Meyer dysplasia in the differential diagnosis of hip disease in young children

OBJECTIVES

To describe a rare developmental disorder of the femoral capital epiphysis in infants and children that is often misdiagnosed and to suggest an evaluation protocol to differentiate it from other hip problems.

DESIGN

Case series.

SETTING

Tertiary care center.

SUBJECTS

Five consecutive patients referred for evaluation of acute onset of limping between January 1990 and December 1997.

INTERVENTION

All clinical and imaging data were collected.

RESULTS

Two of the 5 patients were initially diagnosed as having osteomyelitis and 3 as having Perthes disease. The diagnosis of Meyer dysplasia was confirmed by plain film of the pelvis, a negative bone scan, or normal bone marrow findings on magnetic resonance imaging. The limping resolved without treatment in all patients within 1 to 3 weeks.

CONCLUSIONS

Meyer dysplasia is a benign condition that should be included in the differential diagnosis of hip disease in infants and children. Awareness of this condition may prevent unnecessary hospitalization and treatment.

The natural history of primary herpes simplex type 1 gingivostomatitis in children

Herpetic gingivostomatitis is the most common specific clinical manifestation of primary herpes simplex infection in childhood. The aim of the present study was to describe the clinical signs, symptoms, viral shedding, serologic findings, and complications in community-acquired gingivostomatitis. We prospectively followed children with herpes simplex type 1 gingivostomatitis lasting less than 72 hours. Clinical examination and viral culture were repeated every 2 to 3 days as long as symptoms or signs persisted. Thirty-six children (ages 12-77 months) were included in the study. Mean duration of oral lesions was 12.0+/-3.4 days; extraoral lesions (in 26 children), 12.0 +/-3.9 days; fever, 4.4+/-2.4 days; and eating/drinking difficulties, 9.1+/-3.0 and 7.1+/-3.1 days, respectively. In all children, viral cultures of the oral lesions were positive for herpes simplex virus (HSV) type 1; viral shedding persisted for a mean of 7.1+/-2.5 days (range 2-12 days). The main complications were dehydration, with three children hospitalized for intravenous rehydration, and one case of secondary bacteremia. Herpetic gingivostomatitis is a relatively severe manifestation of primary HSV type 1 infection in young children.

Childhood Behçet's disease: clinical features and comparison with adult-onset disease

OBJECTIVE

To study the clinical spectrum of Behçet's disease (BD) in childhood, in comparison to adult-onset disease.

METHODS

Nineteen children, who fulfilled disease criteria up to the age of 16 yr, were studied. The results were compared to those of 34 adult patients with BD. An activity index and severity score were calculated for both study groups.

RESULTS

The mean age of disease onset was 6.9+/-3.9 yr, similar ages of onset were found in males and females. The clinical spectrum of childhood BD resembled that of adult disease; however, the prevalence of certain manifestations was different between children and adults. Children with BD had significantly less genital ulcers, less vascular thromboses and more non-specific gastrointestinal symptoms, as well as central nervous system involvement and arthralgia. A relatively high prevalence of uveitis was found in childhood BD. The activity index and severity score were significantly lower in children than in adults.

CONCLUSION

Our results point to a similar systemic expression of BD in children and adults; however, the disease seems to run a less severe course in children.

Seasonal variation in systemic onset juvenile rheumatoid arthritis in Israel

OBJECTIVE

To determine whether there is a seasonal peak onset of systemic juvenile rheumatoid arthritis (SOJRA) suggestive of an infectious etiology. We examined the seasonal variability of SOJRA in Israel.

METHODS

A multicenter retrospective chart review of 59 patients with SOJRA, enrolled from 10 rheumatology units or pediatric departments in Israel. All patients met defined criteria of SOJRA.

RESULTS

Fifty-nine patients (31 female, 28 male) were followed from 1982 to 1997. Their mean age was 7.1 +/- 4.3 years (range 0.9-16). Forty-six were Jewish and 13 were Arabs or of Bedouin origin. Eighteen patients (31%) had disease onset in the winter, 16 (27%) in the spring, 12 (20%) in the summer, and 13 (22%) in the fall. Twenty-eight patients had a monophasic disease subtype, while 31 had a chronic or cyclic subtype. The seasonal onset in the patients with the monophasic type versus the chronic or the cyclic type shows 7 versus 11 in the winter, 7 versus 9 in spring, 8 versus 4 in summer, and 6 versus 7 in fall, respectively.

