Congenital cystic adenomatoid malformation of the lung: indications and timing of surgery

We review a single surgeon and surgical centre's experience with congenital cystic adenomatoid malformation of the lung (CCAML) in relation to clinical spectrum, operative experience, and postoperative course. A retrospective hospital record review was done on surgically treated cases of CCAML over a 10-year period, focusing on number with antenatal diagnosis, spectrum of postnatal presentation, type of surgery performed, and outcome. Forty-seven patients from birth to 14 years of age underwent surgery for CCAML. Antenatal diagnosis (ante) was made in 30 cases. Of these, 10 became symptomatic before surgery. Six of the 17 postnatally-diagnosed (pnd) cases were an asymptomatic incidental finding. Overall, 16 were symptomatic in the 1st year of life, and five were symptomatic beyond 1 year of age. Symptoms varied from respiratory distress (seven ante, six pnd) to chronic cough (three, and recurrent chest infection (three ante, two pnd). All preoperative diagnoses were confirmed with chest CT. Most patients (25) were operated on before 3 months of age. Eleven were operated on in the first 2 weeks of life as emergency surgery for respiratory distress. The most common lobe involved was the right upper lobe (16), and lobectomy was performed in 42 cases, segmentectomy in four, and pneumonectomy in one. Seventeen cases were extubated immediately postoperatively; 29 required postoperative ventilation overnight, and nine needed more prolonged ventilation. Early postoperative complications included pneumothorax (two), pleural effusion (one), and chylous effusion (one). Late complications included recurrence in three cases (all segmentectomy), who then subsequently underwent lobectomy. There was one death from respiratory failure. Because there is an increasing trend in the detection of asymptomatic antenatally-diagnosed CCAML, consideration of early surgical excision to prevent complications is suggested by our series. CT scanning is mandatory for postnatal evaluation because chest x-ray could be normal. Safe elective excision after 3 months is supported by our low morbidity and less need for postoperative ventilation. Lobectomy is the procedure of choice to prevent recurrence.

Fossil biotas from the Okanagan Highlands, southern British Columbia and northeastern Washington State: climates and ecosystems across an Eocene landscape

The late Early to early Middle Eocene Okanagan Highlands fossil sites, spanning -1000 km north-south (northeastern Washington State, southern British Columbia) provide an opportunity to reconstruct biotic communities across a broad upland landscape during the warmest part of the Cenozoic. Plant taxa from these fossil sites are characteristic of the modern eastern North American deciduous forest zone, principally the mixed mesophytic forest, but also include extinct taxa, taxa known only from eastern Asian mesothermal forests, and a small number of taxa restricted to the present-day North American west coast coniferous biome. In this preliminary report, paleoclimates and forest types are reconstructed using collections from Republic in Washington State, USA., and Princeton, Quilchena, Falkland, McAbee, Hat Creek, Horsefly, and Driftwood Canyon in British Columbia, Canada. Both leaf margin analysis (LMA) and quantitative bioclimatic analysis of identified nearest living relatives of megaflora indicated upper microthermal to lower mesothermal moist environments (MAT -10-15 degrees C, CMMT > 0 degrees C, MAP > 100 cm/year). Some taxa common to most sites suggest cool conditions (e.g., Abies, other Pinaceae; Alnus, other Betulaceae). However, all floras contain a substantive broadleaf deciduous element (e.g., Fagaceae, Juglandaceae) and conifers (e.g., Metasequoia) with the bioclimatic analysis yielding slightly higher MAT than LMA. Thermophilic (principally mesothermal) taxa include various insects, the aquatic fern Azolla, palms, the banana relative Ensete, taxodiaceous conifers, Eucommia and Gordonia, taxa which may have occurred near their climatic limits. The mixture of thermophilic and temperate insect and plant taxa indicates low-temperature seasonality (i.e., highly equable climate).

