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Background: In 2020, healthcare providers were expected to provide care to individuals with coronavirus disease 2019 (COVID-19), putting them at risk of acquiring COVID-19. The possibility of acquiring poorly understood infectious diseases while providing care may have an impact on the mental health of providers. We conducted a study to explore the effects of COVID-19 on the mental health of healthcare providers. Methods: Between April and August 2021, we conducted in-depth interviews with 60 healthcare providers in the infectious disease unit (IDU) and other units of the hospital (non-IDU). The healthcare providers completed an online self-administered survey form with demographic data (age, sex, average income, and known contact with a COVID-19 patient). We used semi-structured interview guides to understand the healthcare providers’ lived experiences of stress, anxiety, depression, and their associated factors. We transcribed the interviews verbatim and coded and analyzed the transcripts to derive thematic concepts related to mental health experiences. Results: The healthcare providers had a median age of 37 years [IQR 20.0–58.0], and 56.7% were female, 30.0% nurses, 18.3% medical doctors, and 11.7% laboratory technologists. The healthcare providers reported increased stress during the pandemic, attributed to the high demand for patient care, changes in social life, and fear of COVID-19 infection. They also reported experiences of anxiety and depression as a result of limited knowledge at the beginning of the pandemic and the perception that “COVID-19 resulted in death”. Testing positive for COVID-19, high exposure to COVID-19 risks, and the death of patients and colleagues reportedly affected the healthcare providers’ mental health. Additionally, the healthcare providers reported mental health support through debriefing meetings, peer-to-peer support, and psychological counseling, with privacy and confidentiality concerns. Conclusions: Healthcare providers faced mental health issues such as stress and anxiety while taking care of COVID-19 patients. An effective mental health response requires institutional practices that address context-specific challenges such as privacy and confidentiality.

The subcutaneous route offers myriad benefits for the administration of biotherapeutics in both acute and chronic diseases, including convenience, cost effectiveness and the potential for automation through closed-loop systems. Recent advances in parenteral administration devices and the use of additives which enhance drug dispersion have generated substantial additional interest in IV to SQ switching studies. Designing pre-clinical and clinical studies using SQ mediated delivery however requires deep understanding of complex inter-related physiologies and transport pathways governing the interstitial matrix, vascular system and lymphatic channels. This expert review will highlight key structural features which contribute to transport and biodistribution in the subcutaneous space and also assess the impact of drug formulations. Based on the rapidly growing interest in the SQ delivery route, a number of potential areas for future development are highlighted, which are likely to allow continued evolution and innovation in this important area.

Recent advances in subcutaneous drug delivery and device design are transforming the biopharmaceutical sector and improving patient care., (Copyright © 2017 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works.)

Rationale: Tandem mass spectrometry (MS/MS) dissociation pathways can vary markedly between compound classes and can result in challenging and time-consuming interpretation of the data. Compound, class and substructure specific fragmentation rules for protonated molecules require refinement to aid the structural elucidation process., Methods: The application of a predictive science approach using density functional theory (DFT) calculations has been investigated to estimate the abundances of first-generation product ions observed using an ion trap mass spectrometer. This has been achieved by application of Boltzmann population theory to electrospray ionisation (ESI)-MS and MS/MS data., Results: Tandem ESI-MS data for this preliminary study were used to investigate the internal stabilities of protonated species and their product ions. The calculated relative abundances of 11.3%, 96.5%, and 1.1% for the product ion (m/z 192) of three quinazoline structural isomers are compared with the experimental values of 16%, 90% and 0% observed in the first-generation product ion mass spectra., Conclusions: Close correlation between calculated and experimental data has been demonstrated for these initial data. Applying this approach and establishing fragmentation rules, based on structure specific and common fragmentation behaviour, would improve and expedite the structural elucidation process., (Copyright © 2013 John Wiley & Sons, Ltd.)

