Microscopic analysis and significance of vascular architectural complexity in renal cell carcinoma.

The objective of this study was to evaluate the utility of measuring microvessel fractal dimension (MFD) as a parameter of architectural microvascular complexity in localized renal cell carcinoma (RCC). Forty-nine patients with low-stage clear cell RCC were assessed in a 9-year follow-up retrospective study. Tumor vessels were visualized with the endothelial marker CD34. Tumor microvessel density (MVD) was measured by computerized morphometry. Fractal analysis of the RCC microvascular network was performed and the MFD was computed in each case. Correlation between tumor vascular parameters, histological grade, extent of tumor necrosis and patient survival were tested by uni- and multivariate analyses. A significant correlation was found between tumor grade and decreased survival (P = 0.04). The extent of macroscopic tumor necrosis also significantly correlated with poor prognosis (P = 0.0001). Survival analysis revealed a significantly higher MVD in patients who survived longer than 5 years as compared with those who died before the end of the 5-year follow-up period (MVD = 10.8 +/- 4.7% versus 6.4 +/- 3.7%; P = 0.03). MVD was also inversely associated with the extent of tumor necrosis (P = 0.03). Microvessel fractal dimension was significantly higher in low- as compared with high-grade tumors (1.55 +/- 0.11 versus 1.45 +/- 0.15; P = 0.03). Survival analysis revealed a significantly higher MFD in those who lived >5 years as compared with those who died earlier (1.56 +/- 0.11 versus 1.46 +/- 0.15; P = 0.02). The MFD was inversely associated with the extent of tumor necrosis (P = 0.01). Multivariate analysis revealed that the MFD was the only significant factor to correlate with tumor necrosis, and that tumor necrosis was the only independent predictor of patient survival. These results indicate that the analysis of MFD as a marker of tumor microvascular complexity may provide important prognostic information as well as novel insight into the biology of tumor angiogenesis.

Laparoscopic accessory splenectomy in recurrent chronic immune thrombocytopenic purpura.

Splenectomy is the definitive treatment for most cases of idiopathic thrombocytopenic purpura (ITP). We present the case of a patient who was discovered to have ITP at age 5 and was treated medically for 3 years with decreasing response to medication. At age 8, he underwent splenectomy, after which the platelet count stabilized at approximately 200,000/mm3. Two years later he again had symptoms of thrombocytopenia and was treated medically with moderate success. At age 12, during hospitalization for bleeding, his liver/spleen scan gave negative results. Symptoms persisted, and when the patient was 13 a second scan found two small areas of uptake in the area of the splenic bed suggestive of secondary accessory splenic activity. The platelet count at that time was 6,000/mm3. Laparoscopy was performed, and after careful dissection of the left-upper quadrant, two globular masses, the larger of which was 3 x 2 x 2 cm, were removed without incident. The latest platelet count, 3 months after laparoscopic secondary accessory splenectomy, was 169,000/mm3, and a follow-up scan shows no uptake in the area of the spleen.

Horner's syndrome and bilateral esophageal duplications.

Bilateral esophageal duplications are exceptionally rare. A 3-month-old male presented with a left-sided Horner's syndrome. Upon further investigation, bilateral upper thoracic masses with an air-fluid level within the right-sided mass were found. Sequential thoracotomies at 1-week intervals confirmed the presence of bilateral esophageal duplications. At 1 year of age the patient is growing normally and is asymptomatic except for a persistent Horner's syndrome. We believe this to be the first case of bilateral esophageal duplication cysts presenting with Horner's syndrome.

Management of an abdominal cerebrospinal fluid pseudocyst using laparoscopic techniques.

Abdominal cerebrospinal fluid (CSF) pseudocysts are reported to occur in < 1% of ventriculoperitoneal shunts. Management options include various types of shunt revisions with or without aspiration or excision of the pseudocyst. We report a case in which laparoscopy was utilized in a 12-year-old boy to excise a portion of the pseudocyst, remove the shunt catheter tip from the residual pseudocyst, and reposition it in the peritoneal cavity. The patient experienced no complications from the procedure, and there has been no recurrence of the pseudocyst after 12 months of follow-up observation. This case report demonstrates a novel approach to the management of CSF pseudocysts that is minimally invasive, allows direct drainage of the pseudocyst, and permits manipulation and optimal repositioning of the shunt catheter.

m-Acetylanilido-GTP, a novel photoaffinity label for GTP-binding proteins: synthesis and application.

