Endovascular treatment of acutely ruptured and unruptured aneurysms of the basilar bifurcation

The surgical treatment of basilar bifurcation aneurysms is difficult and the need for an alternative approach is frequently stated. To assess the efficacy and safety of endovascular treatment of aneurysms located at the basilar bifurcation, the authors prospectively studied angiographic results, clinical results, and complications in 31 patients treated with Guglielmi detachable coils (GDCs). Patients treated acutely after subarachnoid hemorrhage (SAH) were graded according to the Hunt and Hess classification and clinical outcome was determined at 1- and 6-month intervals according to the Glasgow Outcome Scale (GOS). There were 18 women and 13 men, ranging in age from 34 to 67 years (mean age 48 years). Twenty-three were treated acutely after SAH. Clinical Hunt and Hess grades at presentation were as follows: Grade I, six patients; Grade II, three; Grade III, 11; Grade IV, two; and Grade V, one. The GOS score for the group of patients treated acutely was: GOS I, 18 patients; GOS II, III, and IV, one patient each; and GOS V, two patients. There were seven technical complications in this group, most often asymptomatic, but one patient died after aneurysm rupture during treatment and one had residual diplopia at 4 months. Eight patients were treated for incidental basilar bifurcation aneurysms. One technical complication with no neurological deficit occurred in this group of patients with incidental aneurysms. Immediate angiographic results were considered to be satisfactory in 94% of patients, with complete obliteration in 42% and residual neck and dog ears in 52%. There was no bleeding episode after treatment during clinical follow-up periods ranging from 3 to 42 months (mean 15.5 months in 29 surviving patients). Angiographic results were available for 27 patients at 6 months and were as follows: 30% of the lesions were completely obliterated, 59% presented some residual neck, and 11% showed some opacification of the aneurysm sac. During the follow-up period of up to 42 months, a total of seven recurrences were noted, necessitating retreatment with GDCs in five patients. Endovascular treatment of basilar bifurcation aneurysms prevented rebleeding and could be performed without clinically significant complications in 94% of patients. Clinical results after SAH compared favorably with surgical series. Morphological results appear less satisfactory, and long-term angiographic follow-up review is mandatory to detect recurrences.

In-vitro bactericidal activity of cefpirome in combination with vancomycin against Staphylococcus aureus and coagulase-negative staphylococci

In an in-vitro study of the bactericidal activity of cefpirome in combination with vancomycin against 11 clinical isolates of staphylococci, cefpirome at a concentration of 0.25 times the MIC acted synergistically with vancomycin (at a concentration of 0.5, 1 or 2 times the MIC) against Staphylococcus aureus and coagulase-negative staphylococci susceptible or resistant to methicillin. Moreover, increasing the cefpirome concentration to 0.5 or 1 times the MIC combined with vancomycin at the same concentration (0.5 or 1 times the MIC) improved the bacterial killing rate; a bactericidal effect was obtained in 9 or 24 h instead of in 24 or 48 h, respectively.

[Pneumococcal meningitis resistant to penicillin and nosocomial transmission in pediatric hospitals confirmed by genomic analysis]

BACKGROUND

Careful epidemiological studies and sophisticated diagnostic procedures are necessary to prove that bacterial infection is nosocomial in origin. DNA finger printing method can be useful with this aim in view.

CASE REPORTS

A 11 month-old girl suffered from a febrile pneumonia. She developed acute meningitis 15 days later; culture of CSF grew Streptococcus pneumoniae, serotype 23 F, resistant to beta-lactamines, erythromycin and cotrimoxazole. She died 24 hours later. Five days after this death, a 5 month-old infant hospitalized in the next bed developed an acute pulmonary infection due to the same strain with the same bacterial characteristics; this patient was cured with cefotaxime plus vancomycin and gentamicin. Randomly amplified polymorphic DNA analysis showed an identical profile of both strains.

CONCLUSION

This is the first case of meningitis due to penicillin-resistant Streptococcus pneumoniae (PRSP) associated with nosocomial spread between two children in adjacent beds. This case suggests that it is necessary to isolate patients with PRSP infection during hospitalization.

Genotyping of Helicobacter pylori isolates by sequencing of PCR products and comparison with the RAPD technique

Two genotyping methods were performed on bacterial suspensions of the human pathogen Helicobacter pylori. A total of 29 clinical isolates were analysed by sequencing of a 294-bp PCR-derived internal segment of the essential ureC/glmM gene of H. pylori, and by random amplified polymorphic DNA (RAPD) using a single 11-bp oligonucleotide made up of an arbitrary nucleotide sequence. Each isolate exhibited a distinct sequence over a 210-bp stretch of the ureC/glmM gene. Similarly, the isolates bore different profiles when tested by RAPD fingerprinting. Successive strains arising from patients who relapsed following antibiotic treatment and strains isolated from two patients institutionalized in the same care centre had identical ureC/glmM gene sequences and RAPD profiles. Both methods were found to be discriminatory. However, PCR sequencing of the ureC/glmM gene appeared to be more reproducible and more reliable for distinguishing between strains than the RAPD technique.

