Intractable wheezing in infants with nasopharyngeal reflux

Two infants with intractable wheezing and moist cough were referred to Chiba Municipal Kaihin Hospital. Their symptoms were persistent even after the usual treatment for respiratory disease. No definite etiological agents were detected. They usually gagged while feeding and barium swallow tests revealed nasopharyngeal reflux and cricopharyngeal incoordination. One of the patients had remarkably high titers of IgE and IgE RAST of cow's milk before she received treatment with thickened formula. She also had peripheral eosinophilia and nasal eosinophilia. These findings were thought to be caused by nasopharyngeal reflux. Four months after therapy commenced, those titers and symptoms were greatly reduced. The clinical and roentgenographic findings in these infants, and their response to therapy, strongly support a causal relationship between nasopharyngeal reflux and wheezing. Therefore, nasopharyngeal reflux should be considered when a baby has intractable wheezing, even when there is no developmental problem.     

A New Technique for Reconstruction of the Cervical Trachea for the Treatment of Thyroid Cancer with Tracheal Invasion

We successfully reconstructed the airway after wide and circularresection of the trachea up to 12 rings for the treatment ofadvanced thyroid cancer. The technique is as follows:

1. The affected trachea is resected widely and an end-to-end anastomosisof the cut ends of the remaining trachea with a half defectdue to the insufficient tracheal wall is performed.
2. The tracheostomais built in the above defect.
3. Later, the tracheostoma is closedwith two sequential skin flaps.

We have applied this new technique to three patients so far,and have found no later complications. The technique seems tobe very useful for the treatment of thyroid cancer with trachealinvasion.     

Pull-Through Esophagectomy Without Thoracotomy

Twenty patients with carcinoma of the hypopharynx, esophagusand thyroid underwent pull-through esophagectomy. Seventeenof them received combined resection of the larynx and trachea.Dissection of the lymph nodes at the upper mediastinum was performedin 11 patients by sternotomy. Seven patients received mediastinaltracheostomy after combined resection of the trachea and thelarynx. Pull-through esophagectomy was followed by pharyngogastrostomywithout thoracotomy via the posterior mediastinum. This techniqueis described in detail. Because there is no thoracotomy andligation of the esophageal vessels is ensured, no pulmonarycomplications and no massive mediastinal hemorrhages occurred.There were no operative deaths. This operation offers excellentpalliation and little morbidity. Moreover, the use of sternotomyand mediastinal tracheostomy for pull-through esophagectomymade it possible to dissect the upper mediastinal lymph nodes,and we could resect the affected trachea with certainty.     

Periodic limb movements and sleep-wake disorder

Abstract The relationship of periodic limb movements (PLM) and Sleep-wake disorders in 11 patients was investigated. Two patients complained of insomnia. A patient with cervical spinal canal stenosis had a complaint of difficulty in initiating sleep. Movement index (MI) was 51 and PLM arousal index was 8. A patient with chronic hemodialysis had a complaint of difficulty in initiating and maintaining sleep. MI was 79 and PLM arousal index was 51. One patient with myotonic dystrophy showed 79 in MI and 3 in PLM arousal index. It is suspected that myotonic dystrophy is less sensitive to stimuli during sleep (i.e. PLM). These results suggest that the sleep-wake disorders associated with PLM relate to the threshold of awakening.     

A case of urethral prolapse in a young girl

Urethral prolapse is rarely reported in the pediatric literature. We report a 4 year old female with urethral prolapse and discuss the etiology and the treatments in children documented in the literature.     

A specific chromosome abnormality of t(4;12)(qll-12;pl3) in CD7+ acute leukaemia

Summary. Three cases of acute leukaemia with t(4;12) (qll-12;pl3) karyotypic abnormalities were analysed. They had the following common clinical and biological characteristics: (1) dysplasia of three haemopoietic lineages; (2) absent or low myeloperoxidase activity; and (3) retention of platelets in the peripheral blood and megakaryocytes in the bone marrow. There were increased numbers of basophils in the bone marrow and peripheral blood in two of the cases. In all, the blast cells displayed the unique immunophenotype CD7⁺CD13⁺CD34⁺HLA-DR⁺. The blasts analysed in one case expressed c-kit on the membrane surface. These findings suggest that the t(4:12) (qll-12:pl3) abnormality is associated with a particular type of acute leukaemia, one in which the morphology and immunophenotype suggest that the translocation may have occurred at an early stage of haemopoiesis.     

