Immune expression in children with Wilms tumor: a pilot study.

BACKGROUND: Given improvements in multimodality therapy, survival among children with Wilms tumor (WT) exceeds 90%. However, 15% of children with favorable histology and 50% of children with anaplastic WT experience recurrence or progression. Of patients with advanced disease, only 50% survive to adulthood. In adult malignancies (including renal tumors), patient survival has improved with the advent of immunotherapy. However, little is known about the immune microenvironment of WT, making the potential role of immunotherapy unclear. OBJECTIVE: The objective of the study is to perform an exploratory, descriptive analysis of the immune milieu in WT. STUDY DESIGN: Between 2016 and 2017, all pediatric patients with WT, some of whom received neoadjuvant chemotherapy, underwent ex vivo wedge biopsy at the time of nephrectomy. The fresh tumor tissue and peripheral blood samples were analyzed for infiltrating immune infiltrate and effector cells using flow cytometry. Immunohistochemistry was performed for CD4, CD8, and PD-L1 expression. Matched blood samples were obtained for each patient, and circulating immune cells were analyzed by flow cytometry. RESULTS: A total of six patients were enrolled. One patient with neuroblastoma was excluded. The remaining five patients included the following: two with unilateral WT (resected before chemotherapy), two with bilateral WT (resected after neoadjuvant chemotherapy), and one with Denys-Drash syndrome, end-stage renal disease, and history of WT in the contralateral kidney. Immune analysis showed that WT were infiltrated by immune cells regardless of chemotherapy status. CD8 and CD4 T cells were present in the tumor tissue and exhibited an activated phenotype. Elevated levels of natural killer (NK) cells were observed in the tumors (Figure). Immune checkpoint PD-L1 was also found expressed in one of the tumors stained. DISCUSSION: In this pilot study, it was found that WTs were infiltrated by immune cells (CD45+) both before and after chemotherapy. Elevated levels of NK cells infiltrating the tumor specimens, which were quantitatively increased compared with levels of NK cells circulating in the blood, were noted. T cells, particularly CD4+ and CD8+ T cells, were present in tumor specimens. Tumor-infiltrating CD4 and CD8 T cells displayed an activated phenotype as defined by increased expression of human leukocyte antigen-DR isotype (HLA-DR), programmed cell death protein 1 (PD1), and CD57. Together, these findings suggest that WT microenvironment is immune engaged and may be susceptible to immunotherapy similar to other malignancies. CONCLUSIONS: These pilot data suggest an immune-engaged tumor microenvironment is present within WT. This implies that WT may be susceptible to immunotherapy similar to adult renal tumors and other adult malignancies. Follow-up studies are currently underway.

Congenital diaphragmatic hernia: a systematic review and summary of best-evidence practice strategies.

OBJECTIVES: Recent reports suggest that specific care strategies improve survival of infants with congenital diaphragmatic hernia (CDH). This review presents details of care from centers reporting high rates of survival among CDH infants. STUDY DESIGN: We conducted a MEDLINE search (1995 to 2006) and searched all citations in the Cochrane Central Register of Controlled Trials. Studies were included if they contained reports of >20 infants with symptomatic CDH, and >75% survival of isolated CDH. RESULT: Thirteen reports from 11 centers met inclusion criteria. Overall survival, including infants with multiple anomalies, was 603/763 (79%; range: 69 to 93%). Survival for isolated CDH was 560/661 (85%; range: 78 to 96%). The frequency of extracorporeal membrane oxygenation (ECMO) use for isolated CDH varied widely among reporting centers 251/622 (40%; range: 11 to 61%), as did survival for infants with isolated CDH placed on ECMO: 149/206 (73%; range: 33 to 86%). There was no suggestion of benefit from use of antenatal glucocorticoids given after 34 weeks gestation or use of postnatal surfactant. Low mortality was frequently attributed to minimizing lung injury and adhering to center-specific criteria for ECMO. CONCLUSION: Use of strategies aimed at minimizing lung injury, tolerance of postductal acidosis and hypoxemia, and adhering to center-specific criteria for ECMO were strategies most consistently reported by successful centers. The literature lacks randomized clinical trials of these or other care strategies in this complex patient population; prospective studies of safety and long-term outcome are needed.

