Magnetization transfer and diffusion tensor MR imaging of the optic radiations and calcarine cortex from patients with Leber's hereditary optic neuropathy

Optic nerve abnormalities are easily detectable in patients with Leber's hereditary optic neuropathy (LHON), using magnetic resonance imaging (MRI). However, the presence of structural changes in the optic radiations and calcarine cortex of these patients is still an unresolved issue. In this study, we obtained magnetization transfer (MT) and diffusion tensor (DT) MRI to investigate the integrity of these structures in patients with LHON. Dual echo, MT- and DT-MRI scans of the brain were obtained from 10 men with LHON and 10 healthy sex- and age-matched controls. After image co-registration, we obtained MT ratio (MTR), average diffusivity (D) and fractional anisotropy (FA) maps. MTR, D and FA values for the white matter of the optic radiations and MTR and D values for the calcarine cortex were obtained using a region of interest (ROI) analysis. No macroscopic abnormalities were detected in any of the scans from LHON patients and controls. No statistically significant differences of MTR, D or FA values were found for any of the regions studied in LHON patients and healthy controls. Our results suggest that, in patients with LHON, the optic radiations and the calcarine cortex are spared from structural damage, both at a macroscopic and a microscopic level.

[Cryptohypospadias: Surgical approach and long-term results]

BACKGROUND

Chordee without hypospadias is a rare morphological abnormality of the penis capable of interfering with sexual function. Usually, cases of chordee without hypospadias require surgical correction, and the aim of this study is to assess the efficacy of the techniques normally used in this pathology.

METHODS

The authors analyze the surgical outcomes achieved in 34 patients presenting various degrees of ventral or lateral curvature of the erect penis and operated on in our department over the past 22 years. Twenty-nine subjects attended for follow-up, including 13 who have now reached adulthood.

RESULTS

The milder forms of chordee without hypospadias (Horton and Devine type III and lateral deviations of the penis) all benefited from minor surgery (dermal grafts and Nesbit dorsal plication of the contralateral penile tunica albuginea) and were corrected with a single operation. The most serious forms of chordee without hypospadias where the hypoplasia variously affected the corpus spongiosum, Buck's fascia and the dartos fascia (Horton and Devine types I and II), were submitted to a supplementary extensive urethral mobilization or occasionally a urethroplasty and one-third of them presented persistent residual curvature.

CONCLUSIONS

The authors advocate a more aggressive surgical approach (urethroplasty and/or patches on the ventral tunica albuginea as an alternative to urethral mobilisation) in subjects with more pronounced defects.

Relationship between the morphological evaluation of the pituitary and the growth hormone (GH) response to GH-releasing hormone Plus arginine in children and adults with congenital hypopituitarism

