Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry

OBJECTIVES

To examine the clinical characteristics and outcomes of cancer patients with venous thromboembolism (VTE) in order to identify factors that place these patients at an increased risk for fatal pulmonary embolism (PE) or fatal bleeding.

PATIENTS AND METHODS

Registro Informatizado de la Enfermedad Trombo Embólica (RIETE) is a prospective registry of consecutive patients with symptomatic, objectively confirmed, acute VTE.

RESULTS

Up to January 2006, a total of 14 391 patients with symptomatic acute VTE were enrolled in RIETE, of whom 2945 (20%) had cancer. During the 3-month follow-up period the frequency of fatal PE in cancer patients was 2.6%, and that of fatal bleeding 1.0%. These frequencies were significantly higher than in VTE patients without cancer (1.4% and 0.3%, respectively). In patients with cancer, abnormal renal function, metastatic disease, recent major bleeding and recent immobility for >or= 4 days (42% of the 108 patients who died from PE or bleeding had recent immobility) were factors independently associated with an increased risk for both fatal PE and fatal bleeding. In addition, PE diagnosis on admission was an independent risk factor for fatal PE, while body weight < 60 kg was an independent risk factor for fatal bleeding.

CONCLUSIONS

Both fatal PE and fatal bleeding are more common in cancer patients with VTE than in those patients without cancer. In cancer patients, abnormal renal function, metastatic disease, recent major bleeding and recent immobility for >or= 4 days are associated with an increased risk for both fatal PE and fatal bleeding.

Randomized controlled phase II trial of glatiramer acetate in ALS

The authors conducted a randomized controlled trial to test the safety and immunology of glatiramer acetate in ALS. Twenty treated patients were randomly assigned to daily or biweekly injections. Ten control patients were selected from another trial and followed up concurrently. Injection reactions were the only common adverse event (p = 0.01). Treated patients showed enhanced lymphocyte proliferation (p = 0.02). The safety profile and immune effects support conducting larger trials of dose selection and efficacy.

A two-stage design for a phase II clinical trial of coenzyme Q10 in ALS

BACKGROUND

The combination of a small pool of patients at any given time with the availability of many potential neuroprotective agents to be tested in ALS requires efficient phase II trial designs.

OBJECTIVE

To describe the design of the Clinical Trial of High Dose Coenzyme Q10 (CoQ10) in ALS (QALS study)--a phase II, randomized, placebo-controlled, double-blind, multicenter clinical trial.

METHODS

The study design features two stages. The first stage (dose selection) identifies which of two doses of CoQ10 (1800 mg or 2700 mg) is preferred using a selection procedure rather than a formal hypothesis test. The second stage (early efficacy test) compares the preferred dose of CoQ10 against placebo using a non-superiority or futility design. Data from patients assigned to the preferred dose of CoQ10 in the first stage are also used in the second stage. The primary outcome measure is the decline in Amyotrophic Lateral Sclerosis Functional Rating Scale-revised (ALSFRSr) score from baseline to 9 months.

RESULTS

The total sample size required is 185 patients, as compared to a much larger sample size estimated to be necessary using a conventional superiority design (total: 852 patients). The authors report a bias correction made necessary by the inclusion of patient data from the first stage in the second stage.

CONCLUSIONS

Several features of the Clinical Trial of High Dose Coenzyme Q10 in ALS study design promote efficiency. These features may be beneficial in phase II trials in amyotrophic lateral sclerosis and other fields.

[Home versus inpatient therapy for deep venous thrombosis. A cost-comparative analysis]

AIMS

To compare the home-care management of deep vein thromboses (DVT) by a Home Care Unit (HCU) respect to conventional inpatient treatment.

METHODS

Twenty-one patients with a doppler-ecography diagnosis of DVT were managed by the HCU during 2002. In 7 out 13 a concomitant diagnosis of pulmonary embolism (PE) was made by lung scan. Median age was 81 years, 52% were women and all, except one case, showed severe medical concomitant conditions. All patients received low-weight molecular heparin, followed by oral anticoagulants in 3 patients. No patients died and only one was hospitalized briefly due to a poor thrombosis-related pain control. Costs of this patient were added to those of HCU. A comparison was made between ambulatory and hospitalary costs for EP and DVT. Pharmacological treatment costs were calculated for a 10-days period.