Paediatric population pharmacokinetics of itraconazole and its active metabolite hydroxy-itraconazole in cystic fibrosis and bone marrow transplant patients

Objectives: The aim of the study was to characterise the population pharmacokinetics (popPK) properties of itraconazole (ITRA) and its active metabolite hydroxy-ITRA in a representative paediatric population of cystic fibrosis (CF) and bone marrow transplant (BMT) patients. The goals were to determine the relative bioavailability between the two oral formulations, and to explore improved dosage regimens in these patients. Methods: All paediatric patients with CF taking oral ITRA for the treatment of allergic bronchopulmonary aspergillosis and patients undergoing BMT who were taking ITRA for prophylaxis of any fungal infection were eligible for the study. A minimum of two blood samples were drawn after the capsules and also after switching to oral solution, or vice versa. ITRA and hydroxy-ITRA plasma concentrations were measured by HPLC[1]. A nonlinear mixed-effect modelling approach (NONMEM 5.1.1) was used to describe the PK of ITRA and hydroxy-ITRA simultaneously. Simulations were used to assess dosing strategies in these patients. Results: Forty-nine patients (29CF, 20 BMT) were recruited to the study who provided 227 blood samples for the population analysis. A 1-compartment model with 1st order absorption and elimination best described ITRA kinetics, with 1st order conversion to hydroxy-ITRA. For ITRA, the apparent clearance (ClItra/F) and volume of distribution (Vitra/F) was 35.5L/h and 672L, respectively; the absorption rate constant for the capsule formulation was 0.0901 h-1 and for the oral solution formulation it was 0.959 h-1. The capsule comparative bioavailability (vs. solution) was 0.55. For hydroxy-ITRA, the apparent volume of distribution and clearance were 10.6 L and 5.28 L/h, respectively. Of several screened covariates only allometrically scaled total body weight significantly improved the fit to the data. No difference between the two populations was found. Conclusion: The developed popPK model adequately described the pharmacokinetics of ITRA and hydroxy-ITRA in paediatric patients with CF and patients undergoing BMT. High inter-patient variability confirmed previous data in CF[2], leukaemia and BMT[3] patients. From the population model, simulations showed the standard dose (5 mg/kg/day) needs to be doubled for the solution formulation and even 4 times more given of the capsules to achieve an adequate target therapeutic trough plasma concentration of 0.5 mg/L[4] in these patients.

Fossil trees in ancient fluvial channel deposits: evidence of seasonal and longer-term climatic variability

It has been established that large numbers of certain trees can survive in the beds of rivers of northeastern Australia where a strongly seasonal distribution of precipitation causes extreme variations in flow on both a yearly and longer-term basis. In these rivers, minimal flow occurs throughout much of any year and for periods of up to several years, allowing the trees to become established and to adapt their form in order to facilitate their survival in environments that experience periodic inundation by fast-flowing, debris-laden water. Such trees (notably paperbark trees of the angiosperm genus Melaleuca) adopt a reclined to prostrate, downstream-trailing habit, have a multiple-stemmed form, modified crown with weeping foliage, development of thick, spongy bark, anchoring of roots into firm to lithified substrates beneath the channel floor, root regeneration, and develop in flow-parallel, linear groves. Individuals from within flow-parallel, linear groves are preserved in situ within the alluvial deposit of the river following burial and death. Four examples of in situ tree fossils within alluvial channel deposits in the Permian of eastern Australia demonstrate that specialised riverbed plant communities also existed at times in the geological past. These examples, from the Lower Permian Carmila Beds, Upper Permian Moranbah Coal Measures and Baralaba Coal Measures of central Queensland and the Upper Permian Newcastle Coal Measures of central New South Wales, show several of the characteristics of trees described from modern rivers in northeastern Australia, including preservation in closely-spaced groups. These properties, together with independent sedimentological evidence, suggest that the Permian trees were adapted to an environment affected by highly variable runoff, albeit in a more temperate climatic situation than the modem Australian examples. It is proposed that occurrences of fossil trees preserved in situ within alluvial channel deposits may be diagnostic of environments controlled by seasonal and longer-term variability in fluvial runoff, and hence may have value in interpreting aspects of palaeoclimate from ancient alluvial successions. (C) 2001 Elsevier Science B.V. All rights reserved.