Operative outcome and intermediate term follow-up of neonatal Blalock-Taussig shunts.

BACKGROUND: The neonatal age group is considered to be one of the important risk factors for perioperative morbidity and mortality as well as poor long-term patency following Blalock-Taussig shunts. METHODS AND RESULTS: Out of a total of 190 patients who underwent Blalock-Taussig shunts in our institute between July 1998 and July 2000, 20 patients were aged less than 30 days and this neonatal cohort was studied retrospectively. The mean age was 18+/-11 days (range: 3-30 days). The mean weight of the babies was 3.1+/-0.7 kg, the smallest weighed 2.1 kg. The cardiac anatomy was tetralogy of Fallot with pulmonary atresia in 6, pulmonary atresia with intact ventricular septum in 3, tricuspid atresia in 5 and complex single ventricle physiology in the rest. All patients were deeply cyanotic and preoperative prostaglandin E1 was needed in 10 patients to ensure ductal patency and maintain oxygen saturations prior to the shunt operation. The mean hilar right and left pulmonary artery sizes were 3.99+/-0.44 mm and 3.69+/-0.79 mm, respectively. Three patients (15%) had significant stenosis at the site of duct insertion. The shunts were accomplished with 3.5 mm polytetrafluoroethylene grafts in 7 patients (35%) and 4 mm in the rest. The mean duration of mechanical ventilation was 2.0+/-2.83 days, one patient who developed bronchopneumonia needed prolonged ventilation for 14 days. The mean intensive care unit stay was 4.79+/-2.66 days. The mean hospital stay was 11.7+/-6.4 days. Five patients who developed sepsis stayed beyond 14 days. There were 3 deaths (immediate post-operative shock and possibly shunt malfunction in 1, bronchopneumonia in 1 and late shunt thrombosis at 3 months in 1). Two patients had late shunt block, one of those mentioned above and the other at 3 months secondary to infective endarteritis of the right pulmonary artery. All these infants received 4 mm grafts. All the 3.5 mm grafts were patent at follow-up. Seventeen patients were alive and well at follow-up (mean: 9 months, range: 3-21 months) with a mean resting systemic oxygen saturation of 77% (66%-95%). CONCLUSIONS: The overall shunt patency rate after neonatal Blalock-Taussig shunt is about 80% on intermediate term follow-up. A smaller graft size (3.5 mm) does not appear to be an incremental risk factor for shunt blockade and operative mortality.

Mesenteric panniculitis presenting as a huge retroperitoneal mass--a case report.

A rare case of mesenteric panniculitis occurring in a young patient and presenting as a huge retroperitoneal mass which was mistaken for malignancy, has been described.

Expansion of haematopoietic stem cells in vitro: a challenge to stem cell biologists.

Expansion of haematopoietic stem cells from various sources has gained importance so as to provide a clinically potential graft, which shows ideal growth kinetics, resulting in reduction of the period of neutropenia and thrombocytopenia in any autologous or allogenic transplant setting. Expansion also facilitates transduction of genes for gene therapy. This review examines the various means employed to achieve the expansion of stem cells, and the criteria used to score the extent of expansion based on how stem cells are identified. It tries to analyse the ideal manner in which expansion should be carried out, with emphasis that expansion should not be at the expense of loss of stemness. It also attempts to judge the roles played by the stromal elements and cytokines, which are both part of the complex microenvironment, which in vivo has a strict regulation on haematopoiesis.

Pulmonary atresia with intact ventricular septum--a report of two cases with review of literature.

Two perinatal autopsy cases are reported where a rare congenital anomaly, namely pulmonary atresia with intact ventricular septum in association with tricuspid stenosis and a hypoplastic right ventricle was encountered.

Role of inhaled nitric oxide as a selective pulmonary vasodilator in pediatric cardiac surgical practice.

