Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures

Aim

The ultrasound-guided percutaneous technique of Hickman line insertion has not been widely adopted in pediatric surgical practice. We wished to review our own experience of using this technique for insertion into the internal jugular vein.

Methods

Our vascular access team consists of a consultant surgeon and 2 consultant anesthetists. All procedures were prospectively recorded on a database and were either performed or directly supervised by our team.

Results

Five hundred consecutive Hickman lines were inserted between June 2004 and October 2006. Patients' ages ranged from 14 days to 19 years (median, 44 months). Patients weighed between 600 g to more than 100 kg. Lines inserted were all tunneled silicone Hickman lines with a Dacron cuff (size 2.7F-10F, with 1-3 lumens), of which 60% were 7F double-lumen lines. Successful cannulation occurred in 99.8%. Perioperative complications (within 30 days) occurred in 12 patients (2.4%) and were all treated conservatively with no need for either blood transfusion or chest drain. Catheter-related sepsis rate was 3.16 per 1000 line days.

Discussion

1.

The technique of ultrasound-guided percutaneous insertion of Hickman line to the internal jugular vein is safe and is applicable to all children regardless of size, age, or diagnosis.

2.

Pediatric surgeons and anesthetists can learn this technique without specific training in interventional radiology.

3.

A learning curve does exist, and we recommend concentrating pediatric vascular access procedures to a specialist team.

     

Integrative genomics analysis reveals silencing of beta-adrenergic signaling by polycomb in prostate cancer

The Polycomb group (PcG) protein EZH2 possesses oncogenic properties for which the underlying mechanism is unclear. We integrated in vitro cell line, in vivo tumor profiling, and genome-wide location data to nominate key targets of EZH2. One of the candidates identified was ADRB2 (Adrenergic Receptor, Beta-2), a critical mediator of beta-adrenergic signaling. EZH2 is recruited to the ADRB2 promoter and represses ADRB2 expression. ADRB2 inhibition confers cell invasion and transforms benign prostate epithelial cells, whereas ADRB2 overexpression counteracts EZH2-mediated oncogenesis. ADRB2 is underexpressed in metastatic prostate cancer, and clinically localized tumors that express lower levels of ADRB2 exhibit a poor prognosis. Taken together, we demonstrate the power of integrating multiple diverse genomic data to decipher targets of disease-related genes.     

Celiac artery occlusion encountered during pancreatic resection: a case report

Pancreatic surgeons need to be aware of, and have the expertise available to deal with, unexpected vascular anomalies encountered during pancreatic resections. We present a patient with celiac artery occlusion that was encountered unexpectedly during pancreaticoduodenectomy. As a result of this anomaly, the celiac territory is dependent on retrograde flow via collaterals from the superior mesenteric artery. We discuss the method of identifying this situation, and of revascularising the celiac trunk to prevent ischaemia of upper abdominal viscera. We highlight the implications for surgical training.     

Induction of apoptosis by ginger in HEp-2 cell line is mediated by reactive oxygen species

Ginger (Zingiber officinale Roscoe, Zingiberaceae) is a commonly used medicinal herb throughout the world. Although some studies have demonstrated its antitumour activities on cancer cells in vitro and in vivo, the exact mechanism is not fully elucidated. Hence, the present study was designed to examine the in vitro cytotoxic activities of saline extract prepared from ginger extract on HEp-2 cell line. The cytotoxic effect of the drug was confirmed by 3-(4,5-dimethyl thiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay and cell counting and estimation of protein, DNA and RNA. Meanwhile, propidium iodide staining and agarose gel electrophoresis were performed for determining the induction of apoptosis. In addition, superoxide radical generation, nitrite formation and glutathione studies show involvement of free radicals. The present results show that the extract exerts dose-dependent suppression of cell proliferation; the IC(50) value was found to be 900 microg/ml. At a dose of 250 microg/ml, marked morphological changes including cell shrinkage and condensation of chromosomes were observed. Agarose gel electrophoresis of DNA from HEp-2 cells treated with 250 microg/ml ginger powder for 24 hr showed marked DNA ladder pattern. The involvement of free radicals was confirmed by increased superoxide production, decreased nitrate formation and depletion of glutathione in ginger-treated cells. Further screening of active components using gas chromatography-mass spectrometry analyses showed the presence of clavatol, geraniol and pinostrobin in the extract. The results of the present study suggest that ginger might be useful as a potential antitumour agent.     

