[Giant epignathus in the newborn: report of a case and review of the literature]

Epignathus is a congenital teratoide tumor in the oral cavity. It is extremely rare and usually lethal. The authors present a case treated successfully. Important aspects of the diagnosis, clinical management and surgical procedures are discussed. Extensive review of the literature is presented.

Quality assurance in clinical neurophysiology: the ESTEEM project example

This paper describes the current status of the utilisation of clinical practice guidelines (protocols) in the ESTEEM project as one form of the clinical quality assurance procedures considered in the project. The performance of electrodiagnostic studies, in terms of which types of conclusions need to be inferred during the examination plan, is briefly described. The main focus of the paper is a description of an European multicentre clinical audit in the field of Clinical Neurophysiology, using a common data-entry protocol for prospective EMG case collection and assessment with the ultimate objective of building up a multicentre reference database of EMG cases.

Immunohistochemical characterisation of probable intravascular haematopoiesis in the vasa rectae of the renal medulla in acute tubular necrosis

Immunohistochemistry was applied to identify the nature of the nucleated cells that accumulate in the vasa rectae of the corticomedullary junction in acute tubular necrosis. In all 6 cases studied, there were intravascular cells that reacted with monoclonal antibodies to erythroblast, macrophages, myeloid cells, T and B lymphocytes and rare megakaryocytes. The findings are consistent with the occurrence of intravascular haematopoiesis in the renal medulla in acute tubular necrosis.

Correlation between clinical, electromyographic and dysautonomic evolution of familial amyloidotic polyneuropathy of the Portuguese type

To assess the correlation between the severity of clinical symptoms and sensorymotor and autonomic function in familial amyloidotic polyneuropathy of the Portuguese type (FAP-PT), clinical grade (CG), electromyographic score (ES), sympathetic (SS) and parasympathetic score (PS) were compared in 47 patients. SS and PS were both abnormal in 72% of patients with ES = 0% and in 73% of patients with CG = 0. When SS and PS were compared with either CG and ES, PS progressed more rapidly and stabilized earlier than SS. As a whole, SS and PS were greater as CG and ES were higher. This pattern of autonomic involvement should be taken into account when assessing the course of the disease and evaluating new forms of therapy.

[Stress echocardiography with dobutamine: the importance of adding atropine in inconclusive tests]

OBJECTIVES

To study the feasibility of adding atropine after dobutamine infusion in patients with known or suspected coronary artery disease not achieving 85% of predicted maximal heart rate.

PATIENTS

We studied with dobutamine stress echocardiography 219 patients (174 men e 45 women; mean age +/- SD: 58 +/- 11 years), 126 patients with a previous myocardial infarction and 93 with angor. One hundred and thirty three (61%) also performed coronariography.

METHODS

Dobutamine stress echocardiography protocol consisted of a step-wise infusion of dobutamine from 5 micrograms/kg/min to a maximal dose of 40 micrograms/kg/min or until a new or a worsening wall motion abnormality, 85% of predicted maximal heart rate or any indication for interruption. In patients not achieving any of these end points, intravenous atropine was administered up to 1 mg. Patients were divided in two groups: Group A: infusion of dobutamine alone and Group B: dobutamine plus atropine.

RESULTS

With this protocol the test was interrupted in 41 patients (19%) because of adverse effects that were mild and short lived and resolved with discontinuation of the test. After dobutamine infusion 46% of the tests were nonconclusive, the majority were on beta blocker therapy. After atropine administration there was a significant reduction of the nonconclusive studies to 20% (p < 0.001). In patients with a normal rest echocardiogram the sensitivity and specificity of the test to diagnose significant coronary artery disease was respectively 89% e 100% after atropine. The capacity of the test to detect multivessel disease was also increased after atropine, allowing to reach a sensitivity of 85% and a specificity of 90%.

