Segmental resection of the injured human spleen

The injured spleen of two patients was segmentally resected. After searching for and ligating the segmental vessels belonging to the injured parts the segments were divided. The minimal bleedings were controlled by reinforced sutures, the capsule of the spleen was sutured at the edges with mattress-U-suture-stitches. There were no complications during the postoperative treatment of both patients. Also a good function of the splenic tissue was proved scintigraphically.     

Lymphoid depletion in ileal loops: mechanism and clinical implications

Recent long-term follow-up studies of children undergoing ileal loop urinary diversion have shown a number of complications arising in these patients: recurrent urinary tract infections, deteriorating renal function, and late midloop stricture. We suggest that all three may be related to the same underlying problem, namely, a severe depletion of lymphoid elements in the intestine. In both clinical and animal studies urine exposure to intestinal segments resulted in a marked depletion of lymphoid elements from the Peyer's patches and from beneath the intestinal villi in the intestine. In addition there was an associated hypertrophy of the lymph nodes in the ileal loop mesentery. When the intestine was no longer exposed to urine, there was a prompt regeneration and reappearance of the lymphoid elements. The lymphocytes seemed to "home in" on the submucosal areas and reform Peyer's patches once the urine was removed. The hyperplastic lymph nodes in the ileal loop mesentery regressed when urine exposure was removed. Conventional treatment of ileal loop infections focuses on the upper urinary tracts. Mid-loop stenoses are treated by resection and creation of a new ileal loop conduit. Local therapy in the form of antibiotics and/or steroid enemas may relieve some late midloop obstruction and prevent further damage to renal parenchyma.     

Using mutual information to measure coupling in the cardiorespiratory system

Approximately 2,000 infants with sickle cell disease are born each year in the United States. Sickle cell disease is an inherited disorder of red blood cell hemoglobin. Sickle cells increase adhesion and cause blockage in the small blood vessels, resulting in tissue damage. The cells' production of hemoglobin S results in two major pathophysiologic features of sickle cell disorders: chronic hemolytic anemia and vaso-occlusion. These disorders cause ischemic tissue damage and acute and chronic organ failure. Potential complications for children with sickle cell disease include vaso-occlusive events, splenic sequestration, bacterial septicemia from splenic hypofunction, aplastic crisis, pulmonary compromise including acute chest syndrome, renal tubular dysfunction and renal failure, priapism, aseptic necrosis, gallstones, delayed growth and development, leg ulcers, stroke and premature death. Three major sickle cell complications during the first years of life are dactylitis, splenic hypofunction and splenic sequestration. The risk for pneumococcal meningitis is 36 times greater in children with sickle cell anemia than for black children without the disease, and 314 times greater than for white children.     

Comparison of Doppler US and CT angiography for evaluation of renal artery stenosis

RATIONALE AND OBJECTIVES: The authors compared Doppler ultrasound (US) with computed tomographic (CT) angiography in the evaluation of stenosis of the main renal artery. MATERIALS AND METHODS: Fifty-six patients who had undergone conventional angiography of the renal arteries participated in a prospective comparison of Doppler US (45 patients) and CT angiography (52 patients). US evaluation included both the main renal artery and segmental renal arteries. RESULTS: There were 27 main renal arteries with at least 50% stenosis in 20 patients. In 36 patients, there was no significant stenosis. All cases of main renal artery stenosis detected with Doppler US of the segmental arteries were also identified with Doppler US of the main renal artery. The by-artery sensitivity (63%) of US of the main renal artery was greater than that (33%) of US of the segmental arteries. CT angiography was more sensitive (96%) than Doppler US (63%) in the detection of stenosis, but the specificity of CT (88%) was similar to that of US (89%). The difference in the area under the receiver operating characteristic curve (AUC) between CT (AUC = 0.94) and US (AUC = 0.82) was statistically significant (P = .038). CONCLUSION: Doppler US of the main renal artery is more sensitive than Doppler US of segmental arteries in the detection of stenosis. CT angiography is more accurate than Doppler US in the evaluation of renal artery stenosis.     

The significance of focal glomerular sclerosis in children who have nephrotic syndrome

This study was undertaken to learn the significance of focal glomerular sclerosis in children who have nephrotic syndrome. Tissue obtained by percutaneous renal biopsy 10-15 years previously was re-examined. Initially, two of the 29 biopsy specimens contained focal segmental hyalinosis or sclerosis and five of the 29 had focal glomerular obsolescence. The paraffin blocks were serially sectioned and examined. Following this procedure, seven of the 29 biopsies had focal segmented hyalinosis and 16 of the 29 had focal glomerular obsolescence. The percentages of focal segmental hyalinosis and focal glomerular obsolescence were recorded. Only those patients whose focal segmental hyalinosis exceeded 2% progressed to renal failure. Age-matched autopsy material from patients dying without renal dysfunction was used as a control. Focal glomerular sclerosis was seen in 75.8% of the control specimens, although few glomeruli within each specimen were involved. Focal glomerular sclerosis may be found normally; it may be found in nephrotic children who do not develop renal failure. The quantification of sclerotic lesions may be of prognostic significance in childhood nephrosis.     