RESULTS

The length of inhospital stay was 1 day for HCU vs. 8 days (DVT) and 13 days (EP). There was a estimated cost-saving of 1680 per patient.

CONCLUSIONS

The management of DVT in patients with serious conditions, can be accomplished safely and in a cost-saving manner by a Home Care Unit.

Control of hypertension in patients at high risk of cardiovascular disease

BACKGROUND

Hypertension is a major cardiovascular risk factor, but knowledge about the real magnitude of the problem and its determinants is lacking.

AIM

To assess control of hypertension and evaluate medical resource use, in patients at high risk of cardiovascular disease.

DESIGN

Multicentric cross-sectional study.

METHODS

We collected data for 2205 adult patients from 36 centres, representative of all regions of Spain. Patients had attended out-patient clinics from July 2002 to August 2003, had an absolute cardiovascular risk > or =20% at 10 years (according to the Framingham guidelines), and had a diagnosis of hypertension. Pregnant and terminally ill patients were excluded.

RESULTS

Hypertension was inadequately controlled in 1384 patients (62.8%). LDL cholesterol was higher in patients with uncontrolled hypertension (median 130.2 vs. 120.0 mg/dl, p < 0.001). Haemoglobin A(1c) in diabetic patients was also greater in those with uncontrolled hypertension (median 7.10% vs. 6.90%, p = 0.010). Uncontrolled hypertension was associated with the following variables, in descending strength of association: higher LDL cholesterol, taking antihypertensive medication, living in non-metropolitan areas, and higher body mass index.

DISCUSSION

Hypertension is poorly controlled in most patients with a high risk of cardiovascular disease. Uncontrolled hypertension is frequently associated with poor control of other risk factors.

Osteopathia striata with cranial sclerosis: clinical, radiological, and bone histological findings in an adolescent girl

Osteopathia striata with cranial sclerosis (OS-CS) is a rare skeletal dysplasia characterized by linear striations of the long bones, osteosclerosis of the cranium, and extra-skeletal anomalies. We provide a comprehensive description of the skeletal phenotype in a French-Canadian girl with a moderate to severe form of sporadic OS-CS. Multiple medical problems, including anal stenosis and the Pierre-Robin sequence, were evident in the first few years of life. At 14 years, she was fully mobile, with normal intellect and stature. She suffered chronic lower extremity pain in the absence of fractures, as well as severe headaches, unilateral facial paralysis, and bilateral mixed hearing loss. Biochemical indices of bone and mineral metabolism were within normal limits. Bone densitometry showed increased areal bone mineral density in the skull, trunk, and pelvis, but not in the upper and lower extremities. An iliac bone biopsy specimen revealed an increased amount of trabecular bone. Trabeculae were abnormally thick, but there was no evidence of disturbed bone remodeling. In a cranial bone specimen, multiple layers of periosteal bone were found that covered a compact cortical compartment containing tightly packed haversian canals. Bone lamellation was normal in both the iliac and skull samples. Osteoclast differentiation studies showed that peripheral blood osteoclast precursors from this patient formed functional osteoclasts in vitro. Thus, studies of bone metabolism did not explain why bone mass is increased in most skeletal areas of this patient. Cranial histology points to exuberant periosteal bone formation as a potential cause of the cranial sclerosis.

Posterior quadrantic dysplasia or hemi-hemimegalencephaly: A characteristic brain malformation

INTRODUCTION

Posterior quadrantic dysplasia (PQD), a developmental malformation involving the temporal, parietal, and occipital lobes of one cerebral hemisphere, leads to intractable epilepsy.

OBJECTIVE

To characterize the clinical features of 19 patients with PQD and analyze the postsurgical outcome of those who underwent resection of dysplastic tissue.

METHODS

The extent and nature of the malformation were primarily assessed with high-resolution brain imaging. Fourteen patients underwent complete or partial temporoparieto-occipital resection or temporal resection associated with parieto-occipital disconnection. Postoperative follow-up period ranged from 8 months to 7 years. The authors used the Engel classification for postoperative outcome.