The relationship between the hypothalamus-pituitary morphology and the somatotroph responsiveness to maximal provocative tests exploring the GH releasable pool is still unclear. We evaluated the GH-releasing effect of GHRH plus arginine (GHRH plus Arg) in 36 patients with congenital GH deficiency (GHD) according to their pituitary magnetic resonance imaging findings, consisting of anterior pituitary hypoplasia, stalk agenesis (neural and or vascular component), and posterior pituitary ectopia. Seventeen children (12 boys and 5 girls, aged 1--5.2 yr) were evaluated at the time of diagnosis of GHD (mean age, 3.6 +/- 1.4 yr), and 19 adults (13 males and 6 females, aged 15.9-28.6 yr) with childhood-onset GHD were reevaluated after completion of GH treatment (at least 6 months of withdrawal) at a mean age of 20.5 +/- 3.5 yr. Eleven children had isolated GHD, and 6 had multiple pituitary hormone deficiency (MPHD) whereas 7 adults had isolated GHD, and 12 had MPHD. A residual vascular component of the pituitary stalk was visualized in 7 children and 7 adults with isolated GHD, whereas magnetic resonance imaging showed complete pituitary stalk agenesis (both vascular and neural components) in 10 children and 10 adults, including 16 with MPHD (6 children) and 4 children with isolated GHD. In the children, the median peak GH response to GHRH plus Arg (7.6 microg/L; range, 2.4--40.2 microg/L) was significantly higher than that in the adults (1.8 microg/L; range, 0.8--37.4 microg/L; P = 0.0039); it was also significantly higher in the isolated GHD patients (18 microg/L; range, 3.3--40.2 microg/L) than in those with MPHD (1.9 microg/L; range, 0.8--7.6 microg/L; P = 0.00004). In the patients with residual vascular component of the pituitary stalk the median peak GH responses to GHRH plus Arg (19.1 microg/L; range, 1.6--40.2 microg/L) was significantly higher than that in patients with complete pituitary stalk agenesis (2.2 microg/L; range, 0.8--8.8 microg/L; P = 0.00005). There was a trend toward a decrease with age in peak GH response to GHRH plus ARG: Mean serum insulin-like growth factor I (IGF-I) levels were 36 +/- 7.1 microg/L in the children and 63.5 +/- 22.6 microg/L in the adults (P = 0.0001). The mean IGF-I level did not differ between the children with (35.7 +/- 4.8 microg/L) and those without (36.3 +/- 8.7 microg/L) the pituitary stalk; it was much higher in the adults with residual vascular pituitary stalk (81.1 +/- 17.7 microg/L) than in those with complete pituitary stalk agenesis (47.7 +/- 12.5 microg/L; P = 0.0002). The IGF-I level was 36.1 +/- 6.7 microg/L in the isolated GHD children and 36 +/- 8.6 microg/L in those with MPHD; levels were 82.1 +/- 19.4 and 52.7 +/- 16.8 microg/L respectively, in the adults (P = 0.003). In this study we have confirmed that the partial integrity of the hypothalamic pituitary connections is essential for GHRH plus Arg to express its GH-releasing activity and have shown that this provocative test is able to stimulate GH secretion to a greater extent in those patients with GHD, but with a residual vascular component of the pituitary stalk. This test is reliable in the diagnosis of congenital hypopituitarism in both children and adults when associated with complete pituitary stalk agenesis and MPHD. In younger children with congenital GHD but less severe impairment of the pituitary stalk the GH response to GHRH plus Arg may be within the normal range; deterioration of pituitary GH reserve with a GH response of less than 10 microg/L after 20 yr of age makes this test very sensitive in the diagnosis of adult GHD.

Magnetic resonance imaging, magnetisation transfer imaging, and diffusion weighted imaging correlates of optic nerve, brain, and cervical cord damage in Leber's hereditary optic neuropathy

OBJECTIVES

Leber's hereditary optic neuropathy (LHON) is a mitochondrial disease leading to bilateral loss of central vision and severe optic nerve atrophy. A subtype of LHON presents additional clinical and MRI aspects indistinguishable from those of multiple sclerosis (MS) (LHON-MS). In patients with LHON or LHON-MS, an assessment was made of (a) the severity of optic nerve damage, using MRI and magnetisation transfer imaging (MTI), and (b) the presence and extent of macroscopic and microscopic pathology in the brain and cervical cord, using MRI and MT ratio (MTR) and mean diffusivity (D) histogram analysis.

METHODS

Ten patients with LHON, four with LHON-MS, and 20 age and sex matched healthy controls were studied. For the optic nerve and the brain, dual-echo turbo spin echo (TSE), T1 weighted spin echo, and MT images were obtained. For the brain, fast fluid attenuated inversion recovery (fast FLAIR) and diffusion weighted images were also obtained. For the cervical cord, fast short tau inversion recovery (STIR) and MT images were obtained. The volume and the average MTR value of both the optic nerves were measured. MTR and histograms of the normal appearing brain tissue (NABT) and MTR histograms of the whole cervical cord tissue were created.

