Combination of soy protein and high dietary calcium on bone biomechanics and bone mineral density in ovariectomized rats

OBJECTIVE: To determine if feeding soy in combination with a high-calcium diet would preserve bone mineral density and biomechanical bone strength to a greater extent than either soy or calcium alone. DESIGN: Rats were sham-operated (n = l0) and fed a control diet (AIN93G containing 0.2% calcium, 20% casein) or ovariectomized (n = 40) and randomized to one of the following diets (n = 10 per group): control, high calcium (2.5% calcium, 20% casein), soy (0.2% calcium, 20% soy protein), or soy plus high calcium (2.5% calcium, 20% soy protein) for 8 weeks. Bone mineral density of femurs and lumbar vertebrae 1 through 6 were measured by dual energy x-ray absorptiometry. Biomechanical strength properties of femurs and the fifth lumbar vertebrae were measured by three-point bending and compression, respectively. RESULTS: The dietary combination of soy and high calcium did not result in higher femur bone mineral density compared with other ovariectomized groups, and there were no differences in femur yield load or peak load among groups. In contrast, soy plus high calcium resulted in a higher (P < 0.05) vertebral bone mineral density compared with all other ovariectomized groups. Vertebral strength was preserved among rats fed either soy plus high calcium, soy, or high calcium whereas the ovariectomized group fed a control diet had lower (P < 0.05) vertebral strength than the sham-operated group. CONCLUSION: Bone mineral density of the lumbar spine was the only bone outcome that significantly benefited from the combination of soy and high calcium compared with soy or high calcium alone.     

Methylphenidate HCl: therapy for attention deficit hyperactivity disorder

Methylphenidate is a first-line therapy for attention deficit hyperactivity disorder, the most prevalent neuropsychiatric disorder of childhood. The compound is a piperidine and the D-threo-isomer is considered the biologically active form. The compound is available in multiple short- and long-acting preparations, having different delivery systems leading to varying kinetics without clear superiority in efficacy or tolerability at the group level. Common adverse effects are insomnia, appetite disturbance, stomach ache, headache and dizziness. Its mechanism of action is linked to the monoamines dopamine and norepinephrine. The compound appears to predominantly increase the synaptic concentration of dopamine, presumably via inhibition of the dopamine transporter DAT1. There also appears to be effects on presynaptic vesicular trafficking and distribution of dopamine. Both immediate- and sustained-release preparations of methylphenidate have proven efficacy in children and adults with attention deficit hyperactivity disorder. Analysis of the National Institutes of Health-sponsored multimodal treatment study of attention deficit hyperactivity disorder supports a combined medication and behavioral therapy approach.     

Seizures and metabolic disease

Seizures represent an important clinical manifestation of inborn errors of metabolism. The presence of myoclonic seizures and very early onset are clues to a metabolic disorder. Specific correlations between age of seizure onset and electroencephalogram patterns with inborn errors of metabolism are discussed. The explosion of information in neurogenetics and metabolism mandates increasing awareness of appropriate metabolic diagnostic and therapeutic strategies in the setting of certain epilepsies. Specific laboratory, imaging, and treatment considerations are included to present updated material in a field that continues to expand rapidly.     

Transfusion related acute lung injury: a pediatric perspective

Transfusion-related acute lung injury (TRALI) is the leading cause of transfusion-associated mortality. TRALI occurs in children and adults, but the syndrome has not been reviewed from a pediatric perspective. We reviewed the literature on TRALI from a pediatric perspective. TRALI has been documented in pediatric patients, especially in the setting of hematologic malignancy. Additional TRALI cases have been reported in pediatric patients with a variety of diagnoses. TRALI is likely to be much more common than previously appreciated in the pediatric patient population. TRALI should be considered in the differential diagnosis of all pediatric patients who develop new acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) during or within six hours of a blood product transfusion. When a case of TRALI is suspected, a transfusion reaction report to the blood bank is important to initiate the investigation and identify the implicated donor.     