CONCLUSION

There is no seasonal pattern to SOJRA disease onset in Israel. However, the disease onset of patients having the chronic or the polycyclic subtype tends to be more common in winter and spring. Since patients with this type have more severe disease, it is possible that another specific infectious agent is one of the factors involved in the pathogenesis of the disease. Larger sampling and multicenter studies are required to clarify this point.

Autosomal recessive microcephaly with neonatal myoclonic seizures: clinical and MRI findings

We describe an infant who was born to a consanguineous couple of Palestinian origin. The patient had severe microcephaly, myoclonic seizures, hypsarrythmia, spasticity, hypertonicity, and profound mental retardation. A similar case was reported in another unrelated Palestinian family, suggesting that this condition may be endemic. The condition resembles early onset myoclonic seizures and spasticity described by Tolmie et al.: Am J Med Genet 27:583-594 [1987]. To the best of our knowledge, only four pairs of sibs have been described with this syndrome; however, to date no magnetic resonance imaging (MRI) findings were reported for this condition. We present the clinical and radiological findings in the patients, including the first report of MRI findings.

Colchicine-induced myoneuropathy in childhood

Colchicine is used in the treatment of gouty arthritis, familial Mediterranean fever, amyloidosis, Behcet disease and dermatoses. Myoneuropathy is a rare side-effect reported either with intoxication or in elderly patients with chronic renal insufficiency causing elevated plasma drug levels. We report the first two cases of myoneuropathy in children, both taking appropriate doses of colchicine, and having normal renal function. The myoneuropathic changes were reversible after stopping treatment. The cause of colchicine myoneuropathy is unclear.

CONCLUSION

In children treated with colchicine, neuromuscular phenomena of unknown aetiology may be related to the drug, even with a lack of intoxication or renal insufficiency.

Juvenile Behçet's disease in Israel. The Pediatric Rheumatology Study Group of Israel

OBJECTIVE

Behçet's disease (BD) is a vasculitis mainly observed in young adult males. Juvenile BD is rare and only small series of pediatric cases have been reported. The objective of this study was to define the epidemiology and clinical features of BD among Israeli children.

METHODS

A questionnaire was sent to 8 pediatric rheumatology units in Israel and 30 cases of BD diagnosed before the age of 16 years were identified.

RESULTS

Fifteen patients fulfilled the International Study Group Criteria for BD, while 15 had an incomplete form of BD. Among the patients with complete BD, stomatitis and skin involvement were the most common manifestations. Other symptoms included genital ulcers, uveitis, CNS involvement, arthritis, and gastrointestinal involvement. A positive family history was elicited in 3 patients. HLA B5 was found in 7 of 12 patients (58%). The 15 patients with incomplete BD all had recurrent stomatitis; other manifestations included uveitis, arthritis, and genital ulcers. HLA B5 was found in 94% of this group.

CONCLUSION

Juvenile BD in Israel is not uncommon, and is frequently associated with HLA B5 positivity. This could indicate a genetic susceptibility in our region. Half of the patients in our series had an incomplete form of BD, which may represent a less severe variant of the disease. In any case, careful follow-up is required, since their condition could eventually evolve into complete BD.

Reversible cortical atrophy and cognitive decline induced by valproic acid

An 18-year-old male suffered from familial progressive myoclonic epilepsy from the age of 7 years. In addition to seizures, there was a marked decline in school performance. At the age of 14 years, sodium valproate was started as add-on therapy; 2 weeks later he was hospitalized in a stuporous state. The serum level of valproate was within the therapeutic range. Cognitive evaluation disclosed moderate mental retardation. No metabolic abnormalities were detected. Valproate was discontinued and during the 4 following months, a slow but significant improvement was documented in cognitive functions. Repeated assessment was within the range of mild mental retardation. Initially, magnetic resonance imaging (MRI) showed mild cortical atrophy. A subsequent MRI study performed 2 years later was normal.

Neonatal assessment of babies conceived by in vitro fertilization

PROBLEM

Neonatal outcome of in vitro fertilization (IVF) pregnancies has been described by different authors, but several issues have yet to be resolved. The aim of the present study was to evaluate neonates conceived in vitro and to direct special attention to neonatal morbidity and prevalence of minor abnormalities. The information that has been accumulated so far is scant.