Enhancement of human hematopoiesis by mast cell growth factor in human-sheep chimeras created by the in utero transplantation of human fetal hematopoietic cells.

We have previously described a unique model of long-term, multilineage, human hematopoietic chimerism in sheep created by the in utero transplantation of human hematopoietic stem cells (HSC) into pre-immune fetal lambs. In this study, we examined the effect of chronic administration of recombinant human mast cell growth factor (rhMGF) on 1) human cell engraftment in pre-immune sheep and 2) human cell expression in human-sheep chimeras at 2-years posttransplant. rhMGF (25 micrograms/kg) or saline was administered in utero via chronic intraperitoneal (IP) catheters to three separate sets of twin fetuses on alternate days for 10 doses following transplantation of human HSC. Flow-cytometric and karyotype analyses of peripheral blood from two sets of twins at 45-days posttransplant and of peripheral blood from the remaining set of twins at birth revealed a significant increase in percentages of donor (human) progenitors and cells in rhMGF-treated lambs. rhMGF (60 micrograms/kg/day) was also administered by IP injection to two, 2 year-old, human-sheep chimeras for 18 consecutive days. Flow-cytometric analysis of peripheral blood and bone marrow revealed a six- to seven-fold increase in human cell expression. The effect on early human progenitors (i.e., colony-forming unit-mix [CFU-Mix], CFU granulocyte/macrophage [CFU-GM], and burst-forming unit-erythroid [BFU-E]) was determined by karyotype analysis of individual colonies grown under conditions favoring human cell growth. A three- to five-fold increase in human CFU-Mix and BFU-E occurred with a minimal increase in CFU-GM. This in vivo study supports in vitro data suggesting that MGF is a powerful regulator of human hematopoiesis and preferentially stimulates early hematopoietic progenitors. It also supports the potential value of the human-sheep model for the in vivo study of normal and abnormal human hematopoiesis.

Platelet alpha-2-adrenergic dysfunction in negative symptom schizophrenia: a preliminary study.

The specific binding to platelet membranes (Bmax) of 3H-clonidine, an alpha-2 agonist, and 3H-yohimbine, an alpha-2 antagonist, was measured in nine drug-free male schizophrenic patients and repeated after 2 weeks of chlorpromazine (CPZ) treatment. Patients with a lower pretreatment Bmax for 3H-clonidine showed a significantly smaller change in Bmax after treatment, less improvement in their clinical state, as indicated by the change in the Global Assessment Scale (GAS), and a lower posttreatment GAS. Also, they had a significantly higher score for negative symptoms on the Affect Rating Scale both before and after treatment. These findings suggest that schizophrenic patients with relatively subsensitive platelet alpha-2-adrenergic receptors, as measured by 3H-clonidine binding, tend to have more negative symptoms and a diminished alpha receptor binding response and diminished clinical response to CPZ. There were no clinical correlations to 3H-yohimbine binding.

Experiments with a bowl of saline: the hidden risk of hypothermic-osmotic damage during topical cardiac cooling.

Some of the misconceptions in the application of cardiac hypothermia are that the temperature of cold normal saline solution is necessarily above 0 degrees C, cold saline solution and slush are relatively safe for living tissues, and normal saline will retain normal osmolality even if partially frozen. These postulates were examined in thermodynamic experiments that demonstrated three points: (1) The temperature of unfrozen saline solution may drop way below the freezing point. (2) When liquids and solid components of saline solution are separated, the components will become hypo-osmolar or hyperosmolar. (3) Ice chips and slush ice produced in the operating rooms may reach temperatures as low as -36 degrees C. We recommend that the possibility of these events should be taken into consideration whenever topical cardiac hypothermia is clinically applied.

Bench coronary cineangiography. A possible way to increase the number of hearts available for transplantation.

The method of "bench coronary cineangiography," that is, ex vivo contrast examination of the donor heart before implantation, is presented. The procedure appears to be most effective in detecting pathologic changes in the coronary arterial system of the explanted heart and thus would allow substantial extension of the age limits of donor hearts that may be acceptable for transplantation.

Biological thresholds of cold-induced phrenic nerve injury.

