The c-Jun N-terminal kinase (JNK) inhibitor XG-102 enhances the neuroprotection of hyperbaric oxygen after cerebral ischaemia in adult rats.

AIM: Both hyperbaric oxygenation (HBO) and inhibition of the c-Jun N-terminal kinases (JNKs) by the peptide inhibitor XG-102 (D-JNKI-1) are efficient protective strategies against ischaemia-induced neurodegeneration. The present study investigated whether the combination of HBO and JNK inhibitor, XG-102, provides additive neuroprotection against cerebral ischaemia. METHODS: Rat middle cerebral artery was occluded (MCAO) for 90 min. XG-102 [2 mg/kg, intraperitoneally] or HBO (3 ATA, 60 min) was applied 3 h after the onset of MCAO. For the combination treatment, HBO was started 10 min after the injection of XG-102. Twenty-four hours after MCAO, the infarct area, the neurological score and the immunohistochemistry staining in brain slices for cleaved-PARP, transferase-mediated biotinylated UTP nick end labelling, c-Jun and phosphorylated (activated) c-Jun were observed. RESULTS: XG-102 or HBO alone reduced the total infarct area by 43% and 63%, respectively. The combination diminished total infarct area by 78%, improved the neurological function and reduced brain oedema. Co-application of HBO and XG-102 also significantly reduced the cleavage of PARP, by 96% and 91% in cortical penumbra and ischaemic core, respectively. Moreover, cotreatment significantly attenuated the number of cells labelled with transferase-mediated biotinylated UTP nick end labelling and phosphorylated c-Jun. CONCLUSION: Our study demonstrates that HBO reinforces the efficiency of neuroprotective drugs such as XG-102 and vice versa. Both treatments, physical HBO and pharmacological XG-102, are already in phase I/II studies and promising strategies for clinical use.

Selective hyperactivation of JNK2 in an animal model of temporal lobe epilepsy.

c-Jun N-terminal kinases (JNKs) are members of the mitogen-activated protein kinase (MAPK) family and are derived from three genes, Jnk1-3. These kinases are involved in cellular responses to homeostatic insults, such as inflammation and apoptosis. Furthermore, increased JNK expression and activation are associated with debilitating neurodegenerative diseases, including Alzheimer's and Parkinson's. We previously reported elevated levels of phosphorylated JNK (pJNK), indicative of JNK hyperactivation, in the CA1 hippocampus of chronically epileptic rats. We also showed that pharmacological inhibition of JNK activity reduced seizure frequency in a dose-dependent fashion (Tai TY et al., Neuroscience, 2017). Building on these observations, the objectives of this current study were to investigate the timeline of JNK activation during epileptogenesis, and to identify the JNK isoform(s) that undergo hyperactivation in the chronic epilepsy stage. Western blotting analysis of CA1 hippocampal homogenates showed JNK hyperactivation only during the chronic phase of epilepsy (6-9 weeks post-status epilepticus), and not in earlier stages of epileptogenesis (1 h, 1 day, and 1 week post-status epilepticus). After enrichment for pJNK by immunoprecipitation, we identified JNK2 as the only significantly hyperactivated JNK isoform, with expression of the 54 kDa pJNK2 variant elevated to a greater extent than the 46 kDa pJNK2 variant. Expression of the total amounts of both JNK2 variants (phosphorylated plus non-phosphorylated) was reduced in epilepsy, however, suggesting that activation of upstream phosphorylation pathways was responsible for JNK2 hyperactivation. Since our prior work demonstrated that pharmacological inhibition of JNK activation had an antiepileptic effect, JNK2 hyperactivation is therefore likely a pathological event that promotes seizure occurrences. This investigation provides evidence that JNK2 is selectively hyperactivated in epilepsy and thus may be a novel and selective antiepileptic target.

[Bariatric surgery in children and adolescents]. / Adipositaschirurgie bei Kindern und Jugendlichen.