RESULTS

The mean values of optic nerve volumes and MTR were significantly lower in patients with LHON than in healthy controls. Mean NABT-MTR histogram peak height was significantly lower in patients with LHON than in controls, whereas no significant difference was found for any of the cervical cord MTR histogram derived measures. Average diffusivity (D) was higher in patients with LHON than in controls. Optic nerve volume and MTR value and mean NABT-MTR were lower in patients with LHON-MS than in those with LHON.

CONCLUSIONS

The severity of optic nerve pathology in LHON is measurable in vivo using MRI and MTI. MTR and histogram analysis suggests that microscopic brain damage occurs in LHON and that it is more severe in the MS-like form of the disease.

Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis

OBJECTIVE

To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum.

DESIGN

Prospective therapeutic non-randomized, self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months.

SETTING

Tertiary referral center for treatment of deep endometriosis.

PATIENT(S)

Eleven symptomatic patients with rectovaginal endometriosis.

INTERVENTION(S)

A levonorgestrel-releasing IUD was inserted and maintained for 12 months.

MAIN OUTCOME MEASURE(S)

Severity of dysmenorrhea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography.

RESULT(S)

Dysmenorrhea, pelvic pain, and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment.

CONCLUSION(S)

Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.

Ultrastructural features of solid/trabecular areas in differentiated thyroid carcinoma

The presence of areas exhibiting a solid/trabecular pattern of growth within an otherwise differentiated thyroid carcinoma represents a source of controversy as regards its proper classification and biologic and prognostic significance. The aim of the current study was to investigate the ultrastructural features of solid/trabecular areas in differentiated thyroid carcinoma and to compare those features with the submicroscopic profile of differentiated, poorly differentiated (insular), and undifferentiated (anaplastic) variants of thyroid cancer. The study series included differentiated carcinoma with solid/trabecular areas (3 cases), conventional papillary carcinoma (4 cases), follicular variant of papillary carcinoma (4 cases), poorly differentiated (insular) carcinoma (3 cases), and undifferentiated (anaplastic) carcinoma (3 cases). It was found that the solid/trabecular areas in differentiated carcinoma and poorly differentiated (insular) carcinoma share similar ultrastructural features and overall retain, even if attenuated, many of the submicroscopic attributes of differentiated carcinomas. In particular, nests of neoplastic cells were observed showing a highly developed cytosecretory apparatus and the presence of numerous abortive/rudimentary follicles, and intercellular and intracellular (intracytoplasmic) lumina/canaliculi of variable morphology. The study supports the hypothesis that the solid/trabecular areas do not merely represent an architectural pattern but rather should be regarded as the expression of a process of reduced differentiation similar to that of poorly differentiated (insular) carcinoma.

[Histologic microbiopsy with 14 G needle in the diagnosis of breast lesions. Experience with 1000 cases]

PURPOSE

We report our experience with large core biopsy (LCB: 14-Gauge needles) of questionable or suspicious breast lesions detected at mammography and/or US. All biopsies were performed under instrumental guidance. We also report on technique, costs, time, advantages and disadvantages of the method and, finally, give precise indications on when and why large core biopsy is needed.

MATERIAL AND METHODS

From january 1996 to may 2000 we performed 1000 microhistologic biopsies on breast lesions at the Unità Integrata di Senologia, Azienda Ospedaliera Careggi, Florence; 650 (65%) were non palpable lesions. Large core needles were used (14-Gauge caliber). In the majority of cases (70%) we used US guidance, in the others a stereotactic guidance was employed.

RESULTS

Microhistologic biopsy allowed accurate characterization in most cases. Inadequate samples were obtained in 15 cases. The false negative rate was 6%. Surgery was needed to characterize the lesion unquestionably in 13 cases only.

CONCLUSION

In agreement with literature reports, our results confirm large core biopsy as an adequate alternative to surgical biopsy and, to some extent, to FNAC, thanks to its moderate invasiveness, low costs, short execution time, little patient discomfort and high sensitivity (93.98%) and specificity (99.7%).

Gonadotropin-releasing hormone agonist treatment for endometriosis of the rectovaginal septum

OBJECTIVE

This study was undertaken to evaluate the effectiveness of a 6-month course of gonadotropin-releasing hormone agonist treatment for patients with symptomatic endometriosis of the rectovaginal septum.

