The presence of cardiotropic viral genomes is not increased in atrial tissue of atrial fibrillation patients.

BACKGROUND: Infections with potentially cardiotropic viruses are associated with the development of atrial fibrillation (AF). However, whether direct viral infection of the atria is involved in the pathogenesis of AF is unclear. We have therefore analysed the presence of cardiotropic viral genomes in AF patients. METHODS: Samples of left atrial tissue were obtained from 50 AF patients (paroxysmal, n = 20; long-standing persistent/permanent, n = 30) during cardiac surgery and from autopsied control patients (n = 14). Herein, the presence of PVB19, EBV, CMV, HHV­6, adenovirus and enterovirus genomes was determined by polymerase chain reaction. The densities of CD45+ and CD3+ cells and fibrosis in the atria were quantified by (immuno)histochemistry. RESULTS: Of the tested viruses only the PVB19 genome was detected in the atria of 10% of patients, paroxysmal AF (2 of 20) and long-standing persistent/permanent AF (3 of 30). Conversely, in 50% of controls (7 of 14) PVB19 genome was found. No significant association was found between PVB19 and CD45+ and CD3+ cells, or between the presence of PVB19 and fibrosis, in either control or AF patients. CONCLUSION: The presence of viral genomes is not increased in the atria of AF patients. These results do not support an important role for viral infection of the atria in the pathogenesis of AF.

Atrial inflammation in different atrial fibrillation subtypes and its relation with clinical risk factors.

OBJECTIVE: Inflammation of the atria is an important factor in the pathogenesis of atrial fibrillation (AF). Whether the extent of atrial inflammation relates with clinical risk factors of AF, however, is largely unknown. This we have studied comparing patients with paroxysmal and long-standing persistent/permanent AF. METHODS: Left atrial tissue was obtained from 50 AF patients (paroxysmal = 20, long-standing persistent/permanent = 30) that underwent a left atrial ablation procedure either or not in combination with coronary artery bypass grafting and/or valve surgery. Herein, the numbers of CD45+ and CD3+ inflammatory cells were quantified and correlated with the AF risk factors age, gender, diabetes, and blood CRP levels. RESULTS: The numbers of CD45+ and CD3+ cells were significantly higher in the adipose tissue of the atria compared with the myocardium in all AF patients but did not differ between AF subtypes. The numbers of CD45+ and CD3+ cells did not relate significantly to gender or diabetes in any of the AF subtypes. However, the inflammatory infiltrates as well as CK-MB and CRP blood levels increased significantly with increasing age in long-standing persistent/permanent AF and a moderate positive correlation was found between the extent of atrial inflammation and the CRP blood levels in both AF subtypes. CONCLUSION: The extent of left atrial inflammation in AF patients was not related to the AF risk factors, diabetes and gender, but was associated with increasing age in patients with long-standing persistent/permanent AF. This may be indicative for a role of inflammation in the progression to long-standing persistent/permanent AF with increasing age.

Development of a new therapeutic technique to direct stem cells to the infarcted heart using targeted microbubbles: StemBells.

Successful stem cell therapy after acute myocardial infarction (AMI) is hindered by lack of engraftment of sufficient stem cells at the site of injury. We designed a novel technique to overcome this problem by assembling stem cell-microbubble complexes, named 'StemBells'. StemBells were assembled through binding of dual-targeted microbubbles (~3µm) to adipose-derived stem cells (ASCs) via a CD90 antibody. StemBells were targeted to the infarct area via an ICAM-1 antibody on the microbubbles. StemBells were characterized microscopically and by flow cytometry. The effect of ultrasound on directing StemBells towards the vessel wall was demonstrated in an in vitro flow model. In a rat AMI-reperfusion model, StemBells or ASCs were injected one week post-infarction. A pilot study demonstrated feasibility of intravenous StemBell injection, resulting in localization in ICAM-1-positive infarct area three hours post-injection. In a functional study five weeks after injection of StemBells cardiac function was significantly improved compared with controls, as monitored by 2D-echocardiography. This functional improvement neither coincided with a reduction in infarct size as determined by histochemical analysis, nor with a change in anti- and pro-inflammatory macrophages. In conclusion, the StemBell technique is a novel and feasible method, able to improve cardiac function post-AMI in rats.

Intussusception following a baby walker injury.

Serious abdominal injury as a result of a fall in a baby walker has not been previously reported. We present the case of a 13-month-old boy who developed intussusception following a fall down five stairs in a baby walker. Attempted hydrostatic reduction was unsuccessful. At operation, a bowel wall hematoma, serving as a lead point, was identified. This case adds another type of injury to the list of those previously associated with baby walker use.

