemic venous collaterals, and compared to tolazoline (1 mg/kg) and control studies. With SMA balloon occlusion the maximum decrease in portal flow and pressure occurred between 1 and 2 minutes. During reactive hyperemia following immediately the release of a 2-minute SMA occlusion, portal flow and pressure increased from pre-occlusion values (mean +/- 1 SE, n:4) of 15 +/- 2 ml per min per kg and 25 +/- 1 cm H2O to 32 +/- 5 ml per kg and 40 +/- 2 cm H2O. With reactive hyperemia both significant higher peak iodine concentrations in the portal blood and significant improvement in visualization of the portal system and porto-systemic venous collaterals occurred when compared to tolazoline or control angiograms. With reactive hyperemia both peak blood iodine concentrations and maximum opacification of the portal vein occur 2 to 3 and 4 to 6 seconds earlier than with tolazoline or in controls, respectively. Compared to controls, tolazoline increased peak iodine concentrations in portal vein significantly and improved visualization of the portal system and collaterals in 7 of 12 examinations. Judged from the experience in peripheral arteriography, performance of angiography during reactive hyperemia appears to be a very safe procedure. However, the use of balloon catheters carries additional risks particularly when not properly used.

Carcinoma of the extrahepatic bile ducts.

The records of patients with carcinoma of the extrahepatic bile ducts, including the ampulla of Vater, operated on at the University of Rochester Medical Center between 1960 and 1980 were reviewed. All 47 patients had similar manifestations and laboratory findings; percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography were the two studies that consistently localized the tumor. Seven of eight patients with carcinoma of the ampulla underwent pancreaticoduodenectomy. At this writing five are alive and well without evidence of recurrence (a mean of 47 months). Twenty-three tumors were located at or proximal to the confluence of the right and left hepatic ducts; 16 were distal to this point. The six patients with distal lesions that were resected had a mean survival time of 14 months; the mean survival time was 7 months for the six patients in whom the operation was restricted to drainage of the proximal duct. Of the group of patients subjected to exploratory surgery and biopsy only, none survived longer than a month. Resection was carried out in only one patient for a proximal lesion; this patient died 28 months after the operation. Patients with proximal lesions who underwent drainage procedures lived an average of 7.6 months. In all groups several was longer in patients without metastases at the time of operation. The survival time after the resection was significantly longer than that associated with drainage, which suggests a more aggressive approach to these lesions.

Synthesis and characterization of an affinity label for brain receptors to psychotomimetic benzomorphans: differentiation of sigma-type and phencyclidine receptors.

Brain sigma-type receptors and phencyclidine receptors are thought to mediate the psychotomimetic effects of benzomorphans and phencyclidine in humans. Recently, we reported the characterization of a selective sigma receptor ligand, 1,3-di-o-tolyl-guanidine (DTG), that shows negligible crossreactivity with phencyclidine receptors. Here we describe the synthesis and characterization of an isothiocyanate derivative of DTG, di-o-tolyl-guanidine-isothiocyanate (DIGIT). Guinea pig brain membranes treated with nanomolar doses of DIGIT followed by extensive washing exhibit a dose dependent reduction of [3H]DTG and (+)[3H]3-(3-hydroxyphenyl)-N-(1-propyl)piperidine [+)[3H]3-PPP) binding to sigma receptors. Binding of radiolabelled ligands for phencyclidine, mu-opioid, benzodiazepine and dopamine-D2 receptors is not affected by membrane treatment with DIGIT, indicating specificity of the affinity label for sigma-type receptors. Treatment of DIGIT-derivatized membranes with 2 M NaCl does not result in recovery of sigma binding activity, suggesting that DIGIT's interaction with sigma receptors is not of an ionic nature. Equilibrium saturation binding experiments show that the inhibition of [3H]DTG binding to sigma receptors by DIGIT pretreatment of membranes is attributable to an irreversible reduction in the affinity (increase in Kd) of sigma receptors for DTG. The finding that sigma receptors are irreversibly modified by DIGIT whereas phencyclidine receptors are not affected suggests that sigma receptors are physically separate from phencyclidine receptors. The availability of a selective affinity label for the sigma receptor should facilitate the purification of the receptors and the characterization of sigma-type pharmacological effects in vivo and in vitro.

Adenocarcinoma of the small intestine.