We have developed a novel wet extrusion process to fabricate nonwoven self-assembled microfiber scaffolds with uniform diameters less than 5 μm and without any postmanipulation. In this method, a poly(L-lactic acid) solution flows dropwise into a stirring nonsolvent bath, deforming into liquid polymer streams that self-assemble into a nonwoven microfiber scaffold. The ability to tune fiber diameter was achieved by decreasing polymer spin dope concentration and increasing the silicon oil to petroleum ether ratio of the nonsolvent spin bath. To demonstrate the drug delivery capabilities of scaffolds, heparin was encapsulated using a conventional water-in-oil (W/O) emulsion technique and a cryogenic emulsion technique developed in our laboratory. Spin dope preparation was found to significantly effect the release kinetics of self-assembled scaffolds by altering the interconnectivity of pores within the precipitating filaments. After 35 days, scaffolds prepared from W/O emulsions released up to 45% encapsulated heparin, whereas nearly 80% release of heparin was observed from cryogenic emulsion formulations. The versatility of our system, combined with the prolonged release of small molecules and the ability to control the homogeneity of self-assembling scaffolds, could be beneficial for many tissue regeneration and engineering applications., (Copyright © 2012 Wiley Periodicals, Inc.)

Capillary electrophoresis/mass spectrometry (CE/MS) is predominantly carried out using electrospray ionization (ESI). Recently, atmospheric pressure chemical ionization (APCI) and atmospheric pressure photoionization (APPI) have become available for CE/MS. With the VUV lamp turned off, the APPI source may also be used for CE/MS by thermospray ionization (TSI). In the present study the suitability of ESI, APCI, APPI and TSI for drug impurity profiling by CE/MS in the positive ion mode is evaluated. The drugs carbachol, lidocaine and proguanil and their potential impurities were used as test compounds, representing different molecular polarities. A background electrolyte of 100 mM acetic acid (pH 4.5) provided baseline separation of nearly all impurities from the respective drugs. APPI yielded both even- and odd-electron ions, whereas the other ionization techniques produced even-electron ions only. In-source fragmentation was more pronounced with APCI and APPI than with ESI and TSI, which was most obvious for proguanil and its impurities. In general, ESI and TSI appeared the most efficient ionization techniques for impurities that are charged in solution achieving detection limits of 100 ng/mL (full-scan mode). APPI and APCI showed a lower efficiency, but allowed ionization of low and high polarity analytes, although quaternary ammonium compounds (e.g. carbachol) could not be detected. Largely neutral compounds, such as the lidocaine impurity 2,6-dimethylaniline, could not be detected by TSI, and yielded similar detection limits (500 ng/mL) for ESI, APPI and APCI. In many cases, impurity detection at the 0.1% (w/w) level was possible when 1 mg/mL of parent drug was injected with at least one of the CE/MS systems. Overall, the tested CE/MS systems provide complementary information as illustrated by the detection and identification of an unknown impurity in carbachol., (Copyright (c) 2009 John Wiley & Sons, Ltd.)

We report an approach for fabricating biomimetic surface replicas of cells with nanoscale resolution. Fixed cells serve as a template for a two-stage replica molding process. Cast from the template, the impression replica contains a reproduction of cellular topographical features indented into its surface, and cast from the impression replica, the relief replica contains a copy of these features protruding from its surface. Various polymers and cells can be utilized, and scanning electron microscopy, atomic force microscopy, and white light interferometry analyses confirm the replication of nanoscale features. These replicas are useful for investigating cellular function and for biomimetic tissue engineering.

A child with congenital esophageal stenosis (CES) demonstrates the need for accuracy in the diagnosis and management of this rare problem. Other etiologies of dysphagia must be looked into, but when the expected results are not realized CES should be considered. A range of diagnoses and diagnostic studies may help to get children with dysphagia the treatment that they need to resolve their symptoms.

The enantiomeric resolution of 1,1'-binaphthyl-2,2'-diamine and Tröger's base was investigated using the commercially available zwitterionic surfactants 3-[(3-cholamidopropyl)dimethylammonio]-1-propanesulphonate (CHAPS) and 3-[(3-cholamidopropyl)dimethylammonio]-2-hydroxy-1-propanesulphonate (CHAPSO). Resolution of the weakly basic chiral probes was achieved using varying concentrations of surfactant, above their critical micellar concentrations, in a phosphate buffer (pH 2.5; 100 mM) to ensure ionisation of the analytes. Both CHAPS and CHAPSO were employed in the absence of additional coselectors or surfactants as sole micellar-forming agents. The addition of organic modifiers, methanol and acetonitrile (ACN), to the background electrolyte (BGE) was found to have a detrimental effect on enantioselectivity presumably by alteration of the phase polarity.