STUDY DESIGN

Fifteen patients with rectovaginal endometriosis and moderate to severe pain symptoms were the subjects of the study. None of these patients had either clinical or objective evidence of ovarian endometriosis, nor was there evidence of any obstructive lesions of the intestine or ureters. All patients were given leuprolide acetate depot at 3.75 mg, 1 ampule intramuscularly every 28 days, and treatment had a planned duration of 6 months. Follow-up evaluations were set every 2 months during the treatment phase and every 3 months thereafter until the completion of 1 year after discontinuation of medical therapy. At each follow-up visit pain symptoms were recorded, and clinical exploration, transvaginal ultrasonography, and transrectal ultrasonography were performed.

RESULTS

Two patients stopped the treatment early after the second and fourth leuprolide doses; in both cases the reason was persistence of pain, and both requested a surgical solution. The other 13 patients showed a marked improvement with respect to pain during the 6-month treatment course but had early pain recurrence after drug suspension; 11 of them required further treatment within the first year of follow-up. The failure rate of gonadotropin-releasing hormone agonist therapy to produce 1-year pain relief after treatment discontinuation was 87% (13/15) on an intent-to-treat basis. The endometriotic lesions showed a slight but significant reduction in size during therapy but had returned to the original volume within 6 months after cessation of the gonadotropin-releasing hormone analog treatment.

CONCLUSION

Our results suggest that gonadotropin-releasing hormone analogs should not be considered a real therapeutic alternative to surgical treatment for patients with symptomatic endometriosis of the rectovaginal septum, except possibly in a limited and unpredictable number of cases.

Surgical treatment of chordee without hypospadias

OBJECTIVE

The aim of this study was to retrospectively assess the efficacy of the surgical techniques commonly used in three types of chordee without hypospadias (Devine and Horton classification).

METHODS

Twenty-six patients, ranging in age from 3 to 14 years, had chordee without hypospadias and underwent Nesbit dorsal plication (9 cases out of 12, type III), associated extensive mobilization of the urethra (10 cases out of 10, type II), and vascularized neourethra (3 cases out of 4, type I).

RESULTS

Eleven subjects undergoing follow-up investigation for the milder forms of chordee were satisfied with the outcome achieved; there was no impediment of any kind in the sex lives of 5 adult subjects. Of the 11 patients undergoing follow-up after more complex surgery for Devine and Horton type I-II chordee without hypospadias, a residual abnormal curvature was present in 4 subjects. These patients were submitted to one or more reoperations with outcomes defined as satisfactory.

CONCLUSION

To avoid the risks of persistent chordee, the authors suggest more radical and accurate operations for the treatment of type I and II pseudohypospadias.

Intranasal immunization with mumps virus DNA vaccine delivered by influenza virosomes elicits mucosal and systemic immunity

To improve the efficiency of liposome-mediated DNA transfer as a tool for gene therapy or vaccinology, we have further developed a new delivery system based on the modified immunopotentiating reconstituted influenza virus (IRIV). In this study, we engineered a plasmid DNA vector expressing the mumps virus hemagglutinin or the fusion protein. The administration of this DNA vaccine delivered by influenza virosomes, in combination with the mucosal adjuvant Escheriagen via the intranasal route, was efficient for inducing an immune response, both mucosally and systemically, in mice. The production of IgG2a mumps virus-specific antibodies and the secretion of interleukin 10 (IL-10) by antigen-specific T cells indicated that not only Th1 but also Th2 responses were induced by this DNA vaccine formulation. These results suggest that cationic virosomes in combination with Escheriagen may have great potential as an efficient delivery system for intranasal DNA immunization and provide an immune barrier at the mucosal sites.

