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Post-partum ovarian vein thrombosis (POVT) is uncommon, but the true incidence is not known. Ninety per cent of cases present as right iliac fossa pain within 10 days of delivery. Anti-coagulation and intravenous antibiotics are the mainstay of treatment. We report three cases that were referred to our unit. These cases illustrate the difficulty in the clinical diagnosis of POVT and highlight the importance of its inclusion in the differential diagnoses of an acute abdomen in post-partum patients. POVT can be accurately diagnosed by appropriate noninvasive investigations and a laparotomy avoided.

Objective: To determine the influence of the dose of collagen given nasally on the induction of specific mucosal tolerance in collagen-induced arthritis., Methods: The severity of clinical arthritis induced in DBA/1 mice was studied after the nasal administration (before disease induction) of 1 of 4 doses (across a 2-log range) of bovine type II collagen (CII). Parameters of immunity included lymphocyte proliferation and cytokine production in vitro in response to antigen stimulation, and the production of anticollagen IgG antibody subclasses., Results: The 3 highest doses (20, 80, and 320 microg) ameliorated disease severity, whereas the lowest dose (5 microg) aggravated disease. These findings correlated well with antigen-specific T cell proliferation and cytokine and antibody production. T cell proliferation was suppressed by the higher doses of CII, whereas the low dose enhanced T cell proliferation, indicating it primed the T cells. Suppression of T cell proliferation could be overcome by the addition of exogenous interleukin-2 (IL-2) to these cultures. Decreased T cell proliferation was associated with suppression of both Th1 (interferon-gamma [IFNgamma]) and Th2 (IL-4) cytokines and all the subclasses of anticollagen IgG in mice receiving 20, 80, or 320 microg of collagen. Overall, the highest dose of collagen (320 microg) was less effective at suppressing the immune response and disease than the 20-microg or 80-microg doses. There was an increased production of antibodies of all IgG isotypes, and of the Th1-associated cytokines IFNgamma and IL-2, in animals that had received the lowest dose of 5 microg collagen nasally., Conclusion: Nasal administration of antigens is effective in inducing tolerance and reducing disease severity, but the effects are dose dependent. Low doses can prime the immune system and aggravate disease; high doses may not suppress disease. Suppression of the immune response, which correlates with suppression of disease, is not obviously associated with a type I to type II T cell switch, but rather with an overall suppression of both forms of T cell response, with a potential role for anergy of T cells in this process.

Following significant advances in lymphatic biology, the important role of kidney lymphatics in kidney function and dysfunction is now being more fully appreciated. Kidney lymphatics begin in the cortex as blind-ended lymphatic capillaries and then coalesce into larger lymphatics that follow the main blood vessels out through the kidney hilum. Their function in draining interstitial fluid, macromolecules, and cells underpins their important role in kidney fluid and immune homeostasis. This article provides a comprehensive overview of recent and more established research findings on kidney lymphatics and the implications of these findings for kidney function and disease. The use of lymphatic molecular markers has greatly expanded our knowledge of the development, anatomy, and pathophysiology of kidney lymphatics. Significant recent discoveries include the diverse embryological source of kidney lymphatics, the hybrid nature of the ascending vasa recta, and the effects of lymphangiogenesis on kidney diseases such as acute kidney injury and renal fibrosis. On the basis of these recent advances, there is now an opportunity to link information from across multiple research disciplines to drive a new era of lymphatic-targeted therapies for kidney disease. © 2023 American Physiological Society. Compr Physiol 13:4945-4984, 2023., (Copyright © 2023 American Physiological Society. All rights reserved.)

Objective: To attempt to characterize the diversity and nature of antigens recognized by anti-endothelial cell antibodies (AECA) in patients with systemic lupus erythematosus (SLE) using a molecular cloning strategy., Methods: AECA in sera of 15 SLE patients were measured by ELISA and Western blot analysis was used to examine the diversity of autoantigen targets in two clinically active patients. A human umbilical vein endothelial cell cDNA expression library was immunoscreened with sera from these two patients to identify their autoantigen targets. An anti-ribosomal P peptide antibody ELISA was used to assess the clinical significance of anti-ribosomal P protein antibodies in the sera of one patient., Results: Significantly higher AECA levels were found in five patients with active disease and nephritis than in five patients with clinically inactive disease. Sera from two clinically active patients were found to recognize distinct spectra of autoantigens. The candidate autoantigens that were identified included (1) endothelial cell-specific plasminogen activator inhibitor; (2) the classical lupus antigen, i.e. ribosomal P protein P0; and (3) proteins never before described as putative autoantigens in SLE, including ribosomal protein L6, elongation factor 1alpha, adenyl cyclase-associated protein, DNA replication licensing factor, profilin II and the novel proteins HEAPLA 1 and HEAPLA 2 (human endothelial associated putative lupus autoantigens 1 and 2). In one patient, antibodies against ribosomal P protein P0 were predominant and levels of these antibodies correlated with total AECA levels, anti-DNA antibody titres, overall clinical score and renal disease in a longitudinal study., Conclusions: A panel of candidate endothelial autoantigens in SLE, which includes previously described autoantigens and novel targets, has been identified by a molecular cloning strategy. This novel molecular approach could also be applied to the identification of autoantigens in other autoimmune vascular diseases.