Obesity in childhood and adolescents has gained epidemic proportions; in Germany 15-20 % of boys and girls are overweight, more than 6 % are known to be obese. By now, 25 % of relevant people show a pathological glucose intolerance, 4-5 % are developing type 2 diabetes mellitus (T2DM). In addition, metabolic disorders leading to hypertension and cardiac, renal or ophthalmological complications could be named as serious comorbidities. Medical and behavioural intervention as treatment for obesity in childhood remains largely ineffective: 5-10 % weight loss within 2 years rarely results in significant durable success. In adults, bariatric surgery is being used increasingly as an effective approach to achieve weight loss and to improve serious medical comorbidities, in particular T2DM. Enhancement of quality of life and explicit extension of survival are concomitant phenomenons. To date, a range of different types of bariatric procedures has been performed in adolescents, but studies evaluating and analysing preoperative data, postoperative course and follow-up in a representative number of patients younger than 18 years are still lacking. Nevertheless, current experience suggests significant weight loss and improving obesity-related medical comorbidities after bariatric surgery in adolescents too. Moreover, bariatric surgery in adolescents seems to induce less complications and a shorter hospital stay than in adults. Al-though surgical therapy for obesity in this group of patients remains an individual decision, even though explicit guidelines have been published specifying inclusion and exclusion criterias. Analysis of our own patient group and results of the study of the quality assurance "surgical treatment of morbid obesity" are appropriate tools to evaluate surgical techniques and to provide long-term follow-up.

Functional coupling of neonatal rat Sertoli cells and gonocytes in coculture.

Interaction between Sertoli cells and germ cells is likely to be critical for normal development of the testis. We have established and characterized cocultures of neonatal Sertoli cells and gonocytes and have begun to study the physical and functional relationship between these cells in vitro. Cells were isolated from rat pups by sequential enzymatic treatment and cultured in serum-free medium. When plated on Matrigel, Sertoli cells rapidly attach, and gonocytes adhere to the underlying Sertoli cells shortly thereafter. We observed that some of these germ cells develop cytoplasmic processes and elongate during the first day of culture, essentially mimicking their behavior in vivo. Electron microscopic examination of typical cultures revealed the presence of desmosome-like adhesion sites and apparent gap junctions between Sertoli cells and gonocytes. To determine whether Sertoli cells and gonocytes are functionally coupled in the cocultures, we used the glass bead-loading technique of McNeil and Warder to introduce Lucifer yellow (LY), a gap junction-permeant probe, and Rhodamine-dextran (RD), a larger marker excluded by gap junctions, simultaneously into cultures 24 h after plating. Immediate fixation and viewing of cultures with fluorescence microscopy indicated that all bead-loaded cells received both probes. We studied other living cultures 10 min after bead-loading and located RD-negative (i.e. nonbead-loaded) gonocytes that were in obvious contact with RD- and LY-positive bead-loaded Sertoli cells; these gonocytes were scored for the presence or absence of cytoplasmic LY. This analysis revealed that many gonocytes were able to obtain LY from adjacent Sertoli cells, presumably via gap junctions maintained with these cells. In addition, we quantified the percentage of gonocytes that elongated with increasing time in vitro and correlated the morphology of these cells with their ability to acquire LY from adjacent Sertoli cells. Our findings indicate that although the absolute numbers of gonocytes present decreases, more of those remaining elongate as time in vitro increases. We can also conclude from our data that gonocytes with and without processes are equally likely to be coupled with Sertoli cells under these conditions. These observations provide the first demonstration of functional coupling between Sertoli cells and premeiotic germ cells. Together with our morphological observations, they suggest that gap junction-mediated communication between these cells may be involved in stimulating or regulating changes in the gonocyte population during postnatal development of the testis.

Severe multicore disease associated with reaction to anesthesia.

Multicore disease is a nonprogressive myopathy. To our knowledge, in all previous cases, the clinical course has been benign with no deaths attributed to it. We describe a patient who presented as a floppy baby and remained weaker throughout his life than any other patients previously described. Biopsy findings were characteristic of multicore disease. However, at age 21/2 years, our patient developed congestive heart failure that was easily controlled with digitalis and diuretics. Shortly after cardiac catheterization, the patient developed a high, unexplained fever and died 26 hours later despite aggressive attempts at resuscitation. Therefore, patients with multicores in skeletal muscle may have severe weakness and may also have a predisposition to complications subsequent to anesthesia.

