The management of extensive corrosive esophageal strictures: Do not dilate and procrastinate

Corrosive strictures of the esophagus are difficult to treat, however, prompt and appropriate management of corrosive burns to the esophagus can prevent the formation of strictures. In a developing country like India, where facilities for early treatment are not easily available, strictures are an ineviatable consequence. If the strictures are extensive, dilatational therapy proves ineffective and offers no substantial benefit to the patients. Twenty patients with extensive corrosive strictures of the esophagus were surgically managed; by esophageal bypass in 13 and esophagectomy in 7. Surgical treatment restored normal swallowing in all the patients. The common post-operative complications to occur were: pulmonary complications, anastomotic leak and stricture, gastric outlet obstruction and reflux esophagitis. For extensive corrosive strictures of the esophagus, we advocate early surgical treatment rather than prolonged dilatational therapy.     

Transformation of chick oviduct progesterone receptor in vitro: effects of hormone, salt, heat, and adenosine triphosphate

Effects of salt, heat, and ATP on the rate of sedimentation of chick oviduct progesterone receptor (PR) were examined under various conditions. Cytosol [3H]PR complex (PRc) sedimented as an 8S molecule in 10-35% glycerol or 5-20% sucrose gradients. Incubation of the oviduct cytosol containing [3H]PRc at either 23 or 0 C with 0.3 M KCl or 5-10 mM ATP for 1-4 h resulted in the appearance of a slower migrating form with a sedimentation rate of approximately 4S and a complete and concomitant disappearance of the 8S PR form. This transformation of the receptor was inhibited by molybdate and paralleled an increase in the affinity of the cytosol PRc toward DNA-cellulose, ATP-Sepharose, and isolated nuclei. The 8S to 4S transformation of PR could be achieved with the unliganded receptor. The effect of the hormone on the rate of the transformation of PR was examined. A gradual transformation of the 8S PR occurred with increasing time of incubation at 23 or 0 C with KCl or with 10 mM ATP. The ATP-induced transformation of the 8S form was complete by 2-4 h in both the presence and absence of progesterone. The transformation of PR by salt was complete by 1-2 h of incubation of the cytosol with 0.3 M KCl at 0 C and was slightly accelerated in the presence of the steroid. However, when the cytosol PR was thermally transformed by incubation at 23 C, the appearance of the 4S PR form was significantly accelerated in the presence of the hormone. While the addition of 10 mM ATP to the incubation mixture enhanced the rate of transformation of PRc by heat and salt, lower nucleotide concentrations (0.1-2 mM) inhibited the thermal conversion of the 8S PR (in both its liganded and unliganded forms) to the 4S form. In addition, other nucleoside triphosphates (CTP, GTP, and UTP) were also effective in inducing the 8S to 4S transformation of the unoccupied and the steroid-bound PR. The transforming effects of heat, salt, and ATP were cumulative, and a complete 8S to 4S transformation could be achieved within 5 min when all three were applied simultaneously. We conclude that ATP and other nucleoside triphosphates are effective modifiers of the process of transformation of the chick oviduct PR in vitro.(ABSTRACT TRUNCATED AT 400 WORDS)     

Protracted,gross hematuria in sickle cell trait: response to multiple doses of 1-desamino-8-D-arginine vasopressin

Gross and microscopic hematuria are well-known complications in patients with sickle cell hemoglobinopathy. Most of these episodes of gross hematuria are self limiting, but rarely may be severe and persistent requiring definitive intervention. Before subjecting these patients to surgical management such as partial or total nephrectomy, several medical therapies of variable benefit have been suggested. We report a patient with sickle cell trait who experienced severe, intractable gross hematuria for 5 months and showed a dramatic response to multiple doses of 1-desamino-8-D-arginine vasopressin (DDAVP) infusion. The remarkable response observed in this patient suggests that treatment with DDAVP infusion may be considered in patients with unremitting gross hematuria associated with sickle cell trait.     

