Non-confluent pulmonary arteries in a patient with pulmonary atresia and intact ventricular septum: ? A 5th aortic arch with a systemic-to-pulmonary arterial connection

Major abnormalities of pulmonary circulation are uncommon in the patient with pulmonary atresia and intact ventricular septum. Non-confluent pulmonary arteries have only rarely been described in this setting. In this case report, we describe a patient in whom the pulmonary arteries are non-confluent, with the right pulmonary artery supplied through a right-sided arterial duct, and the left pulmonary artery most likely through a fifth aortic arch, thus providing a systemic-to-pulmonary arterial connection. We discuss the various forms of non-confluent pulmonary arteries in the setting of pulmonary atresia and intact ventricular septum.

Maternity advice survey: sleeping position in Eastern Europe. MAS Study Group for WHO EURO region

AIM

To identify hospitals in Eastern Europe promoting front infant sleeping position.

METHODS

Questionnaires were distributed to maternity units in 22 countries during July to November 1999.

RESULTS

A total of 489 hospitals in 20 countries responded. Preferred position in normal care units was back (26.6%), front (1. 8%), side (65%), or combination/none (6.6%). Corresponding recommendations at discharge were 17.4%, 3.5%, 73%, and 6.1%.

[Permanent central venous catheters for dialysis. The situation in Piedmont-Aosta Valley]

BACKGROUND

Permanent central venous catheters for hemodialysis have become increasingly important as vascular accesses for extracorporeal dialysis. The aim of this study was to evaluate the prevalence and various aspects of these catheters in the chronic dialysis population in Piedmont and Aosta Valley on 30-6-1998 using a multiple-choice questionnaire.

METHODS

A total of 2389 patients were receiving chronic hemodialysis. Permanent central venous catheters were present in 6.2% of the population (149 patients), arteriovenous fistulas in 83.1%, vascular prostheses in 9.3% and temporary catheters in 1.4%. The site chosen for permanent catheters was the internal jugular vein in 88.6% of cases, the subclavian vein in 8.7% of cases and the femoral vein in 2.7% of cases. The double catheter is the most frequently used. In 76% of centres catheters are positioned by nephrologists. Thrombosis prophylaxis is performed in 98% of cases with heparin and the most frequently used disinfectant to dress the cutaneous exit is iodopovidone.

RESULTS

This study highlights the important role played by permanent catheters. The double catheter was used in 64.4% of the entire population, confirming the greater efficiency of these catheters as reported in the literature. Operating autonomy is relative in 76.2% of centres where catheters are positioned by nephrologists who often use the collaboration of other specialists.

CONCLUSIONS

The authors stress the need to reflect on the use of iodopovidone is to dress the cutaneous exit of catheters since this disinfectant is contraindicated by one of the largest manufacturers of silicone catheters owing to its harmful medium long-term effects.

The usefulness of conventional and echo colour Doppler sonography in the differential diagnosis of toxic multinodular goitres

OBJECTIVE

To assess the potential role of conventional sonography and colour flow Doppler (CFD) sonography (CFDS) in the differential diagnosis of toxic multinodular goitres.

SUBJECTS AND METHODS

We investigated 55 patients with untreated hyperthyroidism (24 with typical toxic diffuse goitre of Graves' disease (Group A); 26 with multinodular goitre (Group B); and five with single toxic adenoma (Group C); 22 euthyroid subjects (12 with non-toxic multinodular goitre (Group D) and ten normal subjects (Group E)) were included as controls. In all cases free thyroxine, free tri-iodothyronine, TSH, TSH receptor antibodies (TRAb), anti-thyroperoxidase antibody, anti-thyroglobulin antibodies and anti-thyroid microsomal antibodies were determined and a [(99m)Tc]pertechnetate thyroid scan was performed.

RESULTS

Patients with toxic multinodular goitre displayed two different CFDS patterns: 18 patients (Group B-1) had nodules with normal vascularity surrounded by diffuse parenchymal hypoechogenicity with markedly increased CFD signal and maximal peak systolic velocity (PSV) (a pattern similar to Group A patients with Graves' disease); eight patients (Group B-2) had increased intra- and perinodular CFD signal and PSV with normal extranodular vascularity (a pattern similar to that found in Group C patients with single toxic adenoma). Patients of Group B-1 showed a proportion of clinically evident thyroid ophthalmopathy, positive TRAb and other thyroid autoantibodies similar to that observed in Group A patients, while no evidence of thyroid autoimmunity was found in Group B-2. Sixteen out of 18 (89%) patients from Group B-1 displayed a scintiscan pattern of diffuse uneven radionuclide distribution, while seven out of eight (87.5%) of those from Group B-2 had localized uptake in multiple discrete nodules. Taken together, these data strongly suggest that Group B-1 mostly represents patients with the multinodular variant of Graves' disease, while Group B-2 represents patients with non-autoimmune toxic multinodular goitre.