Characteristic early electroencephalographic changes in herpes simplex encephalitis.

We review electroencephalograms taken from 17 patients with severe meningoencephalitis within seven days of onset of CNS symptoms and prior to cortical brain biopsies. All patients had CNS disease clinically compatible with the diagnosis of herpes simplex encephalitis (HSE). The diagnosis was demonstrated by the isolation of virus from the brain in five patients (group 1) but considered highly unlikely in the other 12 patients (group 2) by negative immunofluorescent studies and failure of viral isolation from the brain tissue. Abnormal but nonspecific EEGs with diffuse or focal slowing were found in all patients. Distinctive high-voltage, 1-cycle-per-2-to-3 seconds periodic sharp waves from unilateral temporal lobes were seen only in three of the five patients with virologically proved HSE but in none of the 12 patients without viral isolation. This EEG pattern is strikingly similar in all three patients, regardless of their age, and may be specific for the early diagnosis of HSE prior to brain biopsy. The EEGs of the other two patients with proved HSE did not contain such abnormalities. Athough periodic EEGs with some resemblance to those previously described may occur in other CNS disorders, their presence strongly suggests the diagnosis of HSE when recorded from patients with viral meningoencephalitis. Moreover, EEGs may help locate the best site for cerebral biopsy since maximal yield of the virus in this study was from unilateral temperoal lobes corresponding with the site of local EEG changes.

Ethotoin in seizures of childhood and adolescence.

Ethotoin is an anticonvulsant that was considered minimally effective when introduced, but due to its apparent lack of side effects, there has been renewed interest in the drug for use in generalized and psychomotor seizures. We have characterized the pharmacokinetics of ethotoin in children and have found nonlinearity. Seizures were controlled in 16 of 17 patients, and there were no side effects reported. Gingival hyperplasia due to previous phenytoin therapy improved in all cases.

Inhibition by adenosine A(2A) receptors of NMDA but not AMPA currents in rat neostriatal neurons.

Whole-cell patch clamp experiments were used to investigate the transduction mechanism of adenosine A(2A) receptors in modulating N-methyl-D-aspartate (NMDA)-induced currents in rat striatal brain slices. The A(2A) receptor agonist 2-p-(2-carboxyethyl)phenethylamino-5'-N-ethylcarboxamidoadenosine (CGS 21680) inhibited the NMDA, but not the (S)-alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) current in a subset of striatal neurons. Lucifer yellow-filled pipettes in combination with immunostaining of A(2A) receptors were used to identify CGS 21680-sensitive cells as typical medium spiny striatal neurons. Dibutyryl cyclic AMP and the protein kinase A activator Sp-cyclic AMPs, but not the protein kinase A inhibitors Rp-cyclic AMPS or PKI(14 - 24)amide abolished the inhibitory effect of CGS 21680. The phospholipase C inhibitor U-73122, but not the inactive structural analogue U-73343 also interfered with CGS 21680. The activation of protein kinase C by phorbol 12-myristate 13-acetate or the blockade of this enzyme by staurosporine did not alter the effect of CGS 21680. Heparin, an antagonist of inositol 1, 4,5-trisphosphate (InsP(3)) and a more efficient buffering of intracellular Ca(2+) by BAPTA instead of EGTA in the pipette solution, abolished the CGS 21680-induced inhibition. The calmodulin antagonist W-7 and cytochalasin B which enhances actin depolymerization also prevented the effect of CGS 21680; the calmodulin kinase II inhibitors CaM kinase II(281 - 309) and KN-93 but not the inactive structural analogue KN-92 were also effective. The calcineurin inhibitor deltamethrin did not interfere with CGS 21680. It is suggested that the transduction mechanism of A(2A) receptors to inhibit NMDA receptor channels is the phospholipase C/InsP(3)/calmodulin and calmodulin kinase II pathway. The adenylate cyclase/protein kinase A and phospholipase C/protein kinase C pathways do not appear to be involved.