The effects of controlled cooling on phrenic nerve signal conduction were investigated by cooling an isolated segment of the phrenic nerve with a constant but variable temperature probe. The conduction of a standard electrical stimulus applied to the nerve proximal to the cooled section was measured by detector electrodes sutured to the diaphragm. Nerve conduction of the applied stimulus ceased between 10 degrees and 12 degrees C but returned within seconds after the probe was removed. The delay in the return of conduction increased as nerve temperature decreased until at a temperature of 4 degrees C the ability to conduct did not return after 4 hours. The amount of fat surrounding the nerve and the blood flow rate along the cooled portion of the nerve were observed to ameliorate the effects of low temperature on stimulus conduction. Total body cooling also appears to offer some protection against loss of conduction.

Morbid prognostic features in patients with chronic liver failure undergoing nonhepatic surgery.

BACKGROUND: Although the risk of portal decompression surgery is accurately predicted by objective scoring systems (Child classification and Pugh score), few useful prognostic criteria exist regarding nonhepatic surgery in patients with chronic liver failure. OBJECTIVE: To evaluate the clinical findings associated with perioperative mortality in patients with chronic liver failure undergoing nonhepatic surgery. DESIGN: A retrospective cohort study. SETTING: University teaching hospitals. PATIENTS: Forty consecutive patients with an International Classification of Diseases, Ninth Revision (ICD-9), diagnosis of chronic liver failure and one or more of the following: jaundice, cirrhosis, chronic hepatitis, or alcoholism. INTERVENTIONS: Forty operations, including 28 abdominal procedures, 2 coronary artery bypass grafts, 5 orthopedic procedures, and 5 miscellaneous procedures. MAIN OUTCOME MEASURES: Thirty-day mortality as related to 19 preoperative clinical and laboratory variables. RESULTS: Eleven (28%) of the patients died within 30 days of surgery. By univariate analysis, the following variables were significantly (P < .05, pearson chi 2 test for categorical data or Mann-Whitney U test for continuous data) associated with nonsurvival: encephalopathy, congestive heart failure, the need for emergent surgery, infection, hyperbilirubinemia, international normalized ratio greater than 1.6, hypoalbuminemia, and an elevated creatinine level. By multiple logistic regression analysis, an international normalized ratio greater than 1.6 and encephalopathy were associated with a greater than 10- and 35-fold increased mortality risk, respectively. Child classification and Pugh score failed to predict 30-day mortality. CONCLUSIONS: We identified 8 clinical and laboratory variables associated with death within 30 days in patients with chronic liver failure undergoing nonhepatic surgery. Two factors-international normalized ratio greater than 1.6 and encephalopathy-independently predicted mortality by multivariate analysis. Neither Child classification nor Pugh score was prognostically helpful. Nonhepatic surgery confers a substantial mortality risk in patients with chronic liver failure.

Results of a pilot trial comparing prolonged intravenous antibiotics with sequential intravenous/oral antibiotics for children with perforated appendicitis.

HYPOTHESIS: For children with perforated appendicitis, the use of a prolonged course of intravenous (i.v.) antibiotics is equivalent to a short course of i.v. antibiotics followed by sequential conversion to oral (PO) antibiotics. DESIGN: Prospective, randomized, clinical trial. SETTING: Multicenter study in tertiary children's hospitals. PATIENTS: Children (aged 5-18 years) with perforated appendicitis found at laparotomy. INTERVENTION: Children were randomized after appendectomy either to a 10-day course of a combination of i.v. ampicillin, gentamicin sulfate, and clindamycin (n = 10); or to a short course of a combination of i.v. ampicillin, gentamicin, and clindamycin, followed by conversion to a combination of p.o. amoxicillin and clavulanate potassium plus metronidazole (n = 16). MAIN OUTCOME MEASURES: The primary outcome measure was clinical success, which was rated as complete, partial, or failure. Secondary outcome measures included return of oral intake, duration of fever, return of normal white blood cell count, and patient charges. Treatment equivalence was determined using confidence interval analysis. RESULTS: We found treatment equivalence between the i.v. and i.v./p.o. groups, with 6 (60%) complete and 4 (40%) partial successes for the 10 patients in the i.v. group and 15 (94%) complete and 1 (6%) partial successes for the 16 patients in the i.v./p.o. group (P< or =.05). There was no difference in return of oral intake, duration of fever, or return of normal white blood cell count between the groups. Conversion to oral therapy results in savings of approximately $1500 per case. CONCLUSION: There is treatment equivalence between prolonged i.v. therapy and i.v. therapy followed by conversion to oral antibiotic therapy in children with perforated appendicitis.