RESULTS

All patients were sporadic. Clinical features included infantile spasms, partial seizures, mental retardation, mild hemiparesis, and visual field defects. Neuroimaging localized the malformation within the posterior cerebral quadrant contralateral to the neurologic deficit and demonstrated hemi-hemimegalencephaly in 14 of 19 patients and multilobar cortical dysplasia in 5 of 19 patients. The authors observed class I outcome in six patients. Two patients had class II and four patients had class III outcome. Class IV outcome was seen in two patients. After surgery, two patients developed mild hemiparesis, and two developed a visual field defect.

CONCLUSIONS

Widespread cortical dysplasia is more frequent in the posterior quadrant. In our series, posterior quadrantic dysplasia represents either hemi-hemimegalencephaly or multilobar cortical dysplasia. Individuals with posterior quadrantic dysplasia share a spectrum of clinical features. The intractable epilepsy in these patients may be alleviated by a large quadrantic temporoparieto-occipital resection.

Factors related to non-participation in a population-based breast cancer screening programme

The main objectives were to describe the measures taken by women to detect breast disease prior to invitation to participate in a screening programme for breast cancer, and to identify factors related to non-participation in this programme. A cross-sectional study was designed at the Breast Cancer Early Detection Program of Sabadell-Cerdanyola (BCEDP), using data collected in interviews conducted face to face or over the telephone with 13 760 women participating in the programme and 280 non-participants. A total of 74.2% of the participants versus 70.4% of the non-participants reported having taken measures to detect breast disease, and 71.7% of the participants had undergone mammography versus 69.6% of the non-participants. Of the 10 057 women who had had mammograms, 58% had done so less than 2 years previously. Factors found to be associated to non-participation in the multivariate analysis were: higher level of education, higher occupational skills or working at home, self- or gynaecological examination of breasts, and having received hormone replacement therapy. Higher age group was the only factor that increased the probability of not having undergone mammography previously. Despite the high prevalence of prior measures to detect breast cancer and the similar prevalence between participating and non-participating women, this behaviour is much less prevalent in the group of women 60 years of age or older.

Resection of the lesion in patients with hypothalamic hamartomas and catastrophic epilepsy

BACKGROUND

Patients with hypothalamic hamartomas (HH) often have severe refractory epilepsy, incapacitating behavioral abnormalities, and cognitive decline. Attempts to control the seizure disorder by resection of apparently epileptogenic mesial temporal or other cortical structures have failed consistently.

OBJECTIVE

To report a series of 13 patients in whom the hamartoma itself was resected.

METHODS

All patients underwent preoperative evaluation between ages 2 and 33 years and had subtotal or complete resection of the hamartoma. Follow-up ranged from 1 to 5.5 years (mean: 2.8 y).

RESULTS

Preoperatively, all patients had variable combinations of gelastic, complex partial, and generalized seizures. Eight had drop attacks. In addition, all had marked behavior abnormalities and cognitive impairment. Postoperatively, two patients are completely seizure-free and 11 are either seizure-free or have achieved a greater than 90% reduction of drop attacks and generalized tonic-clonic seizures. However, minor gelastic, complex partial, and atypical absence seizures have persisted in 11 patients, although at significantly reduced rates. In addition, there has been a dramatic improvement in behavior and cognition. Three patients had an anterior thalamic and one a capsular infarct, which left only minimal long-term deficits. Exact location of the lesion in relation to the interpeduncular fossa and the walls of the third ventricle correlated with extent of excision, seizure control, and complication rate.

CONCLUSION

Resection can alleviate both the seizures and the behavioral and cognitive abnormalities of hypothalamic hamartomas, but complications are frequent.

[New trends in the regulation of medical practice in the context of health care reform: the Mexico case]

The recent panorama of medical practice regulation in Mexico is exposed. The dynamics of regulation changes is observed in different areas, with particular intensity in the labor market. Changes seem to be moving towards the constitution of a new regulatory model. A full state regulation for the last 50 years, is being substituted by a model where private and professional corporations are increasing their influence through informal mechanisms of regulation. In the constitution of this new model, the presence of a wide variety of actors claiming regulatory authority is notorious. Three of these new actors are analyzed: The National Commission for Medical Arbitrage, managed care models of medical services, and Specialists Certification Councils. The changes that have occurred in the process of regulation and its future transformation have an intimate link with the reform of the Mexican health care system.

