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Biomedical subjects

M M Ziegler

Publications and source records attributed to M M Ziegler.

At least 37 records · Page 2Linked to original sources

Inflammatory bowel disease in children.

Inflammatory bowel disease remains a serious chronic illness in children. Recent developments in the care of these patients involves both basic science research into the pathophysiology of ulcerative colitis and Crohn's disease and the development of refinements in the surgical techniques and medical therapies available as treatment options. In Crohn's disease, a new steroid analogue (budesonide) shows some promise as a possible medical treatment that would limit the devastating side effects of steroids in children. In addition, the bowel-sparing technique of strictureplasty has now been reported in children with good results. In ulcerative colitis, the surgical technique of endorectal pull-through continues to evolve with reports of the efficacy of specific pouch designs and surgical techniques. An understanding of pouchitis, the most common complication of endorectal pull-through, has focused on documenting specific alterations in the microbiology and physiology of the pouch, as well as investigating a possible link between autoantibodies and susceptibility to this complication.

Administration, Topical↗

Dietary fish oil enhances macrophage production of nitric oxide.

Nitric oxide (NO) is recognized as an important mediator of hemodynamic regulation and multisystem organ failure (MOF). Although polyunsaturated fatty acids (PUFA) are known to modify the elaboration of some humoral mediators in MOF, their effect upon NO production has not been evaluated. This study was designed to examine the effect of omega-3 (omega 3) and omega-6 (omega 6) PUFA on macrophage production of NO, TNF, PGE2, and PGI2. Rats were fed diets of 18% by calorie safflower oil (omega 6) or fish oil (omega 3) for 12 days. Bronchoalveolar macrophages (BAM) were divided into group A (medium only), group B (0.5 microgram/ml PGE2 or PGI2 + medium) or group C (10 microM indomethacin+medium). Cells were stimulated with 100 U/ml interferon-gamma and 10 micrograms/ml Escherichia coli-LPS. In group A, BAM from animals fed omega 3 produced significantly more NO (3.64 vs 1.92 microM, P < 0.05) and TNF (8.52 vs 1.75 micrograms/ml, P < 0.05) than BAM from omega 6-fed animals. The addition of exogenous PGE2 or PGI2 (group B) ablated the difference in NO and TNF observed in group A. Indomethacin also (group C) ablated the difference in NO and TNF production seen in omega 3- and omega 6-fed animals noted in group A. These data demonstrate that PUFA influence BAM production of NO and TNF. Changes in the omega 6-derived prostanoids may account for the differences in TNF production, but these data suggest that PGE2 and PGI2 are not responsible for the observed differences in NO production.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Meconium ileus.

Meconium ileus is a manifestation of intestinal and pancreatic dysfunction that results in the accumulation of a sticky and inspissated intraluminal meconium, which in most cases results from the autosomal recessive disease cystic fibrosis. Both nonoperative and operative therapies are effective in relieving this small-bowel obstruction; in the past, although less so today, a successful nonoperative treatment was associated with a more favorable outcome. Once the meconium ileus is relieved successfully, and the diagnosis of cystic fibrosis is established, the treatment for the intestinal manifestations of the disease focuses on enzyme replacement to augment patient nutritional status. Simultaneously, the treatment of the life-threatening pulmonary disease focuses on mucous retention and chronic infection in the lungs. Future therapies for patients with cystic fibrosis include lung transplantation, pharmacologic manipulation of the epithelial cell abnormality, and gene transfer therapy into the respiratory epithelium.

Cystic Fibrosis↗

Myocardial calcification: a predictor of poor outcome for myocarditis treated with extracorporeal life support.

Myocarditis is an inflammatory disease of the myocardium with a variety of causes. It is potentially reversible, and has been treated successfully with extracorporeal life support (ECLS). With increasing severity, myocarditis results in significant damage to myocardial cells. Dystrophic calcification of the myocardium may occur, serving as a marker of severe damage. At the authors' institution, from July 1990 to January 1992, five patients (four neonates, one 5 year old) with severe myocarditis refractory to medical management were treated with venoarterial ECLS. Three survived (60%) and two died. All patients were female, and their age range was 2 weeks to 5 years. Nonsurvivors had significant myocardial calcification, which was detected by a chest roentgenogram as well as a two-dimensional echocardiogram; the three survivors had no evidence of calcification. The nonsurvivors had minimal recovery of myocardial function and subsequently had their ECLS discontinued at 83 and 169 hours, respectively. The authors conclude that the development of progressive myocardial calcification in conjunction with a lack of recovery of cardiac function is a sign of severe myocardial damage and poor prognosis. Continuation of ECLS in this setting may not be warranted.