Echocardiography for the assessment of myocardial viability

Splenic marginal zone lymphoma (SMZL) has recently been proposed as a distinctive type of low-grade B-cell lymphoma. Although there is general agreement that this entity exists, its precise definition is blurred by uncertainty in differential diagnosis from other low-grade B-cell lymphomas. There is even more uncertainty as to the histology of splenic hilar and peripheral lymph nodes involved by SMZL. We therefore reviewed the histological and immunohistochemical features of 19 of these lymph nodes (14 hilar and five peripheral) from 14 cases of classical SMZL and compared them with the features of lymph nodes involved by other B-cell lymphomas. The morphology and immunohistology of the lymph nodes resemble those found in the white pulp of the spleen, showing a distinctive pattern, different from that which is observed in other B-cell lymphomas. In these cases, the overall architecture of the lymph nodes is effaced and replaced by a nodular infiltrate, although the sinuses are preserved in most hilar lymph nodes. Some of the nodules contain a central reactive follicular center, around which there is a broad zone of small lymphocytes. In other cases, the central area is partially infiltrated or, more commonly, totally replaced by these small lymphocytes, which in the periphery of the nodules showed a pale, slightly larger cytoplasm. Scattered nucleolated blasts are present, largely confined to the periphery of the nodules. The tumoral cells express immunoglobulin (Ig)D, IgM, and Ig light chain restriction and show a low proliferation fraction. These findings confirm that SMZL is a real entity, and not merely a morphological pattern of splenic infiltration by different types of low-grade B-cell lymphoma.     

Proportional analysis of the kidney arterial segments

The proportional area of each renal arterial segment was analyzed in 49 polyester resin corrosion endocasts of the renal vasculature. We defined a segmental artery as a primary or secondary branch of the renal artery that could be isolated outside the hilum. We found kidneys with five arterial segments in 30 of 49 casts (61.2% of cases) and kidneys with four arterial segments in 19 of 49 casts (38.8%). To enable the evaluation of the proportional areas of the autonomous segments (by using the "point-counting planimetry method"), each arterial segmental branch was injected with different-colored resin. The superior segment (apical) was present in 36 of 49 casts (73.5% of cases) and had a median proportional area of 13.02%. The anterosuperior and anteroinferior segments were present in 30 of 40 casts (61.2% of cases) and had median proportional areas of 21.36% and 17.18%, respectively. The anterior segment was present in 19 of 49 casts (38.8% of cases; when the mid-kidney anterior surface received only one segmental artery) and had a median proportional area of 28.44%. The inferior segment was present in 100% of cases and had a median proportional area of 22.65%. The posterior segment was also present in 100% of cases and was the segment with the greatest median proportional area (33.76%).     

Splenic and renal infarctions complicating atrial fibrillation

Splenic and renal infarctions are common manifestations of cardiac thromboembolism. Usually they remain clinically silent and are not likely to be diagnosed antemortem. Two elderly female patients, in whom nonrheumatic chronic atrial fibrillation was noted, received low-dose aspirin. Both complained of the onset of acute abdominal pain and were found to have splenic and renal infarctions on abdominal computerized tomography. An enlarged left atrium was seen on echocardiogram in both cases. Treatment consisted of hydration, analgesics, and anticoagulation. In one case, liquefactive necrosis of the splenic infarct was observed on subsequent computer tomography studies. Both patients did well and remained free of new embolic events in the following 6 and 10 months, respectively. Clinicians should readily recognize the clinical manifestations of splenic and renal infarctions in patients with atrial fibrillation. Abdominal computerized tomography can confirm the diagnosis.     

Exploratory laparotomy and splenectomy in the diagnosis of Hodgkin''s disease in children

Thirty-three children with histologically proved Hodgkin's disease underwent exploratory laparotomy with splenectomy and biopsy of lumbar lymph nodes, liver, and bone marrow. In 13 patients (39%) the lesion of spleen and/or splenic hilar lymph nodes was diagnosed. The involvement of spleen was mostly found in patients with mixed cellularity type, in the presence of systemic symptoms ("B"), and in the biological stage "b." Involvement of the liver was found in 1 patient, of the hepatic hilar lymph nodes in 3 patients, and of the bone marrow in 4 patients. The lymphographic and histologic data as regards lumbar lymph nodes coincided in 65% of cases. After operation the stage of the disease was changed in 48% patients. The early and late complications were not numerous.     