CONCLUSIONS

Dobutamine stress echocardiogram supplemented with atropine is a safe and accurate method to diagnose significant coronary artery disease and to detect multivessel disease in patients with a previous myocardial infarction with rest wall motion abnormalities.

A Caucasian family with the 3271 mutation in mitochondrial DNA

The second most common mutation associated with MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes) in Japan is the 3271 mutation. This mutation was found in a Brazilian family of Portuguese and Italian descent, indicating that this mutation also exists in a race other than Japanese. The propositus had mild clinical manifestations atypical of MELAS, suggesting that patients with the 3271 mutation exhibit heterogeneous phenotypic expression as seen in the 3243 mutation.

[Primary intrahepatic lithiasis: report of a case and review of the literature]

Primary intrahepatic lithiasis is an entity defined by intrahepatic stones exclusively located in the IH ducts above the emergence of the common bile duct. The disease is classified in two types: Eastern type (stones formed primarily in intrahepatic ducts; frequent in Japan) and Western type (stones formed in the extrahepatic bile system, usually in gallbladder, which migrate up to the intra-hepatic ducts). The mechanisms of lithogenesis in the entity are as yet not fully understood; multiple factors seem to operate synergistically: anatomical changes of the intrahepatic ducts, metabolic disorders, infections, idiopathic alteration. All these factors may facilitate biliary stasis leading ultimately to stone formation. We report on a case of and review the literature on primary intrahepatic lithiasis, which is a rare occurrence in the West and a disease of difficult surgical approach and high mortality.

HLA antigens and lymphocytes in proliferative vitreoretinopathy

An immunohistopathological study was performed on 33 epiretinal membrane specimens obtained during vitreoretinal surgery from patients with rhegmatogenous retinal detachment complicated with proliferative vitreoretinopathy (PVR). Immunofluorescence and immunoperoxidase methods were used to detect major histocompatibility complex or HLA antigens and immunocompetent cells, and to identify the cellular and the extracellular component of the proliferative tissue. The following antigens were detected in epiretinal membranes: cytokeratin in 18 (of 18 cases studied for this antigen), glial fibrillary acidic protein in 20 (of 20), vimentin in 20 (of 20), actin in 16 (of 18), fibronectin in 20 (of 20), macrophage CD68 in 16 (of 18), leukocyte common antigen in 12 (of 18), T-cell CD45R in 13 (of 22), HLA-ABC in 27 (of 33), HLA-DR in all the 33 membranes and HLA-DR alpha chain in 32 of 33 membranes. We observed the presence of macrophages and of an activated T-cell population in PVR membranes. HLA-DR antigen expression was found on pigmented and nonpigmented epithelial cells and on mononuclear cells in all epiretinal membranes. The HLA-DR expression on retinal pigmented epithelial cells could play a role in triggering a local immune response in PVR. These findings suggest the involvement of immunological phenomena and probable interactions between the immune system and peptide growth factors.

Minimal residual coronary obstructions in patients who suffered a first myocardial infarction. A prospective study comparing coronary angiography and exercise thallium scintigraphy

The purpose of the present study was to correlate the presence of minimal coronary obstruction (< or = 50%) assessed by coronary angiography with the presence of myocardial scar and ischemia detected by thallium-201 myocardial perfusion imaging. The study included 83 consecutive patients (74 men and 9 women) with a mean age 55.4 +/- 8.5 years who suffered a first myocardial infarction and did not undergo thrombolytic therapy. In all patients, coronary angiography, left ventriculography, and exercise thallium-201 tomographic scintigraphy were performed within 3 to 5 months of the myocardial infarction. Coronary arteriograms showed minimal residual obstructions in 37 (45%) patients. Of a total of 54 patients with < or = 50% obstruction, 18 showed persistent defects and 22 reversible defects on thallium scintigrams. The present study showing estimated angiographic stenosis of < or = 50% as being responsible either for myocardial scar or myocardial ischemia on postexercise thallium scintigrams leads us to conclude that percent value of stenosis does not accurately predict the pathophysiologic significance of coronary atherosclerotic lesions in patients who suffer a myocardial infarction. After a first myocardial infarction, coronary angiographies and thallium-201 scintigrams are complementary for an optimal treatment strategy for selected subsets of patients.