Can AIDS be prevented after injury with contaminated instruments?

Particulate matter comparable in size with that of human immunodeficiency virus was subcutaneously injected into experimental animals. Such matter remained at the inoculation site long enough to suggest the possibility that human immunodeficiency virus can be destroyed in loco before it invades the host's circulation. These findings may be useful in developing a method to prevent acquired immunodeficiency syndrome after accidental injury with human immunodeficiency virus-contaminated instruments.

Prevention of retrovirus infection after injury with contaminated instruments: an experimental study.

Owing to similarities between human immunodeficiency virus and feline retroviruses, the feline model was chosen for the study to investigate the efficacy of timely topical treatment of accidental human immunodeficiency virus infection in the operating room. Cats were subcutaneously inoculated with either feline leukemia virus or feline immunodeficiency virus. An effort was made to neutralize the virus in loco either by infiltration of the inoculation site with povidone-iodine or with monoclonal antibodies, or by cauterization and excision. The animals were periodically monitored for feline leukemia virus antigens or for feline immunodeficiency virus antibodies. The results indicated that in the feline model, the development of generalized virus infection may be prevented by local measures if applied immediately.

Prenatal diagnosis: essentials for the pediatric surgeon.

Prenatal diagnosis is a rapidly growing field that has supported new treatments for the developing fetus. Improved methods of diagnosing anatomic, biochemical, and molecular defects of the fetus have fostered a parallel growth of better techniques of fetal therapy. A fundamental knowledge of the basic uses and limitation of prenatal diagnosis is essential for the practicing pediatric surgeon. This review summarizes clinical uses and recent advances in various methods of prenatal diagnosis, including ultrasound, fetal echocardiography, amniocentesis, chorionic villus sampling, fetal blood sampling, alpha-fetoprotein, and DNA analysis. For each technique, the common indications, risks, and clinical utility are discussed.

Current management of pediatric inflammatory bowel disease.

Inflammatory bowel disease (IBD) is a relatively rare condition of childhood, although the wide range of presenting complaints, scope of complications, and choices of therapy for this condition make it particularly difficult to treat in children. Novel approaches to the management of Crohn's disease and ulcerative colitis have gained recent favor. This report summarizes the current medical and surgical management of IBD, recent advancements in clinical therapies, and particular aspects of IBD care for children.

Platelet alpha 2-adrenergic receptors in schizophrenic patients before and after phenothiazine treatment.

The specific binding to isolated platelet membranes of 3H-clonidine, an alpha 2-adrenergic receptor partial agonist, and 3H-yohimbine, an alpha 2-adrenergic receptor antagonist, was measured in male, drug-free schizophrenic patients. The maximum number of binding sites (Bmax) for 3H-yohimbine was significantly lower in these patients than in normal subjects. Treatment with chlorpromazine (CPZ) for 2 weeks further decreased the Bmax for both ligands. Plasma catecholamine levels were determined before and after treatment. Before treatment, levels of dopamine and norepinephrine (NE) were within a normal range, while epinephrine (E) levels were significantly elevated. CPZ treatment significantly increased plasma NE levels, but decreased E levels to a normal range. These observations suggest that schizophrenia might be associated with abnormal noradrenergic function that is reflected by a decreased number of platelet alpha 2-adrenergic receptors.

Fluid therapy for the pediatric surgical patient.

The fluid management of the pediatric surgical patient is a crucial aspect of surgical care. This article reviews the fundamental physiology of fluid replacement in children and highlights how standard formulas for fluid therapy can be modified to account for the rapidly changing physiology of the pediatric surgical patient. Novel approaches to fluid treatment of the surgical patient with oral rehydration formulas are discussed. Finally, guidelines for specific management of common pediatric surgical diseases are presented.

Care of the surgical intensive care nursery graduate. The primary care pediatrician's perspective.