Calcinosis↗

Epidermal growth factor enhances intestinal adaptation after massive small bowel resection.

Epidermal growth factor (EGF) has documented trophic effects on several tissues, including small bowel (SB) mucosa. The purpose of this study was to determine the effect of EGF on intestinal adaptation after massive resection. Young Sprague-Dawley rats (weight, 154 +/- 8.6 g) underwent a 75% proximal SB resection, with primary reanastomosis, and were continuously infused with equivalent volumes of either saline or human recombinant EGF (6.25 micrograms/kg/h) via a subcutaneous osmotic pump. In other animals, the SB was transected and reanastomosed without resection and either saline or EGF was infused. The animals were allowed standard rat chow and water ad libitum and were killed after 28 days. SB was harvested and subjected to histological examination. Intestinal mucosa was analyzed for total DNA and protein contents. After massive SB resection, subcutaneous administration of EGF resulted in significantly increased animal weight (294.5 +/- 16 v 242.8 +/- 14g; P < .05), SB weight (52.8 +/- 7.0 v 37.2 +/- 6.0 cm; P < .05), SB length (14.0 +/- 1.3 v 7.4 +/- 1.6 g; P < .05), and mucosal thickness (1.04 +/- 0.2 v 0.68 +/- 0.2 mm; P < .05). DNA and protein analyses suggest that EGF may augment the mucosal hyperplasia response to massive SB resection. Administration of EGF after massive SB loss may be of nutritional benefit to the host through its enhancement of the normal postresection intestinal response.

Adaptation, Physiological↗

Prostaglandin and tumor necrosis factor levels in early wound inflammatory fluid: effects of parenteral omega-3 and omega-6 fatty acid administration.

Monokines are important mediators of wound healing. Specifically, the proportions of proinflammatory (tumor necrosis factor and PGE2) and antiinflammatory (PGF2 alpha) monokines may modulate its early phases. Using a polyvinyl alcohol sponge model of rat wounding, the authors determined the temporal changes in the levels of monokines in wound inflammatory fluid, and examined whether dietary manipulation for 6 days with the precursors (omega 6 fatty acids) and inhibitors (fish oil omega 3 fatty acids) of the prostaglandin-2 series influenced monokine composition of wound fluid. For 3 days before the wounding, adult rats received isocaloric, isovolemic, and isonitrogenous total parenteral nutrition (TPN), in which lipids supplied either 35% (Intralipid [IL] or fish oil emulsion [FO]) or 8% (minimal essential fatty acid; EFA) of the total calories. Control rats received isocaloric enteral chow. The controls were studied at 24, 48, 72, and 96 hours, and the experimentals at 72 hours after wounding. Cell counts were performed, and cell-free fluid was analyzed for PGE2, PGF2 alpha, and TNF. In control rats, the total WBC count was highest at 24 to 48 hours, and decreased significantly by 96 hours. The percentage of mononuclear cells progressively increased throughout the 96 hours, and the total mononuclear cell count peaked at 72 hours. The TNF and prostaglandin levels were highest at 24 hours; these decreased rapidly by 72 hours. At all time-points, the levels of PGE2 remained higher than those of PGF2 alpha.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

Immune-mediated regression of 'metastatic' neuroblastoma in the liver.

It is understood that neuroblastoma (NB) in the liver of patients with clinical stage IV-S disease may disappear, but the mechanism of such regression is unclear. A genetic hypothesis has previously been suggested, although heretofore an immunologic explanation had not been reported. Using C1300 NB in AJ mice, we developed a model of liver metastatic disease by directly injecting tumor cells into a subcutaneously translocated spleen. Intrasplenic inoculation of 2 x 10(6) C1300 NB cells produced liver subcapsular foci of NB in 100% of animals, whose mean survival period was 18 days. Three days after tumor inoculation, interleukin-2 (IL-2) (2,400 U/d) was continuously infused for 14 days via a miniosmotic pump, and daily survival was followed. Animals were sampled serially by histological and immunohistochemical staining. Animal survival was significantly prolonged (P < .05) in the IL-2 group when compared with that of saline controls, but importantly, 50% of the mice were cured. Histological examination showed early infiltration of mononuclear cells, predominantly lymphocytes, around liver metastatic foci; and phenotypic analysis of these cells showed them to be Thy-1.2-positive and asialo GM1-positive, suggesting they are of natural killer (NK) and lymphokine-activated killer (LAK) origin. Most importantly, in cured animals the histological analysis of the liver demonstrated reversion to a scar-free anatomy, akin to that seen in stage IV-S NB survival. These data suggest that immune-mediated regression of NB in the liver is possible; whether the result of therapy or spontaneous, the liver histology reverts to normal.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

The spectrum of bile duct complications in pediatric liver transplantation.