A 6-year-old girl presented for a second opinion with a 1-year history of an enlarging soft tissue mass just lateral to the right areola. She had been seen by a pediatric surgeon elsewhere who reassured the parents that the lesion was benign. Ultrasound scan showed a 1.5- x 1.5-cm cystic structure adjacent to the right breast bud. Excisional biopsy results showed secretory ductal adenocarcinoma. Modified radical mastectomy with axillary node dissection was performed. All 11 nodes were negative for metastatic disease. She is now disease free 3 years after diagnosis. Estrogen-progesterone receptors were negative, as was screening for BCR 1 and 2. This is the first report of cytogenetics showing an abnormal cell line with a reciprocal translocation between 12p and 15q. Although breast cancer is extremely rare in children, a history of a painless, enlarging, firm breast mass should raise concern about possible neoplastic disease. Cystic appearance on ultrasound scan caused by the pseudocapsule around the tumor may be a marker for secretory carcinoma. Histological evaluation of all suspicious masses should be obtained. Because of the risk of local recurrence and axillary metastases, the authors recommend modified radical mastectomy with axillary node dissection for children with secretory carcinoma of the breast.

Purpose: The aim of this study was to assess the accuracy of computed tomography (CT) in the local staging of Wilms' tumor., Methods: Twenty-six patients with unilateral, nonmetastatic Wilms' tumors were accrued over the period of 1990 through 1997. Preoperative CT staging was performed before surgical biopsy or excision. The abdominal CT images were reviewed and staged for local disease according to National Wilms' Tumour Study (NWTS) Group Staging V as either intrarenal disease (Stage I), local extrarenal extension amenable to complete local excision (Stage II), or advanced local disease (Stage III). Patients with metastatic (Stage IV) and bilateral disease (Stage V) were excluded from our study. Results were compared to histological findings., Results: CT scan correctly staged 10 of 26 cases (38%) of Wilms' tumor. CT scan overstaged 12 of 16 (75%) localized renal disease (Stage I) and local extension (Stage II) tumors, and understaged 4 of 10 (40%) localized spread (Stage III) tumors., Conclusions: CT scan appears to have poor correlation to histological staging. Therefore, basing therapy solely on radiological imaging may lead to some patients receiving more intense therapy than necessary, whereas others do not receive sufficient therapeutic regimens. Histological assessment of the excised mass should remain the standard for staging Wilms' tumors.

Objective: Anorectal malformations are usually diagnosed at birth, but some patients have presented to this institution beyond the early newborn period without recognition of their anorectal malformations. To quantify the extent of this problem, we undertook a review of all patients presenting to this hospital with anorectal malformations., Methods: We reviewed all new cases of anorectal malformations treated at British Columbia's Children's Hospital during the past 11 years. We looked specifically at the time of diagnosis, patient age, sex and mode of presentation, the type of anorectal malformations, and any associated anomalies., Results: One hundred twenty new cases of anorectal malformations were seen here, of whom, 15 patients (9 girls and 6 boys) presented beyond the early newborn period. Of these, 1 male infant was diagnosed at 2 weeks of age and another girl at 14 years of age. The remaining 13 presented between 3 and 11 months of age because of increasing constipation, usually associated with the introduction of solid foods. All had low anorectal malformations. Nine patients had at least 1 other feature of the VACTERL complex., Conclusions: Most anorectal malformations are identified at birth, but a significant number of the milder lesions may not be recognized until later. Therefore, this condition must be considered in older infants and children presenting with constipation, particularly if they also have cardiac or genitourinary anomalies. constipation, imperforate anus, VACTERL.