Recurrent intussusceptions in an infant that were terminated by laparoscopic ileocolonic pexie.

For children with ileocolic intussusceptions, laparoscopy has been proposed as an emergency intervention, but it has not been elaborated for elective prevention of recurrencies. We report about an infant who developed his first ileocolic intussusception at the age of 12 months. Radiologic devagination was successful, but had to be repeated for two consecutive recurrences within several days. Six months later, he presented with another episode of intussusception, which again was managed conservatively. At this time, preventive surgery seemed indicated. Diagnostic laparoscopy using three trocars and 5-mm instruments showed an insufficient closure of the ileocecal valve, allowing the surgeon easily to provoke an intussusception. Consequently, the distal ileum was attached to the ascending colon with several interrupted 3-0 sutures. The infants postoperative course was uneventful. Oral feeding was started immediately, and he could be discharged after 3 days. Within a follow-up period of 1 year, no evidence of intussusception was noted. We conclude that for children with recurrent episodes of intussusception, laparoscopic ileocolonic pexie presents a beneficial strategy for protective surgery.

Laparoscopic resection of a congenital liver cyst and simultaneous closure of a diaphragmatic defect in a 5-month-old infant.

Congenital liver cysts are an unusual finding and present a difficult diagnostic challenge. In a 5-month-old infant, routine echocardiography detected a cystic lesion (3 cm in diameter) just below the diaphragm. All conventional diagnostics, including magnetic resonance imaging (MRI), failed to clarify its etiology definitively. Moreover, a phrenic irregularity was suspected at the site of Morgagni. Finally, laparoscopy (5-mm scope and instruments) confirmed the diagnosis of a solitary liver cyst and a diaphragmatic defect. Using a Harmonic scalpel, the cyst was resected and the diaphragmatic defect was closed with interrupted nonabsorbable sutures. The patient's postoperative course was uneventful. Pathological analysis showed a true liver cyst with mesothelial lining and hepatic residues. Retrospective speculation suggests a common embryologic origin for both malformations. In conclusion, laparoscopy allowed final diagnosis and simultaneous treatment of an infant with the rare combination of a liver cyst and a diaphragmatic defect. To our knowledge, this case represents the first endosurgical experience of such a simultaneous procedure.

Laparoscopic repair of an extrahiatal hernia caused by congenital dysplasia: a case report.

A 40-year-old woman with complaints of relapse in the upper abdomen and dysphagia was referred for laparascopic hiatal hernia repair. Chest radiograph, barium-swallow, and upper endoscopy revealed a paraesophageal hernia. Esophageal manometry and 24-h-pH study showed no pathological findings. A laparoscopic gastropexy was planned. Intraoperatively, in contradiction to the preoperative findings, an extrahiatal hernia containing most of the stomach was found. After resection of the hernia sac, the beating heart without covering pericardium was seen. These findings were confirmed by an additional thoracoscopy at the end of the operation. The defect was closed by direct suturing. The postoperative course and 2-month follow-up were uneventful. The resected parts of the hernia sac showed an embryonic and dysgenetic etiology. This rare malformation has been reported in combination with complex syndromes, which appear with serious clinical and morphological signs in the neonatal period. In adults, the pericardial aplasia can be observed during diagnostic or surgical interventions. In these patients, complaints are usually not caused by the malformation but may be due to the occasional herniation of abdominal organs. We consider laparoscopic repair to be a gentle and safe procedure for the treatment of extrahiatal hernias.

Syncope associated with hair-grooming.

We report 20 girls who experienced episodes of unconsciousness while standing for hair grooming. The episodes were syncopal in character, electroencephalograms were normal in most cases, and at least 11 of the 20 had definite episodes of syncope in other circumstances. A number of these girls underwent extensive diagnostic testing. We consider this a form of situational or reflex syncope, perhaps related to orthostatic hypotension, the recognition of which may spare unnecessary diagnostic and therapeutic interventions.

Ventriculoscopy-aided implantation of ventricular shunts in patients with hydrocephalus.

