[Etiology of lower acute respiratory infections in hospitalized infants. 3. Investigation of Chlamydia trachomatis]

Five infants with Chlamydia trachomatis associated pneumonia are analyzed. They were diagnosed out of 80 infants admitted to the hospital with pneumonia whose etiology was studied for virus, bacteria and Chlamydia trachomatis. Serum IgM antibodies to Chlamydia tr. were measured by indirect immunofluorescence (IIF), which is considered to be specific in high titers (1 greater than or equal to 32). The five cases represented 10.4% of infants studied younger than six months. One child was born by cesarean section suggesting the possibility of other non oculogenital still undefined mechanism of transmission. Clinical symptoms and laboratory findings were characteristics of those described in Chlamydia tr. pneumonia. Chlamydia trachomatis must be considered an etiologic agent in infantile pneumonia specially in the first six months of life. The high specificity and sensitivity of the IFF makes this serologic test the best non-invasive method for diagnosis of Chlamydia tr. pneumonia currently available.

Juvenile GM2 gangliosidosis variant B1: clinical and biochemical study in seven patients

We describe seven patients from five different families with GM2 gangliosidosis, variant B1. To our knowledge these are the first juvenile cases reported in the literature.

Autologous bone marrow or peripheral blood stem cell transplantation for patients with chronic myelogenous leukaemia in chronic phase

The progressive and fatal course of chronic myelogenous leukemia has not been affected significantly by chemotherapeutic agents that control the benign phase of the disease. Combination chemotherapy and aggressive treatments may offer some advantages: however, these approaches do not appear to produce stable suppression of Ph1 chromosome or to prolong chronic phase and survival of these patients. Only allogeneic bone marrow transplantation has been demonstrated to be capable of inducing a stable, complete suppression of Ph1+ cells. Recently alpha Interferons (IFN) have been shown to control myeloid proliferation in patients with CML and to determine a progressive and persistent decline of Ph1+ bone marrow cells in some cases. The hypothesis that in most newly diagnosed patients with CML various amount of Ph1 negative cells must still be present, albeit in suppressed state in the bone marrow (BM) or in the peripheral blood (PB), have led some Authors to treat patients with high-dose chemotherapy followed by reinfusion of stem cells collected at diagnosis or after a response to cytoreductive treatments. We report 34 patients with CML treated in chronic phase with Busulohan and Melphalan conditioning regimen followed by reinfusion of BM or PB stem cells.

Cardiac amyloidosis--a case report

A 75-year-old male patient presented with resistant congestive cardiac failure. Echocardiographic examination revealed normal left ventricular size with symmetrical hypertrophy and generalised hypokinesia. In addition, there was a characteristic granular sparkling appearance of the myocardium. Cardiac catheterization showed biventricular diastolic restriction with normal coronary arteries. Possibility of cardiac amyloid was considered, and the diagnosis was confirmed on rectal biopsy.

Responses to smoking-related stimuli and early relapse to smoking

Prior to engaging in treatment for smoking cessation, subjects were tested for their responsiveness to cigarette smoking cues. Subjects performed a role-play with a confederate who lit their preferred brand of cigarette. Heart rate (HR) and galvanic skin conductance were assessed continuously, while urge to smoke and anxiety were rated subjectively after the role-play. Three months after treatment ended, subjects were divided into groups of continuous quitters, verified by expired carbon monoxide measurement, and relapsers. The results showed a significant difference between the groups in the pattern of pretreatment HR response to the lighting of the cigarette; relapsers displayed a sharp HR deceleration in response to the stimulus, while quitters' HR did not decelerate. The theoretical and clinical significance of these results is discussed.