[Pure autonomic failure]

We present the case of a 64-year-old woman who, in the past 5 years, complained of constipation/diarrhea, hyposudoresis, xerostomia and xerophthalmia, dysuria and orthostatic hypotension. Cardiovascular reflexes analysis revealed sympathetic and parasympathetic failure. Norepinephrine was markedly reduced, both lying and after tilt. Norepinephrine infusion determined a significant rise in blood pressure, allowing the diagnosis of denervation hypersensitivity. The diagnosis of pure autonomic failure was made. Therapy with 9 alpha fludrocortisone and metoclopramide was initiated with marked and sustained symptomatic effect.

Protein interactions with DNA elements in variant equine infectious anemia virus enhancers and their impact on transcriptional activity

The long terminal repeats (LTRs) from various cloned equine infectious anemia virus (EIAV) proviruses differ significantly, but all contain cis-acting DNA elements identical to MDBP-, PEA2-, AP-1-, and PU.1 (ets)-binding sites. A prototype EIAV LTR would contain one of each of these conserved elements. The LTR variations originate from the insertion of novel sequences between the PEA2 and AP-1 elements in the transcriptional enhancer unit. Viewed in this way, the LTR from provirus clone lambda 12 has an 11-bp insertion containing a PEA2 site and the LTR of the lambda 6 provirus has a 31-bp insertion/duplication containing PEA2, AP-1, and PU.1 sites. Two other LTRs were cloned by amplification of cDNAs from the persistently infected cell line, EIAV-FEA. A third LTR was generated by site-directed mutagenesis of one of the LTRs from EIAV-FEA cells. The latter three had a single base change in the element next to the TATA box that abolished PU.1 binding; however, the variable regions of these LTRs were shown by gel mobility shift assays to contain one or two PU.1 sites. One variable region was shown to have an octamer site overlapping its tandem PU.1 elements. Basal, PMA-activated, and Tat trans-activated transcriptional activities of the LTRs were compared in several different cell lines by transient transfection. The various promoters displayed different relative levels of activity depending on the cell line used and the condition of activation. This natural set of variant promoters may help define how changes in the components of the transcription complex influence transactivation by Tat. The diverse LTRs could endow their respective proviruses with a unique pattern of expression and activation in vivo.

The PU.1/Spi-1 proto-oncogene is a transcriptional regulator of a lentivirus promoter

The enhancer unit present in the retrovirus equine infectious anemia virus (EIAV) was previously shown to contain binding sites for proteins belonging to MDBP, PEA2, AP-1, and ets families. The EIAV ets motif matches the consensus sequence for both PEA3- and PU.1-binding sites. Here, we show by gel shift analysis that PU.1, present in nuclear extracts from monocyte and B-lymphocyte cell lines, binds to oligonucleotides containing the EIAV ets element. HeLa cells transiently transfected with a PU.1 expression plasmid expressed nuclear factors that formed complexes indistinguishable from those seen with monocyte extracts. Antibodies to PU.1 protein either supershifted or abolished formation of these complexes, depending on the PU.1 epitopes recognized. The binding of PU.1 to the EIAV ets motif in vitro correlated with transcriptional activity of the EIAV promoter in transfected monocyte cell lines. In HeLa cells, the product of PU.1 cDNA bound to the EIAV ets motif and activated transcription from the EIAV promoter. The PU.1-binding site was the primary determinant of EIAV promoter activity in cell lines that express PU.1. Nucleotide determinants of PU.1 binding and a consensus PU.1 binding sequence were defined in gel shift assays using a panel of mutated oligonucleotides. To our knowledge, this is the first report of a retroviral promoter controlled by PU.1.