Ciprofibrate versus gemfibrozil in the treatment of mixed hyperlipidemias: an open-label, multicenter study

Mixed hyperlipidemia is a common risk factor for cardiovascular disease. The aim of this trial was to evaluate the efficacy and safety of ciprofibrate versus gemfibrozil for the treatment of patients with mixed hyperlipidemia carefully selected for similar lipid profiles. A total of 68 patients who had mixed hyperlipidemia after following an isocaloric American Heart Association (AHA) phase I diet for 4 weeks were included. The plasma lipid levels at the inclusion were low-density lipoprotein-cholesterol (LDL-C) > or = 130 mg/dL, cholesterol > or = 240 mg/dL, and triglycerides > or = 200 mg/dL. Patients were randomly assigned to receive ciprofibrate 100 mg/d or gemfibrozil 1,200 mg/d. At the end of the 8-week treatment period, efficacy and safety parameters were compared with baseline values. The primary efficacy parameters of the study were percentage changes in triglycerides and LDL-C from baseline. After 8 weeks, plasma triglyceride concentrations were decreased by 43.5% and 54% compared with baseline during ciprofibrate and gemfibrozil therapy, respectively (P <.001). High-density lipoprotein-cholesterol (HDL-C) concentrations were increased 20.8% and 19.3% during ciprofibrate and gemfibrozil, respectively (P <.001). Apoprotein B, cholesterol, and very-low-density lipoprotein-cholesterol (VLDL-C) concentrations were also improved by the study drugs (18.6%, 13.2%, and 30.9%, respectively, during ciprofibrate and 44%, 13.8%, and 14.4%, respectively, during gemfibrozil). Meanwhile, the effect of the drug was minimal on LDL-C. A significant decrease in non-HDL-C resulted from both treatments (19% and 19.5%, respectively, P <.05). The only statistically significant difference observed between treatments was the effects on fibrinogen concentration, a coronary risk factor. Ciprofibrate significantly decreased its concentration by 18.8%, fibrinogen was slightly increased during gemfibrozil treatment. No patient had a significant modification on any of the safety tests. In summary, ciprofibrate and gemfibrozil are well-tolerated and efficacious treatments for mixed hyperlipidemia. Significant reductions in triglycerides, non-HDL-C, and apolipoprotein B were achieved with both drugs. A significant fibrinogen reduction was obtained with ciprofibrate.

[Prospective assessment of clinical outcomes in patients with lung cancer]

BACKGROUND

The aim of this study was to assess the outcome in patients with lung cancer.

PATIENTS AND METHODS

Prospective study in 93 patients with lung cancer in 3 community hospitals. In each evaluation (4-6 weeks) the following results were obtained: a) questionnaire on the quality of life or performance status (QoL/PS), based on different instruments (Karnofsky Performance Scale [KPS], ECOG, QLQ-C30, and the Nottingham Health Profile [NHP], and b) a clinical questionnaire. Active follow-up was for 18 months and survival tracking was to five years. A descriptive analysis of the outcome variables and a survival analysis (Kaplan-Meier) were done. The prognostic value of each instrument (Cox) and the correlation between the instruments (Spearman) were also evaluated.

RESULTS

The mean values recorded at the time of diagnosis between 60% and 70% of the maximum value possible. Mean survival was 12.4 months; accumulated survival was 30% to one year and 4% to 55 months. Only 17% of patients presented any disease-free period. Toxicity of treatment was almost always irrelevant. The correlation between the KPS, the QLQ-30 and the NHP was acceptable and their initial values were important prognostic factors. The QoL/PS scores for the survivors were similar to their initial values, but the global values were 11%.

CONCLUSIONS

The outcomes measures used in this study provide very useful information, although registration and analysis of the necessary data should be systematic. The KPS was comparable to the other QoL/PS indicators used, but it is shorter, more acceptable and easier to use. Better QoL/PS measurement instruments are needed to evaluate outcomes in the practice of clinical oncology.