Purpose: The purpose of this study was to determine which imaging study, upper gastrointestinal series (UGI) or abdominal ultrasonography (US), is more cost-effective in diagnosing infantile hypertrophic pyloric stenosis (IHPS) using a decision analysis model., Methods: Probabilities were calculated from a review of the records of all infants less than 6 months of age referred for UGI or US to rule out IHPS over a 3-year period from January 1992 to December 1995. Cost-effectiveness was determined from hospital charges for each imaging study and its possible outcomes., Results: The positive predictive value of UGI was 1.0 and US was 0.98 in the 246 infants evaluated for possible IHPS. In patients who had an initially normal study finding (UGI or US), 25% of patients undergoing US first required a second study for persistent symptoms, whereas only 6% of patients who had a negative initial UGI finding required a second study., Conclusions: Cost analysis found UGI to be more cost-effective than US because fewer secondary studies were required. UGI provides information regarding other pathological conditions as compared with US.

Purpose: To analyze changes in the clinical condition at presentation and methods of establishing the diagnosis of infantile hypertrophic pyloric stenosis (IHPS)., Methods: Retrospective review of patients who underwent pyloromyotomy (PM) for suspected IHPS at two institutions from 1969 through 1994 was performed. For the purposes of comparison, the population was divided into five equal time periods., Results: Over the 25-year period, 901 infants underwent PM. Patients presented at a younger age, weighed more, and had a shorter length of illness in the most recent time period. Hypochloremic alkalosis was found half as frequently in the most recent time period compared to the earliest group. A palpable pyloric tumor was present in 79% of patients in the earliest time period compared with 23% in the most recent time period. Sixty-one percent of patients in the earliest group and 96% in the latest group underwent an imaging study, reflecting the referring physician's evaluation before referral to the surgeon., Conclusions: Currently, patients with IHPS less frequently present with the clinical hallmarks of the disease. The use of imaging studies to establish the diagnosis has become common practice. The result has been the diagnosis of IHPS before alkalosis has developed, a shorter clinical course, less morbidity, and a shorter postoperative hospital stay.

Background: Few references exist regarding contemporary complications of pyloromyotomy (PM) for infantile hypertrophic pyloric stenosis (IHPS). Therefore, we reviewed the frequency and outcome of patients with IHPS who developed complications from PM., Method: A 25-year retrospective review was performed in two populations. The first group included all infants who had a PM for IHPS at two pediatric surgery centers. The second group included all infants referred from other institutions who developed complications following PM for IHPS., Results: Between 1969 and 1994, 901 PMs were performed. Intraoperative complications occurred in 40 patients (4%), including 39 duodenal perforations and 1 difficult intubation requiring prolonged ventilation. No unrecognized duodenal perforations or incomplete PMs were found. Postoperative complications developed in 52 patients (6%). The wound infection rate was less than 1%. Postoperative vomiting occurred in 31 infants (3%). The mortality rate was 0.1%, with 1 death due to sepsis from delayed diagnosis of Hirschsprung's disease. During the same study period, 11 patients were referred from other hospitals for postoperative complications. Five had persistent vomiting treated successfully with expectant management. Six infants needed reoperation: 3 for persistent IHPS, 1 for gastric outlet obstruction, and 1 for small bowel obstruction secondary to adhesions; 1 required wound abscess drainage., Conclusion: Pyloromyotomy is not without complications. Duodenal perforation should be infrequent, but when it occurs, it can usually be readily recognized and treated with minimal morbidity. Postoperative vomiting can be managed nonoperatively, but if it persists longer than 5 days, radiologic evaluation should be performed. Incomplete PM is uncommon and should not occur. A second myotomy is needed when the diagnosis of incomplete myotomy is established. A single standard of care should be expected of all surgeons who perform PM for IHPS.