Choosing abdominal incision and closure techniques: a review

This review summarizes contemporary concepts of abdominal surgical incision creation and closure. The Ovid computerized database was searched for articles published in English from 1996 to 2003 using keywords pertaining to the specific topic of interest (e.g., suture, drain, surgical technique, fascia). Human prospective, randomized trials; meta-analyses; and evidence-based-focused reviews were assessed and data abstracted. Several earlier and animal-based studies on specific issues were included. The data indicate that: (1) the direction of the incision should be based upon obtaining adequate exposure; (2) hair should either be left in place or clipped at the time of surgery; (3) a single dose of prophylactic antibiotics should be given 30 minutes prior to surgery; (4) using a "deep" scalpel is unnecessary; (5) a scalpel and electrocautery are comparable for deepening the incision; (6) minimal peritoneal lavage with non-antibiotic containing solutions is adequate; (7) the peritoneum should not be routinely closed; (8) the fascia should be loosely approximated by a continuous mass closure using a slowly absorbable, monofilament suture with the smallest possible caliber and a suture:wound length ratio of at least 4:1; (9) retention sutures, subcutaenous sutures and drains do not appear to reduce the risk of wound complications; and (10) the skin may be closed in a variety of methods, but a semiocclusive dressing should be applied. As scientific evidence accumulates to refute traditional dogma, management of the surgical patient has undergone substantial changes. Surgeons should now be able to create and close an abdominal wound based upon sound scientific principles rather than simply "doing what I always do."     

Preoperative glucocorticoids decrease pulmonary hypertension in piglets after cardiopulmonary bypass and circulatory arrest

BACKGROUND: Glucocorticoids during cardiopulmonary bypass benefit pediatric patients undergoing repair of congenital heart defects and are routine therapy, but underlying mechanisms have not been fully examined. The hypothesis was that glucocorticoids could improve cardiopulmonary recovery after cardiopulmonary bypass and deep hypothermic circulatory arrest. METHODS: Crossbred piglets (5 to 7 kg) were cooled with cardiopulmonary bypass, followed by 120-min deep hypothermic circulatory arrest. Animals were then warmed to 38 degrees C, removed from bypass, and maintained for 120 min. Methylprednisolone (60 mg/kg) was administered in the cardiopulmonary bypass pump prime (intraoperative glucocorticoids) or 6 hours before bypass (30 mg/kg) in addition to the intraoperative dose (30 mg/kg; preoperative and intraoperative glucocorticoids). Controls (no glucocorticoids) received saline. RESULTS: Pulmonary vascular resistance in controls increased from a baseline of 152 +/- 40 to 364 +/- 29 dynes. s/cm(5) at 2 hours of recovery (p < 0.001). Intraoperative glucocorticoids did not alleviate the increase in pulmonary vascular resistance (301 +/- 55 dynes. s/cm(5) at 2 hours of recovery, p < 0.001). However, animals receiving pre and intraoperative glucocorticoids had no increase in pulmonary vascular resistance (155 +/- 54 dynes. s/cm(5)). Plasma endothelin-1 in controls increased from 1.3 +/- 0.2 at baseline to 9.9 +/- 2.0 pg/mL at 2 hours recovery (p < 0.01), whereas glucocorticoid-treated animals had lower endothelin-1 levels (4.5 +/- 2.1 pg/ml, preoperative and intraoperative glucocorticoids; 4.9 +/- 1.7 pg/mL, intraoperative glucocorticoids) at the end of recovery (p < 0.05). Intracellular adhesion molecule-1 in lung tissue was lower in animals receiving pre and intraoperative glucocorticoids (p < 0.05). Myeloperoxidase activity was elevated in control lungs at 2 hours of recovery compared with glucocorticoid-treated groups (p < 0.05). Inhibitor kappaBalpha, the inhibitor of nuclear factor-kappaB, was higher in lungs of animals receiving glucocorticoids compared with controls (p < 0.05). CONCLUSIONS: Glucocorticoids prevented pulmonary hypertension after cardiopulmonary bypass and deep hypothermic circulatory arrest, which was associated with reduced plasma endothelin-1. Glucocorticoids also reduced pulmonary intercellular adhesion molecule-1 and myeloperoxidase activity. Inhibition of nuclear factor-kappaB, along with reduced neutrophil activation, contributed to glucocorticoid alleviation of pulmonary hypertension after cardiopulmonary bypass and deep hypothermic circulatory arrest.     