US of nerve entrapments in osteofibrous tunnels of the upper and lower limbs

The diagnosis of nerve entrapment at osteofibrous tunnels relies primarily on clinical and electrodiagnostic findings. Recently, the refinement of high-frequency broadband transducers with a range of 5-15 MHz, sophisticated focusing in the near field, and sensitive color and power Doppler technology have improved the ability to evaluate peripheral nerve entrapment in osteofibrous tunnels with ultrasonography (US). In the upper limb, osteofibrous tunnels amenable to US examination include the carpal tunnel for the median nerve and the cubital and Guyon tunnels for the ulnar nerve. In the lower limb, these tunnels include the fibular neck for the common peroneal nerve, the tarsal tunnel for the posterior tibial nerve, and the intermetatarsal spaces for the interdigital nerves. High-resolution US allows direct imaging of the involved nerves, as well as documentation of changes in nerve shape and echotexture that occur in compressive syndromes. A spectrum of extrinsic causes of entrapment, such as tenosynovitis, ganglia, soft-tissue tumors, bone and joint abnormalities, and anomalous muscles, can also be diagnosed with US. With continued experience, it is likely that this technique will be increasingly used to evaluate nerve entrapment syndromes.

Ultrasonography of peripheral nerves

During sonographic examination of the extremities using high frequency "small-parts" equipment, peripheral nerves may be identified in virtually all patients. Peripheral nerves have a typical ultrasonographic pattern that correlates well with histologic structure and facilitates differentiation between nerves and tendons. The ability of this technique to depict peripheral nerves makes it possible, in many instances, to study nerve abnormalities in trauma, entrapment syndromes and tumors. Ultrasound can enable differentiation of an endoneural from an extraneural space-occupying lesion and evaluation of the extent and consistency of the lesion, as well as the integrity and dynamic behavior of the nerve involved at follow-up study. The purpose of this review article is to describe the normal ultrasonographic appearance of peripheral nerves and to discuss the potential role of this technique to image nerve lesions noninvasively. A series of paradigmatic ultrasound images of diverse pathologic processes involving peripheral nerves is presented. Although the ultrasound study of peripheral nerves remains in its infancy, with further refinement of ultrasound technology and a more precise knowledge of the ultrasound appearance of the extremities we may be optimistic to the future impact of this technique on diagnosis, treatment and prognosis in patients clinically suspected to have a nerve lesion.

Causes of inconsistency in diagnosing and classifying intraductal proliferations of the breast. European Commission Working Group on Breast Screening Pathology

It is now widely recognised that classifying ductal carcinoma in situ (DCIS) of the breast and diagnosing atypical ductal hyperplasia are associated with significant interobserver variation. Two possible reasons for this inconsistency are differences in the interpretation of specified histological features and field selection where morphology is heterogeneous. In order to investigate the relative contribution of these two factors to inconsistent interpretation of intraductal proliferations, histological sections of 32 lesions were sent to 23 European pathologists followed 3 years later by images of small parts of these sections. Kappa statistics for diagnosing hyperplasia of usual type, atypical ductal hyperplasia and ductal carcinoma in situ were 0.54, 0.35 and 0.78 for sections and 0.47, 0.29 and 0.78 for images, respectively, showing that most of the inconsistency is due to differences in morphological interpretation. Improvements can thus be expected only if diagnostic criteria or methodology are changed. In contrast, kappa for classifying DCIS by growth pattern was very low at 0.23 for sections and better at 0.47 for images, reflecting the widely recognised variation in the growth pattern of DCIS. Higher kappa statistics were obtained when any mention of an individual growth pattern was included in that category, thus allowing multiple categories per case; but kappa was still higher for images than sections. Classifying DCIS by nuclear grade gave kappa values of 0.36 for sections and 0.49 for images, indicating that intralesional heterogeneity has hitherto been underestimated as a cause of inconsistency in classifying DCIS by this method. More rigorous assessment of the proportions of the different nuclear grades present could lead to an improvement in consistency.

