Treatment of congenital cystic adenomatoid malformation-does resection in the early postnatal period increase surgical risk?

OBJECTIVE: The recent development of fetal ultrasonography has allowed for an increasing number of prenatal diagnoses for congenital cystic adenomatoid malformation (CCAM). However, the appropriate surgical timing of these patients has not been studied as of yet. The aim of this study is to suggest a safe strategy for the treatment of CCAM by identifying the relationship between the timing of surgery and postoperative outcome. METHODS: Between 1987 and 2003, 40 patients (28 males, 12 females) underwent surgical resection for CCAM. The mean age was 38.6+/-9.1 (2 days-13 years) months. CCAM was diagnosed by prenatal ultrasonography in eight patients. Early operations were performed in four out of the eight. Operation was deferred until 2-12 months of age for the remaining four patients. RESULTS: Type I CCAM was found in 20 patients, type II in 20 and no patient exhibited type III. Five patients had associated pectus excavatum anomaly. There were no cases of operative mortality. Seventeen minor postoperative complications developed in 16 patients (40.0%): prolonged chest tube drain in 10, wound infection in 4, and 1 case of pneumonia, empyema and pleural space, respectively. The average hospital stay was 11.8 (6-29) days. During the mean follow-up period of 67.5 months, one patient died of accidental aspiration 7 months after operation during the postoperative recovery course of Ravich operation for pectus excavatum. The remaining patients reported doing well with normal physical activity. All five patients who underwent surgery at the age of under 1 month did not exhibit increased postoperative morbidity. CONCLUSIONS: We concluded that surgery for CCAM could be safely performed in all age groups with satisfactory long-term outcomes. It is suggested that early elective surgical correction can be recommended for a patient whose diagnosis was made in utero.     

Mapping the rat somatosensory pathway from the anterior cruciate ligament nerve endings to the cerebrum

The anterior cruciate ligament (ACL) serves as the primary restraint to anterior tibial translation. In addition to this biomechanical function, the ACL appears to have a function in neuromuscular control. This hypothesis was formulated after the discovery of mechanoreceptors within the ACL. The full somatosensory pathway from the ACL to the cerebrum has yet to be elucidated. In order to map this sensory pathway, we conducted a viral trans-synaptic tracing experiment using the neurotropic pseudorabies virus (PRV). The pseudorabies virus was injected into the ACL of rats and allowed to replicate and spread trans-synaptically for 6-7 days. The brain and spinal cord of each sacrificed rat was then removed and processed immunohistochemically to detect the presence of PRV. PRV-immunoreactive neurons were found to be localized in several different regions from the spinal cord to the cerebrum. Four nuclei in the reticular formation of the brain stem demonstrated strong positive labeling: the mesencephalic reticular nucleus, magnocellular reticular nucleus, paragigantocellular reticular nucleus, and gigantocellular reticular nucleus. This finding suggests that the nerve endings of the rat ACL project into the cerebrum and that the reticular formation may play an important role in the afferent pathway of those nerve endings.     

Visualization of maturation of the corpus callosum during childhood and adolescence using T2 relaxometry

Previous studies have shown that maturation of the white matter in terms of its relative signal intensity changes on MRI is almost complete at 2-3 years of age. We hypothesized that quantitative analysis may show maturation of the white matter during childhood and adolescence. In the present study we performed multi-echo T2 relaxometry in 33 healthy subjects (girls, 15; boys, 18) aged 3-15 years. T2 relaxation times of the genu and splenium were measured. In healthy subjects, the T2 relaxation times were significantly correlated with age in both girls (r=0.611, p=.016) and boys (r=0.721, p=.001) in the splenium, but not in the genu (p>.05). To further confirm genu-to-splenium signal intensity ratio changes, a total of 389 brain MRIs were retrospectively selected from the patients who had normal results (189 girls/women, 200 boys/men; age range, 3-20 years). The genu-to-splenium signal intensity ratio was obtained from the T2-weighted images. In patients with normal MRI, the genu-to-splenium signal intensity ratio was significantly decreased with age (p<.001) by 16 years. The T2 relaxation times gradually increase in the splenium during childhood and adolescence, suggestive of maturation.     

Centralisation of a hypospadias repair service--the Warwickshire experience.

An audit of the hypospadias repair service provided in the county of Warwickshire has shown that centralising all referrals to a single surgeon who uses limited, well-practiced techniques, greatly improves outcome. Comparison to previous audit of the service, when provided by a number of surgeons in the region, shows complication rates dropping - fistulae occurrence reducing from 35.8% to 6.7% and urethral stricture rates showing similar improvement from 4.4% to 0%. Overall productivity increased, and referral out of region dropped from 13% to 0%. This provides definitive evidence that restructuring of a service already in place has decreased morbidity and increased efficiency to give results comparable to published data.     

Comparison of functional results with navigation-assisted minimally invasive and conventional techniques in bilateral total knee arthroplasty.