A revised description of Haplosporidium armoricanum, parasite of Ostrea edulis L. from Galicia, northwestern Spain, with special reference to the spore-wall filaments

Haplosporidian spores from Ostrea edulis, previously described as Minchinia armoricana, were reexamined by light and electron microscopy. These spores were either free among host cells or enclosed in sporocysts. They contained two long epispore cytoplasm extensions (ECE), each possessing cytoskeletal structures corresponding to the filaments. After lysis and degradation of the ECE, these extensions disappeared and the spores became devoid of membrane-bound extensions. However, 2 long filaments (approximately 130 microm long) persisted that were closely attached, in opposition to the spore wall, by a bundle of 9-13 fibers each. Thus, we propose a revised description of M. armoricana (= H. armoricana) to confirm its placement in the genus Haplosporidium as H. armoricanum.

Hypothalamic hamartomas and gelastic epilepsy: a spectroscopic study

BACKGROUND

Patients with hypothalamic hamartomas present with epileptic attacks of laughter and later experience multiple seizure types and cognitive decline, suggestive of secondary generalized epilepsy. It has been suggested in the past that gelastic seizures originate in the temporal lobes rather than in the hamartoma, but temporal resections have been ineffective. Recent electrophysiologic evidence suggests that the epileptogenic discharges may originate in the hamartoma itself.

METHODS

We used proton magnetic resonance spectroscopic imaging to quantify the amount of neuronal damage in the temporal lobes and hamartomas of patients with hypothalamic hamartomas and gelastic seizures. Five patients were studied and the relative intensity of N-acetylaspartate to creatine (NAA/Cr) was determined for both temporal lobes as well as for the hamartoma. These values were compared with signals from the temporal lobes and hypothalami of normal control subjects.

RESULTS

NAA/Cr was not significantly different from normal control subjects for either temporal lobe, nor was there a significant asymmetry between the two temporal lobes for any of the patients. NAA resonance signals were present in the hamartomas, and the ratio of NAA to Cr was decreased in the hamartomas compared with the hypothalami of normal control subjects (t = 4.5, p = 0.005).

CONCLUSIONS

We found no detectable neuronal damage in the temporal lobes of patients with hypothalamic hamartomas and gelastic epilepsy. This is further evidence that gelastic seizures do not originate in the temporal lobes of these patients.

[Memory T lymphocytes during infection and tuberculosis infection and disease]

OBJECTIVE

To examine the role of naive and memory T cells (as determined by CD45 isoforms) in recent tuberculosis infection and in pulmonary and pleural forms to the disease. To relate such subpopulations to serum levels of soluble IL-2 receptor (sIL-2R) and interleukin-6 (IL-6).

METHODS

T cell subpopulations (CD3, CD4, CD8), naive (CD45RA), memory (CD45RO) and activated CD24+ T cells (IL-2 receptor) were measured in the peripheral blood and pleura of patients with recent tuberculosis infection (n = 7), pulmonary tuberculosis (n = 22) and tuberculosis pleurisy (n = 12). Serum levels of sIL-2 and IL-6 were determined in 13 patients with pleural or pulmonary tuberculosis and their relation to CD45RA and CD45RO subsets was analyzed.

RESULTS

T lymphocytosis involving all the subpopulations studied, including naive and memory T cells, was detected, although the RA:RO ratio did not change in relation to control levels. Marked increases in memory T cells and CD24+ T cells were found for patients with tuberculous pleurisy. sIL-2 and IL-6 levels were unrelated to naive and memory T cell subpopulations.

CONCLUSIONS

T lymphocytosis involving all T cell subsets can be observed in recent tuberculosis infection; both naive and memory T cells are implicated, although neither one predominates over the other. In tuberculous pleurisy there is compartmentalization of memory and activated T cells, which presumably play important roles in the local immune response to Mycobacterium tuberculosis.

Low-grade astrocytomas in children: evolving management strategies

Developments in imaging and in neurosurgical techniques over the past decade have substantially altered the management of children with low-grade astrocytoma. Indications for surgery have become more clearly defined, and a larger proportion of children undergo complete or subtotal resection than in the past. Fewer receive adjuvant therapy, even though the options in this regard are more numerous now and theoretically likely to result in less morbidity than conventional external beam radiotherapy. This review will address in particular the correlations between location, imaging appearance, and behavior that need to be more widely appreciated, and present recommendations regarding the management of these tumors.