Glucocorticoid increases rat apolipoprotein A-I promoter activity

The observation that glucocorticoids increase the abundance of apolipoprotein A-I led us to a search for potential underlying mechanism(s). In this report, we show that the synthetic glucocorticoid, dexamethasone, injected into rats increases serum levels of apoA-I protein, hepatic mRNA and "run-on' transcription of the gene by 3-, 5-, and 2-fold, respectively. Results of transient transfection studies of the rat apoA-I promoter reveal that effects of dexamethasone are mediated by a cis-acting site B (-170 to -145). Dexamethasone treatment of hepatoma cells enhances the DNA binding activity of nuclear factors that bind this site. Unexpectedly, site B does not contain a consensus glucocorticoid receptor recognition motif nor binds to bacterially expressed glucocorticoid receptor. These results indicate that the actions of glucocorticoids on site B involve indirect mechanisms. Site B is comprised of a direct repeat of a nonanucleotide and mutation of either one abolishes the effect of glucocorticoid. Additionally, the transcriptional activity of site B in response to dexamethasone is amplified by a 5' sequence called site S (-186 to -171). Dexamethasone has no effect on site S in the absence of site B. In summary, our data show that dexamethasone increases rat apoA-I gene expression by an indirect mechanism.

Serum alpha-interferon in lower respiratory tract infections of children

BACKGROUND

Serum alpha-interferon (IFN-alpha) concentrations are high in some children with viral meningitis and other viral infections. We have tried to assess the utility of determining serum IFN-alpha concentrations as a marker of acute viral respiratory infections.

METHODS

Measurement of IFN-alpha via a biologic assay on Madin-Darby bovine kidney cells was performed in 138 patients with lower respiratory tract infection in whom a pathogen was identified.

RESULTS

Serum IFN-alpha was detectable at the early stage of respiratory infections in the era of 59 of 75 (78.7%) of patients with a viral infection and in 4 of 63 (6.3%) of those with bacterial infection (P < 0.001). In the 4 patients with positive IFN-alpha and bacterial infection, a concomitant viral infection was found. The production of IFN-alpha is independent of age, and detectable levels are found in young infants, including the first 3 months of life, and in children with an acute viral disease.

CONCLUSION

This test could be useful in distinguishing between bacterial and viral origins in lower respiratory tract infection (the specificity was 94% and the sensitivity was 79%) and could help guide the use of antibiotics, but more rapid techniques, available in a matter of hours, are required.

Metabolic stress opens K+ channels in hepatoma cells through a Ca2+- and protein kinase calpha-dependent mechanism

These studies of a model liver cell line evaluate the mechanisms responsible for regulated release of K+ ions during metabolic stress. Metabolic inhibition of HTC hepatoma cells by exposure to 2, 4-dinitrophenol (50 microM) and 2-deoxy-D-glucose (10 mM) stimulated outward currents carried by K+ of 974 +/- 75 pA at 0 mV (n = 20, p < 0.001). Currents were inhibited by chelation of intracellular Ca2+ or exposure to apamin (50 nM), an inhibitor of SKCa channels. In cell-attached recordings from intact cells, removal of metabolic substrates (25/28 cells) or exposure to metabolic inhibitors (32/40 cells) opened K+-selective channels with a conductance of 6.5 +/- 0. 2 pS. Channels had an open probability of 0.31 +/- 0.08 and opened in bursts averaging 3.55 +/- 0.27 ms in duration (n = 6). Metabolic stress was associated with rapid translocation of the alpha isoform of protein kinase C (PKCalpha) from cytosol to membrane; and down-regulation of PKCalpha by phorbol esters or exposure to the PKC inhibitor chelerythrine (10 microM) each inhibited currents. Moreover, intracellular perfusion with purified PKCalpha activated currents in a Ca2+- and concentration-dependent manner. These findings indicate that metabolic stress leads to opening of apamin-sensitive SKCa channels in hepatoma cells through a Ca2+- and PKC-dependent mechanism and suggest that PKCalpha may be selectively involved in the response. This mechanism functionally couples the metabolic state of cells to membrane K+ permeability and represents a potential target for modification of liver injury associated with ischemia and preservation.

Responses to opposed directions of motion: continuum or independent mechanisms?