[Role of magnetic resonance in acute capsular-ligamentous pathology of the knee]

Magnetic Resonance (MR) imaging was employed to evaluate musculoskeletal pathoanatomy, and proved to be extremely useful in characterizing knee pathology. Between October 1986 and November 1987, 24 patients with suspected traumatic ligament injuries were examined with high resolution MR imaging in the RMRC diagnostic center, Naples, with a 0.5 T superconducting magnet (5000 Magniscan CGR) using a surface coil and a 500/28 (repetition time: TR: ms/echo time: TE-ms), 1200-1600/35-105 spin-echo pulse sequence. Nineteen patients with positive MR imaging exams underwent diagnostic and/or therapeutic arthroscopy. Arthroscopy confirmed MR diagnosis in the whole of cases. In 6 patients with negative MR findings no arthroscopy followed and the patients' successful outcome confirmed the accuracy of MR negative predictive value. Such results prove MR imaging to have a high diagnostic accuracy in the evaluation of acute joint injuries of the knee. Moreover, MR imaging--an uninvasive screening technique--appears to have high potentials for the evaluation of those cases where diagnostic arthroscopy is not required.

[Magnetic resonance imaging of the knee. Preliminary study of non-neoplastic osteoarticular pathology]

Magnetic Resonance Imaging (MRI) has been applied to musculoskeletal pathoanatomy and has proved to be useful in the detection and characterization of knee pathology. Thirty-two acutely injured knees and 8 normal knees were examined. The images were obtained in the Diagnostic Centre RMRC of Naples on a 0.5 T superconductive magnet system, using a surface coil and a spin-echo pulse sequence (SE 600/28 ms). The examined limb was immobilized and bent at 8-10 degrees, extrarotated for the examination of the anterior cruciate ligament (ACL) only. Images were obtained on a 256 x 256 matrix and had a 2 or 4-mm thickness. MRI clearly showed all the anatomical structures. The anterior and posterior cruciate ligaments (ACL and PCL) and the patellar ligament were shown by sagittal SE images through the intercondylar notch; the tibial and fibular collateral ligaments (TCL and FCL) were evaluated on coronal SE images; the articular capsula and menisci on axial transverse SE images. Objective criteria for ACL and PCL tears were: lack of continuity of the signal and change in signal intensity; in meniscal pathology, menisci with small linear regions of increased signal or with grossly truncated shape were interpreted as tears. Preliminary results of this study indicate that MRI together with clinical evaluation may be an useful non-invasive procedure in the assessment of acute injuries of the knee.

Radiologic imaging of symptomatic ligamentum flavum thickening with and without ossification

Thickening of the ligamenta flava with and without ossification in the thoracic and lumbar regions is a frequent finding on CT scanning; however, it is not widely appreciated as a possible primary cause of compressive cord, cauda equina, and nerve-root symptoms. We present observations from a series of seven patients whose symptoms were caused exclusively or largely by thickened ligamenta flava in the thoracic and lumbar regions. The findings were best demonstrated on myelography. One of our cases had been missed on previous MR, as would be expected with the null signal of calcification. CT scanning necessitates an extended window to ensure discrimination of an ossified ligament from thecal metrizamide. Thickened ligamenta flava are often found in conjunction with degenerative disease and spinal stenosis at multiple levels and should not be ignored as a possible major contributing factor to the patient's symptoms. In addition, those patients with a secondary block from a thickened ligamentum flavum should be studied from above with C1-C2 puncture to rule out other levels of clinically significant disease. Attention to the particular findings of thickened ligamenta flava is important since surgical intervention must involve removal of the entire offending ligament(s); otherwise clinical symptoms may not be relieved.

Long-term treatment with 'Duovent' in elderly patients affected by chronic obstructive lung disease

Twelve patients, aged over 60 years and suffering from chronic obstructive lung disease, were treated for 12 weeks with Duovent (fenoterol + ipratropium bromide). The clinical check-ups and indices of bronchial obstruction (FEV1, VC, RV, sGaw) were performed every 14 days. Improvement in symptoms corresponded to a significant improvement in the functional parameters. No negative cardiovascular effects, significant side-effects, or tolerance were seen after drug administration.

[Subphrenic adipose tissue, an infrequent cause of increased distance between the diaphragm and liver. Radiological study and echographic comparison]

Nine obese patients (4M/5F) showing on a standard chest-X-ray a right subdiaphragmatic radiolucent area were submitted to ecography. This method excluded pathologic causes and showed adipose tissue as the cause of the increased distance between diaphragm and liver. Besides, ecography showed some limits in the evaluation of adipose area, because of the difficulty in studying obese patients.

