Staged reduction of gastroschisis using preformed silos: practicalities and problems.

PURPOSE: Previous single-center studies have reported favorable outcomes when preformed silos (PFS) are used for the staged reduction of gastroschisis. The aim of this study was to assess the frequency and nature of complications associated with PFS in a large population and provide an insight into the practicalities of their routine use. METHODS: A retrospective review was carried out of all cases of gastroschisis managed with PFS in 4 UK neonatal surgical units for a 6-year period. RESULTS: One hundred fifty infants were included, and 139 (92.7%) silos were applied at cot side (no sedation, n = 93). Median silo size was 4 cm, and time of application was 2.5 hours. Enlarging the defect by incision of fascia was required in 17 (11%). Defect closure was performed at a median of 4 days (0-47) with 93 (62%) being at cot side. Methods of closure were adhesive strips/dressings (n = 94), sutures (n = 48), and patch (n = 8). Discoloration of the viscera occurred in 16 (11%), managed successfully by simple methods (change of PFS, aspirating the stomach, or incision of the defect fascia) (n = 8), conversion to operative silo (n = 3), and operative reduction (n = 1). Four required bowel resection. Other complications included missed atresia (n = 5; 3.3%) and nectrotizing enterocolitis (n = 11; 7%). There were 5 deaths in the series (3.3%). CONCLUSIONS: Staged reduction of gastroschisis with PFS is simple, convenient, and safe. The low rates of associated complications and mortality appear favorable when compared to infants managed with more traditional techniques. We recommend that PFS should be used for the routine management of gastroschisis.

Moderate hypothermia as a rescue therapy against intestinal ischemia and reperfusion injury in the rat.

OBJECTIVE: Moderate hypothermia is protective when applied throughout experimental intestinal ischemia and reperfusion (I/R). However, therapeutic intervention is usually possible only after ischemia has occurred. The aim of this study was to evaluate moderate hypothermia when applied at reperfusion as a rescue therapy for intestinal I/R. DESIGN: Prospective, randomized, controlled experiment. SETTING: University research laboratory. SUBJECTS: Adult male Sprague-Dawley rats (240-300 g). INTERVENTIONS: In experiment I, rats underwent 60 mins of normothermic intestinal ischemia (36-38 degrees C) plus 300 mins of reperfusion at either normothermia or moderate hypothermia (30-32 degrees C) with or without rewarming. Hemodynamics were measured invasively and survival was assessed. In experiment II, rats underwent 60 mins of normothermic ischemia plus 120 mins of reperfusion at either normothermia or moderate hypothermia. At kill, organs and a blood sample were collected. MEASUREMENTS AND MAIN RESULTS: In experiment I, all normothermic I/R rats died within 197 mins of reperfusion after developing severe tachycardia and hypotension, whereas hypothermic rats, with or without rewarming, were alive at 300 mins of reperfusion (p < .001 vs. I/R normothermia) and were hemodynamically stable. In experiment II, normothermic reperfusion caused histologic and biochemical damage to the gut, hepatic energy failure, and inflammatory infiltration of the lung. However, hypothermia reduced injury to the reperfused ileum and prevented distant organ injury by counteracting energy failure in the liver, systemic overproduction of nitric oxide, altered cardiac fatty acid metabolism, and infiltration of inflammatory cells in the lungs. CONCLUSIONS: Hypothermia applied as a rescue therapy for intestinal I/R abolishes mortality even after rewarming. Hypothermic protection during early reperfusion appears to be mediated by several pathways, including prevention of intestinal and pulmonary neutrophil infiltration, reduction of oxidative stress in the ileum, and preservation of cardiac and hepatic energy metabolism. Moderate hypothermia may improve outcome in clinical conditions associated with intestinal I/R.

Using self-consistent-field theory to understand enhanced steric stabilization by casein-like copolymers at low surface coverage in mixed protein layers.

We present a statistical mechanical approach to predicting the properties of mixed copolymer layers using the Scheutjens-Fleer self-consistent-field theory. Our model copolymers are based on the primary structures of the major bovine casein monomers, alpha(s1)-casein and beta-casein. Numerical calculations have been carried out to determine the polymer segment density profiles at an isolated hydrophobic surface and the interaction forces as a pair of polymer-coated surfaces is brought to close interlayer separation. For a copolymer model containing hydrophilic and hydrophobic segments, we show how the steric stabilizing capacity of a casein-like macromolecule at very low surface coverage is enhanced in the presence of a thin dense layer of shorter tethered amphiphilic chains. Using a more refined protein model, which also distinguishes between the charged and uncharged hydrophilic segments along the chain, we clearly demonstrate that the enhanced steric repulsion from beta-casein exceeds that from alpha(s1)-casein. These calculations explain how the replacement of just a few percent of beta-lactoglobulin by casein can inhibit the heat-induced thickening and flocculation behavior observed experimentally with some whey protein-stabilized oil-in-water emulsions.