A 14-yr-old, previously healthy boy presented with massive lower GI hemorrhage. After the routine endoscopic and radiological evaluation, laparotomy and intraoperative colonoscopy revealed multiple polyps in the colon. A hemicolectomy was performed because of the severity of hemorrhage. A diagnosis of juvenile polyposis was made based upon histological findings and the family history. This is an extremely unusual presentation of juvenile polyposis and has been reported only once before. The clinical features, diagnosis, and therapeutic options for juvenile polyposis are discussed. Juvenile polyposis, although a rare condition in the pediatric population, should be considered in the differential diagnosis of life-threatening GI hemorrhage.

We explore the extent of "responsible purchasing" by employers--the degree to which employers collect and use nonfinancial information in selecting and managing employee health plans. Most firms believe that they have some responsibility for assessing the quality of the health plans they offer. Some pay attention to plan characteristics such as the ability to provide adequate access to providers and services and scores on enrollee satisfaction surveys. A more limited but still notable number of firms take specific actions based on responsible purchasing information. Because of countervailing pressures, however, it is not clear whether or not the firms most involved in responsible purchasing are signaling a developing trend.

Background/purpose: Fibromatoses represent a spectrum of nonneoplastic spindle cell tumors frequently identified in childhood. Although they may be locally aggressive, they do not metastasize. The authors have reviewed their experience of these lesions in an attempt to identify clinical and pathological features suggestive of recurrence., Methods: Clinical records and pathological specimens from 55 cases of fibromatosis diagnosed and treated at British Columbia's Children's Hospital from 1982 to 1995 were reviewed., Results: Thirty boys and 25 girls with ages ranging from 1 month to 14 years were identified. Eighteen tumors (33%) were congenital. Diagnoses were as follows: musculoaponeurotic fibromatosis (n = 27), infantile myofibromatosis (n = 10), Dupuytren-type fibromatosis (n = 7), fibromatosis colli (n = 7), and digital fibroma (n = 4). Clinical follow-up showed a survival rate of 98%. The single mortality occurred in an infant born with an intraabdominal visceral myofibromatosis, which proved unresectable. Fifteen cases recurred (27%), and nine cases (16%) of infantile myofibromatosis spontaneously regressed. All remaining cases were controlled successfully by surgical resection., Conclusions: Clinical features suggestive of recurrence included (1) presentation at greater than 5 years of age, (2) extremity location of disease, and (3) incomplete surgical resection. Pathological features suggestive of recurrence were (1) microscopic evidence of tumor at resection margins, (2) mitotic index of 5 or more per 10 high-power fields, and (3) areas of necrosis and inflammation within the tumor.

Purpose: With the advent of more aggressive chemotherapy, the incidence of neutropenic enteropathy is increasing. This review was performed to (1) determine which children are affected, (2) identify predisposing factors, and (3) assess efficacy of treatment., Methods: A 10-year (1988 to 1997) review identified 33 children who had 38 episodes of neutropenic enteropathy. Each presented with fever, abdominal pain, and chemotherapy-induced neutropenia. All were treated with fluid resuscitation, bowel rest, and broad-spectrum antibiotics. Surgical intervention was reserved for children with bowel perforation., Results: Neutropenic enteropathy occurred in 24 children with hematologic malignancies and nine with solid tumors. This disease developed in three children after bone marrow transplantation for leukemia. All five patients in whom recurrent episodes developed were receiving chemotherapy for Burkitt's lymphoma. Cytosine arabinoside and VP16 were the most commonly implicated chemotherapeutic agents. Four children required laparotomy and right hemicolectomy, and all survived. Overall survival was 94%., Conclusions: Although previously described in children receiving chemotherapy for hematologic malignancies, neutropenic enteropathy also occurs in children who have solid tumors and after bone marrow transplantation. The use of cytosine arabinoside and VP16 may predispose patients to this disease. Children receiving chemotherapy for Burkitt's lymphoma are at increased risk for recurrent episodes. Excellent survival rate was attained with supportive care being used as the primary treatment modality.