Care of the intensive care nursery graduate may be quite challenging. It is important that primary care pediatricians become familiar with the complications unique to surgical patients so that they may properly prepare and educate parents and provide appropriate long-term follow-up for these often complex patients. Maintenance of a close relationship with the pediatric surgeon with an open line of communication regarding the approach to various surgical problems facilitates the effective integration of the intensive care nursery graduate into the primary care pediatrician's practice and provides the foundation for a successful clinical outcome.

An effective strategy for decontamination, ex vivo expansion, and storage of human fetal liver hematopoietic stem cells.

The transplantation of human fetal tissue has the potential to cure a variety of life-threatening diseases. The strategy for procurement, quality control, and functional assessment of human fetal liver HSC may prove useful for the transplantation of other fetal tissues. In addition to technical limitations, there are ethical and legal issues which need to be resolved before widespread use of fetal tissue. Further development of regulatory standards for the acquisition and distribution of fetal tissues will foster the application of this novel technology.

Vascular control for resection of suprahepatic intracaval Wilms' tumor: technical considerations.

The surgical resection of Wilms' tumor can be complicated by tumor thrombus extension into the inferior vena cava. In cases of suprahepatic Wilms' tumor thrombus that may extend into the right atrium, a median sternotomy and cardiopulmonary bypass (CPB) are used to facilitate tumor resection. However, if the tumor can be localized and controlled below the atrium, resection without the use of cardiopulmonary bypass may limit morbidity. The authors describe a novel approach to tumor thrombectomy for a Wilms' tumor extending to the suprahepatic vena cava without the use of CPB. The authors used transesophageal echocardiography to localize the tumor thrombus and detect any tumor or air embolization and a minimal lower sternotomy to obtain intrapericardial control of the inferior vena cava. This technique may be useful in selected cases of Wilms' tumor as an alternative to median sternotomy and use of cardiopulmonary bypass.

Familial diaphragmatic agenesis: an autosomal-recessive syndrome with a poor prognosis.

Diaphragmatic agenesis is a severe form of congenital diaphragmatic hernia for which an autosomal recessive form of inheritance has been proposed. The authors report six families with 13 pregnancies with diaphragmatic agenesis in which inheritance followed an autosomal recessive pattern, including the first reported case of bilateral diaphragmatic agenesis in twins. None of the thirteen affected fetuses survived. Familial diaphragmatic agenesis appears to be a distinct clinical entity with a worse prognosis than posterolateral diaphragmatic hernia.

Massive thymic hyperplasia: characterization of a rare mediastinal mass.

Thymic hyperplasia is a rare cause of an anterior mediastinal mass in children. True thymic hyperplasia is characterized by massive thymic hypertrophy with retention of normal thymic architecture, and must be distinguished from more commonly seen tumors of the anterior mediastinum. Previous reports of thymic hyperplasia primarily have been descriptive, with minimal analysis of the cellular characteristics of the tumor. To better describe the cellular characteristics of thymic hyperplasia, the authors report on a 10-year-old boy found to have an asymptomatic left paracardiac mass during cardiac evaluation. The mass enlarged rapidly during the following 2 weeks and filled the entire left side of the chest. An open biopsy specimen showed normal thymic architecture. Because of the size and rapid growth of the mass, the authors decided to resect it. Cellular analysis of the mass did not show differences from normal thymic elements. There was conserved thymic architecture. The expression of cell surface markers and the proliferative response of thymocytes to cytokines appeared to be normal. Similarly, a long-term cell culture of the thymocytes did not result in clonal proliferation. Immunohistologic staining of stromal cells showed no striking differences from normal thymic elements. Moreover, immunologic analysis of the patient by standard hematological parameters, lymphocyte subsets, quantitative immunoglobins, and immunoelectrophoresis showed no abnormalities except for lymphocytosis, which resolved after tumor resection. The authors conclude that thymic hyperplasia occurs in immunologically normal children and may exhibit (1) rapid growth with minimal associated symptoms, (2) normal thymic architecture, (3) normal thymocyte and stromal growth characteristics in vitro, and (4) a normal thymocyte response to cytokine stimulation.(ABSTRACT TRUNCATED AT 250 WORDS)