Opponency between opposite directions of motion is a characteristic of many models of movement detection and is commonly invoked in explanations of the motion after-effect. If detection of opposite directions is mediated by a single mechanism, then a single, smooth psychometric function for the discrimination of global direction in random-dot kinematograms should be found as a function of the percent of directional coherence of dots in the display, ranging from 100% coherence leftwards through 0% coherence to 100% coherence rightwards. Moreover, after rightward motion adaptation, a single psychometric function should still be observed if adaptation affects the perceptual system prior to opponent interactions. If, however, leftward and rightward detectors operate independently, then the slopes of the leftward and rightward halves of the function may differ, particularly after unidirectional adaptation. We measured the probability of a "rightward" direction response for nine values of motion coherence for five observers with and without prior rightward motion adaptation. Although a smooth psychometric function was found without motion adaptation, after adaptation, the rightward half of the psychometric function was flattened whereas the leftward half remained unchanged. Such results indicate that movement direction analysers operate in a non-opponent manner.

Identification of functional positive and negative thyroid hormone-responsive elements in the rat apolipoprotein AI promoter

Transcription of the antiatherogenic protein apolipoprotein AI is regulated by the thyroid hormone, L-triiodothyronine. Transient transfection and electrophoretic mobility shift assays were used to identify the cis-acting elements involved. In transient transfection assays, hormone bound to either thyroid hormone receptor alpha or beta exerts a positive effect through a thyroid hormone response element, site A (-208 to -193). In the absence of site A, liganded receptor alpha or beta have a negative effect on promoter activity. This negative effect is mediated by a 40 bp fragment spanning nucleotides -46 to -7. Closer examination of this region of the gene shows there to be a negative thyroid hormone response element at position -25 to -20 which is fused to the 3' end of the TATA element. Electrophoretic mobility shift assays show that bacterially expressed chicken or rat thyroid hormone receptor alpha 1 binds to site A, either as a homodimer or as a heterodimer with the human 9-cis-retinoic acid receptor alpha. In contrast, the negative thyroid hormone responsive element binds chicken thyroid hormone receptor alpha exclusively as a monomer. Site-directed mutagenesis of the negative thyroid hormone response element abolished the inhibitory effects of the hormone and increased basal promoter activity by up to 40-fold. These data suggest that functional positive and negative thyroid hormone response elements coexist within the rat apolipoprotein AI promoter and both elements contribute to the control of apolipoprotein AI gene expression.

[Community-acquired pneumonia in children: importance of Mycoplasma pneumoniae infections and efficacy of antibiotics]

OBJECTIVES

Define a therapeutic management schema adapted to children with community-acquired pneumonia.

METHODS

A prospective survey was conducted in 104 children over 18 months of age with community-acquired pneumonia. The pathogen was isolated in 85% of the cases.

RESULTS

Viral infection alone was proven in 30 children (respiratory syncytial virus in 10). Pneumococci pneumonia was found in 12 patients; the isolated strains were sensitive to penicillin. Apyrexia was obtained in 11/12 cases with amoxicillin. Mycoplasma infections occurred in 42% of the cases (41 alone and in association with pneumococci in 2 cases). Pneumococci and mycoplasma infections could not be differentiated with standard radiography and laboratory tests. Initial treatment with beta lactamines was always unsuccessful in children with mycoplasma infections. Apyrexia was achieved when antibiotics were changed to macrolides.

CONCLUSION

Since lower respiratory tract infections due to pneumococci are much more severe than those due to mycoplasma, beta lactamines should be given as first intention treatment for children over 18 months with pneumonia. Macrolides should be given in case of failure because mycoplasma would then be the most probable infectious agent.

Evaluation of a serological test for diagnosis of Helicobacter pylori infection in children

A serological test for the diagnosis of Helicobacter pylori infection (Cobas Core Roche, IgG, 2nd Generation; Roche, France) was compared with the examination of biopsy samples (culture and histology) obtained after endoscopy in 115 children to assess its value. In 94 children (42 positive and 52 negative), results were concordant. In 10 children a positive serological test was associated with an absence of Helicobacter pylori, while in 11 others a negative serological test was associated with a positive culture. Sensitivity of the test was 79.2% and specificity 83.9%. A relationship between IgG titers and age (r = 0.31, p < 0.05) was found. Serological tests could be useful for the diagnosis of Helicobacter pylori infection, but a negative test result does not rule out infection, particularly in children under 10 years of age.

Direct intraoperative sclerotherapy of an aneurysmal bone cyst of the sphenoid

A young boy presented with a symptomatic aneurysmal bone cyst of the left great wing of the sphenoid bone. Arterial embolization had failed to produce thrombosis, and the lesion could not be resected surgically. Direct intraoperative sclerotherapy resulted in immediate thrombosis of 80% of the volume of the vascular malformation with no progression of symptoms. Two years later, the symptoms had completely resolved, and CT scans showed total ossification of the lesion.