CONCLUSIONS

This study shows that combined conventional sonography and CFDS may easily distinguish nodular variants of Graves' disease from non-autoimmune forms of toxic multinodular goitre and confirms the clinical usefulness of this technique in the first-line evaluation of hyperthyroid patients.

Assessment of peripheral blood lymphocyte subsets in idiopathic myelofibrosis

The objective of this study was to contribute to a better characterization of the immunological profile of idiopathic myelofibrosis (IM) at presentation by analysing the blood lymphocyte subsets and their possible correlations with other disease features. Absolute blood lymphocytes and lymphocyte subsets were assessed in 31 IM patients, compared with those from 34 healthy individuals, and correlated with the patients' main clinical, hematological and bone marrow histologic features. The mean lymphocyte count of the IM patients was 1.1 (SD 0.6) x 10(9)/L, versus 1.6 (SD 0.49) x 10(9)/L in controls (p = 0.0006), with 24 of the 31 patients (77.4%) showing lymphocytopenia (< 1.5 x 10(9)/L). IM patients had significantly lower counts of CD3, CD4, CD8, and CD3 -/ CD56+ cells, and significantly higher CD3 +/CD56 + lymphocyte counts. Although no significant differences were found between patients and controls with regard to CD19+/CD5+ cell counts, increased CD5 + B-cell lymphocytes were observed in three IM patients. In one of the latter patients, Ig gene rearrangement analysis of the heavy chain gene demonstrated such a subpopulation to be clonal, but the patient did not develop features of chronic lymphoid leukemia during a 5-yr follow-up. No correlation was found between the patients' blood lymphocyte counts and other disease features. We conclude that most IM patients have absolute lymphopenia, decreased T cells and increased cytotoxic T cells at diagnosis, and 10% of them show an increased CD5 + B-cell subpopulation.

A longitudinal study of T1 hypointense lesions in relapsing MS: MSCRG trial of interferon beta-1a. Multiple Sclerosis Collaborative Research Group

BACKGROUND

T1 hypointense lesions (T1 black holes) are focal areas of relatively severe CNS tissue damage detected by MRI in patients with MS.

OBJECTIVE

To determine the natural history of T1 hypointense lesions in relapsing MS and the utility of T1 hypointense lesions as outcome measures in MS clinical trials.

METHODS

MR studies were from the Multiple Sclerosis Collaborative Research Group trial. Longitudinal results are reported in 80 placebo- and 80 interferon beta-1a (IFNbeta-1a)-treated patients with mild to moderate disability relapsing-remitting MS.

RESULTS

There was a small but significant correlation between T1 hypointense lesion volume and disability at baseline and on trial (r = 0.22, r = 0.28). In placebo patients there was a 29.2% increase in the mean volume of T1 hypointense lesions (median 124.5 mm3) over 2 years (p < 0.001 for change from baseline), as compared to an 11.8% increase (median 40 mm3) in the IFNbeta-1a-treated patients (change from baseline not significant). These treatment group comparisons did not quite reach significance. The most significant contributor to change in T1 hypointense lesions was the baseline number of enhancing lesions (model r2 = 0.554). Placebo patients with more active disease, defined by enhancing lesions at baseline, were the only group to show a significant increase in T1 hypointense lesion volume from baseline.

CONCLUSION

The development of T1 hypointense lesions is strongly influenced by prior inflammatory disease activity, as indicated by enhancing lesions. These results suggest that treatment with once weekly IM IFNbeta-1a (30 mcg) slows the 2-year accumulation of these lesions in the brain.

Tracheostomy care

The author considers airway maintenance in the care of adult patients by providing a clinical overview of the pre- and post-operative requirements of tracheostomy care, including complications and the longer term implications that can arise immediately after tracheostomy surgery.