Sodium taurocholate effect on beta-glucosidase activity: a new approach for identification of Gaucher disease using the synthetic substrate and leucocytes

In this work we have studied the leucocytes and sera of 3 Gaucher patients, 4 obligate heterozygotes, 11 brothers and sisters of patients and 11 controls. Beta-glucosidase activity with 4-M-U-beta-glucopyranoside has been assayed at different pH's, in the presence of pure sodium taurocholate. At pH 4.5 and 5.0 sodium taurocholate activates the beta-glucosidase of control leucocytes, but inhibits the residual enzyme present in Gaucher leucocytes. The ratio of beta-glucosidase activity in the presence and absence of this effector seems to be a good approach to the diagnosis of Gaucher disease and it has proved indispensible in one patient's diagnosis. The apparent Km of beta-glucosidase determined for the same substrate, at pH 4.5 and 5.5 in the presence of sodium taurocholate showed markedly lower values in the patients than in the controls. An increased serum acid phosphatase activity, previously described as a secondary alteration in Gaucher disease, has also been studied and seems to be a useful complementary test, particularly when its age dependence is taken into account.

Age dependency of serum acid phosphatase in controls and Gaucher patients

Serum acid phosphatase activity has been used as a complementary test for the diagnosis of Gaucher's disease. This study suggests that phosphatase activity is age dependent. The use of controls in the patients' age is strongly recommended.

[Topographic diagnosis of atrio-ventricular conduction defects]

Atrioventricular (A-V) conduction was evaluated in 51 patients who underwent electro-physiological study. Eighteen patients had nodal conduction delay (A-H greater than 150 ms), six of them were congenital, in two others it was associated to a His-Purkinje (H-V) delay. None of them had bundle branch block in the surface ECG. The conduction delay was located within the his bundle in 15 patients (29.4%). In three of them, a split His bundle electrogram was recorded; in the other 12 (80%), His bundle stimulation normalized QRS morphology; in all of these patients H-V interval was longer than 70 ms. His bundle delay was associated to infra H lesion in five patients. In one without ECG changes, atrial and His bundle stimulation demonstrated a left troncular delay with a distal block in the right bundle branch. Thirteen patients had infra His block represented by a long H-V interval (greater than 60 ms). We conclude that His bundle electrograms and stimulation is a low risk procedure very useful in the topographic diagnosis of A-V conduction disturbances.

[Usefulness of electrophysiologic studies. Report of 224 cases]

Two hundred and twenty four electrophysiologic studies were performed in 194 patients during a two-year period. One hundred and six (54.6%) had tachyarrhythmias: 21 had atrial tachycardia, 28 had the Wolff-Parkinson-White syndrome. Of 51 patients with a normal electrocardiogram a concealed left Kent bundle was observed in 21 cases and only one concealed right Kent bundle; functional James fibers were seen in 7 patients and Mahaim fibers in two. In 15 patients A-V nodal reentry was diagnosed and functional ectopy was observed in 5 patients. The sick-sinus-syndrome was seen in 24 patients and atrial arrest in three. Thirty patients underwent a second electrophysiologic study to evaluate proper antiarrhythmic therapy. Atrioventricular conduction was evaluated in 52 patients. A "suprahisian" delay was found in 34%, troncular lesions were diagnosed in 31%, a distal delay in 25% and mixed conduction disturbances in 10%. We conclude that electrophysiologic studies are a useful procedure to: 1) establish the etiologic diagnosis of tachyarrhythmias; 2) evaluate their potential danger; 3) objectively evaluate antiarrythmic therapy; 4) establish the need for surgical treatment; 5) give the topographic diagnosis and severity of A-V conduction disturbances and 6) indicate the need for definitive pacemaker implant.

