Successful recovery of aplastic anemia following orthotopic liver transplantation for non-A-E acute liver failure

This report describes a teenager who developed aplastic anemia (AA) because of non-A-E acute liver failure (ALF) requiring orthotopic liver transplantation (OLT). His AA did not recover spontaneously and he required treatment with ATG 9 months post-OLT. Bone marrow recovery occurred 4 months after immunotherapy and coincided with further intensification of immunusuppression required to treat early chronic rejection of the liver graft. Three years post-OLT he remains well with good bone marrow and liver function. Intensification of immunosuppression can lead to successful resolution of AA associated with non-A-E ALF.     

Pain assessment and intervention for term newborns

A baseline assessment of pain should occur as part of a newborn's health assessment within the first few hours of life. Validation and assessment of pain in the term newborn is important for providing care because newborns may experience pain from a multitude of procedures, ranging from heel sticks to circumcisions. Current assessment tools evaluate both behavioral and physiologic parameters. In addition, providing individualized care requires a knowledge base of the interventions available to reduce or eliminate pain, such as breastfeeding, non-nutritive suck, skin-to-skin contact, and sucrose pacifiers. This article describes three newborn pain assessment tools, the use of valid assessment tools, and evidence-based interventions that are recommended to effectively manage newborn pain.     

Appendicular colic and the non-inflamed appendix: fact or fiction?

AIMS: Appendicoliths cause acute appendicitis and appendicular perforation. Do appendicoliths cause acute abdominal pain in the absence of acute appendicitis? METHODS: A retrospective observational study was undertaken of histology reports of all appendicectomy specimens from children < 16 years of age between January 1995 and December 2001. Specimens were categorised as perforated or uncomplicated acute appendicitis, non-inflamed, and "incidental" (removed during abdominal surgery for other indications). The presence of an appendicolith was noted. Clinical details were supplemented by selected case note review. Specimens in which the diagnosis of appendicitis or the presence of an appendicolith were not clearly defined (n = 20) were reviewed by an experienced, independent pathologist. RESULTS: 601 consecutive appendicectomy reports were analysed. The mean age of the study population was 9 years (range 1 day - 15.9 years) and there were 357 boys. An appendicolith was identified in 31/118 (26%) cases of perforated appendicitis, 60/352 (17%) cases of uncomplicated appendicitis, 12/59 (20%) cases of non-inflamed appendices, and only 1/72 (1%) cases of incidental appendicectomies. All patients with an appendicolith in the non-inflamed appendix group had presented with acute abdominal pain mimicking acute appendicitis. The frequency of an appendicolith in perforated appendicitis was significantly greater than in uncomplicated acute appendicitis (chi (2) = 4.8, 1 df, p < 0.05). There was no significant difference in the frequency of an appendicolith between non-inflamed appendices and acute appendicitis (either perforated or intact). Appendicoliths were rarely found in incidental appendicectomies, but these patients were younger. The frequency of appendicoliths in non-inflamed appendices was much greater than that expected from published autopsy data. CONCLUSION: Appendicoliths may cause acute abdominal pain that mimics acute appendicitis.     

Severity of injury and service utilization following traumatic brain injury: the first 3 months

OBJECTIVE: To describe the medical and rehabilitation service use of model systems by brain injured participants 1 to 3 months postdischarge from inpatient rehabilitation. DESIGN: Prospective follow-up study. SETTING: Georgia Model Brain Injury System (GAMBIS). PARTICIPANTS: Seventy-three GAMBIS subjects consenting to participate in the utilization substudy. MAIN OUTCOME MEASURES: Receipt of services and intensity of service use. ANALYSIS: Chi-square analysis of receipt of services by severity of injury. RESULTS: The likelihood of service use did not vary with severity of injury. Data suggest that intensity of service use was a function of injury severity. CONCLUSIONS: Subjects with mild and moderate injuries were as likely to use a range of medical and rehabilitation services during the 3-month postdischarge period as those with severe injuries. Traditional rehabilitation services, such as physical therapy, were far more likely to be used, than nontraditional services, such as psychological counseling, in spite of the high level of cognitive and social disability associated with traumatic brain injury.     

Treatment of Allergic Bronchopulmonary Aspergillosis with Fluconazole and Itraconazole

Treatment of allergic bronchopulmonary aspergillosis (ABPA) has remained both problematic as well as controversial. Although the sheet anchor in treatment of ABPA still remains steroids, various workers have tried oral antifungals (fluconazole and itraconazole) with encouraging results. This study evaluates the effect of fluconazole or itraconazole in the treatment of ABPA patients and compares them with the patients who had received palliative therapy other than antifungals. Case records of 44 proven cases of ABPA treated at our referral service hospital during February 1998 to April 2001 were analyzed. In addition to oral and inhaled bronchodilators, 16 patients received fluconazole 150 mg OD and 13 patients itraconazole 200 mg OD for six months. Response to therapy was assessed clinically, radiologically and by spirometry every 3 months. Patients who did not receive antifungals had chronic course characterized by airway obstruction, recurrent pulmonary consolidation and obstructive defect on pulmonary function test (PFT). Patients treated with itraconazole had better control of asthma symptoms, less requirement of reliever inhalers, steroids and lesser exacerbations of asthma during follow-up even after stopping antifungal. Fluconazole group had better control of symptoms but improvement in other parameters was not statistically significant. From this study it was evident that itraconazole improved the symptoms of airway obstruction, pulmonary functions, pulmonary opacities and decreased exacerbations during follow up.Key Words: Allergic bronchopulmonary aspergillosis, Fluconazole, Itraconazole     