METHOD

The first 100 babies conceived in vitro, and subsequently born in our institute, were investigated and compared with the general, spontaneously conceived newborn population. All infants were examined by a senior neonatologist, and the data that were recorded included gestational age at delivery, birth weight, gender, major malformations, minor congenital abnormalities, neonatal mortality, and neonatal morbidity (including asphyxia, jaundice, meconium aspiration, hypoglycemia, and hypocalcemia).

RESULTS AND CONCLUSIONS

The data indicate that the IVF neonates assessed had a higher rate of low birth weight (37%), twinning (30%), and preterm birth (20%) in comparison with the general reference population (p < 0.05). However, no differences were encountered either in the rate of small for gestational age infants or the incidence of major malformations and minor abnormalities between these groups of newborns. The overall neonatal morbidity in IVF babies was found to exceed that of the general population. Nevertheless, at birth, there were no clinical pathognomonic signs typical of IVF babies, although more detailed metabolic, endocrine, and neurobehavioral studies are still required to confirm that newborns conceived in vitro do not differ from those conceived spontaneously in any of these respects.

Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study

OBJECTIVES

To examine the efficacy of aciclovir suspension for treating herpetic gingivostomatitis in young children.

DESIGN

Randomised double blind placebo controlled study.

SETTING

Day care unit of a tertiary paediatric hospital.

SUBJECTS

72 children aged 1-6 years with clinical manifestations of gingivostomatitis lasting less than 72 hours; 61 children with cultures positive for herpes simplex virus finished the study.

MAIN OUTCOME MEASURES

Duration of oral lesions, fever, eating and drinking difficulties, and viral shedding.

INTERVENTION

Aciclovir suspension 15 mg/kg five times a day for seven days, or placebo.

RESULTS

Children receiving aciclovir had oral lesions for a shorter period than children receiving placebo (median 4 v 10 days (difference 6 days, 95% confidence interval 4.0 to 8.0)) and earlier disappearance of the following signs and symptoms: fever (1 v 3 days (2 days, 0.8 to 3.2)); extraoral lesions (lesions around the mouth but outside the oral cavity) (0 v 5.5 days (5.5 days, 1.3 to 4.7)); eating difficulties (4 v 7 days (3 days, 1.31 to 4.69)); and drinking difficulties (3 v 6 days (3 days, 1.1 to 4.9)). Viral shedding was significantly shorter in the group treated with aciclovir (1 v 5 days (4 days, 2.9 to 5.1)).

CONCLUSIONS

Oral aciclovir treatment for herpetic gingivostomatitis, started within the first three days of onset, shortens the duration of all clinical manifestations and the infectivity of affected children. Further studies are needed to evaluate the ideal dose and length of treatment.

Lymphedema praecox seen as isolated unilateral arm involvement: case report and review of the literature

Lymphedema praecox, a type of primary lymphedema, becomes evident at puberty, occurs mostly in girls, and is usually confined to the lower extremities. Arms tend to be involved in either congenital or secondary lymphedema. We describe a unique localization in an 11-year-old girl who had primary lymphedema of the right hand and arm. The pertinent literature is reviewed.

Fixed drug eruption of the penis due to hydroxyzine hydrochloride

OBJECTIVE

To report four cases of fixed drug eruption induced by hydroxyzine hydrochloride (Otarex, Teva, Israel).

CASE SUMMARY

Four children with restlessness who were treated with hydroxyzine hydrochloride developed fixed drug eruption of the penis. Drug discontinuation was followed by complete resolution of the skin eruption. Rechallenge resulted in the same drug rash. Macrophage migration inhibiting factor (MIF) assay with hydroxyzine hydrochloride was positive.

DISCUSSION

The pathogenesis of fixed drug eruption and the role of macrophage MIF assay in diagnosis is discussed.

CONCLUSIONS

A fixed drug eruption induced by hydroxyzine hydrochloride is possible, but is a rare phenomenon.

Anti-Ro (SSA) and anti-La (SSB) antibodies and complete congenital heart block

Complete congenital heart block (CCHB) is the most severe manifestation of neonatal lupus syndrome, associated with a mortality rate of up to 31%. It is caused by irreversible damage to the cardiac conduction system due to the transplacental passage of maternal antibodies to the fetus. Anti-Ro (SSA) and anti-La (SSB) antibodies are usually detected in sera of mothers of children with prenatally diagnosed CCHB and in cardiac tissues of affected newborns. Their pathogeneic role in the development of CCHB has been established in several studies. When CCHB is detected during pregnancy, careful monitoring and delivery are needed before heart failure is developed. Treatment strategies are debatable and may include prophylactic therapy for high-risk pregnant women and a combination of intrauterine plasmapheresis with plasma exchange or with corticosteroids. Pacemaker insertion is required in most infants during the first three months of life. Assays for anti-Ro (SSA) and anti-La (SSB) antibodies should be performed on sera of pregnant women with SLE and newborns with CCHB.