[Crossed aphasia: description of a case]

We describe a new case of crossed aphasia in a right-handed patient with a right hemispheric lesion. A right-handed man, 76 year-old, developed a sudden left hemiparesis with sensitive impairment and mutism. He has neither family history of left handeness or ambidexterity or vascular risk factors. CT cerebral scan showed a large infarct of the middle cerebral artery on the right side, with haemorrhagic suffusion. Cerebral MRI and EEG-cartography confirmed the indemnity of the left hemisphere. Aphasia studies confirmed a mutism with spared verbal comprehension, but alexia was present. A year later, left hemiparesis was recovered but aphasia remained. Crossed aphasia is rarely seen. It is caused by a right hemispheric lesion in right-handed subjects. Fluency is most commonly impaired. At onset, mutism is the common symptom, which evolves to expressive aphasia. Several hypothesis have been raised about the possible mechanisms involved. The few number of PET or SPECT studies performed in these patients have disclosed extensive areas of hypometabolism in the right hemisphere, that exceed the size of the image observed with CT scan or MRI.

[Growth hormone deficiency. Treatment with growth hormone and body composition]

Increased fat mass, decreased lean mass, muscular mass and bone mineral density are characteristic of the body composition in GH deficiency, GH treatment reverses these abnormalities. Body composition was determined in 20 young adults with GHD diagnosed in childhood, whose GH treatment was stopped 1 year earlier. Reevaluation of GH secretion in these patients showed that 12 remained GH deficient (confirmed GHD) while eight recovered normal GH secretion (transient GHD). One year after stopping the GH treatment, patients with confirmed GHD showed an increased fat mass as compared with value at the end of the treatment; in addition a decreased bone mineral content was observed in the patients with low physical activity. There was no increased fat mass in transient GHD; however, these patients presented with low bone mineral content, as previously reported in adults with history of delayed growth and adolescence.

Auditory brainstem response in postmenopausal women treated with hormone replacement therapy: a pilot study

OBJECTIVE

To research the nongenital audiological target for gonadal steroids in postmenopausal women who are treated with hormone replacement therapy.

DESIGN

Fifty postmenopausal volunteers were treated with hormone replacement therapy. Women with an intact uterus had sequential weekly transdermal estradiol plus nomegestrole acetate 5 mg orally for 12 days per month or a continuous daily oral dose of conjugated estrogen 0.625 mg and medroxyprogesterone acetate 5 mg tablet. Eighteen surgically postmenopausal women received a weekly transdermal estradiol system. Twenty-five postmenopausal volunteers-5 with a natural menopause and 10 with a surgical menopause-and 20 premenopausal normally cycling women were used as a control group. Each woman performed auditory brainstem response by auditory-evoked potentials for waves I, III, and V and for interpeak I-III, I-V, and III-V intervals.

RESULTS

Women who were treated with hormone replacement therapy showed wave latencies and interpeak latencies shorter than those for postmenopausal women in the control group (p < or = 0.05), overlapping those of the premenopausal women (p > 0.05). Women who were treated with estrogen replacement therapy showed shorter time latencies than those treated with combined hormone replacement therapy (p < or = 0.05).

CONCLUSIONS

Our data suggest that fluctuating hormone levels cause changes in auditory brain-stem response waves, even if the exact mechanism of activity of the gonadal steroids is not clear. However, we believe that estrogen may influence the neuronal plasticity, the metabolic levels of neurotransmitters, and thus the neuronal conduction time into the audiological system.

[Calcifications from cardiac etiology in chest radiography]

OBJECTIVE: Children s chest X-ray calcification images can be related to pulmonary, mediastinal and rarely cardiac parenchymatous pathology. This report describes cases of cardio thoracic calcifications. We emphasize the importance of chest X-ray to track thoracic calcifications. In spite of the fact that it is rare, the cardiac etiology must be considered due to the possibility of surgical treatment.METHODS: Regarding the period from 1988 to 1997 the authors reviewed the chest X-rays of 2108 patients. In 3 of them thoracic calcifications of cardiac etiology were observed.RESULTS: Of these three patients, two were 7 years old and the third was 3 years old. Case 1 presented a calcification in the right atrium topography caused by a heart tumor of Fibroma type. In case 2 the calcification was in the pulmonary trunk, presenting as a calcified aneurysm of the ductus arteriosus. In case 3 the child had pulmonary stenosis and the chest X-ray showed a calcified image on the left cardiac boards caused by a thrombo in the right ventricle wall.CONCLUSION: The authors emphasize the importance of chest X-ray in the diagnosis of thoracic calcifications, and comment that in spite of the being rare, the cardiac causes should be considered due to the possibility of surgical treatment.