Integrative analysis of genomic aberrations associated with prostate cancer progression

Integrative analysis of genomic aberrations in the context of trancriptomic alterations will lead to a more comprehensive perspective on prostate cancer progression. Genome-wide copy number changes were monitored using array comparative genomic hybridization of laser-capture microdissected prostate cancer samples spanning stages of prostate cancer progression, including precursor lesions, clinically localized disease, and metastatic disease. A total of 62 specific cell populations from 38 patients were profiled. Minimal common regions (MCR) of alterations were defined for each sample type, and metastatic samples displayed the most number of alterations. Clinically localized prostate cancer samples with high Gleason grade resembled metastatic samples with respect to the size of altered regions and number of affected genes. A total of 9 out of 13 MCRs in the putative precursor lesion, high-grade prostatic intraepithelial neoplasia (PIN), showed an overlap with prostate cancer cases (amplifications in 3q29, 5q31.3-q32, 6q27, and 8q24.3 and deletions in 6q22.31, 16p12.2, 17q21.2, and 17q21.31), whereas postatrophic hyperplasia (PAH) did not exhibit this overlap. Interestingly, prostate cancers that do not overexpress ETS family members (i.e., gene fusion-negative prostate cancers) harbor differential aberrations in 1q23, 6q16, 6q21, 10q23, and 10q24. Integrative analysis with matched mRNA profiles identified genetic alterations in several proposed candidate genes implicated in prostate cancer progression.     

Association of the steroid synthesis gene CYP11a with polycystic ovary syndrome and hyperandrogenism

Biochemical data implicate an underlying disorder of androgen biosynthesis and/or metabolism in the aetiology of polycystic ovary syndrome (PCOS). We have examined the segregation of the genes coding for two key enzymes in the synthesis and metabolism of androgens, cholesterol side chain cleavage (CYP11a) and aromatase (CYP19), with PCOS in 20 multiply-affected families. All analyses excluded CYP19 cosegregation with PCOS, demonstrating that this locus is not a major determinant of risk for the syndrome. However, our results provide evidence for linkage to the CYP11a locus (NPL score = 3.03, p = 0.003). Parametric analysis using a dominant model suggests genetic heterogeneity, generating a maximum HLOD score of 2.7 (alpha = 0.63). An association study of 97 consecutively identified Europids with PCOS and matched controls demonstrates significant allelic association of a CYP11a 5' UTR pentanucleotide repeat polymorphism with hirsute PCOS subjects (p = 0.03). A strong association was also found between alleles of this polymorphism and total serum testosterone levels in both affected and unaffected individuals (p = 0.002). Our data demonstrate that variation in CYP11a may play an important role in the aetiology of hyperandrogenaemia which is a common characteristic of polycystic ovary syndrome.      

Management of Rh-isoimmunised Pregnancies : Our Experience

Background

The aim of this study was to assess the role of middle cerebral artery peak systolic velocity (MCA-PSV), as measured by doppler ultrasound, in detecting foetal anaemia in Rh- isoimmunised pregnancies. Intra-uterine foetal blood transfusion was performed in such anaemic foetuses to tide over the crisis of foetal immaturity till considered fit for extra-uterine survival.

Methods

Rh-isoimmunised pregnancies reporting to a tertiary institute from 2003 to 2005, were screened by doppler ultrasound to estimate MCA-PSV to detect foetal anaemia. If the foetus developed MCA-PSV of more than 1.5 multiple of median (MoM) for the gestational age, foetal blood sampling through cordocentesis was performed to confirm foetal anaemia, followed by intrauterine foetal blood transfusion to all anaemic foetuses at the same sitting. Neonatal outcome was evaluated by recording gestational age at the time of delivery, duration of gestational time gained and need for blood transfusion in the neonatal period.

Results

A total of thirteen isoimmunised pregnancies were evaluated. Three pregnancies did not require in-utero foetal blood transfusion. Twenty-one intrauterine foetal blood transfusions were performed in the remaining ten patients. Five received blood transfusion in the neonatal period. Intra uterine foetal death occurred in one grossly hydropic foetus and favourable neonatal outcome was recorded in the rest.

Conclusion

The clinical outcome of these pregnancies justifies the use of doppler studies of MCA-PSV in detecting foetal anaemia and intra uterine foetal blood transfusion is the only hope of prolonging pregnancy and salvaging such foetuses.Key Words: Rh-isoimmunisation, Middle cerebral artery peak systolic velocity, Foetal anaemia, Foetal blood transfusion     

The immunohistology of follicle lysis in lymph node biopsies from homosexual men

Follicle lysis is a characteristic alteration of B cell follicles described recently in lymph node biopsies from homosexual men. It consists of disruption of germinal centers by aggregates of small mature lymphocytes variably associated with erythrocyte extravasation. We studied the immunohistology of follicle lysis identified in lymph node biopsies from 11 homosexual men. The results indicate that follicle lysis has two principal immunohistologic features: (1) intrafollicular aggregates of small lymphocytes predominantly of polytypic mantle B cell phenotype (T015+/Leu-8+/mu+/delta+/k+ or lambda+), and (2) disruption of the normal, unified follicular meshwork of R4/23+ dendritic reticulum cells by these B cell aggregates. These structural alterations may affect the functional integrity of the germinal center as it pertains to the abnormal B cell effector function and the increased prevalence of B cell lymphoma recently documented in the acquired immunodeficiency syndrome and related disorders. Because dendritic reticulum cells weakly express the Leu-3 (T4) antigen, which is known to be an essential component of the receptor for human T- lymphotropic virus type III/lymphadenopathy-associated virus (HTLV- III/LAV) retrovirus infection, it is possible that retroviral infection of dendritic reticulum cells may play a role in the pathogenesis of follicle lysis.