Comparative evaluation of cefixime versus amoxicillin-clavulanate following ceftriaxone therapy of pneumonia

Preliminary results have recently shown that an early switch from parenteral antimicrobials to an oral substitute provides an effective means of treating pneumonia in pediatric patients. In a controlled randomized study, 62 children with community-acquired lobar/segmental pneumonia were selected to receive 8 days of cefixime or amoxicillin-clavulanate after an initial therapy of two doses of parenteral ceftriaxone. Enrollment criteria included: age 6 months to 5 years, fever > 38.5 degrees C, white blood cell (WBC) count > or = 15,000/ mm3, and lobar/segmental pneumonia on chest radiograph. Twenty-nine patients were randomized to receive oral cefixime and 33 to oral amoxicillin-clavulanate. The two groups were comparable in the following pretreatment parameters: age, duration of illness, temperature, mean WBC count, erythrocyte sedimentation rate, C-reactive protein, and need for hospitalization. Days of resolution of high fever, tachypnea, cough, grunting, and laboratory test abnormalities were similar in the two groups. Clinical response at the end of treatment showed cure, improvement, and failure in 97%, 3%, and 0%, respectively, in the cefixime group and in 88%, 6%, and 6%, respectively in the amoxicillin-clavulanate group (P = NS). We conclude that young children with community-acquired lobar/segmental pneumonia can be successfully treated with 2 days of parenteral ceftriaxone followed by 8 days of oral cefixime or amoxicillin-clavulanate.

Recombinant human insulin-like growth factor (IGF) binding protein-3 stimulates prostate carcinoma cell proliferation via an IGF-dependent mechanism. Role of serine proteases

Insulin-like growth factor-binding proteins (IGFBPs) modulate IGF action at cellular level, through either inhibition or potentiation, and they also have intrinsic activity that is independent of their binding to IGFs. In prostate carcinoma (PC-3) cells, which are capable of growth for several days in serum-free medium, non-glycosylated recombinant human IGFBP-3 (rhIGFBP-3) had a biphasic mitogenic effect, stimulation being dose-dependent up to 20 ng/ml, followed by progressive depression down to zero stimulation at 150-200 ng/ml. This mitogenic effect was not intrinsic activity, but involved IGF-II secreted by the cells, since stimulation was abolished in the presence of anti-type 1 IGF receptor antibody (alpha IR-3). Western ligand- and immunoblot analysis of the culture media revealed several IGFBP species, in particular IGFBP-3 which exhibited an electrophoretic profile characteristic of limited proteolysis. The amounts of the proteolytic fragments increased in parallel with the concentrations of added rhIGFBP-3, but a large amount of intact protein remained at the highest concentrations added. When a serine protease inhibitor, 4-(2-aminoethyl)-benzenesulphonyl fluoride (Pefabloc SC), was added at concentrations demonstrated to be non-toxic to the cells, IGFBP-3 proteolysis was diminished and rhIGFBP-3-induced stimulation of proliferation was suppressed. Conversely, in the presence of plasminogen transformed to plasmin by urokinase secreted by the cells, proliferation stimulated by rhIGFBP-3 and its proteolysis were enhanced. Our results suggest that the biphasic mitogenic effect of rhIGFBP-3 on PC-3 cells reflects changes in the availability to the cells of the IGF-II they secrete. This availability depends on the extent of IGFBP-3 proteolysis (which promotes release of bound IGF-II) and on the proportion of intact forms (which sequestrate secreted IGF-II).

A 'sweet' indication for ovulation induction

In diabetic patients, euglycaemia at the time of conception is crucial for the success of the pregnancy. In consideration of the difficulty in achieving and maintaining tight glycaemic control for long periods, we administered clomiphene citrate, which is usually indicated in cases of absent or infrequent ovulation, to enhance fecundability in 10 pregestational diabetic patients. All conceived within one to three cycles of the drug, and nine delivered healthy term babies after uneventful pregnancies; one aborted spontaneously in the eighth gestational week. No effect of the drug on the diabetes was noted as based on measurements of glycosylated haemoglobin and fructosamine concentrations and the absence of changes in the patients' insulin requirements. In the light of these successful results, and in view of the importance of euglycaemia at the beginning of diabetic pregnancies, we suggest a new 'sweet' indication for the use of clomiphene citrate.