Alanyl-aminopeptidase activity decrease in cerebrospinal fluid of Alzheimer patients

We analyzed the amino acid concentrations and aminopeptidase activities in plasma and the cerebrospinal fluid (CSF) of Alzheimer patients. Correlations were calculated between these parameters and the degree of cognitive impairment, duration of the disease and age. In comparison with a control group, no changes were found in the levels of amino acids in CSF or plasma of Alzheimer patients. Alanyl-aminopeptidase activity was significantly lower in the CSF of Alzheimer patients, whereas no differences in CSF were detected as regards the remaining aminopeptidases. The plasma/CSF ratio for aminopeptidase activities was higher in AD patients than in controls, although the difference was only significant for alanyl-aminopeptidase. Amino acid ratios did not show this general tendency. The correlations between plasma aspartate and glutamate concentrations and the stage of the disease, measured with the Mini Mental State Examination, were studied. Changes in aminopeptidase activities and their role in protein dysfunction underlying Alzheimer disease are discussed.

[Achalasia, alacrima without adrenal insufficiency with peripheral and autonomic neurological dysfunction (Allgrove's syndrome)]

OBJECTIVE

To present a patient with Allgrove's syndrome and peripheral and autonomic neurological dysfunction. This pathological entity has not been previously reported in national medical literature.

BACKGROUND

Allgrove's syndrome is comprised of achalasia, alacrima and adrenal insufficiency. It is a rare disease. Some isolated cases have been informed in the literature. The most extensive series was published by Grant et al in 1993. In this study, 20 patients from various european countries were analyzed.

METHOD

We describe a patient with diagnosis suggestive of Allgrove's syndrome and expose the results of a review of the medical literature concerning this syndrome. We emphasize in neurological dysfunction of these patients. Such abnormalities are not actually well defined in this syndrome.

RESULTS

A twelve-year-old male patient was admitted to the hospital for dysphagia. A diagnosis of achalasia was performed with endoscopy and esophagogram and confirmed with esophageal manometry. Physical examination showed alacrima and neurological dysfunction. Stimulation of adrenal function with ACTH (Cortosin) was normal. Neurologic examination revealed: peripheral neuropathy, autonomic dysfunction; corticospinal, psychomotor and intellectual impairment.

CONCLUSION

Allgrove's syndrome must be in mind in physicians who see children with achalasia. Nevertheless adrenal insufficiency is not always present in cases when diagnosis is performed. It may appear several years afterwards. Neurological dysfunction seems to be the most prominent feature.

Molecular cloning of TvDAO1, a gene encoding a D-amino acid oxidase from Trigonopsis variabilis and its expression in Saccharomyces cerevisiae and Kluyveromyces lactis

The DAO1 gene of Trigonopsis variabilis encoding a D-amino acid oxidase (EC 1.4.3.3) was isolated from genomic clones selected for their specific hybridization to synthetic oligodeoxyribonucleotide probes based on regions of the enzyme that have been conserved through evolution. The nucleotide sequence of the gene predicts a protein with similarities to human, pig, rabbit, mouse and Fusarium solani D-amino acid oxidases. The open reading frame of the T. variabilis DAO1 gene was interrupted by an intron. The Dao1p sequence displays two regions, one in the N-terminal section--the FAD binding site--and the other near the C-terminal region that contains conserved signatures found in all the D-amino acid oxidases. The three C-terminal amino acids suggest that the enzyme may be located in peroxisomes. Northern blot experiments showed that no transcriptional activation occurred in the presence of D-methionine. The cDNA encoding Dao1p was expressed in Saccharomyces cerevisiae and Kluyveromyces lactis. Both yeast species are able to synthesize a functional enzyme under the control of the GAL1 promoter. In K. lactis, up to six times more enzyme units per gram of dry weight are produced with a multicopy plasmid in comparison with the wild-type strain of T. variabilis. The yeast expression system we describe may constitute an alternative source for the production of D-amino acid oxidases at industrial level.

Aesthetic reductive thyroid chondroplasty

A modified technique to reduce the prominent laryngeal cartilage is presented.

Traumatic aneurysm from shaken baby syndrome: case report

OBJECTIVE AND IMPORTANCE

We present a 6-week-old infant who developed a traumatic aneurysm from clearly documented shaken baby syndrome. Despite the theoretical similarity in the mechanism of such injuries, this is the first aneurysm reported that resulted from such a cause. The infant is also the youngest reported patient to have suffered from a traumatic aneurysm.