A common beta ig-h3 gene mutation (delta f540) in a large cohort of Sardinian Reis Bücklers corneal dystrophy patients. Mutations in brief no. 180. Online

Reis-Bücklers' corneal dystrophy (RBCD) is a relatively rare autosomal dominant disease originating in the Bowman's membrane, which causes severe visual impairment. Recently RBCD, together with lattice corneal dystrophy type I (LCDI), granular corneal dystrophy (CDGG1) and Avellino stromal dystrophy (ASD), all mapped on 5q31, were found to be associated to four different mutations in the beta ig-h3 gene which codify for kerato-epithelin. We identified several cases of RBCD in Sardinia. We reconstructed through genealogical search two eight generation-families, originating from the same village (Arbus), indicating a common ancestor for RBCD in Sardinia. Linkage studies on these families confirmed the association of the disease with the 5q31 region. Sequence analysis of beta ig-h3 gene revealed a trinucleotide deletion in exon 12, corresponding to the loss of F540 in the protein sequence (delta F540). Our data describe a new mutation in the beta ig-h3 gene causing RBCD. This dominant negative mutation is located in the fourth internal repeat of kerato-epithelin which is a protein domain highly conserved across species. This suggests the basic role of this domain in maintaining the proper kerato-epithelin structure which when altered can cause the typical precipitates in the RBCD cornea.

Important role of carotid chemoreceptor afferents in control of breathing of adult and neonatal mammals

This review provides a summary and prospective on the importance of carotid/peripheral chemoreceptors to the control of breathing during physiologic conditions. For several days after carotid body denervation (CBD), adult mammals hypoventilate (+10 mmHg increase in Pa(CO(2))) at rest and during exercise and CO(2) sensitivity is attenuated by about 60%. In addition, if the rostral ventrolateral medulla is cooled during NREM sleep after CBD, a sustained apnea is observed. Eventually, days or weeks after CBD, a peripheral ventilatory chemoreflex redevelops and there is a normalization of breathing (rest and exercise) and CO(2) sensitivity. The site (s) of the regained chemosensitivity has not been established. This plasticity/redundancy after CBD appears greater in neonates than in adult mammals. These data suggest the carotid and other peripheral chemoreceptors provide an important excitatory input to medullary respiratory neurons that is essential for breathing when wakeful stimuli and central chemoreceptors are absent.

Endoscopic revision of failed external dacryocystorhinostomy

Obstruction of the lacrimal pathways is a relatively frequent problem usually corrected by external dacryocystorhinostomy. Failure of the external approach may be due to an inadequate rhinostomy, excessive scar tissue production, anatomical anomalies or concomitant paranasal sinus infectious. The introduction of direct and angled endoscopes for paranasal sinus surgery and the refinement of endoscopic surgical procedures allows a complete intranasal exposure and surgical management of the lacrimal sac, even in cases of recurrent obstruction. The present work offers a retrospective review of the records of seven patients who underwent a revision endoscopic dacriocystorhinostomy (ENDCR) between January 1994 and June 1997 for failed external dacryocystorhinostomy. The preoperative evaluation of the patients, the surgical technique and the postoperative management are examined in detail. A permanent dacryocystorhinostomy was obtained in six patients. One patient underwent a successful bilateral procedure. One patient experienced a persistent stenosis. There were no complications related to the surgical procedure. In our experience the revision endoscopic dacryocystorhinostomy offered several advantages, including a complete exposure of those anatomical anomalies or inflammatory changes of the normal structures that commonly hinder conventional external surgery. Although a larger series will further elucidate the efficacy of this procedure in failed external dacryocystorhinostomy, we recommend considering revision ENDCR as an alternative to the external revision technique.

[Clonidine hallucinations: description of a clinical case]

Authors report a case of hallucinations related to clonidine treatment in an elderly man with hypertension and renal failure. The symptoms appeared shortly after treatment is starting. The hallucinations disappeared after clonidine withdrawal. Implications for clinical practice are evocated.

Effects on breathing of carotid body denervation in neonatal piglets

The purpose of these studies was to test the hypothesis that carotid chemoreceptor activity is necessary for postnatal maturation of the ventilatory control system. By using a lateral surgical access, 17 piglets were carotid body denervated (CBD) and 14 were sham denervated at 3-25 days of age. After surgery, there was no irregular breathing in any group. There was no significant hypoventilation when CBD was performed at less than 5 days of age (n = 5) and only a mild (arterial PCO(2) 5 Torr; P < 0.05) to moderate, transient (arterial PCO(2) 8 Torr; P < 0.5) hypoventilation in piglets denervated at 10-15 (n = 6) and 20-25 (n = 6) days of age, respectively. Three weeks after surgery, both breathing of a hypoxic gas mixture and jugular venous NaCN injections elicited a hyperpnea in the CBD piglets that was attenuated compared with that in sham CBD piglets. In the CBD piglets, there was no response to injections of NaCN in the carotid arteries, but there was a response to NaCN injected into the proximal descending aorta, suggesting the residual peripheral chemosensitivity was of aortic origin. Carotid chemoreceptor-intact piglets had carotid and aortic NaCN chemosensitivity by 2 days of age. The carotid response persisted for the 40 days of the study, but the aortic reflex persisted only until approximately 8 days of age. We conclude that 1) the major effect of CBD per se in neonatal piglets is age-dependent hypoventilation and 2) there is a high degree of plasticity in peripheral chemosensitivity in neonates that may contribute to minimizing the changes in breathing after CBD.