Viscosity and refractive index of follicular fluid in relation to in vitro fertilization

PURPOSE

To set the standard values of follicular fluid viscosity and refractive index, and to investigate a possible relationship between these physiological parameters and the outcome of in vitro fertilization treatment.

DESIGN AND RESULTS

128 samples of follicular fluid were collected from 40 in vitro fertilization patients. Viscosity determinations (centipoise; mean +/- SD) for shear rates of 23, 46, 115, and 230 were 2.04 +/- 0.86, 1.84 +/- 0.49, 1.48 +/- 0.27, and 1.38 +/- 0.22, respectively. The average (+/- SD) refractive index was 1.030 +/- 0.002. There was no significant difference between the values of thawed frozen fluids and fresh samples of the same specimens. The data showed no correlation between follicular fluid viscosity or refractive index and the presence of oocytes, their maturation grade or their fertilizing capacity.

CONCLUSIONS

For the first time, values of the viscosity and refractive index of follicular fluid obtained during in vitro fertilization have been determined. However, these preliminary results did not reveal any relationship between the physiological parameters examined and the outcome of in vitro fertilization treatment.

Serum-sickness-like reaction associated with minocycline therapy in adolescents

OBJECTIVE

To describe a serum-sickness-like reaction in five adolescents treated with minocycline.

CASE SUMMARY

Five adolescents developed a rash and arthralgias/arthritis after taking minocycline for 10-30 days. Symptoms resolved gradually after the medication was stopped.

DISCUSSION

Serum sickness is not described in the pharmacology literature as an adverse effect of minocycline, and in the English literature there are only two case reports. The migration inhibitory factor assay and mast cell degranulation test were positive in four of the five patients. The results of these assays were consistent with a role for minocycline in causing these reactions.

CONCLUSIONS

Clinicians should be aware of the possibility of serum-sickness-like reaction as an adverse effect of minocycline.

Parental presence during lumbar puncture: anxiety and attitude toward the procedure

We evaluated the anxiety state of 57 parents whose children required lumbar puncture (LP) as part of a diagnostic workup. We also examined parental attitude about their presence during the procedure. The parents were randomly divided into two groups: 29 (51%) were present during the LP (group A) and 28 (49%) remained outside (group B). There were no differences in the anxiety scores between the two groups. All parents in group A and seven in group B (25%) reported a preference for staying with the child should he/she need LP in the future. The results also showed that allowing the parents to be present during LP does not aggravate their anxiety compared with controls.

Normal diurnal variation in serum cortisol concentration in asthmatic children treated with inhaled budesonide

BACKGROUND

Twenty-four-hour serum cortisol secretion is a sensitive parameter for the assessment of the pituitary-adrenal function of asthmatic children treated with inhaled corticosteroids. This study was undertaken to determine the effect of the long-term administration of inhaled budesonide on 24-hour cortisol production in young children with asthma.

METHODS

We studied 11 children, aged 7 to 12 years, with severe perennial asthma. All had been receiving 100 micrograms of inhaled budesonide twice daily, administered with a spacer device, for 3 to 5 years. Serum cortisol concentration was measured at 8:00 A.M., 60 minutes after intravenous administration of 0.25 mg of corticotropin, and every 30 minutes for 24 hours in an open-design study. Urinary cortisol secretion was measured by 24-hour urine collection. All determinations were made with a radioimmunoassay kit.

RESULTS

The individual morning serum cortisol concentration and the serum cortisol concentration at 60 minutes after corticotropin stimulation were within normal limits in all children. The 24-hour urinary cortisol excretion was also normal. The individual 24-hour serum cortisol concentration showed a normal pattern in all children, with no evidence of nocturnal suppression of serum cortisol concentration.

CONCLUSION

Prolonged (3 to 5 years) administration of 200 micrograms/day of inhaled budesonide in young children with severe asthma does not impair pituitary-adrenal function, even according to the sensitive test for 24-hour serum cortisol secretion.

