Effect of vitamin D status improvement with 25-hydroxycholecalciferol on skeletal muscle growth characteristics and satellite cell activity in broiler chickens.

Skeletal muscle satellite cells (SC) play a critical role in the hypertrophic growth of postnatal muscle. Increases in breast meat yield have been consistently observed in broiler chickens fed 25-hydroxycholecalciferol (25OHD3), but it is unclear whether this effect is mediated by SC. Thus, our objective was to determine the effect of vitamin D status improvement by replacing the majority of dietary vitamin D3 (D3) with 25OHD3 on SC activity and muscle growth characteristics in the pectoralis major (PM) and the biceps femoris (BF) muscles. Day-old, male Ross 708 broiler chickens (n = 150) were fed 1 of 2 corn and soybean meal-based diets for 49 d. The control diet (CTL) contained 5,000 IU D3 per kg of diet and the experimental diet (25OHD3) contained 2,240 IU D3 per kg of diet + 2,760 IU 25OHD3 per kg of diet. Ten birds per treatment were harvested every 7 d. Two hours before harvest, birds were injected intraperitoneally with 5'-bromo-2'deoxyuridine (BrdU) to label mitotically active cells. Blood was collected from each bird at harvest to measure circulating concentrations of 25OHD3, a marker of vitamin D status. The PM and BF muscles were weighed and processed for cryohistological determination of skeletal muscle fiber cross-sectional area, enumeration of Myf-5+ and Pax7+ SC, and mitotically active (BrdU+) SC using immunofluorescence microscopy. Circulating 25OHD3 concentrations were greater in 25OHD3-fed birds on d 7, 14, 21, 28, 35, 42, and 49 when compared with CTL (P < 0.001). Growth performance and feed efficiency did not differ among dietary treatments (P > 0.10). Improved vitamin D status as a result of feeding 25OHD3 increased the number of mitotically active (Pax7+;BrdU+) SC (P = 0.01) and tended to increase the density of Pax7+ SC (P = 0.07) in the PM muscles of broilers on d 21 and 35, respectively. Broiler chickens fed 25OHD3 also tended to have greater Myf-5+ SC density (P = 0.09) on d 14, greater total nuclear density (P = 0.05) on d 28, and a greater muscle fiber cross-sectional area (P = 0.09) on d 49 in their PM muscles compared with CTL birds. Collectively, these results suggest that improvement of vitamin D status by replacing the majority of D3 in the diet with 25OHD3 can stimulate SC activity in the predominantly fast-twitch PM muscle and provide evidence toward understanding the mechanism behind previously observed increases in breast meat yield in 25OHD3-fed commercial broiler chickens.

H-type tracheo-oesophageal fistula with congenital oesophageal stenosis.

H-type tracheo-oesophageal fistula (H-TOF) and congenital oesophageal stenosis (COS) are both rare anomalies. Only six cases of H-TOF in association with COS have been described in the literature. Characteristically, diagnosis is delayed, often well beyond the neonatal period. We report a patient who was accurately diagnosed on day 12 of life, and outline several of the key clinical dilemmas encountered in managing a neonate with this combination of rare congenital anomalies.

Renal fungal balls and pelvi-ureteric junction obstruction in a very low birth weight infant: treatment with streptokinase.

Renal candidiasis is a rare but well recognised complication of intensive care treatment in neonates. We report a problematic case with obstructing pelvi-ureteric junction (PUJ) fungal balls that was refractory to standard measures of adequate nephrostomy drainage, pelvic irrigation with amphotericin B, and systemic antifungal treatment. In an attempt to avoid potentially difficult open surgery, a novel treatment using a streptokinase solution (3,000 IU/ml) for irrigation was performed. This was successful in clearing the fungal balls, relieving obstruction and rendering the urine sterile. The present case highlights a potential role for streptokinase in cases of renal candidiasis refractory to current treatment protocols.

Altered enteroendocrine cell expression in T cell receptor alpha chain knock-out mice.

Mice lacking T cell receptor alpha chain (TCRalpha(-/-)) develop inflammation of the colon. We have examined the effect of this inflammation on the colonic epithelium by studying markers of epithelial cuff, enteroendocrine, and immune cell differentiation. Using immunohistochemical techniques, colons were compared in normal C57/BL6 and murine TCR alpha(-/-) mice aged 2 and 3 weeks and 3-11 months. TCR alpha(-/-) mice aged 3-11 months had histologic evidence of inflammation with increased expression of CD45, CD4+, CD8+, and B220+ cells and a decrease in expression of IgA+ cells. There was a decrease in the number of cholecystokinin, serotonin, and neurotensin enteroendocrine expressing cells in the colon of TCR alpha(-/-) mice. These changes were not present in 2-3-week-old suckling/weaning mice. In contrast, peptide tyrosine tyrosine (PYY), glucagon-like peptide-1, and gastrin expression did not change and small intestinal enteroendocrine cells remained unaltered. The change in colonic enteroendocrine cell expression appears to be a specific response, since only a subset of these cells was altered, and the epithelium was intact by histologic analysis. The absence of functional T cells in TCR alpha(-/-) colon has a marked effect on differentiation of a specific subpopulation of enteroendocrine cells, prior to loss of integrity of the epithelium.