This study was undertaken to compare the clinical and radiological results achieved using navigation-assisted minimally invasive surgery (NA-MIS) and conventional (CON) techniques in 42 bilateral total knee arthroplasty (TKA) patients with a minimum follow-up of one year. Clinical evaluations were performed using range of motion (ROM), Hospital for Special Surgery (HSS) scores, and Western Ontario and McMaster University (WOMAC) scores (pain, functional, and total) at 3, 6 and 9 months and one year postoperatively. Patients' subjective preferences and radiological indices, including mechanical axis and coronal inclinations of the prostheses, were compared at one year postoperatively. NA-MIS TKA yielded better HSS and WOMAC total scores than CON TKA up to six months, and a better WOMAC pain score up to 9 months. However, these differences were not significant at one year postoperatively. ROM was comparable in both groups at all times, but more patients preferred the NA-MIS side to the CON side. Radiological results showed no differences in mean values between the two surgical groups, although the NA-MIS group contained fewer outliers than the CON group. In conclusion, NA-MIS TKA was associated with better clinical results up to 6 or 9 months after surgery, giving more accurate leg alignment than CON TKA.     

Characteristics of teenage mothers and predictors of breastfeeding initiation in the Michigan WIC Program in 1995. Women, Infants, and Children.

Although breast milk is recommended as the optimal source of infant nutrition, breastfeeding initiation is below recommended levels, especially among teenage mothers. Breastfeeding initiation rates among Michigan (US) teenage mothers (12-19 y) were compared by demographics and health behaviors. Multivariate analyses determined which factors were significant independent predictors of breastfeeding initiation among teenage mothers enrolled prenatally in the Michigan Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in 1995. Significant predictors independently associated with breastfeeding initiation were race/ethnicity, education, marital status, postpartum anemia status, parity, prenatal trimester of WIC enrollment, and smoking. The strongest predictor of breastfeeding initiation differed for white mothers (positive predictor: education beyond high school [OR = 3.13]) and black mothers (negative predictor: multiparous [OR = 0.25]). Initiation rates for this population of teenage mothers fall below the national average for mothers of all ages and the US Healthy People 2010 goals. Research is needed concerning how breastfeeding support and education can be improved to reach the US national health goals.     

Reversible Verbal and Visual Memory Deficits after Left Retrosplenial Infarction

The retrosplenial cortex is a cytoarchitecturally distinct brain structure located in the posterior cingulate gyrus and bordering the splenium, precuneus, and calcarine fissure. Functional imaging suggests that the retrosplenium is involved in memory, visuospatial processing, proprioception, and emotion.We report on a patient who developed reversible verbal and visual memory deficits following a stroke. Neuropsychological testing revealed both anterograde and retrograde memory deficits in verbal and visual modalities. Brain diffusion-weighted and T2-weighted magnetic resonance imaging (MRI) demonstrated an acute infarction of the left retrosplenium.     

Stereoselective metabolism of lansoprazole by human liver cytochrome P450 enzymes.

The stereoselective metabolism of lansoprazole enantiomers was evaluated by incubation of human liver microsomes and cDNA-expressed cytochrome p450 (p450) enzymes to understand and predict their stereoselective disposition in humans in vivo. The intrinsic clearances (Clint) of the formation of both hydroxy and sulfone metabolites from S-lansoprazole were 4.9- and 2.4-fold higher than those from the R-form, respectively. The sums of formation Clint of both metabolites were 13.5 and 57.3 microl/min/mg protein for R- and S-lansoprazole, respectively, suggesting that S-lansoprazole would be cleared more rapidly than the R-form. The p450 isoform selective inhibition study in liver microsomes, and the incubation study of cDNA-expressed enzymes, demonstrated that the stereoselective sulfoxidation is mediated by CYP3A4 and that the hydroxylation is mediated by CYP2C9 and CYP3A4 as well as by CYP2C19. Total Clint values of hydroxy and sulfone metabolite formation catalyzed by all these p450 enzymes were consistently higher for S-lansoprazole than for the R-form. The CYP3A4 produced the greatest difference of Clint between S- and R-enantiomers, mainly due to a difference of sulfoxidation metabolism (Clint 76.5 versus 10.8 microl/min/nmol of p450, respectively), whereas CYP2C19-catalyzed hydroxylation resulted in a minor difference of Clint between S- and R-enantiomers (179.6 versus 143.3 microl/min/nmol of p450, respectively). However, the affinity of CYP2C19 on hydroxylation was 5.7-fold higher for S-enantiomer than for the R-form (Km 2.3 versus 13.1 microM), suggesting that the role of CYP2C19 on stereoselective hydroxylation would be more prominent at concentrations around the usual therapeutic level. These findings suggest that both CYP2C19 and CYP3A4 are major enzymes contributing to the stereoselective disposition of lansoprazole, but stereoselective hydroxylation of lansoprazole enantiomers is mainly influenced by CYP2C19, especially at the usual therapeutic doses.