Esophagogastric disconnection for gastroesophageal reflux in children with severe neurological impairment.

PURPOSE: Fundoplication has been used successfully to treat gastroesophageal reflux in the pediatric population; however, the results are poorer in those children with neurological impairment. We propose an alternative approach to the needs of these special patients and report the use of esophagogastric disconnection to control reflux in children with profound neurological impairment. METHODS: Between 1991 and 1997, 27 esohagogastric disconnections were performed. All patients were severely neurologically impaired with symptomatic gastroesophageal reflux confirmed by an upper gastrointestinal radiographic study. There were 16 boys and 11 girls with ages ranging from 6 months to 40 years. Three had undergone previous fundoplications that failed, whereas the remaining underwent esophagogastric disconnection as a primary antireflux procedure. Follow-up ranged from 1 month to 6.3 years (average, 2.8 years). The operative approach used a midline incision. The gastroesophageal junction was divided, and the gastric side was closed. A 30- to 40-cm jejunal limb was prepared for Roux-en-Y reconstruction and brought up to the esophagus in a retrocolic manner. Esophagojejunal and jejunojejunal anastomoses were then performed. A Stamm tube gastrostomy was placed, and the appendix was removed. A pyloroplasty and tube jejunostomy were performed when felt to be clinically indicated. RESULTS: Gastroesophageal reflux symptoms resolved, and bolus feedings were tolerated by all patients. Oral feedings were tolerated except in those children limited by their swallowing abilities. Early postoperative complications occurred in eight patients (30%) with two (7%) requiring reoperation (esophageal leak and enterocolitis). Late reoperation was necessary in four patients (15%) for small bowel obstruction, paraesophagcal hernia, gastrostomy revision, and enterocolitis. There were no perioperative deaths, but three patients (11%) died of late surgical complications (two of small bowel obstructions, and one of improper reinsertion of a gastrostomy tube). Three other children died of unrelated causes. CONCLUSIONS: Esophagogastric disconnection effectively eliminates gastroesophageal reflux while allowing both bolus tube feedings and oral supplementation. This operation provides an alternative method of controlling gastroesophageal reflux in children with profound neurological impairment.

Appendicitis in children.

A study of 406 consecutive children operated upon for appendicitis from July 1982 to July 1987 was compared with a previously published study of 657 children with the same diagnosis operated upon between 1972 and 1982. This was done to determine if the methods of therapy continue to yield low complication rates and zero mortality rates. The routine use of antibiotic coverage for both aerobic and anaerobic bacteria in perforated appendicitis resulted in low complication rates, 3.2 per cent for major and 2.5 per cent for minor complications. Major complications included small intestinal obstruction and intra-abdominal abscess. Minor complications included wound infection and prolonged ileus. These rates are similar to those of the first investigation. The mortality rate continued to be zero. Complete peritoneal lavage was used in patients with generalized peritonitis or extensive localized peritonitis. Operative lysis of adhesions for small intestinal obstruction was required in four of these patients. This did not occur in patients with perforated appendicitis with abscess formation or more localized peritonitis who had no lavage. The technique rather than the disease process may be responsible for the complication.

Spontaneous focal gastrointestinal perforation in very low birth weight infants.

Spontaneous, focal gastrointestinal perforation occurred in six very low birth weight infants. The first recognized clinical sign of perforation in five of the six infants was striking blue-black discoloration of the abdominal wall. In all cases the clinical and radiographic presentations, as well as the histologic findings, were distinct from those associated with necrotizing enterocolitis. All 4 infants who underwent exploratory laparotomy and repair had excellent surgical outcomes.

Evaluation of factors in high risk neonatal necrotizing enterocolitis.

Fifty-four neonates with necrotizing enterocolitis (NEC) were separated on basis of outcome. Of 35 factors compared between a high-risk and a low-risk group, only six were found to be statistically significant and useful in the development of a NEC score: number of days before beginning enteral feedings; blood pH; serum bicarbonate concentration; white blood cell differential; abdominal tenderness; and presence of portal vein gas. All laboratory values and physical and radiographic findings were from the initial presentation of NEC. Neonates with a score of 3 or more are at an increased risk of developing severe NEC with a greater than 50% mortality. The study suggests that enteral feedings should be withheld from neonates at risk of developing NEC for the first 12 days of life.

Appendicitis in children.