[Neurophysiological methods for the diagnosis of genitourinary dysfunctions]

Genito-urinary function is a watershed field interesting several areas of medical concern. Neurophysiological studies allow objective assessment of central, peripheral and autonomic pathways in the nervous system contributing to topographical localisation of lesions. The authors describe different methods used, namely somatosensory evoked potentials by pudendal nerve stimulation, bulbo-cavernous reflex, cutaneous sympathetic reflex, transcranial cortical or spinal magnetic stimulation and single fiber EMG. Abnormalities in neurological diseases are presented.

Immunofluorescence on skeletal muscle and skin biopsy specimens in muscle diseases

A series of 110 muscle and 40 skin biopsy specimens were examined using direct immunofluorescence aiming to identify features that may differentiate the myopathy of connective tissue disease from other muscle diseases. The skeletal muscle fluorescence was positive in 75% of the patients with muscle diseases. The sarcolemmal staining was higher in mitochondrial encephalomyopathy. Fiber and vascular staining occurred in all muscle diseases, except in cases of myasthenia. Our results showed that 42% of patients with polymyositis and 43% of patients with peripheral motor neuron diseases have vascular deposits of immune complexes suggesting that these two diseases could result from an immune-complex-induced vasculopathy. The IF test in skin specimens was positive in 60% of the patients with muscular diseases. The absence of immunoglobulin deposit at the dermoepidermal junction and at epidermal nuclei in cases of peripheral motor neuron disease suggest that this skin test may be useful in the differentiation of muscle diseases.

Postexercise changes of the QTc interval in patients with recent myocardial infarction

A lack of the QTc ratio decrease at maximal exercise is considered as an index of exercise-induced ischemia in patients with coronary artery disease. The authors studied 51 patients with recent myocardial infarction in order to evaluate the QTc changes with exercise in assessing the presence of remaining ischemic myocardium. All patients were submitted to exercise stress tests, coronary angiographies, and exercise thallium 201 scintigraphies within 3-5 months of the myocardial infarction. Of the patients studied, 18 showed one-vessel disease and 33 showed multivessel disease. All vessels were classified as patent or occluded. In all patients with reversible thallium 201 defects both at distance and in the infarct zone, the QTc interval following exercise either showed a prolongation or no change from the resting electrocardiogram. In patients with only fixed perfusion defects, the QTc shortened at the end of the test. This study showed a low sensitivity and specificity for inducible ST-segment depression compared with the delayed redistribution on the postexercise thallium 201 scintigram. QTc variations at the end of exercise electrocardiograms are valuable as a noninvasive, low-cost identification of residual ischemic myocardium in patients after myocardial infarction.

Physical and functional characterization of transcriptional control elements in the equine infectious anemia virus promoter

Equine infectious anemia virus (EIAV) is a lentivirus that causes a chronic disease of horses characterized by cyclic episodes of fever, anemia, and viremia. Although the genome and promoter of EIAV are much less complex than those of its relatives the primate immunodeficiency viruses, the cellular proteins that activate and regulate transcription of EIAV have not yet been identified. In this report, we show by electrophoretic mobility shift assays and DNase I footprinting that the EIAV promoter contains multiple binding sites for ubiquitous, cell type-specific, and inducible cellular proteins. Functional analysis by transient transfection of canine osteosarcoma (D17) and human epithelial carcinoma (HeLa) cells with EIAV promoters containing deletions or individually mutated DNA-binding sites demonstrated that these DNA-binding elements cooperatively regulate transcriptional activity. A methylated DNA-binding site (MDBP; also designated EF-C or EP) acts as either a positive or negative regulator of promoter activity, depending on the cell type or condition. Two PEA2 elements, an AP-1 site, and an ets/PEA3 motif confer a positive effect on promoter activity. The EIAV promoter is shown to be activated by treatment of HeLa cells with phorbol myristate acetate (PMA). DNA-binding activities were induced in PMA-treated HeLa cells and formed complexes on oligonucleotides that contain the EIAV AP-1 and ets/PEA3 elements. Functional analysis of mutated promoters indicated that the ets/PEA3 motif was the principal mediator of PMA activation.