Multimodality imaging assessment of meniscal ossicle

A case of meniscal ossicles occurring in the left knee of a 23-year-old woman is presented. Radiographs showed two calcified lesions at the posteromedial aspect of the knee which were interpreted as loose bodies. Sonography, computed tomography arthrography and magnetic resonance imaging showed the fragments within the posterior horn of the medial meniscus permitting a diagnosis of meniscal ossicles. These techniques can detect meniscal ossicles and exclude intra-articular loose bodies.

Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases

OBJECTIVE

To evaluate the surgical feasibility and the long-term anatomic and functional results of a new procedure that uses the endoscopic approach to treat uterovaginal agenesis, known as Rokintansky syndrome.

DESIGN

Evaluation of surgical feasibility and recording of clinical data over a 12-month follow-up.

SETTING

Tertiary referral center for the treatment of female genital malformations.

PATIENT(S)

Fifty-two patients with vaginal agenesis.

INTERVENTION(S)

The laparoscopic version of the Vecchietti method was used to create a neovagina.

MAIN OUTCOME MEASURE(S)

Anatomic success was defined as a neovagina >/=6 cm long, allowing easy introduction of two fingers, within 6 months after corrective surgery. Functional success was considered achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery.

RESULT(S)

The surgical procedure was performed with no major complications and with 100% anatomic success; functional success was obtained in 98.1% of the study population.

CONCLUSION(S)

In patients with Rokitansky syndrome, the laparoscopic approach for creating a neovagina by the Vecchietti method is simple, safe, and effective.

Sonographic evaluation of digital annular pulley tears

OBJECTIVE

To evaluate the sonographic (US) appearance of digital annular pulley (DAP) tears in high-level rock climbers.

DESIGN AND PATIENTS

We performed a retrospective analysis of the US examinations of 16 high-level rock climbers with clinical signs of DAP lesions. MRI and surgical evaluation were performed in five and three patients respectively. The normal US and MRI appearances of DAP were evaluated in 40 and three normal fingers respectively.

RESULTS

Nine of 16 patients presented a DAP tear. In eight subjects (seven with complete tears involving the fourth finger and one the fifth finger), US diagnosis was based on the indirect sign of volar bowstringing of the flexor tendons. Injured pulleys were not appreciated by US. Tears concerned the A2 and A3 in six patients and the A3 and A4 in two patients. A2 pulley thickening and hypoechogenicity compatible with a partial tear was demonstrated in one patient. MRI and surgical data correlated well with the US findings. Four patients had tenosynovitis of the flexor tendons but no evidence of pulley disruption. US examinations of three patients were normal. In the healthy subjects US demonstrated DAP in 16 of 40 digits.

CONCLUSION

US can diagnose DAP tears and correlates with the MRI and surgical data. Because of its low cost and non-invasiveness we suggest US as the first imaging modality in the evaluation of injuries of the digital pulley.

Relationships between hepatic melanogenesis and respiratory conditions in the newt, Triturus carnifex

The Kupffer cells (melanomacrophages) in the livers of lower vertebrates contain varying quantities of melanin according to the season. Specimens of Triturus carnifex raised for 2 months at 6 degrees C and then transferred to water at 22 degrees C show a rapid increase in the hepatic accumulation of the pigment. The Kupffer cells make up more than one fourth of the liver mass in chlorbutol-anesthetized animals isolated for 6-7 hr in hypoxic water at 18 degrees C (to bring the oxygen content in a 620-mL respiratory chamber from 1.1 ppm to 0.0). Thus, hepatic melanin is synthesized when the newt's oxygen supply is inadequate to meet its metabolic needs; melanogenesis, however, requires the presence of oxygen and does not occur in anesthetized specimens immersed in a totally anoxic fluid such as paraffin oil. The intraperitoneal injection prior to hypoxic treatment of 1 mg/g of body weight of kojic acid (inhibitor of the enzyme tyrosinase which catalyzes melanin synthesis) blocks melanogenesis and doubles oxygen consumption. The combination of hypoxia and tyrosinase inhibition causes permanent damage to essential functions of the nervous system, while hypoxic treatment alone has no irreversible consequences. The genic expression of tyrosinase in hypoxia appears to be a physiological response aimed at prolonging survival time in anaerobiosis by lowering the metabolic level; melanin would be an inert subproduct of this function.