Inhibition of heat-induced aggregation of a beta-lactoglobulin-stabilized emulsion by very small additions of casein.

Heat stability has been studied in model systems of oil-in-water emulsions (3 wt.% total protein, 45 vol.% n-tetradecane, pH 6.8, ionic strength 30-50 mM) with pure beta-lactoglobulin (beta-lg) as the main emulsifier. The effect of small additions of sodium caseinate, beta-casein or alpha s1-casein prior to emulsion preparation has been investigated. Samples heated for 3 min at 90 degrees C were monitored with respect to changes in viscosity and particle-size distribution. As expected, the pure beta-lg-stabilized emulsions were susceptible to heat-induced changes. But the replacement of just 1% of the beta-lg by sodium caseinate (0.03 wt.% caseinate in the total emulsion) led to complete elimination of any heat-induced viscosity or particle size increase. These findings show that a very small proportion of casein can inhibit the susceptibility of a beta-lg-based emulsion to heat-induced destabilization. The magnitude of the effect is dependent on the type of casein, with the order of effectiveness being beta-casein>sodium caseinate>alpha s1-casein. This work has potential implications for the development of milk protein-stabilized emulsions of improved shelf life.

Iduronate-2-sulphatase protein detection in plasma from mucopolysaccharidosis type II patients.

The lysosomal storage disorder mucopolysaccharidosis type II (MPS II) is caused by a deficiency in the activity of the lysosomal exohydrolase iduronate-2-sulphatase (IDS). MPS II patients present within a spectrum of clinical phenotypes, which reflects the dynamic balance between the level of mutant protein, its residual enzyme activity and the resultant level of storage product. In this study, we have developed an immunoquantification assay for the accurate detection of iduronate-2-sulphatase protein and applied this methodology to the analysis of mutant iduronate-2-sulphatase protein in plasma samples from MPS II patients. The detection limit for the assay was defined as 20 ng/ml for wild type iduronate-2-sulphatase, but could be extended to a detection limit of 0.3 ng/ml by heat denaturation of the protein/plasma sample. The mutant protein detected in plasma from MPS II patients displayed similar properties to heat denatured wild type iduronate-2-sulphatase, suggesting an altered protein conformation. The ratio of heat denatured to native ELISA reactivity could be used to confirm the diagnosis of MPS II (i.e., a ratio of >1 for normal protein and

Hypothermia throughout intestinal ischaemia-reperfusion injury attenuates lung neutrophil infiltration.

BACKGROUND/PURPOSE: Secondary organ damage to the lungs is an important consequence of intestinal ischaemia reperfusion (IIR) injury. Moderate hypothermia ameliorates gut necrosis and liver energy failure after IIR but potential beneficial effects on lung neutrophil infiltration after reperfusion of ischaemic bowel have not been investigated. METHODS: Adult Sprague-Dawley rats underwent 60 minutes intestinal ischaemia followed by 120 minutes of reperfusion. The animals were maintained at either normothermia (36 degrees to 38 degrees C) or moderate hypothermia (30 degrees to 32 degrees C). Four groups were studied: (A) sham normothermia; (B) IIR normothermia; (C) sham hypothermia; and (D) IIR hypothermia. Lungs and terminal ileum were removed for measurement of myeloperoxidase activity (a marker of neutrophil infiltration). Results are expressed as milliunits per milligrams protein, mean +/- SEM, and one-way analysis of variance (ANOVA) with Tukey post-test was used for group comparisons. RESULTS: Lungs: IIR at normothermia significantly increased lung neutrophil infiltration assessed by myeloperoxidase activity compared with sham-operated controls (normothermia sham 4.6 +/- 1.0, n = 8; normothermia IIR 37.7 +/- 13.8, n = 8; P =.011). Moderate hypothermia during IIR significantly attenuated lung neutrophil infiltration (7.2 +/- 2.1, n = 9) compared with normothermia IIR (P =.016) such that myeloperoxidase activity was similar to that found in sham normothermia (4.6 +/- 1.0, n = 8) and sham hypothermia (3.1 +/- 1.3, n = 8). Intestine: Gut myeloperoxidase activity was 0.9 +/- 0.5 in sham normothermia (n = 9) and 2.3 +/- 0.6 after normothermic IIR (n = 8). After IIR at hypothermia gut myeloperoxidase activity (0.5 +/- 0.2; n = 8) was significantly less than normothermic IIR (P =.035) and higher than sham hypothermia (0.2 +/- 0.1, n = 9; P =.01). CONCLUSIONS: These results indicate that moderate hypothermia may prevent damage to another distant organ, ie the lungs, by preventing recruitment of neutrophils. This may be of benefit in decreasing distal organ damage in diseases in which intestinal ischaemia-reperfusion is implicated in the pathogenesis.

