PERNICIOUS ANEMIA IN CHILDHOOD REPORT OF CASE IN SIX YEAR OLD GIRL RESPONDING TO REFINED LIVER EXTRACT, FOLIC ACID AND VITAMIN B12 IN SUCCESSIVE RELAPSES

A case of megaloblastic anemia without specific neurologic complications in a6 year old girl is presented as an example of pernicious anemia in childhood despitethe fact that a small amount of free hydrochloric acid was present in the gastricjuice after injection of histamine. Prompt hematologic response was obtained following administration of refined liver extract, folic acid and vitamin B₁₂ in successive relapses.

     

FIBRIN CUFF LYSIS IN CHRONIC VENOUS ULCERS TREATED WITH A HYDROCOLLOID DRESSING

Background. Pericapillary fibrin cuffs (PFC) are a recognized part of the pathology of venous stasis ulcers. A hydrocolloid dressing capable of lysing wound surface fibrin was tested in venous ulcers for its capacity to lyse pericapillary fibrin below the wound surface. Methods. Tissue biopsies from the rims of 19 venous ulcers were evaluated for thickness of shallow and deep dermal PFCS before and after treatment with DuoDERM covered by Unna's boot and a compression bandage (DD+UB; n=9) versus the same treatment without the hydrocolloid dressing (UB; n=10). Frozen sections of all biopsies were stained with an immunofluorescent antibody to fibrin for rating of PFC thickness. Separate sections were stained with hematoxylin and eosin to assess capillary frequency, histopathology, and inflammation. All ratings and pathology assessments were performed blinded to treatment conditions. Results. Both deep and shallow PFCS were reduced in 89% of ulcers treated with DD+UB versus 40% of ulcers treated with UB (α < 0.04). No other significant differences in inflammation, histopathology, or capillary frequency were observed. Conclusions. Treatment with DD+UB reduced PFCS in twice the number of ulcers than UB alone in 1 week. This is the first scientific documentation that a topical wound dressing could reduce the pathophysiology associated with venous ulcers, beyond the known beneficial effect of graduated compression. Not all hydrocolloid dressings are fibrinolytic, so this effect may not generalize to other dressings.     

Antibodies to Plasmodium falciparum gamete surface antigens in Papua New Guinea sera

Sera from individuals living in malaria endemic areas of Papua New Guinea were tested for their effect on infectivity of Plasmodium falciparum gametocytes grown in culture to Anopheles freeborni mosquitoes. Consistent reduction of infectivity to less than 5% of control was observed with nine out of the 41 sera from the endemic area tested and also with three out of seven sera tested from individuals rarely exposed to malaria infection. Gamete surface antigens recognized by the sera were investigated by immunoprecipitation from 125I surface-labelled gametes extracted in SDS and Triton X-100. The main antigens recognized were of the same mol. wt (230, 48 and 45 kD) as those known to be targets of transmission-blocking monoclonal antibodies. A significant negative correlation was observed between the total ct/min immunoprecipitated from surface-labelled gametes by the sera and the average number of oocysts per gut observed in membrane feeding experiments with these sera. Spearmann's rank correlation coefficient indicated that suppression of infectivity correlated strongly with the presence of antibodies against the 230 kD protein; there was no significant correlation between suppression and antibodies to the 48/45 kD proteins. The antibody response to the different gamete surface antigens varied greatly in sera from the endemic areas suggesting that individuals respond differently to each gamete antigen.     

Disclosure,Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation

Context: The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. Methods: Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. Findings: We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles. Conclusions: Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.     

Postoperative Heart Block in Children with Common Forms of Congenital Heart Disease: Results from the KID Database

Postoperative Heart Block in Congenital Heart Disease. Introduction: Cardiac conduction system injury is a cause of postoperative cardiac morbidity following repair of congenital heart disease (CHD). The national occurrence of postoperative complete heart block (CHB) following surgical repair of CHD is unknown. We sought to describe the occurrence of and costs related to postoperative CHB following surgical repair of common forms of CHD using a large national database. Methods and Results: Retrospective, observational analysis performed over a 10‐year period (2000–2009) using the Kids’ Inpatient Database (KID). Visits for patients ≤24 months of age were identified who underwent surgical repair of ventricular septal defects (VSD), atrioventricular canal defects (AVC), and tetralogy of Fallot (TOF). Patients were identified who were diagnosed with postoperative CHB, further identifying those requiring a new pacemaker placement during the same hospitalization. Costs associated with visits were calculated. There were 16,105 surgical visits: 7,146 VSD, 3,480 AVC, and 5,480 TOF. There was a decrease in postoperative mortality (P = 0.0001) with no significant change in postoperative CHB. Hospital stay and cost were higher with CHB and placement of a permanent pacemaker. Repair of AVC (OR 1.77; [1.32–2.38]) was associated with a higher rate of postoperative CHB. Length of hospital stay and total cost were significantly increased with the development of postoperative CHB and increased further with placement of a permanent pacemaker. Conclusion: There has been little change over time in the frequency of postoperative CHB in patients undergoing repair of VSD, AVC, and TOF. Postoperative CHB results in major added cost to the healthcare system. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1349‐1354, December 2012)     

Endoscopic Diagnosis of a Giant Esophageal Leiomyosarcoma

A giant polypoid lesion of the cervical esophagus was discovered on barium swallow in a patient with minimal dysphagia. Endoscopy revealed a whitish, polypoid intraluminal mass with superficial ulcerations and mucosal biopsies, necrotic epithelium plus spindle cells consistent with leiomyoma. At exploration, a leiomyosarcoma with microvascular invasion was excised. The clinical features and value of endoscopic biopsies are reviewed for this and other cases reported in the literature.     

Immunological properties of recombinant proteins of the transmission blocking vaccine candidate, Pfs48/45, of the human malaria parasite Plasmodium falciparum produced in Escherichia coli

A precondition for the development of a transmission blocking vaccine based on the sexual stage-specific surface antigen Pfs48/45 of Plasmodium falciparum is its heterologous synthesis in a native state. Here we describe the production of recombinant Pfs48/45 in Escherichia coli . Two recombinant proteins, of which one is a glutathione-S-transferase fusion protein, were produced. Enzyme-linked immunosorbent assays showed that at least a subfraction of the recombinant proteins had a conformation capable of binding transmission blocking monoclonal antibodies. However, despite the fact that both proteins were very immunogenic, they did not induce transmission blocking immunity in mice or rabbits. Immunological studies with congenic mouse strains demonstrated that immune responses could be boosted with gametocyte extracts and were not restricted to a particular class II major histocompatibility complex haplotype .     

Evaluation of a Flexible Endoscope for Laparoscopy

Thirty patients underwent diagnostic laparoscopy using an unmodified Olympus GIF-P2 fiberendoscope. Both feasibility and safety of the fiberoptic instrument were evaluated. Compared to conventional laparoscopy, a greater area of the peritoneal cavity was visualized, and biopsies and photographs were successfully obtained. There were neither mechanical nor infectious complications. As has occurred in other areas of endoscopy, use a flexible instrument for laparoscopy appears to offer advantages over conventional rigid laparoscopes.