Transient neurologic disturbances, brain tumors, and normal computed tomography scans

During a 4-year period, four patients presented with transient disturbances in neurologic function that were diagnosed as seizures in two and transient ischemic attacks in the other two. Computed tomography (CT scan), both with and without contrast, was normal in all four patients. Isotopic brain scans (3 patients), cerebral angiograms (4 patients), and lumbar punctures (4 patients) were normal. Electroencephalograms (EEG) were normal in two patients and abnormal in two patients (consisting of focal slowing). Within 4.5 months, all patients developed symptoms and signs of a brain tumor, and in all four, CT scan now revealed a large mass lesion which at surgery was shown to be a malignant astrocytoma. These four patients constituted 4% of the total number of patients with malignant astrocytomas that were seen at the NYU Medical Center during this same time period. It is stressed that the CT scan may be normal early in the course of patients with brain tumors, particularly if they present with a transient disturbance in neurologic function. The first evidence of the tumor in such patients may be a slow-wave abnormality on the EEG. Patients who are suspected of having a brain tumor should, if the initial CT scan is normal, have the scan repeated later.

[Changes in colloido-osmotic pressure in patients on extracorporeal circulation]

Changes in colloidosmotic pressure (COP) were observed in 15 patients submitted to hemodilution for extracorporeal circulation. Preoperative laboratory tests were within normal limits. COP before hemodilution was above 15 mmHg in 14 cases and 12.6 mmHg in one 9-month-old patient, the mean CP was 18.17 mmHg. During extracorporeal circulation the mean COP decreased to 55% of its initial value (9.92 mmHg). Within the first 4 hrs of the postoperative recovery 13 had COP over 11 mmHg; the remaining two died of cardiorespiratory failure with a COP of less than 7 mmHg. One patient that recovered 100% of its initial COP value between 20 and 24 hrs of the postoperative period had his COP decreased to 6 mmHg and developed fatal pulmonary edema. One patient -who died acute bleeding did not diminish his COP under 12.5 mm Hg. We can conclude that COP lower than 10 mmHg can produce fatal cardiorespiratory failure. Extracorporeal circulation time does not influence the COP recovery. Acute bleeding does not diminish COP values. Hemodilution significantly reduces COP; its recovery and stabilization over 11 mmHg are of prognostic value. COP monitoring is a simple and useful method.

[Amiodarone in the control of supraventricular tachyarrhythmias]

The clinical efficacy of amiodarone was observed in a group of 20 patients (9 women and 11 men) with a total 21 supraventricular tachyarrhythmias (16 paroxysms or premature supraventricular beats (PSB) and 5 with established arrhythmias), to whom amiodarone was given during one month: 800 mg/day the first week and 400 mg/day for 3 weeks. An electrocardiogram and a 24 hour Holter were taken before and after treatment. The results observed for paroxysmal arrhytmias and PSB were excellent in 94% and satisfactory in one patient. As for established arrhythmias the results were excellent or satisfactory in 80%. We conclude that ammiodarone is an effective drug with a wide security range in the treatment of supraventricular arrhythmias.

[Diffuse gastric pseudolymphoma or reactive lymphoid hyperplasia (RLH). Apropos of a case]

The authors report a case of superficial diffuse gastric pseudolymphoma studied by double contrast examination induced by pharmacologic agents and full filling of the stomach after compressive manoeuvres. The authors emphasize the importance of this nosologic entity and the problems of differentials diagnosis with all the stages of gastric cancer, with the peptic ulcer, with the healed ulcer, with lymphomas, with erosive gastritis, with nodular benign lesions. The stress that the certitude of diagnosis is given only by the histologic examination.

The totally occluded internal carotid artery. Preliminary observations using rapid sequential computerized tomographic scanning

Cerebral angiography often cannot distinguish between complete thrombosis or fibrosis of the internal carotid artery (ICA) and nonvisualization due to a total occlusion of the common carotid or origin of the ICA. Whereas surgery may be beneficial if the distal carotid is patent (type 1), thromboendarterectomy may be contraindicated if thrombus or fibrosis extend to the intracranial branches (type 2). Rapid sequential computerized tomography (RSCT) was used to examine 15 patients whose ICAs appeared occluded by angiography. Of four ICAs classed as type 1 by RSCT, three were found to be patent during surgical exploration, and carotid reconstruction was successfully performed. Three other ICAs classed as type 2 by RSCT were also surgically explored, and complete thrombosis was confirmed. The RSCT technique provides an effective and nonoperative means of determining whether a nonvisualized ICA is reconstructible.