Differences in tobacco assessment and intervention practices: a regional snapshot.

BACKGROUND: This research describes tobacco attitudes and practices of health care providers in the Upper Midwest. A baseline measure of preventive practices by providers was needed to plan effective tobacco intervention education programs. METHODS: Health care providers in a 16-county region received a mailed survey regarding tobacco assessment practices, intervention practices, attitudes, skills/knowledge, barriers, and desire for tobacco education. The survey was sent to all chiropractors, dentists, nurse practitioners/physician assistants, physicians (primary care and specialist), and public health nurses in the region. A total of 51.9% (n = 614) of all providers returned usable surveys. RESULTS: Significant differences were found between provider groups on all measured concepts. Primary care physicians, nurse practitioners/physician assistants, and public health nurses were more likely than specialist physicians, dentists, and chiropractors to assess, intervene, be supportive of tobacco cessation, have skills/knowledge about cessation, perceive fewer barriers, and want further education. CONCLUSIONS: In this region, provider groups differed in tobacco use assessment and treatment. All provider groups desired education regarding tobacco intervention. Region-wide tobacco cessation educational initiatives need to take into account differences between provider groups.

Selective use of cutaneous vesicostomy in prenatally detected and clinically presenting uropathies.

OBJECTIVES: To determine if the indications for cutaneous vesicostomy have changed with the advent of prenatal diagnosis and to assess if temporary vesicostomy remains an effective measure in preventing urinary infection and stabilising renal function in children with severe uropathy. METHODS: Retrospective case note review. RESULTS: Nineteen patients underwent temporary cutaneous vesicostomy over a 12-year period. Of these, 10 had a prenatally detected uropathy. Children with prenatal findings were diverted at a significantly younger age than cases presenting clinically (33 (range 10-240) vs. 182 days (range 28-425), p = 0.02). In addition, there were significantly more boys diverted in the prenatally detected group (p = 0.02). The majority of clinically presenting infants were diverted because of severe or recurrent urosepsis whereas most prenatally detected cases underwent surgery for progressive renal impairment. In both groups vesicostomy was successful in preventing further urosepsis and resulted in improved renal function. Follow-up data, however, revealed 9 (50%) of 18 patients with chronic renal failure. One patient died prior to stoma closure from septicaemia and renal disease. CONCLUSIONS: The timing and indications for vesicostomy may be changing in the light of prenatal diagnosis. Temporary vesicostomy diversion remains a simple, effective and easily reversible method of preventing urosepsis and stabilising upper tract function. The poor renal outcome on follow-up may reflect the fact vesicostomy is reserved for infants and children with severe disease.

Aggressive out-of-hospital treatment regimen for severe closed head injury in patients undergoing air medical transport.

The impact of aggressive out-of-hospital management on disposition for 1286 patients with closed head injuries in ground advanced life support (ALS) and helicopter services was evaluated over 60 months in San Diego County. The case group included 196 air medical patients with a scene Glascow coma scale (GCS) < 9 who were treated according to a standard head injury protocol. The frequency matched control group included 1090 ground ALS patients receiving airway management with hyperventilation but neither induction agents nor mannitol. The trauma registry provided admission and discharge dates, neurosurgical interventions, and disposition. Patient age, scene GCS, head and neck abbreviated injury scale (HNAIS), and injury severity score (ISS) served to stratify study groups. Case-control distribution of mortality was compared with the two-tailed Mantel-Haenszel weighted odds ratio (OR) and chisquared test; significance at P < or = 0.05. The case group displayed an 11% decreased mortality (P < 0.01), remaining significant after adjusting for age (P = 0.05) and scene GCS (P = 0.06). The case group displayed 10% (P < 0.01) greater survivor discharges to rehabilitation and 6% (P < 0.05) fewer discharges to extended care facilities. This study's data indicate a strong possibility for improved patient morbidity and mortality in severe closed head injuries treated with an aggressive treatment protocol and rapid air medical transport.

Reconstruction of the anterior cruciate ligament in patients who are at least forty years old. A long-term follow-up and outcome study.