CLINICAL PRESENTATION

Police records documented shaking of the child as well as direct impact on the child's head. Three weeks later, the patient developed an intracerebral hemorrhage, which was revealed by angiography to have resulted from a pericallosal artery aneurysm.

TECHNIQUE

The aneurysm was totally resected through a porencephalic cyst, which had developed secondary to ischemic injury to the brain.

CONCLUSION

The temporal course, as well as the location of this traumatic aneurysm, is similar to that in older patients.

Identification of immunogenic epitopes of the 170-kDa subunit adhesin of Entamoeba histolytica in patients with invasive amebiasis

Entamoeba histolytica causes amebic dysentery (AD) and liver abscess (ALA). Little is known about protective immunity to amebiasis, and studies in this area have been complicated by the paucity of defined ameba antigens. We examined the proliferative responses of peripheral blood mononuclear cells (PBMC) from patients with AD and ALA to a recombinant protein containing a portion of the 170 kDa adhesin of E. histolytica (170CR), and to two synthetic peptides (1 and 2) derived from the 170 kDa sequence that were predicted to contain T cell epitopes. A significant number of patients with AD and ALA had PBMC that proliferated to 170CR molecule, and several individuals with ALA and AD had T cells that recognized one or both peptides. Contrarily, individuals from a non-endemic region for amebiasis did not respond to 170CR protein, or to both peptides. In regard to antibody response, nine of fifteen patients with ALA showed antibodies to 170CR protein. These same patients had antibodies to peptide 2. We identified peptides from 170-kDa adhesin that may contain both T and B cell epitopes recognized by some patients with invasive amebiasis. These peptides may be valuable reagents in studies of the immune response to amebiasis.

Stereotactic external beam irradiation in previously untreated brain tumors in children and adolescents

Stereotactically guided external beam irradiation may be a useful form of treatment for small, well-circumscribed, but surgically inaccessible, primary brain tumors that are either benign or of low malignant potential. Between March 1988 and December 1991, 10 children and adolescents with previously untreated primary brain tumors were treated with stereotactic external beam irradiation (SEBI) using a linac-based dynamic technique. Eleven lesions were treated in the 10 patients. Treatment was given using a collimator diameter of 1.5-4 cm (median 2 cm). Single fractions of 18, 20, and 25 Gy were used for 3 lesions in 2 patients. A fractionated schedule delivering a median dose of 42 Gy in 6 fractions over 2 weeks was used in the remaining 8 patients. Morbidity related to treatment was minimal. Three patients suffered a temporary worsening of preexisting neurological symptoms and/or signs at 2, 5, and 5 months posttreatment, with subsequent recovery in all. With a median follow up post-SEBI of 17.5 months (range 5-47 months), improvement in neurological findings related to the lesion was noted for 5 treated lesions; 6 remained clinically stable. Seven of the 11 treated lesions improved radiologically, and only 2 showed evidence of progressive disease. Stereotactic external beam irradiation represents a potentially valuable therapeutic option for selected primary brain tumors in the pediatric and adolescent age group. Morbidity related to the treatment appears acceptable in frequency and type, and preliminary data with regard to response are encouraging. However, in order to assess the impact of such treatment on long-term tumor control and survival, further experience with a larger cohort of patients followed for a longer period of time will be necessary.

[Percutaneous mitral valvuloplasty. Immediate results with the 30 mm diameter dilatation balloon]

Percutaneous balloon dilatation of the mitral valve is a promising alternative to surgical treatment for patients with mitral stenosis. We analysed echocardiographic and haemodynamic results in 62 consecutive patients who underwent mitral dilatation with a big and one chamber balloon (30 mm diameter). The relationship between the dilatation balloon area and body surface was 4.2 (in 98% of patients it was bigger than 3.5). In the whole series we get significant improvements in the haemodynamic parameters and mitral areas (0.91 cm2 versus 1.78 cm2)(p < 0.005). According to the echocardiographic score, patients were divided in two groups. Good results (mitral area > 1.5 cm2, and final, valve area 50% greater than the initial area), were obtained in 93% of patients with a score of 8 or less, and in 45% of patients with a score bigger than 8. Seventy-five percent of patients with bad results (mitral area < 1.5 cm2) were in atrial fibrillation versus 37% of patients where we get a good results. Mortality of procedure was nulle, and two patients required surgery because of procedure failure for mitral insufficiency. We can conclude: percutaneous mitral valvuloplasty with single balloon is valid alternative, and good results can be expected if there is a good relationship between the area of balloon and patient's body-surface. The echocardiographic score and presence of atrial fibrillation can predict immediate results of this technique.