A double-blind comparison of cimetidine and ranitidine as prophylaxis against gastric aspiration syndrome

Preoperative cimetidine, ranitidine, or placebo were administered, orally or intravenously to 190 patients in a double-blind study. The volume and pH of gastric aspirate samples, obtained after tracheal intubation and before extubation, were measured. Both cimetidine and ranitidine produced higher mean pH levels and thus fewer patients "at risk" should gastric aspiration occur (pH less than or equal to 2.5) than did placebo. Intravenous ranitidine (in both 40- and 80-mg doses) produced fewer patients at risk in the event gastric aspiration should occur than did cimetidine, 300 mg, and the 80-mg dose produced a higher mean pH level. Oral ranitidine, 150 mg, produced a significantly higher mean pH level than did oral cimetidine, 300 mg, and tended to give fewer patients at risk. The volumes of gastric contents aspirated were similar following each of the drugs except that the volume was significantly less two hours following oral ranitidine, 150 mg, than after oral cimetidine, 300 mg.     

Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns

OBJECTIVE: To assess the predictive ability of a universal predischarge serum bilirubin measurement to screen for risk of subsequent significant hyperbilirubinemia in the direct Coombs negative healthy term and near-term newborn during the first postnatal week. METHODS: Total serum bilirubin (TSB) levels were obtained at the time of the routine metabolic screen in all term and near-term newborns cared for in the Pennsylvania Hospital Well Baby Nursery (n = 13 003). Postnatal age (in hours) at the time of TSB measurement was recorded. A percentile-based bilirubin nomogram for the first week was constructed from hour-specific predischarge and postdischarge TSB values of newborns (n = 2840; median BW = 3230 g and median gestational age = 39 weeks) who met classification criteria for healthy newborns (excluding those with a positive direct Coombs test or those requiring phototherapy before age 60 hours) and who were enrolled in a hospital supervised home or outpatient follow-up program. The accuracy of the predischarge TSB as a predictor of subsequent degree of hyperbilirubinemia was determined. RESULTS: The study patients in the nomogram were racially diverse. Nearly 60% were breastfed. Predischarge, 6.1% of the study population (172/2840) had TSB values in the high-risk zone (>/=95th percentile) at 18 to 72 hours; of these, 39.5% (68/172) remained in that zone (likelihood ratio [LR] = 14.08, sensitivity = 54%; specificity = 96.2%, probability = 39.5%). Predischarge, 32.1% of the population (912/2840) had TSB values in the intermediate-risk zone. In a clinically significant minority of these newborns (58/912 or 6.4%), the postdischarge TSB moved into the high-risk zone (LR of this move: 3.2 from the upper-intermediate zone and.48 from the lower-intermediate risk zone). The predischarge TSB in 61.8% of the newborns (1756/2840) was in the low-risk zone (<40th percentile) and there was no measurable risk for significant hyperbilirubinemia (LR = 0, sensitivity = 100%; specificity = 64.7%; probability = 0%). CONCLUSIONS: An hour-specific TSB before hospital discharge can predict which newborn is at high, intermediate or low risk for developing clinically significant hyperbilirubinemia (specifically defined as TSB levels >/=95th percentile for age in hours). Risk designation and subsequent increases or decreases of in TSB can be easily monitored on an hour-specific percentile based predictive bilirubin nomogram. A predischarge TSB measured as a universal policy would facilitate targeted intervention and follow-up in a safe, cost-effective manner. In conjunction with bilirubin practice parameter of the American Academy of Pediatrics, it could reduce the potential risk for bilirubin-induced neurologic dysfunction.     

Anti-erythropoietin antibodies followed by endogenous erythropoietin production in a dialysis patient

We present a case of a young girl with end-stage renal disease secondary to anti-glomerular basement membrane disease who was receiving maintenance peritoneal dialysis and developed pure red cell aplasia secondary to anti-erythropoietin (EPO) antibodies. This occurred 13 months after the initiation of EPO alfa therapy for anemia. Initially, the patient required intermittent red blood cell transfusions. After immunosuppressive therapy had been initiated with corticosteroids and cyclosporine, the EPO antibody levels decreased precipitously, associated with an increased level of endogenous EPO production. For the following 6 months, the patient maintained adequate (>10 g/dL) hemoglobin levels and did not require red cell transfusions.