Fat trajectory after birth in very preterm infants mimics healthy term infants.

BACKGROUND: Infants born very preterm experience poor postnatal growth relative to intrauterine growth, but at term equivalent age, they have increased percentage body fat compared with infants born at term. OBJECTIVES: The aim of this study was to assess body composition in very preterm infants born before 32 weeks postmenstrual age and to compare this with infants born at 32-36 weeks of gestation. METHODS: Percentage fat, fat mass and fat-free mass were measured in 87 very preterm infants born <32 weeks of gestation and studied at 32-36 weeks and in 88 control infants born at 32-36 weeks of gestation and measured on days 2-5 postnatally. RESULTS: At 32-36 weeks, very preterm infants were lighter and shorter, had significantly greater percentage fat and absolute fat mass and had a significantly lower absolute fat-free mass than the control group. The trajectory in percentage fat over increasing postnatal age in very preterm infants was closely aligned to that in term infants. CONCLUSIONS: Infants born very preterm accumulate fat rapidly after birth and have a deficit in fat-free mass. Fat accumulation may be triggered by birth or associated events. If this rapid fat accretion is not taken into account, assessment of growth based on weight alone will underestimate the deficit in fat-free mass.

Management of malignant esophagotracheal fistulas with airway stenting and double stenting.

Prognosis of inoperable or recurrent esophageal carcinoma is, at best, poor. Once an esophagotracheal fistula has developed, the overall condition of the patient declines rapidly. Aspiration pneumonia and severe coughing are common. The introduction of esophageal tubes does not always seal the fistula sufficiently and may compromise the airway causing stridor and dyspnea. In 30 patients (25 male, 5 female; age 23 to 74 years; mean, 56 years) with very large fistulas and airway problems, we inserted an airway stent (Dynamic) (n = 12) or an esophageal tube combined with a Dynamic airway stent (n = 18) with the aim of sealing the fistula and restoring patency of the airway and GI passage. The tracheobronchial Dynamic stent was chosen because its slightly concave, flexible posterior silicone membrane adapts ideally to the convex esophageal tube. The stents were well tolerated and significantly improved the quality of life. Of 30 patients, 16 could breathe and swallow unimpaired until shortly before their death. Moderate complaints persisted in five patients, dysphagia in eight patients, and dyspnea in one patient. Mean survival time in the double stent group was significantly greater (110 days) than in the airway stent-only group (24 days) or comparable groups in the literature treated with esophageal tubes only. We conclude that carefully selected patients can benefit from double stenting of esophagus and airways.

Detection of Clostridium perfringens and its enterotoxin in cases of sporadic diarrhoea.

AIMS: To determine the incidence of sporadic and apparently non-food related diarrhoea associated with Clostridium perfringens enterotoxin. METHODS: Enzyme linked immunosorbent assay (ELISA) and reversed phase latex agglutination (RPLA) were used to detect C perfringens enterotoxin in faecal specimens from 818 sporadic cases of diarrhoea. RESULTS: C perfringens enterotoxin was identified as a cause of sporadic diarrhoea in 56 of 818 (6.8%) cases. Diarrhoea was prolonged (three days or more) in most cases. Ages ranged from 3 months to 89 years, although most patients were over 60 years of age. CONCLUSIONS: These results suggest that C perfringens may be a cause of sporadic cases of diarrhoea when causes such as food consumption or cross-infection are absent, particularly in the elderly.

Myocardial perfusion and metabolism at normothermic and hypothermic levels.

Changes in intramyocardial carbon dioxide tension (Pco2) and arterial oxygen tension (Po2) were recorded in dogs with a mass spectrometer after temporary occlusion of the aorta and the proximal part of the anterior descending coronary artery at normothermic and hypothermic levels. Patterns of hypoxic and hypercapnic changes and their recovery were favorably modified with moderate hypothermia. Deep levels of hypothermia seemed to enhance this protective effect and progressively slow the myocardial metabolism. Occlusion of the proximal part of the anterior descending coronary artery for 30 minutes had a regional effect similar to the general myocardial changes recorded after aortic clamping, while the posterior myocardial probe showed stable control values. These data support previous studies showing that moderate hypothermia halves the oxygen consumption and doubles the "safe" period of anoxic arrest.

Single-lung transplantation in a patient with cystic fibrosis and an asymmetric thorax.

We report metachronous single-lung transplantation for cystic fibrosis after contralateral pneumonectomy. Kyphoscoliosis and mediastinal shift required careful donor-lung sizing with computed tomography and was not dependent on typical parameters. Severe reperfusion injury was treated with nitric oxide, C1-esterase inhibitor, and continuous venovenous hemodialysis. The patient was extubated on the fifth postoperative day and is alive and well. We conclude that single-lung transplantation after contralateral pneumonectomy for patients with cystic fibrosis and an asymmetric chest and evident lung volume mismatch may be an acceptable functional therapeutic option.

Computed tomography of the normal larynx.