Dysplastic gangliocytoma (Lhermitte-Duclos disease): CT and MR imaging

Dysplastic gangliocytoma (Lhermitte-Duclos disease) is a rare entity. Usually presenting as a posterior fossa mass, dysplastic gangliocytoma is not a true neoplasm but a hard-to-characterize lesion that may represent an abnormality of cell migration or a phacomatosis. Previous reports of CT findings are rare in the radiologic literature, and high-field (1.5 Tesla) MR images have never been described in the pediatric age group. We present a case of dysplastic gangliocytoma in a one-year-old boy with CT and MR findings.

[Fetal hemoglobin in children with different neoplasms]

The rate of HbF was studied in 123 children with different malignancies in order to assess its changes and relationship with other values of peripheral blood. The cases were distributed into 34 with acute lymphoblastic leukaemia (ALL), 19 with acute myelogenous leukaemia (AML), 23 cases of Hodgkin's disease (HD), 16 of non-Hodgkin lymphoma (NHL) and 31 of different solid tumors (ST). ALL and AML groups had the highest HbF rates (2.88 +/- 1.93% and 2.63 +/- 2.7%, respectively), followed by HD and NHL (1.89 +/- 1.09% and 1.81 +/- 1.68%, respectively), whereas the ST group showed the lowest values (1.32 +/- 1.74%). When comparing these figures with the findings in a group of adult leukaemia and lymphoma (1.6 +/- 0,7% and 1.2 +/- 0.5%, respectively), it was found that HbF was increased in the children to a higher extent. The analysis of the gamma G and gamma A chains of HbF, performed on 14 of the patients, showed in 7 cases a correlation similar to the newborn pattern, while this was similar to the adults in the remainders. These findings suggest that some factors intrinsic to the neoplasm might favour, in a different degree, the re-expression of HbF, which, in turn, would not necessarily mean a reversion to the foctal stages since the correlation of the gamma chains was similar to the adult pattern in 50% of the cases studied.

Ascitic fluid polymorphonuclear cell count and serum to ascites albumin gradient in the diagnosis of bacterial peritonitis

The analysis of ascitic fluid has been complicated by several recently reported new tests. To simplify this assessment, we evaluated nine parameters prospectively and simultaneously in blood and ascitic fluid from 285 patients with ascites to determine which were the most reliable for immediate diagnosis of the etiology of the ascites and of its complications. Subjects were first divided into four groups: sterile cirrhotic ascites (n = 201), spontaneous bacterial peritonitis (n = 41), malignant ascites (n = 34), and miscellaneous ascites (n = 9). An ascitic fluid polymorphonuclear count greater than 500/microliters was the test with the greatest accuracy (96%) for the diagnosis of spontaneous bacterial peritonitis. Neither the most precise cutoff values for ascitic fluid pH (less than 7.32) and ascitic fluid lactate (greater than 32 mg/dl), nor their respective blood-ascitic fluid gradients (greater than 0.11 and less than -20 mg/dl) were more reliable indexes of spontaneous bacterial peritonitis, mainly due to the decreased ascitic fluid pH and increased ascitic fluid lactate observed in malignant ascites, tuberculous peritonitis, and pancreatic ascites. A blood-ascitic fluid albumin gradient less than 1.1 g/dl was the most accurate parameter for the diagnosis of malignant ascites (diagnostic efficacy, 93%). Therefore, the etiologic analysis of ascitic fluid might be simplified and the single practice of two tests, ascitic fluid polymorphonuclear cell count and blood-ascitic fluid albumin gradient, provides immediately useful information.

Emergency aortic valve replacement in Brucella endocarditis: report of two cases

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