Ventriculoscopy represents a new concept in the surgical treatment of children with hydrocephalus. Optimal catheter position can now be achieved with the help of a new method consisting of endoscopically controlled implantation of ventricular shunts. In addition, interventional ventriculoscopy enables or improves new operative procedures such as the fenestration of intracranial cysts or the removal of dislodged parts of catheter tips from the corresponding ventricle under direct optical control. Ventriculoscopy has been performed on 17 pediatric patients, with no complications to date.

Multiple intestinal stenoses and peripheral gangrene: a combination of two rare surgical complications in a child with Kawasaki disease.

Kawasaki disease (KD) often presents with a challenging variety of clinical symptoms. Severe gastrointestinal complications are rare and mainly appear as pseudo-obstruction. However, the authors report the unique case of a 4-month-old girl with KD suffering from a mechanical ileus. The optimal timing of surgery presented a dilemma, because she received lytic treatment for gangrenes of both her hands and feet and additionally had large coronary artery aneurysms. Finally laparotomy had to be performed while the patient was on an anticoagulant medication, and it showed a 30-cm-long jejunal segment with multiple filiforme stenoses, requiring resection and anastomosis. The postoperative course was uneventful regarding the abdominal situation; however, the left hand and left foot remained gangrenous and had to be amputated. In patients with KD, not only pseudo-obstruction, but irreversible intestinal obliteration has to be encountered. This combination of intestinal stenosis and acral gangrene has not been described before. J Pediatr Surg 36:651-653.

Critical validation of colour Doppler ultrasound in diagnostics of acute scrotum in children.

Acute scrotum in children is generally a symptom. Several pathologies of the testis, scrotum or groin may cause it, including inflammatory as well as ischaemic processes. Testicular torsion with ischaemia of the testis is an emergency requiring prompt surgical intervention. Even experienced paediatric surgeons and urologists may have difficulties differentiating an ischaemic from an inflammatory aetiology solely on the basis of clinical signs and symptoms. In cases of aetiologic uncertainty, operative exploration has to be performed to rule out ischaemia, which led in the past to a high rate of surgery. More recently, colour Doppler ultrasonography (CDUS) has become an imaging modality for the examination of the acute scrotum with the purpose of detecting ischaemia, thus reducing the need for explorative surgery. In this study we examined the reliability of CDUS, comparing the sonographical diagnoses with both the intraoperative findings and the clinical course. We present here 132 consecutive cases of acute scrotum in children, who were admitted from 01/98 through 10/02 to our hospital. All patients underwent CDUS. Patients with ultrasonographic signs of ischaemia of the testis (group A) and patients with demonstrated perfusion and suspicious or severe clinical symptoms (group B) were operated immediately. Patients with demonstrated perfusion without suspicious or severe symptoms (group C) were treated conservatively. Thirty-eight patients (28.8%) were treated operatively. Eleven cases of testicular torsion in group A (12 pat.) could be confirmed intraoperatively, in one case there was no testicular torsion but a severe inflammation of the testis with torsion of the appendix testis. In group B (26 pat.) operative exploration revealed one case of testicular torsion. In group B two cases of sonographically suspected torsions of the appendix testis also emerged as epididymitis intraoperatively. In the other cases postoperative diagnosis was in agreement with the preoperative CDUS. The clinical course of 94 conservatively treated patients (71.2%) (group C) confirmed in all cases a non-ischaemic aetiology. There was a total of 12 cases (9.1%) where acute scrotum was caused by testicular torsions. This relatively low rate underlines the necessity to differentiate between ischaemic and other aetiologies, thus avoiding operation in many patients. 71.2% of our patients could be treated conservatively. However, it is essential to exclude an ischaemic cause before opting for conservative therapy. Even though CDUS is a very valuable diagnostic tool in this sense, this exclusion cannot be ensured in every case and is highly dependent on the expertise and technique of the investigator. Therefore in cases with any doubts an operative exploration has to be performed to avoid the most dreaded complication in the treatment of acute scrotum.

Laparoscopy combined with conventional operative techniques.