Peutz-Jeghers syndrome is characterized by hamartomatous polyposis of the small and large bowel and mucocutaneous pigmentation. The authors describe a 9-year-old girl with small bowel obstruction related to duodenal intussusception caused by polyposis in the fourth portion of the duodenum. Operative reduction of the intussusception and excision of the polyps were performed, at which time the pancreas appeared to have mild pancreatitis. A liver biopsy specimen showed mild portal fibrosis and ductal proliferation. The patient did well postoperatively, but later presented with symptoms consistent with biliary obstruction. Percutaneous transhepatic cholangiography showed pancreatic and biliary duct dilatation as well as obstruction of the common bile duct, which extended into the left upper quadrant. Exploration showed ampullary obstruction several centimeters proximal to the line of resection. Sphincteroplasty was performed. The postoperative course was uncomplicated. The authors conclude that Peutz-Jeghers syndrome with polyps in the duodenum can markedly distort duodenal and ductal anatomy and can lead to ampullary obstruction.

Recent advances in biochemical and imaging studies have improved the diagnostic accuracy of Cushing's syndrome. To better define roles for these studies in children, the authors reviewed their experience with this rare group of patients. Fifteen children, aged 11 weeks to 17 years, were treated for noniatrogenic Cushing's syndrome over a 33-year period. All children presented with signs of hypercortisolism. Nineteen different diagnostic tests were used, reflecting changes in how these patients are evaluated. Pathological diagnoses were adrenal cortical carcinoma (3), primary adrenocortical nodular dysplasia (PAND) (2), and pituitary adenoma (10). Children with adrenal cortical carcinoma presented with an adrenal mass and at a younger age (mean, 22.3 months). Key diagnostic features of patients with PAND were a low plasma adrenocorticotrophin hormone (ACTH) and no suppression with high-dose dexamethasone. Children with a pituitary cause of Cushing's syndrome presented at an older age (mean, 15.7 years) and were diagnosed using a combination of high-dose dexamethasone testing, simultaneous inferior petrosal sinus sampling, and/or ovine corticotrophin-releasing hormone stimulation test. A strategy for the diagnosis of Cushing's syndrome in children is presented.

Objective: To define the epidemiological and clinical characteristics of human brucellosis, which is being detected in increasing numbers of patients in Queensland., Design and Setting: Thirty-four cases of brucellosis diagnosed according to standard clinical and microbiological criteria were studied either retrospectively or prospectively over a two-year period from October 1989 to October 1991., Results: Cases were assessed by means of standard laboratory investigations and a questionnaire documenting clinical symptoms, occupation and recreational activities, treatment and response, relapse rate and complications. Blood cultures taken from 11 patients were positive for Brucella suis; in three others, Brucella suis was cultured from other sites. In the 12 months before diagnosis, all affected individuals were involved in the killing and slaughter of feral pigs. Most infections occurred in rural Queensland but six were contracted in metropolitan Brisbane from feral pig abattoirs. All patients responded to appropriate antibiotic therapy; the relapse rate was 66% in those treated for less than four weeks. Complications (multiple splenic abscesses, epididymitis, cervical lymphadenitis and septic arthritis) occurred in four patients, who were ill for more than one month before diagnosis., Conclusions: Brucellosis due to Brucella abortus is a disappearing disease in Australia as a result of effective eradication programs in cattle. However, the disease is re-emerging in Queensland because of recreational and occupational exposure to feral pigs infected with Brucella suis. The population at risk is increasing as the lucrative export industry based on field-shot feral pigs expands.

Four children were treated at the Oregon Health Sciences University for perforated peptic ulcer disease over the last 15 years. All children were being treated for other severe underlying diseases at the time of perforation. All of the children were receiving corticosteroids; one was receiving ulcer prophylaxis. Presenting symptoms were those of a perforated viscus, and pneumoperitoneum was present in all patients. Simple closure and omental patching of the ulcer resulted in no operative mortality or morbidity. None of the ulcers have recurred. In reviewing the literature, corticosteroids were associated with perforated peptic ulcer disease in 17.8% of children with perforated peptic ulcer. Despite controversy regarding the role of corticosteroids in the causation of peptic ulcer, we recommend prophylaxis for all children receiving corticosteroids.