Six hundred and fifty-one patients with appendicitis were reviewed and an over-all perforation rate of 36.5 per cent accompanied by a major complication rate of only 3.38 per cent and an over-all complication rate of 9.06 per cent was reported. This low complication rate despite a high level of perforation can be attributed to the use of antibiotic regimens effective against both aerobic and anaerobic organisms. A thorough irrigation and flushing of debris and exudate from the abdominal cavity of patients with ruptured appendicitis may improve these rates.

Appendiceal abscess masquerading as acute urinary retention in children.

Two boys with acute urinary retention were found to have a persistent pelvic mass after bladder decompression. Evaluation in each disclosed a large pelvic abscess secondary to a ruptured appendix. The diagnosis of appendicitis may be difficult and appendiceal abscess presenting with acute urinary retention in children has been reported previously in only 7 instances. History, physical examination, laboratory studies, and radiographic and ultrasonic evaluations should lead to the correct diagnosis, and surgical intervention restores normal voiding.

Inguinal ovaries in children demonstrated by high resolution real-time ultrasound.

High resolution real-time ultrasound of two female infants showed normal ovaries located in the inguinal canal and demonstrated cysts within the solid ovarian tissue. As this appearance is quite distinct from that of the solid homogeneous testis, ultrasound can determine the nature of the gonad present.

Esophageal function after repair of esophageal atresia.

The results of this study demonstrate that there is abnormal esophageal function in patients who have undergone repair of esophageal atresia. The diagnostic tests used may be too sensitive as the abnormalities demonstrated have little clinical relevance. In addition, there was an inverse relationship between signs and symptoms of esophageal dysfunction and the age of the child. The abnormalities are probably intrinsic and only secondarily affected by surgical treatment. Increased tension at the gastroesophageal junction is a likely factor in the production of gastroesophageal reflux. Esophageal dysfunction does not necessarily lead to detrimental gastroesophageal reflux with the sequela of repeated respiratory infections, failure to gain weight or esophageal stricture. Only patients who have such signs or symptoms need to undergo evaluation of esophageal function to determine if there is an abnormality. The results of the studies then document the need for an antireflux procedure.

Histiomonocytic malignancy. A spectrum of disease in an 11-month-old infant.

The initial pathologic diagnosis in an 11-month-old girl presenting with a suprarenal mass was true histiocytic lymphoma. The histiocytic nature of the cells was verified by ultrastructural, histochemical, and immunologic studies. The subsequent course featured widespread dissemination as both tumorous masses and diffuse tissue infiltrates, including extensive soft tissue, leptomeningeal, and bone marrow involvement, with a terminal histiomonocytic leukemic phase. Subsequently, this tumor was reclassified as malignant histiocytosis with atypical features, and this case exemplifies the difficulties in classifying some malignant histiomonocytic neoplasms. The overlapping clinical, pathologic, and theoretic features of true histiocytic lymphoma, malignant histiocytosis, and histiomonocytic leukemia are discussed in the context of this case.

Necrotizing enterocolitis in premature infants transferred back to community hospitals.

The return of stable premature infants to community hospitals from level III neonatal intensive care units is becoming more common. While these infants usually need only to gain weight, they are still at risk for significant neonatal problems. We report four cases of necrotizing enterocolitis (NEC) in nine stable, growing premature infants who weighed less than 1,300 g and returned to community hospitals. The onset of NEC was within 60 hours of transport, suggesting that transport and early feeding after transport may have been contributory to NEC.

Intussusception following resection of Wilms tumor.

Postoperative intussusception is a documented complication of pediatric surgical and pediatric urologic abdominal operations. In contrast to "primary" intussusception's triad of crampy abdominal pain, palpable abdominal mass, and "currant jelly" stools, postoperative intussusception is generally characterized by abdominal pain and vomiting. An abdominal mass is not usually palpable, and few children have bloody stools. Proper diagnosis and treatment may be delayed because of similar abdominal symptoms in children who may be receiving radiation and chemotherapy, or with prolonged ileus. Two children operated on for Wilms tumor demonstrate the need for awareness of this potential problem in the postoperative patient.

Hepatic abscess as a complication of Crohn's disease.

A 17-year-old male with Crohn's disease presented with persistent fever and right upper quadrant tenderness. Ultrasonography and abdominal computerized axial tomography (CAT scan) showed two large loculated abscess cavities in the right lobe of the liver. Surgical drainage and antibiotic therapy led to resolution of both cavities over a 5-month period. Unlike six previously reported patients, our patient had no evidence of pylephlebitis or mesenteric abscess formation at surgery. We speculate that his abscesses arose through seeding of mesenteric vessels and portal bacteremia.