Energy failure in astrocytes increases the vulnerability of neurons to spreading depression

A neuroprotective role of astrocytes has been hypothesized, but the mechanism is debated and in vivo evidence is limited. To test this hypothesis, a sublethal stressor (spreading depression) and fluorocitrate (FC), a selective inhibitor of the astrocytic Krebs cycle, were used in urethane-anaesthetized adult rats. Neuronal damage was assessed 24 h after treatment with silver stain and immunoreactivity for a 72-kDa heat-shock protein. ATP levels and mitochondrial aconitase activity, a marker indicating exposure to reactive oxygen species, were measured after 4 and 24 h. Spreading depression alone did not affect ATP levels, mitochondrial aconitase activity, or induce neuronal injury in the cortex. Local or intraventricular injection of FC significantly decreased ATP levels and mitochondrial aconitase activity, but did not produce neuronal damage. In animals receiving injections of FC and then spreading depression, there was evidence of significant neuronal stress and damage. Isocitrate, which bypasses the metabolic inhibition produced by FC, prevented all of the changes seen after the combination of FC and spreading depression. One-hour pretreatment with dimethyl sulfoxide (a scavenger of hydroxyl radicals), deferoxamine (an iron chelator) or fructose-1,6-bisphosphate also blocked inactivation of mitochondrial aconitase, ATP depletion and the neuronal damage induced by FC and spreading depression. These experiments demonstrate that inhibition of the metabolism of astrocytes, with a decrease in ATP levels, will increase the susceptibility of neurons to the stress induced by spreading depression. The neuroprotective effects of dimethyl sulfoxide, deferoxamine and fructose-1,6-bisphosphate suggest that oxidative stress contributes to the neurotoxicity in this situation.     

Return to TRI: Winston Churchill Fellow and Salford University Scholar travel to Miami and the Keys

During May and June 2003, the 2 authors visited the internationally renowned Touch Research Institute based at the University of Miami and Jackson Memorial Hospital. For one of the authors, Peter Mackereth, this was a return visit. Both authors are Ph.D. students who have successfully obtained travel scholarships to participate in seminars and laboratory work. The paper will report on the experience of their visit, the current and future work of the TRI and its collaborators. Jacqui took the opportunity to spend time at the Dolphin Research Centre, this provided insight into the therapeutic value of interacting with these amazing mammals. Peter also took the opportunity to visit a group of massage therapists working in Key West.     

A cost-effectiveness analysis of management strategies for cervical intraepithelial neoplasia grades 2 and 3

OBJECTIVE: This study was performed to compare the cost-effectiveness of strategies for the management of cervical intraepithelial neoplasia, grades 2 and 3 (CIN 2 and CIN 3). STUDY DESIGN: A decision analysis compared six management strategies. The model was applied to hypothetic cohorts of 100,000 patients with CIN 2 and CIN 3. RESULTS: In both analyses, cryotherapy (CRYO) was the least expensive and least effective strategy; total vaginal hysterectomy was the most expensive and most effective strategy. For CIN 2, loop electrosurgical excision procedure (LEEP) was more effective than CRYO but at a cost of $31,437 per additional cure and $1.8 million per additional cancer prevented. For CIN 3, LEEP was more effective than CRYO, but at a cost of $17,592 per additional cure and $1.0 million per additional cancer prevented. CONCLUSION: CRYO is a cost-effective strategy that is appropriate in resource-poor settings. LEEP is also cost-effective, but the improved efficacy compared with CRYO comes at a significant cost. Total vaginal hysterectomy is very effective but is economically unsound because of excessively high costs.     

Orthotopic liver transplantation for acute liver failure secondary to autoimmune hepatitis in a child with autoimmune polyglandular syndrome type 1

Autoimmune polyglandular syndrome type 1 (APS-1) is an autosomal-recessive condition characterized by hypoparathyroidism, autoimmune Addison's disease, and chronic mucocutaneous candidiasis. Autoimmune hepatitis develops in 10-20% of affected patients and has a variable course ranging from asymptomatic chronic liver disease to lethal fulminant hepatic failure. Liver transplantation has been documented previously in only two patients. We report a 14-yr-old boy with APS-1 who developed acute liver failure secondary to associated autoimmune hepatitis. He did not respond to corticosteroid therapy and was successfully treated with an orthotopic liver transplant.     

Electronic removal of encrustations inside the Steinheim cranium reveals paranasal sinus features and deformations,and provides a revised endocranial volume estimate

Features in the endocranium, as revealed by computed tomography (CT) scans of largely complete mid-Pleistocene crania, have helped elucidate unexpected affinities in the genus Homo. Because of its extensive encrustations and deformations, it has been difficult to repeat such analyses with the Steinheim cranium. Here, we present several advances in the analysis of this Homo heidelbergensis cranium by applying filter algorithms and image editing techniques to its CT scan. First, we show how the encrustations have been removed electronically, revealing interesting peculiarities, particularly the many directions of the deformations. Second, we point out similarities and differences between the frontal and sphenoidal sinuses of the Steinheim, Petralona, and Broken Hill (Kabwe) crania. Third, we assess the extent of the endocranial deformations and, fourth, their implications for our estimation of the braincase volume.