A novel photoaffinity label, m-acetylanilido-GTP (m-AcAGTP), was synthesized and used to identify GTP-binding proteins (G-proteins). This GTP analogue is easily prepared and can be used for photoaffinity labelling of G-proteins without chromatographic purification. In the presence of the beta-adrenergic agonist isoprenaline, it activates turkey erythrocyte adenylate cyclase. This activation persists even when the beta-adrenergic receptor is subsequently blocked by antagonist, indicating that the GTP analogue is resistant to hydrolysis. The apparent Ka for activation of turkey erythrocyte adenylate cyclase by m-AcAGTP was found to be 0.21 microM, a value similar to that for guanosine 5'-[beta,gamma-imido]triphosphate. m-AcAGTP also effectively inhibited the light-dependent GTPase of Musca fly eye membranes. Photoaffinity labelling of fly eye membranes with [alpha-32P]m-AcAGTP, followed by immunoprecipitation of G-protein Gq, identified a labelled protein band with the mobility of a 41.5 kDa protein on SDS/PAGE. Labelling of this protein was enhanced 9-fold in blue over red illuminated membranes, containing metarhodopsin and rhodopsin respectively. Labelling of alpha-subunits of heterotrimeric G-proteins was also demonstrated in turkey erythrocyte membranes. The ease of preparation of m-AcAGTP and the chemical properties of the photoreactive acetophenone make this affinity label an important new tool in studies of cellular phenomena mediated by guanine nucleotide-binding proteins.

Digitally assisted laparoscopic drainage of multiple intraabdominal abscesses.

Laparoscopic drainage of multiple walled off intraabdominal abscesses may be difficult to perform safely due to a lack of tactile sensation. A single finger introduced through a small abdominal incision can be used to aid in the dissection and may obviate the need for open laparotomy in some cases. Digitally-assisted laparoscopic exploration and dissection utilizes the superior visualization of laparoscopy without completely sacrificing the benefits of tactile sensation. A case is reported in which this technique was successfully employed to drain multiple intraabdominal abscesses in a young boy.

Laparoscopic cholecystectomy in teenagers.

The positive experience with laparoscopic cholecystectomy (LC) in the adult surgical community encouraged us to perform LC in our last nine adolescent patients requiring cholecystectomy. There were no operative or postoperative complications, and the average hospital stay was less than 3 days. All the teenagers resumed their normal activities 1 week after surgery and were pleased with the small operative scars. Once the technique has been mastered and adequate experience gained with the new instrumentation, laparoscopic cholecystectomy would seem to offer many advantages in the teenage patient.

Aerocele, an unusual complication of anterior cricoid split.

Since its introduction, the anterior cricoid split has proven to be a safe and effective procedure for the management of infants with acquired subglottic stenosis. In this article we report an unusual complication--an aerocele, which occurred on the 14th day following an anterior cricoid split on a 9-month-old child. The possible etiology and successful management of the aerocele are reviewed.

Necrotizing enterocolitis in infancy.

The most common gastrointestinal emergency in the newborn is necrotizing enterocolitis. Premature babies are the most likely victims, but it also occurs in full-term infants. Although great strides have been made in elucidating some of the factors responsible for necrotizing enterocolitis, such as intestinal ischemia, bacterial overgrowth, and feeding dysfunction, the exact etiology is as yet unclear. The timing and indications for surgery differ from institution to institution, but the long-term outcome is similar in most large series. The overall mortality rate remains about 20% to 40%, and of the survivors, about one half seem to have no sequelae, the remaining infants having neurologic and gastrointestinal deficits of various degrees of significance.

The irreducible ovary: a true emergency.

The management of a child with an irreducible ovary remains inconsistent in pediatric surgical centers. An informal survey of senior pediatric surgeons and an extensive review of the literature showed a prevailing view that the trapped ovary is not at significant risk of vascular compromise. Two recent cases prompted a review of our experience from 1984 to 1989, during which 1,699 children with inguinal hernias underwent operation, 386 (23%) of whom were girls. Fifteen girls (4%) had irreducible ovaries present at the time of operation and in 4 of the 15 (27%) the ovary was twisted and infarcted. Two of the 4 girls were known to have an irreducible ovary prior to the day of operation--1 was noted 2 months earlier and 1 was noted 1 month earlier. At the time of the initial diagnosis, neither patient had physical findings of vascular compromise of the ovary. In the other two girls, evidence of an infarcted ovary was present when the hernia was first diagnosed and an emergency operation was performed. A 27% incidence of torsion and strangulation of irreducible ovaries appears to be high, but reports of strangulated ovaries have been reported in 2% to 33% of other series. The normal anatomy is altered when an ovary is trapped in a hernia sac, and these changes make torsion more likely. Although an irreducible ovary is not at great risk of compression of its blood supply, this report identifies a significant risk of torsion. This risk warrants treating the asymptomatic irreducible ovary as any other incarcerated hernia--as a true emergency.