Bulbous splenic vein as a cause of renal pseudotumor

A number renal and suprarenal pseudotumors have been described during the past two decades, paralleling the development of selective visceral angiography. An apparent left upper pole renal mass in a 71-year-old hypertensive man was found to ba a bulbous portion of the splenic vein during angiography. The anatomical basis of this renal pseudotumor is discussed.     

Regulation of the IL-12 receptor beta2 subunit by soluble antigen and IL-12 in vivo

Sympathetic innervation of lymphoid tissues is localized to specific tissue compartments, but little is known of the "factors" that are important in establishing this pattern during development. Numerous studies have shown interactions of nerve growth factor (NGF) with the immune system, which may include modulation of immune innervation. We previously have shown that NGF transgenic mice, which overexpress NGF in skin and not immune tissues, have a dramatic hyperinnervation of splenic marginal zone and peripheral lymph node medulla and capsule. The purpose of the current studies was to determine if the presence of elevated NGF would alter immune system development and the process of sympathetic ingrowth. The results show that the splenic innervation in NGF transgenics gradually diverged from controls during the first two postnatal weeks, with the greatest change occurring between postnatal days 13 and 16 when the splenic organization was reaching the adult pattern. In contrast, the peripheral lymph nodes were hyperinnervated at an earlier age. mesenteric lymph nodes never diverged from the normal pattern. NGF levels in transgenic spleen were much higher than controls at postnatal days 1 and 2, when little innervation was present, and declined as the tissue matured, possibly because of NGF uptake by the ingrowing sympathetic fibers. This suggests that immune tissues are capable of concentrating NGF, which in turn may modulate the level of innervation by the sympathetic nervous system.     

Partial nephrectomy in cancer of the upper pole of kidney. Anatomical bases

On the basis of their importance for nephron-sparing surgery in tumors of the superior pole of the kidney, we analyzed 3-dimensional endocasts of the intrarenal structures. In 86.6% the superior pole was related to 3 arteries involved in its resection. Management of the superior (apical) segmental artery is in general simple as well as the ligature of the artery related to the anterior surface of the upper infundibulum. Ligature of the branch of the posterior segmental artery, that is related to the upper infundibulum, is critical due to the risk of injuring this segmental artery with loss of a great portion of renal parenchyma. The posterior segmental artery (retropelvic artery) is involved and must be preserved in all cases of superior pole resection. A retropelvic vein with its upper dorsal plexus was present in 69% of the cases. This vein must be previously ligated to provided safe management of the arteries during superior pole resection.     

Splenectomy: its place in operations for inflammatory disease of the pancreas

Involvement of the spleen or its vasculature in inflammatory disease of the pancreas may result in life-threatening hemorrhage. Retrospective analysis of six patients having direct splenic involvement and/or occlusion of the splenic vein secondary to pancreatitis or pseudocyst showed that removal of the spleen as a portion of an appropriately timed operation for complications of pancreatitis uniformly resulted in an uncomplicated course and survival (3 patients). Leaving the spleen in place when it was directly involved in a pseudocyst and/or when the splenic vein was occluded resulted in postoperative bleeding, the requirement for reoperation, and death from septic sequelae (2 patients). One patient died of progressive respiratory and renal failure because initial operation was inappropriately delayed. We recommend splenectomy as a portion of an appropriately timed operation for complications of pancreatitis when the splenic vessels are involved and/or when the spleen is directly involved in a pseudocyst or lesser sac collection.     

Smoking habits and risk of fatal stroke: 18 years follow up of the Oslo Study

A case of splenic large B-cell lymphoma with hemophagocytic syndrome is reported. The difficulties of diagnosis are emphasized especially when peripheral lymph nodes or bone marrow lymphomatous infiltration are not present. Diagnostic criteria for hemophagocytic syndrome and their relationship with the pathogenesis of the disease are also stressed.     

Diagnosis of liver metastases from colorectal adenocarcinoma. Comparison of spiral-CTAP combined with intravenous contrast-enhanced spiral-CT and SPIO-enhanced MR combined with plain MR imaging