The long-term results were reviewed for seventy-two patients (seventy-five knees) who had had a bone-patellar ligament-bone intra-articular reconstruction of the anterior cruciate ligament between August 1984 and May 1992. The mean age of the patients at the time of the operation was forty-five years (range, forty to sixty years). Three patients had a bilateral procedure. The primary mechanisms of injury were accidents that occurred during skiing (thirty-two knees), tennis (fourteen knees), and soccer (five knees). We analyzed the responses to subjective questionnaires, the functional results, and the objective clinical data. The clinical examination included assessment of the range of motion, performance of Lachman and pivot-shift tests, and measurements with use of a KT-1000 arthrometer. All knees were evaluated with use of three common rating scales: that of Lysholm and Gillquist; that of The Hospital for Special Surgery, as modified by Insall et al.; and the International Knee Ligament Standard Evaluation Form. At the latest follow-up evaluation, at a mean of fifty-five months (range, twenty-six to 117 months), three patients reported pain or swelling. No patient reported giving-way or symptoms related to the patellofemoral joint. The mean range of extension was -12 to 6 degrees, compared with -8 to 42 degrees preoperatively, and the mean range of flexion was 112 to 150 degrees, compared with 52 to 154 degrees preoperatively. Flexion was limited to 112 degrees in one patient, but this was 5 degrees greater than that of the uninvolved knee. Sixty knees (80 per cent) had a negative pivot-shift test, and ten knees (13 per cent) had a grade of 1+. On testing with the KT-1000 device at maximum manual pressure, the mean difference between the injured and uninjured knees was found to have improved by 5.1 millimeters, from 6.4 millimeters preoperatively to 1.4 millimeters postoperatively (p < 0.01). The grade on the International Knee Ligament Standard Evaluation Form improved markedly; seventy-two knees (96 per cent) had a grade of C or D preoperatively, whereas seventy knees (93 per cent) had a grade of A or B postoperatively. The Hospital for Special Surgery score improved from a mean of 69 points preoperatively to a mean of 92 points postoperatively (p < 0.01). The mean score according to the scale of Lysholm and Gillquist increased from a mean of 63 points preoperatively to a mean of 94 points postoperatively (p < 0.01). All patients indicated that they were pleased with the result of the procedure. Bicycling was resumed at a mean of four months; jogging, at a mean of nine months; skiing, at a mean of ten months; and tennis, at a mean of twelve months.

The quick look airway classification. A useful tool in predicting the difficult out-of-hospital intubation: experience in an air medical transport program.

The unpredictable nature of the out-of-hospital care environment poses unique challenges for active airway management techniques. This descriptive study was conducted in the helicopter air medical transport (AMT) environment for a period of 32 months to determine whether initial direct airway visualization classification may provide a useful tool to predict the difficulty of intubation. Data extracted from documented oral intubation attempts included initial airway visualization grade, number of attempts, final airway management method, and procedural complications. Oral intubation was attempted on 429 patients. Initial airway visualization grades were found with the following frequency for grades I through IV: 65.6%, 21.5%, 8.6%, and 5.4%, respectively. Similarly, the average number of attempts was 1.34, 1.65, 1.97, and 2.39, respectively. The serious complication rate was 24%, 46%, 62%, and 65%, respectively. A statistically significant correlation (Spearman's rho) was found between increasing grade and both the number of intubation attempts (0.52) and the number of complications (0.45). Initial visualization classification may serve as a useful indicator in the out-of-hospital environment to help anticipate the difficulty of intubation and the need for early alternative airway management strategies. In this program, such classification is used to monitor airway management skills.

Use of restraints in air medical transport: a survey.

Although the practice of restraining combative patients is commonplace, restraint has been neither uniform nor scrutinized in the air medical transport environment. The objective of this study was to identify and characterize the use of physical and chemical restraining methods in air medical and critical care transport settings. A retrospective study was performed through faxed questionnaires to 92 medical directors who were members of the Air Medical Physician Association (AMFA). Neither program size nor program type correlated with the use of a particular restraint method. Cloth, including gauze, was the most common physical restraint (73%); both benzodiazepines and paralytics were the most common chemical restraints (53%). Injury to crew members was not widespread. This study of air transport services reported a lower incidence of injury to personnel (17%) than is reported in studies from emergency departments (EDs) (60%). This study also indicated that air transport services possess protocols governing actions toward violent patients (65%) more often than has been reported in studies on EDs (50%). Protocols varied in nature and extent. Consensus protocols should be established and implemented with the aid of detailed data acquisition to standardize personnel education in managing violent patients.

Prenatally detected posterior urethral valves: qualitative assessment of second trimester scans and prediction of outcome.