[Familial amyloidotic polyneuropathy --Portuguese type-- clinical and neurophysiologic course]

Sixteen (16) patients with Familial Amyloidotic Polyneuropathy-Portuguese Type (FAP) were evaluated longitudinally, using the EMG and Clinical protocols with the aim of establishing the clinical and neurophysiological evolution rate of FAP. We conclude that spontaneous evolution of FAP patients shows a linear progression. Clinical and neurophysiological evolution times are parallel, with the EMG scores being higher than Clinical ones. We propose that Clinical and EMG scores should be used in the evaluation of future therapeutic trials, namely immunodepuration and liver transplantation.

[Significance exercise-induced ST elevation in patients with myocardial infarction]

In 52 patients with previous myocardial infraction, 49 men and 3 women (mean age 56 +/- 7.1 years) the significance of ST-segment elevation during the stress-test, was evaluated. Of the 52 patients 15 (29%) showed St-segment elevation and 37(71%), showed no alteration of the ST-segment. Extension of coronary disease, degree of obstruction, wall motion abnormalities and the presence of residual ischemia were evaluated by coronary angiography, technetium-99M pyrophosphate imaging and exercise TL-201 scintigraphy. From the results of the study one may conclude that, in patients with previous myocardial infraction exercise, ST-segment elevation is a consequence of sub-occlusion of the left anterior descending coronary artery with severe ventricular dysfunction either in patients with one or multiple vessel disease.

Octreotide--a new treatment for diarrhoea in familial amyloidotic polyneuropathy

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[Doppler echocardiography in the diagnosis of mechanic complications of acute myocardial infarction]

OBJECTIVES

To evaluate the ability of bedside emergency Doppler/Echocardiographic (ECOCG/DP) studies in the diagnosis of mechanic complications during acute myocardial infarction (AMI).

DESIGN

Retrospective analysis of 44 fatal AMI cases, studied by ECOCG/DP and with diagnostic confirmation by surgery and/or necropsy.

SETTING

Patients (pts) with AMI admitted to an Intensive Care Unit of a tertiary Hospital (UCIM), Hospital de Santa Maria.

PATIENTS

44 fatal AMI cases were analysed (24 men and 20 women; mean age +/- SD: 72 +/- 9 years) and were divided in two groups according to Killip classification in Group 1 (III/IV): 35 pts and Group 2 (I/II): 9 pts.

METHODS

ECOCG/DP was performed in a routine basis at admission, using all standard views and by subcostal view when in an emergency scenario.

RESULTS

In 20 pts with bad left ventricular function (LVF) (Group 1) at admission, ECOCG/DP monitoring showed that death was due to worsening of LVF, which was confirmed by necropsy. In the other 15 pts of this group, ECOCG/DP documented the clinical diagnosis of cardiac rupture (free wall: 4 pts; papillary muscle: 4 pts; interventricular septum: 7 pts) which was confirmed by surgery and/or necropsy. In the 9 pts of Group 2, ECOCG/DP disclosed, at admission, good LVF in all. In 5 pts there was a sudden worsening clinical status, and ECOCG/DP showed a severe pericardial effusion with right chambers collapse, highly suggestive of free wall rupture also confirmed at necropsy. In the other 4 pts, ECOCG/DP showed aggravation of wall motion abnormalities and of LVF without rupture, once again in agreement with necropsy. Five clinical cases are presented for illustration of this issue.

CONCLUSION

In the 44 fatal AMI cases of our study there was complete agreement between the ECOCG/DP and necropsy studies. In AMI patients, ECOCG/DP monitoring can in a routine basis, evaluate wall motion abnormalities and LVF. In an emergency setting ECOCG/DP can diagnose all the mechanic complications with a great certainty.