Allergenic epitopes of ovalbumin (OVA) in patients with hen's egg allergy: inhibition of basophil histamine release by haptenic ovalbumin peptide

We studied allergenic determinants that induce hypersensitivity to OVA, the major allergen in egg allergy, using immunoblot and histamine release assays. Immunoblot analysis demonstrated a part of the OVA epitope was in the C-terminal region comprising residues 347-385 (OVA347-385). Histamine was released from basophils of a patient with egg allergy upon stimulation with the OVA fragment corresponding to OVA347–385. Furthermore, detailed epitope mapping using overlapping peptides (residues 347-366, OVA-A; residues 357-376, OVA-B; and residues 367-385, OVA-C) in the OVA 347-385 region was carried out using the histamine release assay. In order for histamine release from basophils to occur, the allergen must possess two or more allergenic determinants located on the protein molecule at distances that would be equivalent to the distances between IgE molecules on the membrane surface. These results suggest that there are at least two epitopes that bind IgE antibodies on each OVA peptide. In addition, one epitope that binds IgE antibodies in two patients appears to reside in the haptenic peptide OVA357-366 (OVA-B1). The histamine release from basophils stimulated by OVA-B was completely inhibited by OVA-B1 in one of these patients. Similarly, OVA-B1 inhibited the histamine release produced by OVA-A in the other by more than 40%. These results suggest that haptenic synthetic peptides could regulate the allergic reaction in the effector phase if common epitope(s) recognized by IgE antibodies in the patients with egg allergy can be found. These are the first studies that provide an antigen-specific approach to inhibiting histamine release from basophils by a haptenic peptide recognized by IgE antibodies in an allergic disorder.     

Assessment of energy status and fructose metabolism of liver in obstructive jaundice by 31P magnetic resonance spectroscopy

The effect of cholestasis on hepatic energy status and fructose metabolism in jaundiced rats and patients was investigated using ³¹P magnetic resonance spectroscopy. Rats with obstructive jaundice (OJ group) were studied 7 days after bile duct ligation. Drainage rats were studied at 3 days (DR3 group) and 7 days (DR7 group) after the relief of 1 week obstruction of the common bile duct. In the bile duct ligated rat, the β-adenosine triphosphate (ATP)/Pi (inorganic phosphate) ratio was significantly lower than in sham-operated controls. This ratio recovered rapidly in the DR3 and DR7 groups. The maximum increase in the phosphomonoester peak (PMEmax) after an intravenous bolus of fructose was significantly reduced in both the OJ and DR3 groups, and was accompanied by a decrease in hepatic fructokinase activity. The PMEmax and the fructokinase activity recovered in the DR7 group. In a clinical study, the β-ATP/Pi ratio in six healthy volunteers was comparable to that of 15 patients with obstructive jaundice, regardless of their biliary drainage status. The PMEmax in all patients (serum bilirubin ≥ 5 mg/dL), irrespective of biliary drainage, was significantly lower than in volunteers. Furthermore, the PMEmax in four of the eight patients with biliary drainage (serum bilirubin < 5 mg/dL) was lower than in volunteers. It is concluded that while energy status in jaundiced patients is well maintained, fructose phosphorylation is inhibited and recovery is delayed after the relief of obstruction compared with serum bilirubin. For the non-invasive evaluation of damaged liver function in jaundice, ³¹P magnetic resonance spectroscopy is a useful technique.     

Nasopharyngeal colonization with Haemophilus influenzae type b among infants and children in Japan

Healthy carriers of Haemophilus influenzae type b (Hib) play an important role in the spread of invasive Hib disease. The aim of the present study was to estimate Hib colonization among infants and children in Japan. Specimens from throat and nasopharyngeal cultures were obtained by thorough swabbing of both tonsils and the posterior pharynx. Specimens were inoculated on Hib antiserum agar. This was prepared with Levinthal base and Hib antiserum. Conventional methods were used concomitantly. Four of 474 infants from 1–48 months of age (0.84%) had Hib cultured from their nasopharynx. The carriage rate in 1–12 month old infants was 0.62% (2/322 cases), and that in 13–48 month old children was 1.32% (2/152 cases). Five of 167 (3.0%) 13-year-old children, and five of 154 (3.2%) 9-year-old children were asymptomatic carriers. Thirty-five of 104 household contacts of a patient with invasive Hib disease (33.6%) had Hib colonization. The carriage rate in healthy Japanese children may not be different from that in the USA prior to the availability of the conjugate Hib vaccine. The Hib carriage rate in household contacts of patients with invasive Hib disease was higher than in healthy children (P < 0.005). Our results suggest the possibility of an outbreak of invasive Hib disease in Japan.