Lymphedema as a presenting sign of toxocariasis

Toxocariasis in children is usually an asymptomatic infection and those with clinical illness have non-specific systemic or local manifestations. We present a 24-month-old boy with bilateral lymphedema of the feet as the main clinical manifestation of toxocariasis. The child presented with limping and nonpitting edema of both feet. Laboratory investigation revealed leucocytosis of < 20,000/mm3 with a differential count of < 50% eosinophils. No other cause of edema was found. The ELISA for toxocariasis revealed a high titer of > or = 1:4,096. The limping and the lymphedema disappeared during the third week of his illness. We suggest that toxocariasis should be considered as a possible cause of lymphedema and eosinophilia in young children.

The grand multipara

Grandmultiparity (GMP) has long been considered an obstetric complication for both mother and fetus, although recent studies indicate that, with proper perinatal care, women with high-parity rates are no longer at high risk. The current study examines the outcome of delivery in 1700 women in their fifth or more delivery, as compared with two control groups: 622 primiparas and 735 multiparas (two to three previous deliveries). Excellent prenatal care was available free of charge to all parturients. Our objectives were to evaluate the management of GMP in contemporary obstetrics and to assess whether grand multiparas are still high-risk patients. The age of the grandmultiparas was significantly higher compared with with the control groups, which may explain the higher incidence among them of antenatal medical disorders, such as diabetes mellitus and hypertensive disease. No significant differences were found among the three groups for preterm or post-term births, small-for-gestational-age infants, polyhydramnios, oligohydramnios, perinatal death, fetal distress, multiple births, placenta previa, abruptio placentae or cord prolapse. Macrosomia was markedly higher in the grandmultiparas and multiparas than in nulliparas. Thus, our results indicate that good perinatal care can ensure better results in grandmultiparas, and that grandmultiparity no longer needs to be considered a high-risk obstetric category in our population.

Great grand multiparity--beyond the 10th delivery

OBJECTIVE

To investigate the perinatal outcome and obstetric complications of women delivering for the 10th time or more.

METHODS

Four hundred twenty women of great grand multiparity were analyzed in a modern health care setting and compared with our general population of obstetric patients, with regard to past history, maternal age, gestational age, mode of delivery, fetal outcome and intercurrent medical/obstetric problems.

RESULTS

The study group showed significantly lower rates of low birth weight infants and instrumental delivery. No significant difference was seen in the incidence of cesarean section, pathologic fetal presentation, maternal hypertension, gestational diabetes, hemorrhage, or perinatal morbidity or mortality. There was a slightly higher incidence of twin births compared with the general population.

CONCLUSION

It is probable that women capable of reaching their 10th delivery are basically healthy. If offered adequate perinatal care, they are not a high-risk group during subsequent deliveries.

Arthritis after mumps and measles vaccination

Measles, mumps, and rubella vaccine carries a risk of joint symptoms particularly in children under 5 years. A boy who presented with an inflamed knee after measles and mumps vaccination is reported; synovial fluid aspirated from the joint contained 4.3 x 10(9)/l leucocytes. It is thought that the mumps component is the aetiological cause of acute monoarthritis.

The treatment of rheumatic carditis: a review and meta-analysis

We performed a meta-analysis of the literature on the treatment of established rheumatic carditis to determine if corticosteroid therapy is superior to salicylates in preventing the sequela of inflammation--valvular damage. We identified 22 reports of comparative trials published since the introduction of corticosteroids in 1949. Five of the 22 studies met the criteria we established for the meta-analysis, which included using randomization and a 1-year follow-up for the presence of a new pathologic apical systolic murmur. Based on the meta-analysis, the advantage of corticosteroid treatment over salicylates in preventing a pathologic murmur at 1 year posttreatment is not statistically significant (estimated odds ratio 0.88; 95% confidence interval: 0.53 to 1.46). However, the meta-analysis is dominated by 1 large negative trial, and there was significant heterogeneity in the results obtained from the studies in the meta-analysis; thus, the question of whether corticosteroid therapy is marginally superior to salicylates for the prevention of valvular heart disease from rheumatic fever remains open.

Ultrastructural alterations of the amniocytes in 2 patients with rubella during the first trimester of pregnancy

The amniotic fluid cells of 2 patients with rubella at the 18th week of pregnancy were obtained during therapeutic abortion and examined with a transmission and a scanning electron microscope (SEM). In comparison with amniocytes of healthy women, those of rubella patients showed marked alterations, consisting of lack of heterochromatin, almost complete disappearance of the electron-dense cytoplasmic layer and membrane changes. The membrane damage was clearly demonstrated by SEM and was expressed by a decrease in the number and size of microvilli. Although more experience is needed for evaluation of the ultrastructure of the amniotic fluid cells in rubella patients, these findings may serve as an additional tool for the intrauterine diagnosis of rubella.