Our aim was to assess the role of inhaled nitric oxide (NO) therapy in post operative cases of congenital heart defects who developed pulmonary arterial hypertensive (PAH) crisis and had no response with conventional management. From February '95 to January '97, inhaled NO therapy was used in 21 children. Age ranged from 2 months to 9 years (mean 5.6 years) and duration of therapy ranged from 1 to 13 days. Of 21 patients, 17 responded well with 5-20 ppm while 4 did not. The preoperative mean pulmonary systolic pressure was 88 mm Hg against mean systemic pressure of 96 mm Hg. Post operatively, their PA pressure reduced to 62 mm Hg, with systemic pressure of 98 mm Hg. After using inhaled NO, PA pressure dropped to 24 mm Hg (mean systolic) (p < 0.007), after excluding the non responders. Of 4 non responders, two died due to irreversible pulmonary vascular disease and remaining two died due to residual defects. The study shows that inhaled NO is a selective pulmonary vasodilator, which is useful in postoperative PAH crisis and also reduces the transpulmonary gradient in single ventricle repair cases. It is safe and effective for prolonged use. It is very useful in Indian perspective, when more number of cases with congenital heart defects (CHD) along with severe PAH are encountered routinely.

Effect of Hepatogard--an indigenous formulation on dexamethasone induced antihealing effects in male albino rats.

Hepatogard, is a multi-ingredient phytopharmaceutical product containing crude powders of eleven plants. Its effect on the different parameters of wound healing was assessed alone and in the presence of dexamethasone. The parameters chosen for the study were the breaking strength of incised wound, breaking strength of granulation tissue and hydroxyproline content. The result showed that Hepatogard increased the breaking strength of granulation tissue but not of incised wound. It reversed the dexamethasone induced decrease in breaking strength in both incised wound and granulation tissue. Even though it had no effect of its own on hydroxyproline concentration, it reversed the dexamethasone induced decrease in the hydroxyproline content of granulation tissue. Thus, Hepatogard has the potential for antagonizing the antihealing effect of steroids in patients receiving steroid therapy.

Gastric teratoma in an infant--a case report.

Gastric teratoma is an extremely rare tumour. We report a gastric teratoma in a four month old male infant who presented with a large abdominal mass. There is no evidence of recurrence 1 1/2 years after the tumour was excised. Our case is an addition to the few cases reported in the World literature.

Apoptosis in granulosa cells induced by intrafollicular peptide.

Ovarian follicular fluid peptide (OFFP) purified from sheep ovaries has been earlier shown to induce degeneration of ovarian follicles in mice. In the present study, whether the effect of OFFP on granulosa cells was similar to apoptosis was studied using three parameters. Immature mice injected with pregnant mare serum gonadotropin on day 0 were administered with 10 or 20 J.lg of OFFP on day 1 and autopsied on day 2. The granulosa cells were collected from the ovarian follicles. The presence of apoptotic bodies were observed by staining the cells with acridine orange. DNA profiles of DAPI-stained cells analysed by flow cytometry also revealed apoptotic response to OFFP. Furthermore, agarose gel electrophoresis of low molecular weight DNA fraction extracted from the cells of OFFP-treated animals confirmed ladder formation and induction of apoptosis and not necrosis in granulosa cells. In conclusion, all the three parameters indicated apoptotic changes in granulosa cells of ovarian follicles in .mice treated with OFFP. The effect of OFFP seems to be exerted directly on the granulosa cells showing its autocrine role in the process of follicular atresia. This is discussed in the light of other intra/extra ovarian factors.

Metastatic bone tumours.

A total of 24 cases of metastatic bone tumours were encountered over the last 6 years. Majority of these lesions (70.8%) were found in the 4th to 6th decades of life with a slight male preponderance. The axial skeleton was involved in majority of the cases (62.5%), the spine being the commonest site of tumour metastasis. A large proportion of the metastatic bone tumours were adenocarcinomas (62.5%) and the lung was the commonest primary site followed by the breast and large intestine. In 41.7% of the patients the bone metastasis was the initial manifestation of the malignant disease which was subsequently detected after investigations. In 20.8% of the cases the primary tumour remained undetected even after through investigations.