Immune response to enzyme replacement therapy: single epitope control of antigen distribution from circulation.

Immune response to replacement therapy has been reported for a range of therapeutic strategies being developed for the treatment of patients with genetic disease. The potential problem of immune response to enzyme replacement therapy has been investigated in alpha-L-iduronidase immunized rats, representing a model of the lysosomal storage disorder Hurler syndrome (alpha-L-iduronidase deficiency). The antibody response to alpha-L-iduronidase showed that the positional location of antibody reactivity was similar for different immunized rats, but the precise linear sequence epitopes identified, varied between rats. A monoclonal antibody reacting to an epitope in close proximity to one high antigenicity site on alpha-L-iduronidase was used to reproduce the in vivo effect of altered enzyme tissue distribution, previously observed in immunized rats infused with alpha-L-iduronidase. The study demonstrated that during an immune response, antibody reacting to a single epitope could partially control the tissue distribution of antigen from circulation.

Mucopolysaccharidosis type VI (Maroteaux-Lamy syndrome): a Y210C mutation causes either altered protein handling or altered protein function of N-acetylgalactosamine 4-sulfatase at multiple points in the vacuolar network.

The lysosomal hydrolase N-acetylgalactosamine 4-sulfatase (4-sulfatase) is required for the degradation of the glycosaminoglycan substrates dermatan and chondroitin sulfate. A 4-sulfatase deficiency results in the accumulation of undegraded substrate and causes the severe lysosomal storage disorder mucopolysaccharidosis type VI (MPS VI) or Maroteaux-Lamy syndrome. A wide variation in clinical severity is observed between MPS VI patients and reflects the number of different 4-sulfatase mutations that can cause the disorder. The most common 4-sulfatase mutation, Y210C, was detected in approximately 10% of MPS VI patients and has been associated with an attenuated clinical phenotype when compared to the archetypical form of MPS VI. To define the molecular defect caused by this mutation, Y210C 4-sulfatase was expressed in Chinese hamster ovary (CHO-K1) cells for protein and cell biological analysis. Biosynthetic studies revealed that Y210C 4-sulfatase was synthesized at a comparable molecular size and amount to wild-type 4-sulfatase, but there was evidence of delayed processing, traffic, and stability of the mutant protein. Thirty-three percent of the intracellular Y210C 4-sulfatase remained as a precursor form, for at least 8 h post labeling and was not processed to the mature lysosomal form. However, unlike other 4-sulfatase mutations causing MPS VI, a significant amount of Y210C 4-sulfatase escaped the endoplasmic reticulum and was either secreted from the expression cells or underwent delayed intracellular traffic. Sixty-seven percent of the intracellular Y210C 4-sulfatase was processed to the mature form (43, 8, and 7 kDa molecular mass forms) by a proteolytic processing step known to occur in endosomes-lysosomes. Treatment of Y210C CHO-K1 cells with the protein stabilizer glycerol resulted in increased amounts of Y210C 4-sulfatase in endosomes, which was eventually trafficked to the lysosome after a long, 24 h chase time. This demonstrated delayed traffic of Y210C 4-sulfatase to the lysosomal compartment. The endosomal Y210C 4-sulfatase had a low specific activity, suggesting that the mutant protein also had problems with stability. Treatment of Y210C CHO-K1 cells with the protease inhibitor ALLM resulted in an increased amount of mature Y210C 4-sulfatase localized in lysosomes, but this protein had a very low level of activity. This indicated that the mutant protein was being inactivated and degraded at an enhanced rate in the lysosomal compartment. Biochemical analysis of Y210C 4-sulfatase revealed a normal pH optimum for the mutant protein but demonstrated a reduced enzyme activity with time, also consistent with a protein stability problem. This study indicated that multiple subcellular and biochemical processes can contribute to the biogenesis of mutant protein and may in turn influence the clinical phenotype of a patient. In MPS VI patients with a Y210C allele, the composite effect of different stages of intracellular processing/handling and environment has been shown to cause a reduced level of Y210C 4-sulfatase protein and activity, resulting in an attenuated clinical phenotype.