Procalcitonin as a marker for the early diagnosis of neonatal infection

Serum procalcitonin was determined in newborn infants at the time of admission to the pediatrics or obstetrics unit. Increased levels were found in all neonates with bacterial sepsis. Neonates with viral infection, bacterial colonization, or neonatal distress had normal or slightly increased levels. These data suggest that procalcitonin might be of value in diagnosing neonatal sepsis.

Does Bilio-intestinal Bypass Still have a Role in the Treatment of Super-obesity?

BACKGROUND: Super-obesity (BMI > 50) is life-threatening. The jejunoileal bypass had Potential long-term problems, and weight loss with gastroplasty May be inadequate. METHODS: From 1988 to 1995, 19 Patients with morbid obesity had jejunolleal bypass with anastomosis of the fundus of the gallbladder to the proximal end of the bypassed jejunum. Of these patients, 11 were superobese, with ages 19-49 years, weight 125-172 kg, mean excess weight 97 kg (73-119) and BMI 56 (50-67). RESULTS: Mean weight loss at 3 years was 60 kg. There was no mortality and no major complications. Patients had 5-6 stools per day and some flatulence. There have been no hepatic, renal, calcium or electrolyte problems. Diseases secondary to obesity resolved. CONCLUSION: Billo-intestinal bypass has been effective and safe thus far.

The effect of exercise on gait patterns in older women: a randomized controlled trial

BACKGROUND

This study was undertaken to determine (a) whether a program of regular exercise can improve gait patterns in older women, and (b) whether any such improvement in gait is mediated by increased lower limb muscle strength.

METHOD

A 22-week randomized controlled trial of exercise was conducted as part of the Randwick Falls and Fractures Study in Sydney, Australia. Subjects were 160 women aged 60-83 years (Mean age 71.1, SD = 5.2) who were randomly recruited from the community. Exercise and control subjects were tested prior to and at the end of the trial. At initial testing, exercisers and controls performed similarly in the strength and gait parameters. They were well matched in terms of age and a number of health and life-style characteristics.

RESULTS

At the end of the trial, the exercise subjects showed improved strength in five lower limb muscle groups, increased walking speed, cadence, stride length, and shorter stride times as indicated by both reduced swing and stance duration. There were no significant improvements in any of the strength or gait parameters in the controls. Within the exercise group, increased cadence was associated with improved ankle dorsiflexion strength, and increased stride length was associated with improved hip extension strength. Exercise subjects with initial slow walking speed showed greater changes in velocity, stride length, cadence, and stance duration than those with initial fast walking speed.

CONCLUSION

These findings show that exercise can increase gait velocity and related parameters in older persons, and that part of this increase may be mediated by improved lower limb muscle strength.

Small-bowel bacterial overgrowth in children with chronic diarrhea, abdominal pain, or both

OBJECTIVE

To evaluate the frequency of small-bowel bacterial overgrowth (SBBO) as a cause of chronic digestive symptoms in a large cohort of children, using the glucose breath hydrogen test (BHT).

DESIGN

Patients were 53 children (aged 2 months to 12 years) with chronic diarrhea, abdominal pain, or both. Diagnosis of SBBO was defined with a BHT by a change in H2 concentration of 10 ppm H2 or more in expired air after an oral glucose load. Patients with a positive BHT result were included in group 1 and treated with a combination of colistin and metronidazole for 10 days; a second BHT was performed 1 month later. Group 2 comprised patients with a negative BHT result. Group 3 (n = 15) was a control group of healthy subjects, and group 4 (n = 6) a comparison group of subjects with bacteriologically documented SBBO.

RESULTS

Eighteen patients (34%) had a positive BHT result and 35 a negative result. The BHT results were comparable in groups 1 and 4 and in groups 2 and 3, respectively. Fasting H2 levels were higher in group 1 than in groups 2 (p < 0.001) and 3 (p < 0.01). In group 1, children were younger than in group 2 (1 +/- 1 year vs 3.9 +/- 3 years; p < 0.001) and diarrhea was frequent (83%), but 17% of patients had abdominal pain alone. Fetid stools (p < 0.01), mucus in stools (p < 0.01), and flatulence (p < 0.05) were more frequent in group 1 than in group 2. Antibiotic treatment of children in group 1 led to a rapid disappearance of symptoms and normalization of BHT results.

CONCLUSION

SBBO appears to be a frequent cause of chronic digestive symptoms in children, especially before the age of 2 years. The BHT provides a simple and noninvasive method of detecting it. The recognition of SBBO in children leads to effective treatment.