The effects on milk composition and processing characteristics of varying grass supply by changing stocking density and of offering a concentrate supplement were investigated. The experiment was conducted over 28 weeks of the lactation (April-October) using 48 spring-calved Friesian-Holstein cows. Three herds each of 16 cows were offered a restricted grass supply, a standard grass supply and a standard grass supply with a supplement of 3 kg concentrate/d. Treatment groups were grazed separately with a residence time of 3 d/paddock. Milk production, composition and processing characteristics such as renneting properties, ethanol stability and plasmin activity were measured weekly. Increasing stocking density above the standard system resulted in significant reductions in milk fat and protein yields, the concentrations of total protein, casein and whey proteins, and a deterioration in most processing characteristics. Imposing concentrate supplementation on the standard system increased total protein, casein and whey protein concentrations but generally did not improve processing characteristics except for ethanol stability. These results suggest that the standard grass supply in a rotational grazing paddock system can support efficient production of quality milk, and concentrate supplementation will not improve processing characteristics when an adequate supply of good quality herbage is available.

Cows on pasture were fed full fat soybeans (toasted, flaked, and pelleted) or ground full fat rapeseeds to investigate effects on cis-9, trans-11-octadecadienoic acid in milk. Three herds of 16 cows each that were on pasture were fed 3.1 kg/d of unmolassed beet pulp (control), 3.0 kg/d of rapeseed concentrate, or 3.1 kg/d of a soybean supplement. The concentration of cis-9, trans-11-octadecadienoic acid in the milk of cows fed the rapeseed and soybean supplements was significantly higher than in the milk of cows fed the control diet during the feeding trial. Over the trial, the cis-9, trans-11-octadecadienoic acid concentration in the milk of individual cows varied from 6.8 to 25.7 mg/g of fat in the control herd, from 10.6 to 33.5 mg/g of fat in the herd fed the rapeseed concentrate, and from 8.8 to 30.5 mg/g of fat in the herd fed the soybean supplement. The concentration of cis-9, cis-12-octadecadienoic acid, the substrate for cis-9, trans-11-octadecadienoic acid synthesis in the rumen, was 4.9 g/100 g of fatty acid methyl esters in the milk fat of cows fed the soybean supplement, 2.5 g/100 g of fatty acid methyl esters in the milk fat of cows fed the rapeseed concentrate, and 2.3 g/100 g of fatty acid methyl esters in the milk fat of the control cows. Milk yield and milk constituent yields were not affected by supplementation of either full fat soybeans or rapeseeds compared with controls, but milk protein concentration was significantly reduced by both oilseed supplements.

Context: Understanding whether and to what degree changes in young men's attitudes explain increases in condom use over time can be useful in developing more effective disease prevention strategies., Methods: Data from the 1988 and the 1995 National Survey of Adolescent Males are used to determine changes in attitudes toward condoms, pregnancy prevention and HIV and AIDS. Two-limit tobit models are employed to investigate the association between these attitudes and condom-use behavior and to examine how this relationship may have changed over time., Results: Between 1988 and 1995, young men's attitudes toward partner appreciation of condom use, condom-use embarrassment and pleasure reduction from condom use all changed in a direction suggestive of more consistent condom use. However, attitudes related to pregnancy prevention and AIDS avoidance changed in a direction suggestive of less-consistent condom use. Changes over time in the strength of the relationship between three attitude measures (masculinity, pleasure reduction and partner appreciation) and condom use also were predictive of lower levels of condom-use consistency. Only the strength of the relationship between condom-use embarrassment and consistent condom use changed in a direction corresponding to observed increases in rates of condom use among young men., Conclusions: Many of the significant changes in young males' attitudes toward condoms do not explain the increase in consistent condom use among adolescent males that occurred between 1988 and 1995. However increasing male contraceptive responsibility and emphasizing the risks and consequences of contracting HIV appear to be viable routes for policymakers to explore. Efforts particularly need to be targeted toward Hispanics.

An experiment with a multiple Latin square design using 36 midlactation Friesian cows was carried out to determine the effect of fish meal or soybean meal in a supplement fed at two amounts (3.5 or 7 kg/d) with grass silage. The diets were also fed to four ruminally and duodenally cannulated cows to determine digestibility, ruminal fermentation, and nutrient flows. Dry matter intake, milk production, milk constituent yields, and concentrations of protein and lactose were significantly increased by the supplements when provided at 7 kg/d. The supplement containing fish meal increased milk production, protein and lactose yields, and milk protein concentration, but the increases were smaller than those obtained by increasing the amount of supplement fed. Neither the type nor the amount of supplement fed affected digestibility of dry matter or organic matter, and few significant effects on ruminal fermentation were observed. Supplements fed at the higher allowance significantly increased the flow of dry matter, organic matter, all nitrogenous components, and amino acids to the duodenum. The supplement containing fish meal significantly increased the duodenal flow of nonammonia nonmicrobial N and some amino acids. Results indicated that an increase in the concentration of supplement in the diet is more effective in increasing milk production, protein concentration and yield, and flow of amino acids to the duodenum than is increasing the concentration of ruminally undegradable protein in the supplement.