Density-dependent inhibition of mouse embryo fibroblast growth: involvement of IGFBP-3

Up until now the phenomenon of density dependent inhibition of growth has remained unexplained; one hypothesis suggests that autocrine growth inhibitory molecules are secreted in the medium of dense cultures and inhibit cell growth. From medium conditioned by mouse fibroblasts we purified a 45-kDa inhibitory factor which is an insulin-like growth factor binding protein (IGFBP-3). Based on different results we assumed that IGFBP-3 is a bifunctional molecule and has inhibitory function independent of its known function of binding IGF. In the present publication we attempted to verify whether IGFBP-3 is involved in DDI of growth. IGFBP-3 was secreted by mouse embryo fibroblasts (MEF). Its concentration in the medium increased with the cell density of the culture and was large at saturation density when DNA synthesis was minimum. Medium conditioned (CM) by dense culture was inhibitory compared to fresh medium and this inhibition disappeared when CM was preincubated with anti-IGFBP-3 IgG. Addition of FGFb to MEF dense cultures increased but transiently DNA synthesis which decreased as soon as 24 h after growth factor addition. By contrast accumulation of IGFBP-3 in the medium increased with time and was large at the time when DNA synthesis was minimum. Our results suggest that the rapid decrease of DNA synthesis in stimulated dense culture was the result of both depletion of the medium (particularly of FGFb) and the increase in concentration of inhibitory molecules like IGFBP-3. Addition of FGFb and preincubation of CM with anti-IGFBP-3 IgG were able to greatly reduce the inhibition.

Difference in biological effects between insulin-like growth factor binding protein 1 and 3

Insulin-like growth factor binding proteins 1 and 3 are essentially known as regulators of IGF bioactivity. However, we previously showed that IGFBP-3 was able, in chick embryo fibroblast (CEF), to 100% inhibit DNA synthesis stimulated by calf serum, while the maximal inhibition found with IGFBP-1 was 60%, suggesting a difference between the two IGFBPs in their biological functions. Results of the present work agree with this assumption: (a) Recombinant human IGFBP-3, like rat IGFBP-3, was able to 100% inhibit DNA synthesis stimulation induced by human serum, while this stimulation was 75% decreased by IGFBP-1. However, the most striking difference was observed when the effects of the two IGFBPs were compared for stimulation induced by a serum growth factor (SGF) fraction depleted in IGFs. Stimulation induced by the SFG fraction was more significantly decreased (p < 0.001) by IGFBP-3 than by IGFBP-1. The mean percent inhibition +/- SEM was 67.1 +/- 2.5 in the presence of IGFBP-3 (200 ng/ml) and 29.3 +/- 2.7 and 34.2 +/- 4 in the presence of 200 and 400 ng/ml IGFBP-1 respectively. Inhibition by 200 ng/ml IGFBP-1 and inhibition by 6 ng/ml IGFBP-3 were additive. However, inhibition by IGFBP-3 and that by IGFBP-1 were no longer additive at high concentrations of IGFBP-3, which might thus replace IGFBP-1. (b) FGF stimulation of CEF was similarly inhibition (65% and 70%) by IGFBP-1 and IGFBP-3. (c) TGF beta stimulation of CEF was more strongly decreased by IGFBP-3 (90%) than by IGFB-1 (60%).(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of methotrexate on radiologic progression in juvenile rheumatoid arthritis

OBJECTIVE

To assess the effects of methotrexate (MTX) therapy on radiologic progression in juvenile rheumatoid arthritis (JRA).

METHODS

We evaluated serial wrist radiographs for carpal length in 23 JRA patients with bilateral wrist involvement, before and during MTX treatment. These carpal length measurements were compared with established norms for carpal length in a healthy pediatric population.

RESULTS

Both clinical responders to MTX (17 of 23 patients) and nonresponders (6 of 23) had decreasing carpal length prior to initiation of the treatment. Eleven of the 17 clinical responders had improved carpal length after a mean of 2.5 years of MTX treatment. All 6 clinical nonresponders had progressive loss of carpal length.

CONCLUSION

MTX treatment resulted in radiologic improvement, as measured by carpal length, in the majority of children with JRA who had a clinical response to MTX.