Erythrocyte depletion of human umbilical cord blood using dextran sedimentation.

We report on the results of a study using high molecular weight dextran for depletion of red blood cells (RBCs) from cord blood. Our technique achieved efficient RBC depletion by sedimentation without a significant loss in haemopoietic stem cells. Cord blood units were fractionated for erythrocyte depletion by unit gravity sedimentation in 3 per cent high molecular weight dextran. Dextran sedimentation enabled recovery of more than 80 per cent of the total nucleated cells present and 100 per cent mononuclear cell (MNC) recovery as compared to unfractionated cord blood. A four-fold increase in the colony forming unit-granulocyte macrophage (CFU-GM) number per 2 x 10(5) cells was observed after dextran treatment suggesting that this step also resulted in the enrichment of stem cells.

Gestational choriocarcinoma presenting as an extradural mass--a case report.

We report an unusual case of a 23 year old female who presented with symptoms of spinal cord compression by an extradural metastasis from a gestational choriocarcinoma. She gave the history of evacuation of a hydatidiform mole five months prior to presentation, following which she had been totally asymptomatic and had not attended any follow-up. She responded to conventional chemotherapy.

Inhaled nitric oxide as therapy for pulmonary hypertension in postoperative cases of congenital heart defects.

This is a prospective study using inhaled nitric oxide (NO) as a selective pulmonary vasodilator in postoperative cases of CHD. From February 1995 to December 1995, NO was used selectively in 10 patients postoperatively in whom conventional management of PAH crisis failed and PA pressures were more than half the systemic pressure. The age of the patients varied from 2 months to 3 years and duration of NO inhalation ranged from 1 day to 13 days. Of 10 patients, 8 patients responded well with 5-20 ppm and 2 did not respond, even after increasing the NO to 120 ppm. The preoperative mean pulmonary systolic pressure was 83 +/- 17.1 mm Hg against mean systemic systolic pressure of 84 +/- 9.2 mm Hg. Postoperatively, their PA pressure reduced to 54 +/- 16.1 mm Hg (mean systolic) with systemic pressure of 85 +/- 15.9 mm Hg (mean systolic). After using inhaled NO, PA pressure dropped to 19 +/- 2.5 mm Hg mean systolic (p < 0.0078), after excluding the nonresponders. The two nonresponders died postoperatively. Our study shows that NO selectively reduces the PA pressure unlike conventional vasodilators. This helps to decrease the incidence of postoperative PAH crisis, thereby reducing the morbidity and mortality. However, long-term beneficial effects are yet to be studied.

Cell death by apoptosis and cancer chemotherapy.

The ways by which cell death takes place have generated great interest in recent years particularly in the field of cancer. The exact mechanisms which are responsible for tumour regression by drug treatment are also largely unknown and involve both enhanced cell death and arrested cell proliferation. Cell death is caused either by necrosis or by an active process in response to a specific stimulus which leads to elimination of a definite proportion of cells. This process of programmed cell death is referred to as apoptosis (a term coined by developmental biologists) and is a part of the morphogenetic processes, characterized by shrinkage of cells, condensation of nuclear chromatin, nuclear fragmentation and blebbing. Many successful cancer treatments presently undertaken depend upon induction of an apoptotic response in the target tumour cells. As apoptosis is considered to be an active gene-directed process, in tumours the precise mode of cell death after chemotherapy is important. Understanding the role of apoptosis in cancer will greatly broaden our knowledge of all stages of the disease process and its treatment. Thus, the role of apoptotic response modulation during the generation of neoplasia is an important issue and will remain an active area of present day investigations for improving the efficiency of chemotherapy. It is likely to become a valuable weapon in the war against cancer.