Purpose: Cougar attacks on humans appear to be on the rise. A review of all attacks on children was performed to determine the method of attack and injury patterns so that a treatment regimen as well as possible preventative measures could be determined., Methods: A review of all attacks, including attacks on children, was performed, including three recent attacks treated at our institution. Situation, adult supervision, patient age, injuries recorded, survival, and mode of attack, if known, were reviewed., Results: There were 50 documented attacks on children with a 25% fatality rate. Most children were not alone at the time of the attack (92%), and in many instances adult supervision was present or nearby. Severe head and neck lacerations along with puncture wounds were the most common injury. Examples of typical cervical injuries include a nonfatal vertebral artery injury, phrenic nerve injury, a fatal internal carotid artery injury, and a fatal cervical spine injury. The cougar was rabid in two cases. Pasteurella resulted in late infections in two patients., Conclusions: Based on the pattern of injuries, the authors recommend aggressive evaluation for occult cervical injuries as well as surgical debridement. Antibiotics should cover oropharyngeal flora including Pasteurella multocida. Rabies prophylaxis is indicated. Adult supervision in wilderness areas is not necessarily protective.

Milk was collected from three spring-calving herds, on different daily herbage allowances (DHA) of perennial rye-grass (16, 20 or 24 kg dry matter (DM)/cow for a 17 week period. On five occasions, at weekly intervals in the middle of the period, the three different milks were converted into low-moisture part-skim Mozzarella cheese. Increasing the DHA resulted in significant increases in the concentrations of protein in the cheesemilk (P < 0.05) and cheese whey (P < 0.02). The moisture-adjusted cheese yield increased significantly (P < 0.01) on raising the DHA from 16 to 24 kg grass DM/cow. DHA had no significant effects on any of the gross compositional values of the cheese (although moisture and fat-in-DM levels tended to decrease and increase respectively with increasing DHA). The hardness of the uncooked cheese and functionality of cooked cheese (i.e. melt time, flowability, stretch and viscosity) were not significantly influenced by DHA over the 115 d ripening period at 4 degrees C.

The human Burkitt lymphoma Ramos B cell line can be induced to undergo apoptosis in response to a variety of different agents, including calcium ionophores, anti-immunoglobulin (Ig) and macromolecular synthesis inhibitors. In addition, following up-regulation of the Fas (CD95) surface receptor by CD40 ligation, these cells also become susceptible to apoptosis induction by Fas ligation. We have previously shown that protection from calcium ionophore- and macromolecular synthesis inhibitor-induced apoptosis by CD40 ligation is associated with a rapid up-regulation of Bcl-xL followed by a more moderate and delayed up-regulation of Bcl-2. We show here that overexpression of Bcl-xL, like Bcl-2, protects Ramos cells from apoptosis induction in response to calcium ionophore, anti-Ig and macromolecular synthesis inhibition. However, in contrast to Bcl-2, ectopic overexpression of Bcl-xL does not rescue from Fas-mediated apoptosis. Thus, in Ramos B cells, the Fas apoptotic pathway exhibits differential sensitivity to inhibition by Bcl-2 family members. These findings also suggest that CD40 signaling provides a switch which renders the cells susceptible to Fas-ligand mediated apoptosis through up-regulation of Fas whilst affording protection from anti-Ig-induced apoptosis through up-regulation of Bcl-xL.

An experiment was carried out to determine the effect of a grass diet and a concentrate supplement on rumen fermentation and nutrient flows to the duodenum. Perennial ryegrass was cut and fed indoors to eight rumen- and duodenum-cannulated Friesian cows with or without 3 kg/d of molassed beet pulp in a randomized design experiment. The dry matter intake of grass was significantly lower for cows fed the concentrate supplement (13.6 vs. 11.5 kg of dry matter/d), but total dry matter and organic matter (OM) intakes were similar for cows fed both diets. Cows fed the supplement had higher mean concentrations of total volatile fatty acids (108 vs. 89 mmol/L) and a higher percentage of butyrate in total volatile fatty acids (13.5 vs. 11.6 mol/100 mol). There were no differences between the diets in the flow of OM to the duodenum or in the extent of OM digestion in the rumen. Flows of nonammonia N, microbial N, and amino acids to the duodenum tended to be higher for cows fed the supplemented diet than for those fed ryegrass only. The efficiency of microbial protein synthesis also tended to be higher for cows fed the supplemented diet (42 vs. 37.7 g/kg of OM apparently digested in the rumen and 28.2 vs. 26 g/kg of OM truly digested in the rumen). Overall, there were indications that the supplement caused better capture of N in the rumen and increased the efficiency of microbial protein synthesis.