Interleukins, hematopoietic growth factors, and adhesion molecules mediate multiple components of the inflammatory response. Conventional methods for purification of cytokine-producing cells are time consuming and can, therefore, depending on the conditions of cell purification and the nature of the mRNA being purified, result in both over- and underestimates of mRNA content. Therefore, it has been difficult to quantify such factors in ways that are unambiguously reflective of in vivo cytokine production. We describe herein a method for such rapid preparation of peripheral blood mononuclear leukocytes (PBML) that amounts of cytokine mRNA derived from these cells, apart from readily quantifiable losses during RNA preparation, will be reflective of quantities in vivo. Small quantities (10(5) of normal PBML were isolated by density centrifugation of heparinized blood for 1.25 min in a capillary tube. Poly(A)+ RNA isolated by oligo(dT)-cellulose column chromatography was sufficient to reverse transcribe both antigen-specific T-cell-receptor beta-chain mRNA and interleukin 6 (IL-6) mRNA and subsequently amplify the cDNA with Taq polymerase in reverse transcription-polymerase chain reactions (RT-PCR). Although IL-6 mRNA was not present in normal PBML, PBML incubated in culture medium for only 3 h contained approximately one molecule per cell. Because of its rapidity this technique will permit quantification of cytokine mRNA in the steady state and in clinical setting of inflammation. Because the method requires only a small quantity of blood it can be applied to clinical research studies involving children.

We identified 21 children (14 boys and seven girls) with long-segment Hirschsprung's disease defined as aganglionosis extending proximal to the ileocecal valve. Long-segment Hirschsprung's disease is difficult to diagnose and treat; symptoms may be mild, and diagnosis delayed. Abdominal distention and constipation or delayed passage of meconium are the most common symptoms. Radiologic studies are unreliable in establishing the diagnosis. The morbidity rate is high because of the high transition zone and short gut. The long-term outcome of patients after the standard Duhamel procedure is satisfactory, except with extremely high transition zones. Pull-through procedures should not be performed in the small infant, but should be delayed until patients are old enough to be continent.

An infant who presented with signs of duodenal atresia had proximal duodenal obstruction by upper gastrointestinal barium study, but had a small amount of air in the distal bowel. Exploration showed an annular pancreas and microperforation of a duodenal diaphragm. Prior to concluding that pancreaticobiliary duct anomalies are the path of air into the distal bowel in patients with duodenal atresia, microperforation of a duodenal diaphragm must be excluded.

Congenital cystic adenomatoid malformation (CCAM) is a regional overgrowth of bronchioles with suppression of alveolar development in fetal and newborn lung. Twelve patients with CCAM were treated. Six premature infants had acute respiratory distress. Prenatal ultrasound was performed in only five patients and was abnormal in all five. Five premature neonates also had patent ductus arteriosus complicating their courses. Six older children presented with recurrent pneumonitis. Radiographs showed asymmetry of the chest and radiolucent masses in all 12 patients. Seven had type I lesions, two had type II lesions, and three had type III lesions. Hydramnios and hydrops were present in three, and hydrops alone was present in one of the six neonates. These four patients died. One other neonate died of respiratory failure and persistent fetal circulation. Seven patients survived for an extended period. Ultrasound makes the prenatal diagnosis of hydramnios and hydrops possible. It is in this group that fetal interventions can be considered. For the remaining patients, surgical intervention is indicated at the time of diagnosis.

Two newborn infants with neurenteric cysts have been evaluated with recently developed imaging techniques. Magnetic resonance imaging or computed tomography can provide the evaluations needed to facilitate removal of the entire cyst at one operation. Appreciation of the extent of the problem allows for expeditious evaluation and early definitive surgical intervention.

A rare type of congenital diaphragmatic hernia occurs in which there is a large opening in the anterior diaphragm between the pericardial and peritoneal cavities without a sac. This hernia is invariably associated with defects in the anterior abdominal wall and with sternal defects. More commonly, it is associated with cardiac anomalies as in the Pentalogy of Cantrell. The etiology of this hernia is undoubtedly different from the more common hernia of Morgangni, which has a sac and few associated anomalies. The etiology may be failure of fusion of the pars sternis area of the septum transversum. Only five other cases have been described.