A computed tomographic analysis of normal laryngeal anatomy was undertaken using cadaver larynxes. This was part of a larger project in which patients with laryngeal carcinoma were routinely evaluated in the computed tomographic (CT) body scanner. The appearance of normal laryngeal anatomy had to be delineated before disease processes of the larynx were evaluated, and this was accomplished using a computed tomographic technique with 5-mm slice thicknesses and a 3-mm overlap. The scan slices were then compared with anatomic sections taken at the same levels. The comparisons demonstrate an ideal level of accuracy that can be approached in the in-vivo larynx only with use of the latest-generation scanners. However, CT scanning is of immediate usefulness in the diagnosis of laryngeal pathology.

Biologic fate of valves in reversed and nonreversed arterial vein grafts.

The cusps of valve-bearing segments of canine cephalic, femoral, and jugular veins were completely divided and were used in interposition grafts in the femoral and carotid arteries in the nonreversed position. Three control grafts had intact valves in the reversed position, and one control graft in the reversed position had division of the leaflets. Nine grafts were studied up to 2 months postoperatively with gross and microscopic observations. The cusp tissue, which shrinks immediately after complete division, disappears very early in the postoperative period in the reversed and nonreversed positions. Two reversed intact valves were still grossly microscopically normal 5 and 7 weeks postoperatively. The complete disappearance of the divided valve with a nonreversed coronary graft 101/2 months postoperatively has been documented at autopsy for the first time in a human subject. The significance of these findings and the superiority of the valveless nonreversed autogenous vein graft in clinical cardiovascular surgery has been discussed.

Culture media for the isolation and enumeration of pathogenic Vibrio species in foods and environmental samples.

The genus Vibrio now includes a large number of species. Clear evidence is only available for the aetiological role of V. cholerae, V. vulnificus and V. parahaemolyticus in foodborne diseases. Until recently, V. cholerae serogroup 0:1 was accepted as the cause of epidemic cholera. However, the designation of outbreaks of diarrhoeal diseases caused by V. cholerae 0:139 as clinical cholera has lead to renewed interest in Non 0:1 serogroups of V. cholerae. A wide range of enrichment and selective media for the isolation of vibrios has been developed. These media are reviewed with respect to their ability to recover and differentiate the target vibrios. Alkaline peptone water (APW) remains the recommended enrichment medium for vibrios in parallel with either salt polymyxin broth (SPB) or glucose teepol (or sodium dodecylsulphate) salt broth (GTSB) when tests for V. parahaemolyticus are required. Thiosulphate citrate bile salt agar (TCBS) in parallel with polymyxin mannose tellurite (PMT) or sodium dodecylsulphate polymyxin sucrose agar (SPS) are the recommended selective plating media.

Mitochondrial encephalomyopathy: a rare genetic cause of sensorineural hearing loss.

A 44-year-old man with a documented 12-year history of progressive sensorineural hearing loss developed a generalized tonic-clonic seizure followed by a visual field deficit and apraxia. Six months later he developed a peripheral neuropathy and muscle fatigue followed by a slowly progressive aphasia and cortical blindness as well as increased seizure activity. A computed tomography scan showed bilateral basal ganglion calcification. The serum lactate level was elevated at 3.4 mEq/dL. A muscle biopsy enabled the diagnosis of mitochondrial myopathy. This disorder is presented as an unusual cause of progressive sensorineural hearing loss in adults.

Canine carotid allograft changes after photochemotherapy and external polyester sheathing.

BACKGROUND: The purpose of this study is to define and refine the changes in canine carotid allografts after photochemotherapy and polyester sheathing. Photochemotherapy with 8-methoxy psoralen (8MOP) and UVA (PUVA) was given alone or combined with intraluminal visible light (VL) 450 nm in proper dosages to speed the depopulation of endothelial (EC) and smooth muscle cells (SMC) and to modulate the immune response. METHODS: Novel apparati were made for photochemotherapy of 19 right canine carotid arterial allografts with 19 paired untreated controls in the left carotid. External UVA and internal visible light (VL 450 nm) were used with 8-methoxy psoralen (8-MOP) as a sensitizer. RESULTS: With moderate dosage of 8-MOP (1 microg/cc) and 2-4 J/cm2 of external UVA (PUVA), smooth muscle cells (SMC) disappeared faster from the media and fibroblasts (FB) appeared earlier in the adventitia of the treated right allografts, reducing but not eliminating the immune response. Intraluminal VL did not enhance the PUVA effect. At 68 days, treated and control allografts showed similar dimensions with subsided immune reactions. The media thickness was reduced from 0.38 mm to 0.18 mm and the host adventitia increased from 0.22 to 0.60 mm. Variable reactions peaked between two and three weeks and subsided after one month. All allografts remained open with canine carotid i.d.s of 2-3 mm and 80 to 100 cc/ minute arterial flows. Although the UVA dosage was moderate) similar doses sterilized log 7 of staph aureus cultures in saline. The allografts without smooth muscle showed moderate but stable cylindrical dilatation without spasm or stenosis and with an adequate adventitial buttress for a small vessel. A polyester sleeve around four treated grafts was inseparable from the allograft in less than 3 weeks and tolerated well over a 70-day period. CONCLUSIONS: Biodegradable graft sheaths with bioerodible hydrogels with growth factors (FGF) for local delivery may provide a faster and more complete matrix remodeling for a superior conduit in the future.