Ultrasonography of peripheral nerves

With recent improvements in ultrasound (US) imaging equipment and refinements in scanning technique, an increasing number of peripheral nerves and related pathologic conditions can be identified. US imaging can support clinical and electrophysiologic testing for detection of nerve abnormalities caused by trauma, tumors, and a variety of nonneoplastic conditions, including entrapment neuropathies. This article addresses the normal US appearance of peripheral nerves and discusses the potential role of US nerve imaging in specific clinical settings. A series of US images of diverse pathologic processes involving peripheral nerves is presented.

5-Hydroxytryptophan, but not L-tryptophan, alters sleep and brain temperature in rats

The precise role of serotonin (5-hydroxytryptamine) in the regulation of sleep is not fully understood. To further clarify this role for 5-hydroxytryptamine, the 5-hydroxytryptamine precursors L-tryptophan (40 and 80 mg/kg) and L-5-hydroxytryptophan (25-, 50-, 75-, 100 mg/kg) were injected intraperitoneally into freely behaving rats 15 min prior to dark onset, and subsequent effects on sleep-wake activity and cortical brain temperature were determined. L-5-hydroxytryptophan, but not L-tryptophan, induced dose-dependent changes in sleep-wake activity. During the 12-h dark period, non-rapid eye movement sleep was inhibited in post-injection hours 1-2 by the two lowest L-5-hydroxytryptophan doses tested, while the two highest doses induced a delayed increase in non-rapid eye movement sleep in post-injection hours 3-12. These highest doses inhibited non-rapid eye movement sleep during the subsequent 12-h light period. The finding that L-5-hydroxytryptophan, but not L-tryptophan, induced a dose-dependent and long-lasting decrease in cortical brain temperature regardless of whether or not non-rapid eye movement sleep was suppressed or enhanced contributes to a growing list of conditions showing that sleep-wake activity and thermoregulation, although normally tightly coupled, may be dissociated. The initial non-rapid eye movement sleep inhibition observed following low doses of L-5-hydroxytryptophan may be attributable to increased serotonergic activity since 5-hydroxytryptamine may promote wakefulness per se, whereas the delayed non-rapid eye movement sleep enhancement after higher doses may be due to the induction by 5-hydroxytryptamine of sleep-inducing factor(s), as previously hypothesized. The period of non-rapid eye movement sleep inhibition beginning 12 h after administration of L-5-hydroxytryptophan doses that increase non-rapid eye movement sleep is characteristic of physiological manipulations in which non-rapid eye movement sleep is enhanced. The results of the present study suggest that the complex effects of 5-HT on sleep depend on the degree and time course of activation of the serotonergic system such that 5-HT may directly inhibit sleep, yet induce a cascade of physiological processes that enhance subsequent sleep.

[Surgical treatment of thyroid microcarcinoma]

Thyroid microcarcinoma is nowaday defined as a tumor of one centimeter or less in the maximum diameter. It occurs in less than five per cent of all thyroid carcinomas. In personal experience four thyroid microcarcinomas have been found in specimens from 121 thyroidectomies and have been retrospectively reviewed clinical data and the long term follow-up of the patients. Total thyroidectomies nor prophylactic lymphadenectomies were never performed. All patients at present are well. Our purpose was to focus on the current surgical treatment of microcarcinoma. Many hypotheses are done to explain pathogenesis and fairly good prognosis of thyroid microcarcinomas, without univocal conclusions. Almost all authors agree that microcarcinoma of the thyroid gland is a low-aggressive tumor, with good biological behaviour, but the therapeutic strategies are not codified yet. Particularly, doubt still exists about the choice between total thyroidectomy and more conservative procedure, and lymphadenectomy, especially when tumor is found in specimens after surgery for benign disease. In conclusion, in our opinion conservative management is the best choice, provided that the patient is included in a correct long-term follow-up.