The amino (AA) profile of eight feedstuffs (two samples of fishmeal, soybean meal [SBM], formaldehyde-treated SBM, sopralin, cotton-seed meal [CSM], rapeseed meal [RSM], corn distillers grains [CDG], and corn gluten feed [CGF]) was determined before and after ruminal incubation for 8 and 12 h in three lactating Friesian cows using nylon bags. The profile of AA disappearing during intestinal passage was also measured by inserting the bags into the duodenum through T-piece cannulas after ruminal incubation and recovering them in the feces. The AA profile changed for all feedstuffs, except sopralin, following ruminal incubation. Changes were greater for the more degradable feedstuffs. The profile of AA disappearing during intestinal passage was generally similar to the profile after ruminal incubation, but some differences were found with feedstuffs that had low (< 84%) intestinal disappearance of AA (RSM, CDG, CGF). For the other feedstuffs, intestinal disappearance of AA was greater than 93%. The two fishmeal samples had the highest concentrations of methionine and lysine in their residues after ruminal incubation, whereas CDG and CGF had low lysine concentrations. Residues of these latter two and RSM were quite high in methionine concentration, whereas residues of SBM, sopralin, and CSM had the lowest concentrations. Corn distillers grains had 13% of its AA remaining after ruminal incubation followed by intestinal passage. These results show that feedstuffs vary in the proportion of their AA that escape ruminal degradation, in the profile of those AA, and in their intestinal digestibility. These factors should be considered in protein evaluation systems and in assessment of the protein quality of feedstuffs.

This experiment examined the effect of complete diets composed of 60% grass silage and 40% concentrate based mainly on beet pulp, ground wheat, wheat treated with NaOH, or ground corn on milk production and ruminal fermentation of dairy cows. Milk production and fat yield were 19.8, 20.7, 20.1, and 21.2 kg/d and 0.71, 0.76, 0.72, and 0.78 kg/d, respectively (18 cows per treatment). Cows fed the diet based on ground corn had higher milk production and fat yield, but lower milk protein concentration, than did cows fed the diet based on beet pulp. Cows fed the diet based on ground corn also had higher fat yields than did cows fed the diet based on wheat treated with NaOH. Cows fed the diet based on ground wheat had lower ruminal pH than did cows fed the diet based on beet pulp (6.34 vs. 6.59) and higher ruminal NH3 concentrations (6.2 vs. 5.2 mmol/L) than did cows fed the diet based on ground corn. These results showed little difference in milk production based on wheat processing method and little advantage to replacing beet pulp with either wheat type in a high forage diet. However, milk production and fat yield were increased by replacing beet pulp with ground corn.

Objectives: To determine the impact of Escherichia coli O157:H7 infection in children on the need for surgical assessment in a pediatric surgical practice and whether clinical and bacteriologic variables might contribute to that need., Design: Examination of a case series., Setting: A tertiary-care pediatric hospital., Patients: Between 1990 and 1994, E. coli O157:H7 gastrointestinal infections were documented among 85 children, 29 of whom suffered from hemolytic-uremic syndrome., Intervention: Surgical consultation for presumed or proven complications of the infection., Main Outcome Measures: The frequency of and reasons for surgical consultation, clinical and bacteriologic variables between patients who did or did not require surgical assessment., Results: Of the 85 children, 17 (20%) were assessed by the surgical service. The majority of these children were inpatients. Two required abdominal surgery. Female gender, older age and progression to hemolytic-uremic syndrome were factors associated in univariate analyses with a likelihood of need for surgical assessment; variation in bacterial genotype was not., Conclusion: There is the potential for verotoxigenic E. coli O157:H7 infection to have a considerable impact on the utilization of pediatric surgical services.

Mesenteric lymphangiomas are rare benign tumours of lymphatic vessels. We present the case of a mesenteric lymphangioma in a 14 year old boy.