Long-term follow-up of children with gastroschisis has been made possible by the increased survival of these infants over the past 20 years. We have observed that children with isolated gastroschisis defects exhibit normal growth and development beyond 5 years of age without significant bowel sequelae. Infants with gastroschisis with concomitant bowel atresia or complications who require small bowel resection are at a greatly increased risk for long-term bowel problems and abdominal complaints.

Appendicitis is a disease that continues to be characterized by a high morbidity rate that has changed little over the past 50 years. A significant proportion of patients (39 percent in this study) still present with advanced disease (gangrene, perforation, or abscess), as determined at operation. Duration of symptoms was the factor most closely associated with advanced disease. Patients with advanced disease had 88 percent of the morbidity. Primary care physicians referred patients who had symptoms for a longer period of time and who ultimately were found to have a more advanced stage of disease compared with patients who were referred from emergency rooms. This difference did not correlate with third party insurance coverage, as both referral groups exhibited a similar profile of coverage. In this study, the number of normal appendices removed was 5 percent. Early intervention remains the most promising means to reduce morbidity, mortality, and discomfort for the child and expense to the family or insurance carrier of a child with suspected appendicitis.

Myasthenia gravis is considered to be an autoimmune disorder of neuromuscular transmission. Thymectomy is an effective mode of treatment which produces either remission or stabilization of symptoms especially in young female patients with short duration of disease. The present study, records the experience in ten pediatric patients with early thymectomy done via the transcervical approach. There were no operative deaths or serious complications. Follow-up for a mean of 37 months has shown one to be in complete remission requiring no medication and eight to have improved or stable symptoms. Thymectomy via the transcervical approach is an effective mode of treatment for patients with myasthenia gravis. Since this approach involves a small dissection and avoids sternotomy, the transcervical approach results in a very short postoperative recovery period. It is ideal for those patients not in respiratory failure. It can also be safely done in patients requiring intubation for acute respiratory failure preoperatively.

A guanidine-HCl extraction of lens capsule basement membrane dissolves collagenous material. This material was fractionated on an Agarose A-5M column. Fractions 1, 2 and 3 were further purified and partially characterized immunochemically and by amino acid analysis. Fraction 3 has a molecular weight of 55,000 when compared with collagen type I standard. The CNBr peptide pattern and composition of fraction 3 are different from those of alpha 1 (IV) 95K and alpha 2 (IV) 95K chains. The results described suggest the presence of a new chain in lens capsule basement membrane.

In continuing our earlier studies (Biochem. Biophys. Res. Comm. 130, 1-8, 1985) on a new collagenous component (Type XIII) from lens capsule basement membrane, we report here the isolation and characterization of a 26K protein from the 4.5 M guanidine-HCl extracts of lens capsules. The 26K protein was purified by molecular sieve and DEAE-cellulose chromatography. The protein has been characterized by amino acid composition, NaDodSO4-polyacrylamide gel electrophoresis and by immunochemical analyses. On rotary shadowing, the 26K protein appears as a globule. The available information suggests its location at the terminal end of the collagenous component. The presented data show clearly that the 26K protein is a distinct new protein, different from the earlier reported NC-1 domain of type IV collagen.

Hypoxia and hypovolemia result in similar ultrastructural changes. These changes are characterized by aggregation of platelets and leukocytes in the vascular space, focal endothelial cell disruption, and appearance of increased amounts of perivascular edema, and loss of ultrastructural organization of the mucosal cell. These changes appear to relate to variations in blood flow to the mucosa of different areas of the bowel and to follow the distribution observed for necrotizing enterocolitis in the human infant.

Progressive atrophy of ileal crypts and villi following daily administration of cytosine arabinoside to mice was found to be the result of suppression of mitosis and marked enhancement of apoptosis in the crypt epithelium. The amount of apoptosis produced by each dose decreased as the atrophy advanced. Mucosal regeneration after cessation of administration of the drug was due to increased mitosis in the crypts, and was associated with complete restoration of susceptibility of the crypt cells to further doses. During early regeneration, the wave of increased mitosis was accompanied by a wave of mildly increased apoptosis.