Normal and altered cytoarchitecture of the inner ear

Scanning electron microscope gave new insights into real morphology of the inner ear and has enhanced basic research. In fact, during the last twenty years, the cellular system that composes the organ of Corti and the vestibular apparatus has been clearly described by many authors. We now have a better understanding of each cell type and that they have a physiological functioning as ear and vestibular system. In addition, new insights into the damage caused by many drugs, such as aminoglucosides, can be investigated by studying the morphological changes and the reparative process following the injury. Animals such as guinea pigs can be used as ideal models to investigate the alterations in the sensory epithelium of the cochlear and vestibular receptors following ototoxic poisoning.

Randomized comparison of coronary stent implantation and balloon angioplasty in the treatment of de novo coronary artery lesions (START): a four-year follow-up

OBJECTIVE

The purpose of this study was to test the hypothesis that stent implantation in de novo coronary artery lesions would result in lower restenosis rates and better long-term clinical outcomes than balloon angioplasty.

BACKGROUND

Placement of an intracoronary stent, as compared with balloon angioplasty, has proven to reduce the rate of restenosis. However, the long-term clinical benefit of stenting over angioplasty has not been assessed in large randomized trials.

METHODS

We randomly assigned 452 patients with either stable (129 patients) or unstable (323 patients) angina pectoris to elective stent implantation (229 patients) or standard balloon angioplasty (223 patients). Coronary angiography was performed at baseline, immediately after the procedure and six months later. End points were the rate of restenosis at six months and a composite of death, myocardial infarction (MI) and target vessel revascularization over four years of follow-up.

RESULTS

Procedural success rate was achieved in 84% and 95% (balloon angioplasty vs. stent, respectively). The increase in the minimal luminal diameter was greater in the stent group both after the intervention (2.02 +/- 0.6 mm vs. 1.43 +/- 0.6 mm in the angioplasty group; p < 0.0001), and at six-month follow-up (1.98 +/- 0.7 mm vs. 1.63 +/- 0.7 mm; p < 0.001). The corresponding restenosis rates were 22% and 37%, respectively (p < 0.002). After four years, no differences in mortality (2.7% vs. 2.4%) and nonfatal MI (2.2% vs. 2.8%) were found between the stent and the angioplasty groups, respectively. However, the requirement for further revascularization procedures of the target lesions was significantly reduced in the stent group (12% vs. 25% in the angioplasty group; relative risk 0.49, 95% confidence interval 0.32 to 0.75, p = 0.0006); most of the repeat procedures (84%) were carried out within six months of entry into the study.

CONCLUSIONS

Patients who received an intracoronary stent showed a lower rate of restenosis than those treated with conventional balloon angioplasty. The benefit of stenting was maintained four years after implantation, as manifested by a significant reduction in the need for repeat revascularization.

Tyrosine kinase-dependent ubiquitination of CD16 zeta subunit in human NK cells following receptor engagement

We investigated whether aggregation of the low-affinity immunoglobulin G receptor (CD16) on human NK cells results in receptor ubiquitination. We found that the CD16 zeta subunit becomes ubiquitinated in response to receptor engagement. We then investigated whether protein tyrosine kinase (PTK) activation is required for CD16-mediated receptor ubiquitination. Pretreatment with the PTK inhibitor genistein substantially decreased ligand-induced zeta ubiquitination, suggesting a requirement for PTK activation in receptor ubiquitination. We further analyzed PTK involvement in controlling receptor ubiquitination by using the vaccinia virus expression system. Overexpression of wild-type active lck, but not a kinase-deficient mutant, enhanced both ligand-induced tyrosine phosphorylation and ubiquitination of the CD16 zeta subunit. Taken together, our data demonstrate that CD16 engagement induces zeta chain ubiquitination and strongly suggest a role for lck in regulating this modification.