It has been noted that reduced-size liver transplants are associated with increased rates of biliary complications, and it has been suggested that some of these complications can be handled nonoperatively. In a 6-year period, 91 orthotopic liver transplants were performed in 77 children. The medical records were reviewed to analyze the effect of reduced-size grafts on the incidence of bile duct complications and to investigate the utility of interventional radiology techniques for treatment. Forty-two children received 47 whole-organ transplants, and 35 children received 44 reduced-size transplants. The median age and weight were greater for children receiving whole-organ transplants (age, 4.25 years; weight, 16 kg) than for those receiving reduced-size grafts (age, 1.0 year; weight, 8 kg). The overall incidence of bile duct complications was 19.5% (n = 15). The incidence was not different between the whole organ group (17%) and the reduced-size group (16%). Four of the children with bile duct complications had associated hepatic artery thrombosis, two of whom had another transplant. Complications included anastomotic stricture (n = 6), anastomotic leak (n = 5), intraparenchymal biloma (n = 3), and multiple strictures (n = 1). Twelve of 15 children presented within 3 months of transplantation. Six children had initial percutaneous drainage or placement of transanastomotic stents (external). Operative repair was eventually required for all 15 children, three of whom received a second transplant. There was a 40% incidence of cytomegalovirus infection involving the liver or extrahepatic bile ducts near the time of presentation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

Surgical implications of genitourinary tract anomalies in patients with imperforate anus.

Genitourinary anomalies in patients with imperforate anus are a frequent source of significant morbidity. We report a retrospective study of 64 genitourinary procedures performed on 23 patients. Renal, collecting system, bladder and perineal anomalies were encountered in 65%, 83%, 87% and 65% of these complex cases, respectively. A total of 70% of the patients required intermittent catheterization due to bladder dysfunction. Surgical alternatives, complications of management and functional outcomes are reviewed in detail. Genitourinary reconstruction is best undertaken as an integral part of imperforate anus reconstruction. Failure to do so results in the loss of surgical alternatives, unnecessary reoperative procedures and compromised outcomes.

Abnormalities, Multiple↗

Kinetic partitioning during protein folding yields multiple native states.

The prevailing view in the field of protein folding holds that the native state is the most stable structure possible. A corollary of this thermodynamic hypothesis is that the native state is in equilibrium with all other conformations of the protein. We have found an example of a protein that may exist in two different states, both of which may be regarded as 'native', but which cannot equilibrate on a timescale that is biologically meaningful. We propose that the active conformation of this protein is at only one of several energy minima, and that during the process of refolding in vitro--and, we assume, folding in vivo--the choice of which state the polypeptide finally attains is determined by kinetic partitioning between folding pathways.

Kinetics↗

Intensive nutritional support and remedial surgical intervention for extreme short bowel syndrome.

Management of extreme short bowel syndrome (SBS) has changed dramatically over the last 20 years with notable improvements in survival and quality of life in patients with this syndrome. A review of our institution's medical records over a 12-year period (1980-1992) revealed 32 patients with < 100 cm (range, 14-94; median, 40) of functional small bowel after intestinal resection. The causes of intestinal loss included necrotizing enterocolitis (11 cases), atresias (8 cases), long-segment Hirschsprung's disease (5 cases), midgut volvulus (5 cases) and gastroschisis (3 cases). The mean follow-up period was 4.2 years, and four deaths were recorded (12.5%). Survival of eight of nine (88.9%) patients without an ileocecal valve (ICV) and with < 40 cm of small bowel was noted. The absence of an ICV, however, was associated with significantly prolonged total parenteral nutrition. Follow-up surgical procedures, including intestinal lengthening, tapering enteroplasty. Martin's procedure, longitudinal myectomy-myotomy, and ostomy take-down, were performed in 20 of the patients (64%). Prolonged survival and normal development can be expected for the patient with severe SBS who is given meticulous nutritional support and treated with carefully planned secondary surgical intervention. These results are also seen in patients with extreme SBS (< 40 cm residual small bowel length) and no ICV.