Sildenafil citrate alleviates pulmonary hypertension after hypoxia and reoxygenation with cardiopulmonary bypass

BACKGROUND: Sudden reoxygenation of hypoxic neonates undergoing cardiac operation exacerbates the systemic inflammatory response to cardiopulmonary bypass secondary to reoxygenation injury, worsening cardiopulmonary dysfunction. Reports suggest sildenafil decreases pulmonary hypertension and may affect myocardial function. Sildenafil's efficacy for treating postbypass cardiopulmonary dysfunction remains unknown. STUDY DESIGN: Fourteen neonatal piglets (5 to 7 kg) underwent 90 minutes of hypoxia, 60 minutes of reoxygenation with cardiopulmonary bypass, and 120 minutes of recovery. Six animals received 50 mg oral sildenafil and eight received saline at hypoxia. Data are presented as mean +/- SD. RESULTS: Sildenafil prevented the high pulmonary vascular resistance observed in controls (controls baseline 81 +/- 37 dynes. s/cm(5) versus recovery 230 +/- 93 dynes. s/cm(5), p = 0.004; sildenafil baseline 38 +/- 17 dynes. s/cm(5) versus recovery 101 +/- 60 dynes. s/cm(5), p = 0.003). Despite lower pulmonary vascular resistance after sildenafil, arterial endothelin-1 (ET-1) was increased in both groups (control baseline 1.3 +/- 0.5 pg/mL versus recovery 4.5 +/- 3.7 pg/mL, p = 0.01; sildenafil baseline 1.3 +/- 0.3 pg/mL versus recovery 9.8 +/- 4.9 pg/mL, p = 0.003). Intravenous nitric oxide (NO) levels were preserved after sildenafil treatment (sildenafil baseline 340 +/- 77 nM versus recovery 394 +/- 85 nM). IV NO levels in controls were decreased when compared with baseline (control baseline 364 +/- 83 nM versus recovery 257 +/- 97 nM, p = 0.028). Although levels of exhaled NO decreased in both groups, the sildenafil-treated animals had higher levels of exhaled NO when compared with controls at the end of recovery (0.6 +/- 0.4 parts per billion versus 1.8 +/- 0.9 parts per billion, respectively, p = 0.029). CONCLUSIONS: Sildenafil alleviated pulmonary hypertension after reoxygenation with cardiopulmonary bypass. Despite increased ET-1 levels, pulmonary vascular resistance was lower with sildenafil treatment, suggesting sildenafil's effect on the pulmonary vasculature is capable of countering vasoconstriction by ET-1. Further study into the role of sildenafil in perioperative therapy and its interactions with ET-1 are warranted.     

Recipients of blood from a donor with multiple HLA antibodies: a lookback study of transfusion-related acute lung injury

BACKGROUND: The effects of transfusion of HLA antibodies to patients with corresponding antigens are not well known. STUDY DESIGN AND METHODS: Records of patients who received blood from previous donations of a donor implicated in a case of transfusion-related acute lung injury (TRALI) were examined. The donor had multiple HLA antibodies reactive with 96 percent of HLA Class I antigens and 88 percent of HLA Class II antigens. RESULTS: Among 103 patients (40 with a pretransfusion white blood cell [WBC] count of >/=3.5 x 10(9)/L), 1 patient met criteria for TRALI and had clinical evidence for diffuse alveolar hemorrhage. Among the subset of 55 patients (17 with a pretransfusion WBC count of 3.5 x 10(9)/L) with known HLA types, none developed TRALI even though 54 (98%) had one to five corresponding HLA antigens. In a subgroup of patients four of 62 patients with chest radiographs, developed new or worse bilateral infiltrates with implicated but not control units (p = 0.0625). CONCLUSION: Transfusion of HLA antibodies from this donor to nonneutropenic patients did not cause TRALI, but there was a trend of an association with new or worse bilateral pulmonary infiltrates. Further research is needed to determine why transfusion of HLA antibodies to recipients with corresponding antigens causes TRALI in some cases and not in others.     

Treatment of Nevus comedonicus with topical tazarotene and calcipotriene

Nevus comedonicus is a rare developmental defect of the pilosebaceous unit. It is also thought to be a variant of epidermal nevus. Previously reported treatments include surgical excision, CO2 laser, dermabrasion, extraction, topical retinoic acid, and numerous topical keratolytics. We present a case of a 7-year-old boy with bilateral nevus comedonicus who experienced cosmetic improvement with topical tazarotene and calcipotriene cream. This combination represents a novel therapeutic approach to the treatment of this cutaneous abnormality.