PURPOSE: We attempted to determine if the degree of second trimester dilatation and/or other qualitative sonographic features of the fetal urinary tract are predictive of postnatal outcome in male neonates with posterior urethral valves. MATERIALS AND METHODS: We reviewed ultrasound reports and/or hard copy imaging in 17 cases of posterior urethral valves initially detected on second trimester scans (median gestation 18 weeks, range 15 to 23.5). Ultrasound appearance was categorized according to the pattern and severity of dilatation, cystic change or echogenicity of the renal cortex and presence of oligohydramnios. Outcome was reviewed at a median followup of 5.7 years (range 4.4 to 10). RESULTS: Of the 17 cases there was a poor outcome in 10, including death in 4 and chronic renal failure in 6. Seven patients were alive and well with normal renal function at followup. The prognosis in cases of moderate or severe upper tract dilatation was poor. Of the 9 patients with marked prenatal hydroureteronephrosis 8 (89%) were dead or had chronic renal failure at followup. In contrast, only 2 of the 8 patients (25%) with mild upper tract dilatation or dilatation limited to the bladder had chronic renal failure at review (p = 0.05). Three cases of prenatal renal parenchymal change and 3 of subsequent oligohydramnios had a poor outcome postnatally. CONCLUSIONS: The prognosis for boys with prenatally detected posterior urethral valves is closely associated with qualitative aspects of second trimester scan findings. This information may be of clinical value in the prenatal counseling of parents.

Cutaneous periarteritis nodosa: a clinicopathological study of 79 cases.

Cutaneous periarteritis nodosa (PAN) is a well-recognized entity characterized by tender subcutaneous nodules and livedo that may ulcerate. The pathogenesis of cutaneous PAN is not known. The objective of the study was to evaluate the clinical and histological features of 79 cases of cutaneous PAN and to investigate any clinical, pathological and immunological differences that may distinguish those cases likely to have a prolonged course. A retrospective analysis of 79 cases was conducted. Thirty-nine patients had ulcers during the course of their illness. Women were affected more than men. Painful nodules on the lower extremities, with oedema and swelling, were the most common clinical finding; 22% of patients had some evidence of neuropathy. Most of the laboratory findings were non-specific. There was no evidence for hepatitis B infection and hepatitis C infection was present in only one patient. Most patients (60%) had no associated medical condition. The disease course was prolonged but benign, and systemic PAN did not develop in any patient. Corticosteroids given systemically induced remission in most acute cases. The ulcerative form of disease was more prolonged and frequently associated with neuropathy.

Detection of integrins in formalin-fixed, paraffin-embedded tissues.

Integrins are heterodimeric transmembrane receptors, which are expressed in many cells. In vitro experiments have demonstrated that integrins may be important in tumor progression and organ development. The functions of integrins were previously studied in cell cultures and their tissue expression was detected by immunofluorescence or immunoperoxidase in frozen sections. The purpose of this study was to determine the optimal conditions for detection of integrins in formalin-fixed, paraffin-embedded tissues. We utilized microwave heating and enzyme digestion in routinely processed, surgically removed tissues. Our results demonstrate that integrins can be reliably detected in archival material. This approach will facilitate further investigation of the role played by integrins in human malignancies and in developmental processes.

The pathophysiology of tension pneumothorax in ventilated swine.

It remains unclear as to whether the cardiovascular collapse observed in tension pneumothorax (TP) is strictly a mechanical pressure-related phenomenon or secondary to hypoxemia. This study describes the pathophysiologic changes associated with a surgically induced progressive TP in a ventilated swine model. With a balloon occlusion catheter surgically placed into the pleural space, progressive volumes of pneumothorax were created in six anesthetized pigs on positive-pressure ventilation. Air was introduced into the right hemithorax in 100-mL increments every 4-5 min, with measurements of heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), mean intrapleural pressure (MIP), oxygen saturation (O2%), arterial blood gas (ABG), and cardiac output (C.O.). With the induced progressive TP, results showed that O2% measures decreased immediately and continued to decline throughout the experiment to levels below 50% prior to cardiovascular collapse. The MAP and HR remained relatively stable until approximately 57% total lung capacity progressive TP (600 mL) was reached. At this point, a significant decline in MAP and increase in HR was noted, indicating tension physiology. The C.O. showed a small but significant decrease after 200 mL of air was injected, with a progressive decline after this point. At > 97% total lung capacity TP, lethal cardiovascular collapse occurred in all animals and was associated with an abrupt drop in C.O., HR, and MAP. There was a concurrent equalization of MIP with CVP at the point of collapse. Arterial blood gas measures correlated with O2% trends during the trials. We conclude that the findings of this study support the alternative hypothesis that significant hypoxemia occurs early and precedes hypotension in ventilated animals with TP. Occlusive mechanical compression, suggested by equalization of MIP and CVP, is probably a late event.