Follow-Up Studies↗

The significant relationship between platelet count and haemorrhagic complications on ECMO.

Haemorrhagic complications, which occur in up to 35% of infants during extracorporeal membrane oxygenation (ECMO), often produce devastating sequelae. Although many complex factors interact to control haemostasis, platelet number and function has significant impact on the development of primary haemostasis. The optimum platelet count on ECMO, however, has not been defined. At our institution prior to August 1987, platelet counts were maintained at greater than 100,000/mm3. After August 1987, however, platelet counts of greater than 200,000/m3 were maintained. In a retrospective study, patients were randomly chosen from these two treatment periods: group 1--March 1986 to July 1987; and group 2--June 1988 to June 1989. The average platelet count, platelets administered, hours on ECMO, and bleeding complications were compared to each other and to the July 1992 ELSO Registry. There was a significant difference in average platelet counts between group 1 and group 2. However, the amount of platelets administered per kg per day was similar. There was a significant difference in overall bleeding complications between Group 2 (12%) and the ELSO Registry (35%) (p < 0.01). There was a trend towards decreased complications in all subgroups, although sample size precluded significance. We conclude that increasing platelet counts to greater than 200,000/mm3 decreases the overall bleeding complication rate. This advantage is achieved without a continuous need for increased platelet administration once the desired level is reached and without an increase in perfusion time, mechanical complications, or mortality.

Extracorporeal Membrane Oxygenation↗

Refolding of luciferase subunits from urea and assembly of the active heterodimer. Evidence for folding intermediates that precede and follow the dimerization step on the pathway to the active form of the enzyme.

Conditions have been established that allow reversible refolding of luciferase from 5 M urea. The kinetics of formation of the active enzyme showed a concentration-independent lag, suggesting the existence of intermediate structures on the pathway of refolding. The rate of approach to the final level of activity was strongly concentration-dependent at protein concentrations below 10 micrograms/ml, but at concentrations above about 20 micrograms/ml, the rate of approach to the final activity value did not change with concentration. The concentration dependence presumably reflects the second-order step yielding the heterodimeric structure. The finding that at concentrations above 20 micrograms/ml, the rate becomes insensitive to concentration suggests that under these conditions, some step subsequent to dimerization become rate-limiting. When the refolding reaction was initiated by dilution out of 5 M urea at 50 micrograms/ml followed at various times by a secondary dilution to a final concentration of 5 micrograms/ml, it was found that the increase in activity continued at the rate characteristic of the higher protein concentration for a period of about 1-2 min following the dilution before slowing to the rate expected for the lower protein concentration. These observations indicate that there are inactive heterodimeric species that form from assembly of the individual subunits and that these species must undergo further folding to yield the active heterodimeric species. At protein concentrations of 5-50 micrograms/ml, the final yield of active enzyme was about 65-85%, decreasing at higher and lower concentrations. At higher concentrations, aggregation probably accounts for the limit in recovery, whereas at lower concentrations, it appears that the reduced yield of activity is due to the competing process of the folding of one or both individual subunits into some form incompetent to interact with each other. These experiments demonstrate the existence of slow steps in the refolding of luciferase subunits from urea and the formation of the active heterodimeric structure, both preceding and following the dimerization. Furthermore, the failure of protein at low concentrations to efficiently reassemble into the active heterodimer is consistent with the prior finding that luciferase subunits produced independently in Escherichia coli fold into conformations that cannot interact to form the active heterodimer upin mixing (Waddle, J. J., Johnston, T. C., and Baldwin, T. O. (1987) Biochemistry 26, 4917-4921).

Cloning, Molecular↗

Contribution of folding steps involving the individual subunits of bacterial luciferase to the assembly of the active heterodimeric enzyme.