In order to establish minimal invasive methods further, it should be guaranteed that laparoscopy is not only performed in a few pediatric surgical centers. A simple approach to gain experience would be the performance of diagnostic laparoscopy. However, benefit could be increased if the surgeon combines the minimal invasive laparoscopy to establish the diagnosis with the conventional surgical technique to continue. This approach for example applies to complicated cases of appendicitis. In a combined procedure, even bowel resections and tumor extirpations can be performed with minimal invasion. In twenty-seven cases--11 appendicectomies, 14 resections of cystic ovarian tumors and 2 resections of Meckel's diverticulum--we applied this technique and found no complications so far. The surgical method presented is convenient and safe.

Ileoileal intussusception caused by a Ewing sarcoma tumour. An unusual case report.

Intussusception typically occurs in childhood, presenting with a well-known medical history and clinical symptoms. Pathologically, a "leading point" may be attributed to lymphadenomatosis, polyps, or a tumour. In older patients and adolescents, the diagnosis can be complicated due to the lower incidence and variable subacute symptoms. We report on an 18-year-old patient with increasing abdominal discomfort over several weeks. External diagnostics showed no pathological signs or were misinterpreted as a malfunction of intestinal motility. The patient experienced increasing colics, recurrent vomiting, dehydration and weight loss. Finally he was transferred to our paediatric surgical department and laparotomy had to be performed for the clinical and radiological signs of an ileus. An ileoilealic intussusception was found, caused by a small bowel tumour, which almost completely obstructed the intestinal lumen. It was resected and bowel continuity was re-established. Histopathology revealed a very rare, highly malignant mesenchymal Ewing sarcoma, infiltrating the complete bowel wall. After the postoperative course, the patient was transferred to our oncological department for chemotherapy. In older children or young adults, intestinal malignancies are extremely rare. Nevertheless, if these patients suffer from unspecific complaints of chronic intestinal obstruction, a tumour must be ruled out. A Ewing sarcoma may be responsible for an intussusception.

Postpericardiotomy syndrome after minimally invasive pectus excavatum repair unresponsive to nonsteroidal anti-inflammatory treatment.

A 14-year-old boy developed postpericardiotomy syndrome after an otherwise uneventful minimally invasive pectus excavatum repair. Dyspnoea, chest pain, and pericardial effusion progressed despite nonsteroidal anti-inflammatory treatment. The symptoms rapidly resolved with intravenous methylprednisolone, and pericardiocentesis was thus avoided. This is the first report of postpericardiotomy syndrome after the Nuss procedure treated with systemic steroids.

Gradient LC separation of macromolecules: theory and mechanism.

The theory and mechanism for the reversed-phase liquid chromatographic separation of macromolecules was somewhat vague and controversial until recently when the Flory-Huggins theory of dilute polymer solutions was used to provide the technique with a firm theoretical foundation. As a result of this treatment, the concept of a critical mobile phase composition (Xc) has been introduced to liquid chromatography. Macromolecular solutes below Xc are completely retained, while above Xc they are rapidly eluted. Because the capacity factor of a solute is related to Xc, traditional chromatographic parameters such as theoretical plate number have little meaning. A brief summary of the history of chromatographic polymer separations that foreshadows the current theory is given. A review and an evaluation of the current mechanistic status of macromolecular chromatography are presented. Also considered is the use of adsorption theory, "small molecule" theory, and solvophobic chromatographic theory for macromolecular separations. The theory and separation mechanism are relatively straightforward for synthetic polymers but tend to be more complex and less clearcut for biological polymers.

[Assessment of diabetic autonomic neuropathy by heart rate monitoring].

Assessment of diabetic autonomic neuropathy in a representative sample of 91 noninsulin-dependent diabetics was performed in 3 community clinics. A difference of less than 10 beats/min in heart rate between deep inspiration and deep expiration determined by ECG recording served as the criterion for autonomic neuropathy. By this test, 86% of the patients had diabetic autonomic neuropathy, a slightly higher proportion than that reported by others using similar criteria in more selected populations. The test is very sensitive and can be used for screening.