The role of interleukin-4 (IL-4) and CD40 signaling in negative regulation of apoptosis in human Ramos B cells induced in response to different agents was investigated. CD40 ligation protected cells from apoptosis induced by calcium ionophore through an initial, rapid and apparently Bcl-2-independent mechanism, associated with up-regulation of Bcl-XL. However, rescue from apoptosis induced by inhibition of macromolecular synthesis required several hours of prior stimulation with CD40 ligand/antibody and was accompanied by up-regulation of Bcl-2. In contrast, IL-4 did not up-regulate Bcl-2 or Bcl-XL and did not inhibit apoptosis induced by inhibitors of macromolecular synthesis. However, IL-4 did protect Ramos cells from apoptosis induced by calcium ionophore and this effect was accompanied by inhibition of ionophore-induced expression of an immediate early gene encoding a 36-kDa zinc-finger protein, Berg36. Antisense blockade of Berg36 expression partially inhibited ionophore-induced apoptosis to an extent commensurate with the level of IL-4 protection, implicating Berg36 function as a requirement for apoptosis induced through calcium signaling and as a target for IL-4 through which this cytokine inhibits apoptosis in Ramos B cells. These distinct mechanisms for rescue from apoptosis by CD40 and IL-4 may help explain the co-operative roles of these T cell-derived signals for B cell survival.

The protein kinase C activator bryostatin induces differentiation and antagonizes the effects of tumour-promoting phorbol esters in a number of different cell types. We show here that bryostatin preferentially inhibits phorbol 12-myristate 13-acetate (PMA)-induced proliferation compared with differentiation in a number of different B chronic lymphocytic leukaemia (BCLL) cell populations examined. By using a panel of 11 early-response gene probes in Northern hybridization analysis, we found that the profile of genes induced in response to bryostatin and PMA was qualitatively similar and displayed comparable sensitivities to inhibition with the serine-threonine kinase inhibitor 1-(5-isoquinolinylsulphonyl)-2-methylpiperazine hydrochloride (H7), consistent with common signalling through protein kinase C. However, the nuclear oncogene. c-myc, which was induced strongly in response to PMA treatment, was only marginally up-regulated by bryostatin. In addition, bryostatin selectively inhibited the magnitude of PMA-responsive induction of c-myc, to a degree commensurate with its antagonistic effects seen at the biological level. Finally, an anti-sense oligonucleotide blockade of c-myc inhibited PMA-induced proliferation but not the differentiation of BCLL cells, implicating this nuclear oncogene as an important determinant distinguishing PMA from bryostatin-coupled biological responses and also as a candidate third-messenger effector target for the anti-tumour effects of bryostatin.

We report on a surviving four-year-old female with sirenomelia. She was born with the features of fused lower extremities, imperforate anus, colon atresia, pelvic and sacral dysplasia. Despite these severe anomalies, she had functional renal units. Maldevelopment of the genitourinary tract in patients with severe variant of caudal regression syndrome is usually incompatible with life. The case report includes the most current imaging studies of her unusual pelvic anomalies which poses a reconstructive challenge to the pediatric surgeon.

Echocardiography is now considered to be the key investigation when heart failure is suspected, and should improve clinical management. An open-access echocardiography service was piloted to 24 general practitioners and the service was audited after 250 cases. The impact on clinical management was assessed by reviewing general practice notes 2 months after the echocardiogram. Significant impairment of left ventricular function was found in 49 patients (20%). Out of these subjects, 38 had been started on an ACE inhibitor. Twenty patients were considered to have a significant valve lesion by echocritiera, of whom 14 had been referred for a cardiological opinion. The provision of an open-access echocardiography service was popular with general practitioners and the information resulted in appropriate management decisions being made.

Despite proper technique, pull-through operations for Hirschsprung's disease sometimes fail to deliver normal or effective bowel evacuation. Ten patients, described herein, had had a pull-through procedures. The procedures had been performed by various pediatric surgeons. Five cases had been diagnosed in the newborn period and had undergone colostomies. The remainder had been diagnosed later (at 2 months to 2 years of age). They too had undergone colostomy initially, and all had an elective pull-through procedure. The techniques varied; two had Soave procedures, seven had Duhamel procedures, and one had a Kimura-Soave procedure (the only case of total colonic Hirschsprung's disease in the series). All the patients had manifested difficulty in passing stools after the pull-throughs. The problem was described as "severe constipation," "obstipation," or "fecal retention." Four patients had been treated with many laxatives, suppositories, enema routines, and diet regimens for years, with no success. All had been examined radiographically to detect megarectum or megacolon. All had additional biopsies to confirm the presence of ganglia in the pulled-through segments. At 21 months to 12 years of age, these patients underwent full posterior internal sphincterotomies. Nine of the 10 had a good or excellent outcome, with resolution of the megarectum or megacolon. Three patients still require small doses of senna compound, which are being decreased continuously. Therapy failed for a patient with Down's syndrome and a, Duhamel pull-through, and a stoma was required.