Biochemical and functional characterization of the Tn-specific lectin from Salvia sclarea seeds

SSL, the lectin isolated from Salvia sclarea seeds, recognizes the Tn antigen (GalNAcalpha-O-Ser/Thr), a specific marker of many human carcinomas. Two-dimensional electrophoresis, amino-acid and amino-sugar analysis, and MALDI-TOF MS showed that SSL is an acidic (pI 5.5), 60-61-kDa dimeric glycoprotein composed of apparently identical subunits linked by a single disulfide bond. The apparent molecular mass of SSL in solution determined by equilibrium sedimentation analytical ultracentrifugation was 59 +/- 9 kDa. This value did not change in the pH range 2.5-8.5, indicating that SSL does not associate into higher order structures. Tandem mass spectrometry and methylation analysis of N-glycans released from SSL by hydrazinolysis indicated that SSL possesses 2-3 glycosylation sites occupied with the typical plant glycans Manalpha1-6[(Manalpha1-3)(Xylbeta1-2)]Manbeta1-4 -GlcNAcbeta1-4(Fucalp ha1-3)GlcNAc and [(Manalpha1-3/6)(Xylbeta1-2)]Manbeta1-4-GlcNAcbeta1 -4(Fucalpha1-3)Glc NAc. The influence of adjacent Tn structures on the binding of two Tn-specific lectins (SSL and the isolectin B4 from Vicia villosa) and an anti-Tn monoclonal antibody (mAb 83D4) was evaluated using synthetic Tn glycopeptides. The binding of both lectins to the synthetic Tn glycopeptides was independent of the density of Tn structures. On the other hand, mAb 83D4 only reacted with glycopeptides displaying two or three consecutive Tn structures.

Laparoscopic creation of a neovagina in a woman with a kidney transplant: case report

The successful use of Vecchietti's technique for creating a neovagina in a case of Rokitansky syndrome with an associated transplanted kidney is reported. The technique is performed by means of a laparoscopic approach, adapted to the special anatomical situation, in order to avoid renal injuries. The accomplishment of a normally functioning neovagina, with no intra-operative or post-operative complications, proves that this technique can also be applied satisfactorily to this type of patient.

US and MR imaging of peripheral nerves in leprosy

OBJECTIVE

To analyze peripheral nerves with ultrasonography (US) and magnetic resonance imaging (MR) in leprosy and assess the role of imaging in leprosy patients.

DESIGN AND PATIENTS

Fifty-eight nerves with abnormal clinical features or electromyograms were examined in 23 leprosy patients by means of gray-scale US, Doppler US and MR imaging. Image analysis included: measurement of nerve cross-sectional area; assessment of nerve structure and MR signal intensities; identification of nerve compression within osteofibrous tunnels; detection of endoneural color flow signals and Gd-DTPA enhancement. Correlations were made with clinical findings and a control group of 20 subjects. Fourteen nerves in active reversal reaction were followed up after therapy.

RESULTS

Leprosy nerves were classified into three groups based on imaging appearance: group I consisted of 17 normal-appearing nerves; group II, of 30 enlarged nerves with fascicular abnormalities; group III, of 11 nerves with absent fascicular structure. Group II nerves were from patients subjected to reversal reactions; 75% of patients with group III nerves had a history of erythema nodosum leprosum. Nerve compression in osteofibrous tunnels was identified in 33% of group II and 18% of group III nerves. Doppler US and MR imaging were 74% and 92% sensitive in identifying active reactions, based on detection of endoneural color flow signals, long T2 and Gd enhancement. In 64% of cases, follow-up studies showed decreased color flow and Gd uptake after steroids and decompressive surgery.

CONCLUSIONS

US and MR imaging are able to detect nerves abnormalities in leprosy. Active reversal reactions are indicated by endoneural color flow signals as well as by an increased T2 signal and Gd enhancement. These signs would suggest rapid progression of nerve damage and a poor prognosis unless antireactional treatment is started.