The formation of microaggregates of platelets and leukocytes and the infusion of these aggregated blood elements in pulmonary ultrastructure and function have been extensively studied. This study was undertaken to document the formation of platelet microaggregates during storage of platelet concentrate and to determine what effect the infusion of stored platelets has on pulmonary ultrastructure. The screen filtration pressure of platelet concentrate stored at 4 degrees C. for a period of 48 hours was measured after six, 24 and 48 hours of storage. Screen filtration pressure progressively rose from a mean of 47.20 millimeters of mercury to a mean of 237.40 millimeters of mercury at 48 hours, p less than 0.02 between six and 48 hours of storage. Specimens of the lung taken for biopsy from ten patients undergoing open heart operations were examined for ultrastructural alterations. Those specimens obtained following cardiopulmonary bypass, but prior to the infusion of platelet concentrate, showed only mild ultrastructural abnormalities. Those specimens obtained for pathologic study following the infusion of platelet concentrate exhibited extensive accumulations of platelet aggregates in the pulmonary microcirculation and widespread degenerative changes in the capillary endothelial cells, intra-alveolar septae and alveolar epithelial cells. In areas in which cellular discontinuities occurred, protein exudates, fibrin clumps and red blood cells were observed in the interstitium and in the alveolar air spaces. The storage of platelet concentrate results in the formation of aggregate material. The infusion of platelet concentrate results in the formation of aggregate material. The infusion of platelet concentrate results in the formation of ultrastructural lesions, similar to those observed in situations known to lead to pulmonary dysfunction, such as following massive transfusion, hypovolemia, sepsis and hypoxia.

Mortality of patients with gastroschisis has decreased from nearly 90% to 13% (14 of 106) during the period from 1967 to 1984. Coincident with advances in perioperative management, including parenteral nutrition and mechanical ventilation, has been the introduction of staged reduction of the viscera using prosthetic material. To assess the relative merits of primary closure, skin flap coverage, and silo reduction, operative treatment of 106 consecutive infants with gastroschisis was reviewed. Primary fascial closure was accomplished in 54 patients (52%). When fascial approximation resulted in excessive intra-abdominal pressure, the viscera were covered with lateral skin flaps in 10 infants (10%), or the defect was closed after staged reduction with a prosthetic silo in 40 infants (38%). Detailed analysis of the hospital records revealed no significant differences between the primary closure, skin flap, and silo groups with regard to duration of ileus (22 +/- 25, 30 +/- 27, 31 +/- 30 days), length of hospitalization (39 +/- 36, 54 +/- 37, 53 +/- 39 days), or mortality (6, 20, 18%). Respiratory, septic, hemorrhagic, renal, and wound complications occurred in significantly fewer patients with primary closure (36%) and skin flap coverage (30%) than in those with silos (68%) (p less than 0.05). Postoperative mortality was 12% (12/104) and was most often due to respiratory insufficiency (35%) or nonviable small bowel (19%). Primary fascial closure may be accomplished safely in a majority of patients with gastroschisis. However, no single operative strategy is ideal for all patients with gastroschisis, and initial treatment of individual defects should be tailored to the degree of visceroabdominal disproportion.

Angiotensin converting enzyme (ACE), a glycoprotein, is found in high concentration in pulmonary capillary endothelial cells. Several investigators have studied the relationship between various direct and indirect pulmonary insults and ACE activity and in some cases have found conflict. In an attempt to clarify this relationship we have examined the effect of endotoxin on rat plasma ACE activity in vitro and in vivo. We used the synthetic ACE substrate 3H-BPAP and the assay described by Catravas and Gillis [J Pharmacol Exp Ther 217:263-270, 1981]. In vitro, a statistically significant concentration-dependent reduction in ACE activity was demonstrated (p less than .005). In vivo an intravenous dose of endotoxin (20 mg/kg) alone resulted in no significant change in plasma ACE activity. However, the combination of intravenous endotoxin (20mg/kg) and mild hemorrhage (5-10% of blood volume) caused a statistically significant reduction in plasma ACE activity by 15 min as compared to control rats with hemorrhage only (39% vs. 66%, p less than .005). This reduction persisted at 30 and 60 min. However, by 180 min ACE activity was no longer statistically different from control values. We have demonstrated an acute reduction of plasma ACE activity in the endotoxemic rat that appears to be dependent on the amount of circulating endotoxin and the presence of mild blood loss.