Traumatic splanchnic artery pseudo-aneurysms are uncommon; only two cases have been reported among the pediatric population. The authors describe their experience with four patients in whom splanchnic artery pseudoaneurysms developed after blunt abdominal trauma. Splenic artery pseudo-aneurysms were found in a 6-year-old boy and an 8-year-old girl after blunt splenic injuries. In both cases, spontaneous thrombosis of the pseudo-aneurysms occurred after a period of observation. Hepatic artery pseudoaneurysms were found in a 7-year-old boy and a 10-year-old girl after major liver lacerations. The boy had successful angiographic embolization of the lesion, but the girl required direct ligation of the pseudo-aneurysm after nearly exsanguinating from acute hemorrhage. All four children have recovered completely, with no long-term sequelae. Traumatic splanchnic artery pseudo-aneurysms are potentially life-threatening complications that can occur after blunt abdominal trauma. The investigation and management of these lesions must be individualized according to the clinical scenario.

In some children, contrast radiography and endoscopy fail to confirm suspected Crohn's disease, or fail to evaluate the extent of disease. This report documents seven cases in which laparoscopy was used to look for creeping mesenteric fat involving the small intestine, a pathological finding reported only for Crohn's disease. One child had extensive Crohn's colitis and possible terminal ileitis that remained clinically disabling despite intensive immunosuppression therapy. The lack of creeping fat in the small intestine was used to justify colon resection and forego further aggressive medical therapy. The patient had complete resolution of her symptoms after the colectomy. Six children had suspected Crohn's disease and underwent diagnostic laparoscopy after other studies were inconclusive. In three, creeping mesenteric fat of the small intestine was found, and all three responded to treatment for Crohn's disease, with resolution of symptoms. The other three children had Crohn's disease excluded based on the absence of creeping mesenteric fat, and subsequently other pathological conditions were identified. The usual radiographic and endoscopic studies will diagnose most cases of Crohn's disease, but this report emphasizes that, in select cases in which other investigations are inconclusive, laparoscopy can be useful to search for creeping mesenteric fat, a finding characteristic of Crohn's disease.

Henoch-Schönlein purpura (HSP) is an immunologically mediated systemic vasculitis of small blood vessels that frequently involves the gastrointestinal tract. Surgeons often are asked to assess patients with HSP for abdominal pain. Common complications that lead to surgical intervention include intussusception, perforation, necrosis, and massive gastrointestinal bleeding. However, the development of multiple entero-entero fistulae has not been described previously. Herein the authors describe the case of a 10-year-old girl with HSP who had a typical rash, seizures secondary to central nervous vasculitis, and gastrointestinal involvement. The abdominal pain persisted for several days until marked fever and hypotension developed, which necessitated surgical intervention. During laparotomy, multiple entero-entero fistulae of the ileum were found, which required resection and primary anastomosis. Histological examination of the ileum was consistent with HSP vasculitis. The patient made an unremarkable recovery and has had no recurrence of symptoms.

B lymphocytes are activated following antigen stimulation of the B cell receptor but require co-stimulation with accessory molecules provided by interleukin (IL)-4/CD40 ligand for cell cycle progression and proliferation. By analyzing a panel of 11 early response genes induced by cross-linking of surface immunoglobulin, we show that CD40 signaling alone induces only 2 genes, c-myc together with an anonymous gene, 3L3, and that these are distinct from the set of genes induced in response to IL-4. Co-stimulation with the proliferative combination of anti-mu, IL-4 + CD40 signaling led to a fourfold enhancement of egr-2/krox 20 expression over that seen with anti-mu alone. Egr-2 expression/activity was selectively inhibited by the immunosuppressive drug cyclosporin A, and antisense oligonucleotide blockade of Egr-2 activity elicited a dose-dependent inhibition of B cell proliferation. Taken together, these observations show that the early gene regulatory programs coupled to different surface receptors on B cells are largely distinct from each other, but that certain genes, exemplified by egr-2, may represent a point of convergence in the integration of different signaling pathways into the B cell proliferative response.