Bacterial luciferase is an alpha beta heterodimer with a single active center in which the reaction of reduced FMN, O2, and an aliphatic aldehyde yields a photon of blue-green light. We have shown that refolding of the luciferase subunits from 5 M urea occurs via the intermediacy of several species, one of which is an inactive heterodimeric structure, resulting from the dimerization of alpha and beta, which isomerizes to the active alpha beta structure in a first-order reaction (Ziegler, M. M., Goldberg, M. E., Chaffotte, A. F., and Baldwin, T. O. (1993) J. Biol. Chem. 268, 10760-10765). We have also demonstrated the existence of an inactive heterodimeric species that is well populated at equilibrium in the presence of 1.6-2.8 M urea (Clark, A. C., Sinclair, J. F., and Baldwin, T. O. (1993) J. Biol. Chem. 268, 10773-10779). We have separated the alpha and beta subunits by ion exchange chromatography and investigated the effects on reformation of active luciferase of allowing the individual subunits to refold separately prior to mixing. These investigations show that the lag in formation of active luciferase is due to slow steps in folding of the individual subunits. The beta subunit appears to fold faster than the alpha subunit, but folding of the beta subunit also shows a distinct lag. When the alpha and beta subunits were allowed to refold from urea for periods of several hours or more prior to mixing, the yield of active heterodimeric luciferase was compromised, which is consistent with the finding that individual subunits produced in vivo fold into structures incompetent to interact with each other to form the active heterodimer (Waddle, J. J., Johnston, T. C., and Baldwin, T. O. (1987) Biochemistry 26, 4917-4921). It appeared that the rate with which the beta subunit assumed the heterodimerization-incompetent structure was faster than the rate with which the alpha subunit became heterodimerization-incompetent. These observations support a model for folding and assembly of the subunits of luciferase in which the two subunits fold into assembly-competent structures that associate to form the heterodimer. In a slow competing process, the subunits undergo a conformational rearrangement to form stable structures incompetent to form heterodimers. It appears that the association of the luciferase subunits might constitute an example of one polypeptide modifying the folding pathway of another, a model that is consistent with the suggestion that the formation of the heterodimeric structure of luciferase is a kinetic trap on the folding pathway of the individual subunits (Sugihara, J., and Baldwin, T. O. (1988) Biochemistry 27, 2872-2880).

Escherichia coli↗

Management of the short bowel syndrome in the pediatric population.

The short bowel syndrome in the pediatric population most commonly results from neonatal necrotizing enterocolitis. Multiple remedial surgical procedures have been developed to manage the rapid intestinal transit, decreased mucosal surface area, ineffective peristalsis, and short intestinal length in these patients. Despite significant morbidity, the overall outcome is favorable and warrants aggressive nutritional support, medical management, and surgical intervention in selected patients.

Adaptation, Physiological↗

Extended myectomy-myotomy. A therapeutic alternative for total intestinal aganglionosis.

OBJECTIVE: That total intestinal aganglionosis (extended Hirschsprung's disease) is uniformly incompatible with life as reported in 1985, is challenged by this series of patients treated over the last 7 years with an alternative therapy, extended myectomy-myotomy of the small bowel. SUMMARY BACKGROUND DATA: A total of 16 neonates worldwide presented with intestinal obstruction secondary to total (extending to the stomach) or near total (to 40 cm of jejunum) intestinal aganglionosis confirmed at one or more leveling operations. METHODS: A patient questionnaire was answered by the surgeon of all 16 patients. RESULTS: The sex distribution was eight boys and eight girls. The definitive operation included extending an antimesenteric myectomy-myotomy from the ganglionic-aganglionic transition zone for variable lengths, the operative design being to create sufficient small bowel length to support life (40-cm minimum, total small bowel maximum). The myectomized bowel was terminated as an end-stroma or as an isolated jejuno-ileal segment. Ten of 16 patients have survived (62.5%) whose length of ganglionated bowel varies from 0 to 40 cm (mean, 12.4 cm; median, 6.0 cm). Six patients have died from 1 to 33 months after operation (mean, 9.5 months; median, 5.0 months) of gut-induced infection (n = 5) and respiratory failure (n = 1); their ganglionated bowel length was similar to survivors (range, 0-26 cm; mean, 9.2 cm; median, 8.0 cm). Of the 16 patients, 15 have received enteral nutrients through the myectomized bowel. Of ten survivors, strikingly two are totally gut nourished (2 cm, 7-cm length of ganglionated bowel), six receive from 1/5 to 4/5 of total calories enterally, and one receives minimal enteral feeding. CONCLUSIONS: From these patients we have learned that (1) extended myectomy-myotomy relieves the obstruction of extended Hirschsprung's disease; (2) aganglionic bowel after extended myectomy-myotomy acts as a passive conduit for proximally propulsed nutrients; and (3) aganglionic bowel after extended myectomy-myotomy undergoes adaptive change and is capable of absorbing life-supporting nutrients. These data demonstrate extended myectomy-myotomy to be a therapeutic option for otherwise fatal extended Hirschsprung's disease, either as a potentially definitive therapy or as a putative bridge to intestinal transplantation.

Female↗