Sixty-five patients with adenocarcinoma of the small intestine were encountered over a 31 year period. The duodenum was the most common location, with a decreasing frequency distally. Associated malignancies were present in a fourth of the patients. Presenting signs and symptoms were vague and related to either obstruction or bleeding. Barium contrast examination and endoscopy for duodenal tumors were the primary diagnostic modalities. Curative treatment was wide resection of bowel and mesentery for jejunal and ileal tumors and pancreaticoduodenectomy for duodenal tumors. Favorable prognosticators included jejunal location, absence of nodal metastases, and a well-differentiated grade. Stage for stage, the prognosis of patients with adenocarcinoma of the small intestine parallels that of patients with adenocarcinoma of the colon. With greater awareness of this tumor, it is possible that earlier detection will lead to improved overall survival.

Corrosive jejunitis due to ingestion of nitric acid.

Corrosive damage to the small bowel is not common; stasis of acid in the stomach usually prevents extensive jejunal damage. The case presented herein is unusual because the patient had a gastroenterostomy and sustained extensive injury of the jejunum after ingesting acid. The patient survived but developed a jejunal stricture that eventually required resection.

Diagnostic laparotomy for fever or abdominal pain of unknown origin.

Diagnostic laparotomy performed on twenty-four patients with FUO and twenty-seven patients with obscure abdominal pain resulted in a positive yield of 87 and 82 per cent, respectively. No deaths occurred in either group and the complication rate was minimal. These findings indicate that it is appropriate to include laparotomy in the armamentarium for diagnosis of the cause of FUO and abdominal pain.

Vascularity of gastrointestinal staple lines demonstrated with silicone rubber injection.

Gastrointestinal stapling devices were applied across canine small intestine, and then the blood supply of the stapled segments was immediately filled with silicone rubber. After tissue clearing and microdissection, the outstanding vascularity of the staple lines was clearly demonstrated. The B configuration of the closed staple allows blood vessels of substantial size to pass through it. This might make staple technique especially advantageous whenever vascularity is critical.

Pharmaco-cholangiography with anticholinergic drugs in the dog.

The effect of atropine and pipenzolate bromide (PB) in different dosage levels was investigated in intravenous cholangiography with 0.6 ml/kg iodipamide infused over 30 minutes in six cholecystectomized dogs (20-36 kg) equipped with Thomas cannulas through which the common bile duct could be cannulated. Doses of 1 mg atropine and 20 mg PB, half the dose given intravenously just prior to the contrast agent and the other half with the iodipamide infusion, had the greatest effect in decreasing the bile flow (atropine-24% at 60, PB-23% at 30 minutes) and increasing the bile iodine concentration (atropine + 16%, PB + 14%). The biliary iodipamide excretion rate was not affected.

Streptococcus mitis infection in newborns.

Although neonatal infections caused by Streptococcus viridans have been suggested to be less severe than those caused by classic neonatal pathogens, little is known about neonatal infections caused by specific species within this group of bacteria. We report six infants who had S. mitis isolated from blood culture. All were infected at < or = 3 days of age; five of the mothers had perinatal risk factors for neonatal sepsis. Five infants were preterm and three had birth weights < or = 2500 gm. Hematologic abnormalities were common. Two died as a result of the infection. Antibiotic susceptibility testing of four isolates revealed resistance to penicillin and ampicillin in three and resistance to gentamicin in two. In vivo resistance was not observed. S. mitis is not part of normal skin flora, should not be assumed to be a contaminant, and can cause severe neonatal disease. If S. mitis or S. viridans are recovered from a normally sterile body site and the patient fails to improve with penicillin therapy, it seems prudent to switch to vancomycin until susceptibility results are available.

Analysis of the radiographically visualized deep hepatic lymph drainage in the dog.

The deep hepatic lymph drainage of 9 cholecystectomized dogs was analyzed after radiographic visualization with retrograde biliary infusion of Ethiodol. No drainage from the deep to the superficial lymph system of the liver was found with the described method. Primary stations of the deep hepatic lymph drainage are the hepatic, left gastric and splenic lymph nodes although the latter two were not always opacified. On the average 9 (6-11) hepatic lymph nodes were opacified which is a significantly higher number than previously reported. Retrograde contrast material filling of splenic, mesenteric, aortic, iliac and some intrathoracic lymph nodes occurred with various frequencies but the opacification of these nodes was usually incomplete.