BACKGROUND/AIMS: Doppler arterial resistance indices are used to evaluate alterations in arterial hemodynamics in the liver, spleen, and kidney. The purpose of this study was to determine the interobserver and interequipment variability of hepatic, splenic, and renal arterial Doppler resistance indices, and the influence of a cooperative training program of the operators on the reproducibility of the results. METHODS: In the first part of the study, hepatic (PI-L, RI-L), splenic (PI-S, RI-S), and renal (PI-K, RI-K) pulsatility and resistive indices were measured by echo-color-Doppler in eight control subjects and ten patients with cirrhosis by three operators using three different machines. In the second part of the study, measurements were taken by the three operators in nine controls and nine patients with cirrhosis, after cooperative training, with a single machine. RESULTS: Significant interobserver variability was present for all parameters except RI-L. Significant interequipment variability was present for all parameters except PI-S and RI-S. Only 0-3% of variance was equipment- or operator-related, while 58-72% was patient-related. Hepatic and renal coefficients of variation were similar in patients with cirrhosis and controls, while splenic coefficients of variation were higher in patients with cirrhosis than in controls. After training, differences among operators disappeared for all variables except RI-K, and the operator-related component of variance nearly disappeared for all parameters. CONCLUSIONS: Hepatic, splenic, and renal arterial resistance indices show small but significant interobserver and interequipment variability. Interobserver variability can be decreased to non-significant levels by a common training program. Thus, these indices can be widely applied to the study of arterial circulation in these organs.     

The CT nephrogram: implications for evaluation of urinary tract disease

The urographic nephrogram is an important indicator of underlying functional and structural renal disease. With expansions in use of cross-sectional imaging, the computed tomographic (CT) nephrogram (ie, contrast material enhancement within the renal parenchyma) has assumed a greater role in the evaluation of urinary tract disorders. Both quantitative and qualitative nephrographic abnormalities are well demonstrated by CT, including global or segmental absence or persistence of the nephrogram, slowed temporal progression, striated pattern, and rim pattern. Global absence is nearly always unilateral and is most often seen with blunt abdominal trauma with renal pedicle injury. Segmental absence is attributable to focal renal infarction, most likely due to arterial emboli. Global persistence, which is much more common than segmental persistence, may be unilateral (caused by renal artery stenosis, renal vein thrombosis, or urinary tract obstruction) or bilateral (due to systemic hypotension, intratubular obstruction, or abnormalities in tubular function). Striated nephrograms may be unilateral or bilateral and are caused by ureteric obstruction, acute pyelonephritis, contusion, renal vein thrombosis, tubular obstruction, hypotension, and autosomal recessive polycystic kidney disease. The rim pattern is most often associated with renal infarction and occasionally with acute tubular necrosis and renal vein thrombosis. Careful evaluation of the CT nephrogram is an integral part of the abdominal CT examination.     

High-dose interferon-gamma alters the distribution of B lymphocytes and macrophages in rat spleen and lymph nodes

Continuous intravenous infusion of rat interferon-gamma (IFN-gamma) for 3 days provokes profound alterations of splenic architecture in LEW rats. The marginal zone of the white pulp is almost totally depleted of B lymphocytes and the follicles are reduced to small remnants. IgM kappa + plasmablasts and plasma cells increase substantially in the outer periarteriolar lymphatic sheath (PALS) and in the splenic red pulp. In addition, marginal metallophilic and marginal zone macrophages are augmented, partially by proliferation. It is discussed whether the activation and proliferation of these macrophages prevent replenishment of the marginal zone and follicles with recirculating B cells. Changes in B lymphocyte and medullary macrophage distribution are also present in submandibular and mesenteric lymph nodes.     

Splenic torsion in the presence of renal agenesis

A 14-year-old male with left renal agenesis presented with a history of intermittent abdominal pain for over 1 year. At laparotomy, the cause was found to be splenic torsion. The case is presented with a literature review. A theory of the cause is also presented based on the regional anatomy and embryology.     

Trichomonas foetus meningoencephalitis after allogeneic peripheral blood stem cell transplantation

The authors report a case of adrenal metastasis contralateral to a renal cell carcinoma in a 74-year-old patient who had undergone right radical nephrectomy for renal cell carcinoma. Nine months later, computed tomography revealed a hypervascular mass considered to be an aneurysm of the splenic artery. Arteriography led to the diagnosis of hypervascular adrenal tumour. Left adrenalectomy was performed. Histological examination showed a metastasis from renal cell carcinoma. This is an unusual form of renal cancer metastasis. Its treatment and prognosis are discussed.     

Expression of the mucosal T cell integrin alpha M290 beta 7 by a major subpopulation of dendritic cells in mice

Dendritic interdigitating cells isolated from lymph nodes, Langerhans' cells from skin and dendritic cells from the spleen have been tested for expression of the mucosal T cell integrin alpha M290 beta 7. Almost all interdigitating cells isolated from mesenteric lymph nodes expressed the integrin at high levels; 50-60% of those from lymph nodes draining non-mucosal sites also expressed this adhesion molecule. In contrast, alpha M290 beta 7 was not detected on either Langerhans' cells or splenic dendritic cells. Because this integrin has recently been shown to recognize a ligand that seems to be expressed mainly or exclusively by epithelial cells; it is proposed that this adhesion pathway may be important for antigen sampling by dendritic cells in mucosal tissues.