Six children have undergone lung biopsy for evaluation of fine structure. Four children demonstrated increased DAVO2 preoperatively and had marked ultrastructural changes in their lungs. Such changes appear to result from embolization of microthrombi or microaggregates to the lung from under-oxygenated tissue.

Previous studies have suggested that delayed gastric emptying occurs in severely mentally retarded patients with gastroesophageal reflux. Based on this data, pyloroplasty was employed in such patients. A retrospective analysis of 99 consecutive patients who underwent primary fundoplication for GER was performed. Gastric emptying, as measured by successful removal of the nasogastric tube or elevation of the gastrostomy tube, was studied. Children with neurologic disorders had no clinically significant difference in gastric emptying after fundoplication (3.31 days) when compared with neurologically normal patients (2.21 days). When added to Nissen fundoplication, pyloroplasty did not hasten the return of gastrointestinal function in the severely impaired patients (4.91 days). A prospective study employing gastric isotope bolus feedings before and after Nissen fundoplication will determine if pyloroplasty improves gastric emptying when used in conjunction with Nissen fundoplication for patients with severe neurologic disorders.

Twenty-three patients with gastroschisis or omphalocele undergoing delayed ventral herniorrhaphy were reviewed. The ventral defects resulted from elective skin flap coverage in 15 patients, prosthetic silo failure in five, and nonoperative management using escharotic agents in three. Herniorrhaphy was performed at 2 months to 15 years of age. Fascial closure was achieved in a single procedure in 15 patients (65%) and with multiple operations involving prosthetic material in five patients (22%). Three patients (13%) had prosthetic material left in their defects without sequelae. There was no operative mortality from interval herniorrhaphy, and complications were minor. We conclude that conversion of a gastroschisis or an omphalocele to a ventral hernia is strategically useful in an infant with a giant defect, prosthetic silo failure, or when associated anomalies preclude early definitive surgery.

Neonatal necrotizing enterocolitis was seen in 42 of 5,030 infants (0.83 percent) admitted to our neonatal intensive care units. The condition developed more than 1 week after birth in most infants. This group included most of the very low birth weight infants. Forty-one of the 42 infants had enteral feedings before the onset of enterocolitis, which developed within 72 hours from the start of feedings in 19 infants (45 percent). Twenty-nine patients (69 percent) underwent surgery. Mortality in this group was 38 percent overall and 28 percent in the infants considered salvageable at laparotomy. The interval from diagnosis to surgery was 24 hours or less in 65 percent of cases, emphasizing the fulminant nature of the disease in many patients. Three of the 14 patients who died underwent no surgery. Pneumoperitoneum was one of the initial radiologic signs in 10 patients (24 percent). The necrotizing enterocolitis observed was similar clinically to that reported by others. The strikingly low incidence of enterocolitis in the neonatal intensive care units in Oregon (0.83 percent) contrasts with the generally reported incidence of 3 to 8 percent in other neonatal intensive care units. We attribute the low incidence of necrotizing enterocolitis in our experience to delay of enteral feedings and reliance on prolonged peripheral or central total parenteral nutrition, or both, for nutritional maintenance of stressed or low birth weight infants.

Juvenile aponeurotic fibromas, although locally recurrent, generally do not metastasize. This observation supports the practice of incomplete excision of the tumor to preserve the function of the involved extremity. We report on a patient with a juvenile aponeurotic fibroma of the palm, who returned 5 years after the second local surgical excision with metastatic fibrosarcoma of the lungs and bones.

Colon replacement for the esophagus was used successfully in 20 of 21 pediatric patients. Intrathoracic placement of the colon segment was done in 18. Careful preparation and operative experience combined to reduce operative morbidity and mortality in an unfortunate group of patients. Satisfactory long-term results have been achieved. Careful technique, attention to detail, and perfection of a single technique may be more important than performing new surgical techniques when they are reported. Colon interposition performed by the Waterston technique utilizing the transverse colon is an effective means of substitution for a diseases esophagus in children.