Utero-vaginal hypoplasia. Sonographic, embryologic and clinical considerations.

Congenital absence of hypoplasia of the uterus is a cause of primary amenorrhea in approximately 15% of cases. Ultrasound is often employed as an early imaging modality in the evaluation of patients with primary amenorrhea. Demonstration of total absence or marked hypoplasia of the uterus in the presence of normal ovaries during pelvic ultrasound examination, suggests the diagnosis of congenital uterine aplasia or hypoplasia. Sonography may obviate the need for laparoscopy and for other imaging modalities. A case report of uterovaginal hypoplasia in association with anal atresia and recto-vaginal fistula is presented, and the value of ultrasound in the diagnosis of this entity is discussed. The embryology and clinical features of this anomaly are also reviewed.

Idiopathic intestinal perforations in the newborn: an increasingly common entity.

Between 1982 and 1987 seven neonates ranging in age from 24 hours to 1 week were treated for idiopathic intestinal perforations at the Montefiore Medical Center, Albert Einstein College of Medicine. Four of the infants were born prematurely; three were full term. Five were being treated in an intensive care nursery when the perforation was diagnosed. All infants whose perforations were due to necrotizing enterocolitis, appendicitis, Hirschsprung's disease, meconium ileus, intestinal atresias, or drug therapy are excluded from the series. None of the infants had associated anomalies. The sites of the perforations were as follows: two in the jejunum, two in the ileum, one in the cecum, and two in the transverse colon. Six of the perforations were on the antimesenteric aspect of the bowel; one was on the mesenteric aspect. The sizes of the perforations ranged from pinhole to 1 cm in diameter. All the infants did well. Pathologic examination of the resected specimens failed to reveal an etiology for the perforations. There were no cases of duplication or muscular hypoplasia. We believe the etiology of this condition may be ischemic necrosis, secondary to a localized vascular accident in the wall of the affected viscus, but we do not have a good explanation for the upsurge in cases we are seeing.

Characterization of human papilloma virus types in condylomata acuminata in children by in situ hybridization.

The presence of human papilloma virus (HPV) DNA sequences of types 6, 11, 16, and 18 was determined by in situ hybridization under stringent conditions on archival paraffin-embedded tissue sections in eight condylomata acuminata observed in children below the age of 12 years. Viral sequences were detected in seven of eight cases: all of them contained HPV 6, four contained also HPV 11, and one contained HPV 16 and 18. Papilloma virus common antigen was detected in only three of eight cases, all of them being positive also by in situ hybridization. We conclude that most condylomata acuminata in children are associated with the same types found in anogenital lesions in adults. Since little is known about the long-term significance of genital condylomas in children the identification of the papilloma virus type may prove to be important as a prognostic tool particularly in patients infected with HPV types 16 and 18, thought to have high oncogenic potential.

The management of surgery in infants and children with the acquired immune deficiency syndrome.

Between January of 1981 and June of 1984, 53 infants and children with the diagnosis of AIDS were seen at our institution. Twenty-one of these patients have required 35 operations to determine or administer the proper therapy. We have taken every precaution to minimize the risks of exposure of all health care personnel.

A role for endoscopy in the placement of ventriculoperitoneal shunts.

Compartmentalization of the lateral ventricle may prevent adequate functioning of ventriculoperitoneal shunts. We recently treated a patient with postinfectious hydrocephalus who required bilateral shunts. In addition, the left ventricle was shown to contain a large noncommunicating cyst. Prior to placement of the shunt, ventriculoscopy was performed and a channel established surgically between the cyst and the remainder of the ventricular system. Application of this new interventional technique may be indicated in complicated cases of compartmentalized hydrocephalus.

Regulation of brain temperature in pigeons: effects of corneal convection.

The effect of direct ventilation of the eyes on cooling in the brain was investigated in domestic pigeons (Columba livia, mean mass 0.27 kg) with thermocouples chronically implanted in the hypothalamus and anterior eye chamber. During conductive heating in still air body-brain temperature difference (delta T) was 2.6 degrees C. During exclusive ventilation of ocular surfaces, with air flowing at about flight speed, delta T increased to 3.5 degrees C and returned to preventilation values on cessation of ventilation. When the eyes were sealed then ventilated, delta T was not different from that in still air. Administration of phenylephrine caused iridial vasoconstriction and a significant decrease in intraocular temperature, but no changes in brain temperature. This suggests that compensation may occur via other evaporating cranial surfaces. Our findings suggest that the eyes contribute to the control of brain temperature by dissipating heat. Blood cooled while flowing through the ocular vasculature apparently contributes to the venous flow through the ophthalmic rete, serving as a heat sink for arterial blood flowing to the brain.