IGF binding protein-3 secreted by the prostate adenocarcinoma cells (PC-3): differential effect on PC-3 and normal prostate cell growth

Deregulation of growth in malignant cells has been suggested to be the result of increased secretion by these cells, of autocrine growth factors; alternatively, this deregulation has been assumed to be related to loss of sensitivity by malignant cells to secreted inhibitory molecules. The results of the present publication lend new support to both hypotheses. We recently showed that human prostate adenocarcinoma cells (PC-3 cells) secreted insulin-like growth factor binding proteins (IGFBP) of 45, 34 and 25 kDa. From medium conditioned by dense cultures of PC-3 cells, we have now purified two IGFBPs of M(r) 45 kDa and 34 kDa. The N-amino terminal sequences were determined, and it was shown that they are IGFBP-3. IGFBP-34 appeared to be a deglycosylated form of IGFBP-45. The two IGFBPs had more affinity for IGF-II than for IGF-I. IGFBP-45 and IGFBP-34 were growth-inhibitory factors of chick embryo fibroblasts (CEF): they totally inhibited DNA synthesis stimulated by serum in CEF. Our results point to a clear difference between the effects of these IGFBPs upon growth of normal prostate cells and malignant PC-3 cells. At a concentration of 150 ng/ml, they inhibited growth of normal prostate cells even in the presence of 1 microgram/ml insulin. This suggests that such inhibition was not simply the result of a decrease by the IGFBP of stimulation induced by serum IGF or IGF secreted by the cells. At a concentration of 150 ng/ml, IGFBP did not modify the growth of PC-3 cells. In contrast, it stimulated growth of PC-3 cells when added at a concentration lower than 50 ng/ml (about 1 nM). Our results thus provide new insight concerning the regulation of growth in PC-3 cells.

Endometrial suction in luteal phase as a method of late postcoital contraception

In a pilot study group of 25 women presenting in our clinic after exposure at ovulation to undesired pregnancy, endometrial suction by means of a Pipelle catheter was performed. Sixteen of the 25 women had proven fertility and 9 had never tried to conceive. The women were aged 18 to 38 years. Pathological dating of endometrial sampling verified that the patients were actually post-ovulation in all cases studied. hCG tests were performed 10 to 14 days after endometrial suction and all were negative. We conclude that endometrial suction in the luteal phase is a possible means of postcoital non-hormonal contraception, and we are currently expanding our study.

Insulin-like growth factor binding protein (IGFBP-3), an inhibitor of serum growth factors other than IGF-I and -II

Our results show that an insulin-like growth factor binding protein, IGFBP-3, purified from rat serum, is an inhibitor of chick embryo fibroblast (CEF) growth. It abolished DNA synthesis in CEF stimulated by IGF-I as well as by human serum. Rat IGFBP-3 and IDF45 (an inhibitory diffusible factor secreted by mouse cells) had the same activities, confirming that they have an intrinsic capacity to inhibit serum stimulation and may be considered as growth inhibitors. Our data show that inhibition by IGFBP-3 of serum stimulation was not simply the result of its inhibition of IGF present in the serum: 1) While anti-IGF-I IgG was able to completely inhibit stimulation induced by added IGF-I, it did not decrease stimulation induced by 1% human serum. Anti-IGF-II IgG inhibited the stimulation induced by added IGF-II, but only 25% decreased the stimulation induced by 0.7% serum. The percent inhibition was not significantly increased when the concentration of serum was decreased to 0.2%, which induced 140% stimulation of DNA synthesis; 2) stimulation by 0.2% serum was much more inhibited by IGFBP-3 than by IgG anti IGF-II; 3) after separation of IGF-I and IGF-II from serum by chromatography of acidified serum proteins on BioGel P150, the remaining serum proteins (with a molecular mass greater than 45 kDa) which were depleted in IGF-I and -II (verified by RIA determination) still stimulated DNA synthesis, and this stimulation was 80% inhibited by IGFBP-3.

Stimulation by TGFβ of chick embryo fibroblasts—Inhibition by an IGFBP-3

The multiple effects of TGF beta on cell proliferation are not well understood. Our results show that TGF beta was a good but transient mitogen for chick embryo fibroblasts. DNA synthesis was three- to fourfold increased, even at high concentrations of TGF beta. We did not show a bimodal effect. An inhibitor of cell growth, that inhibits 100% of stimulation induced by serum in CEF, was purified to homogeneity from medium conditioned by mouse 3T3 cells. This inhibitor has been shown to be an IGF-binding protein (mIGFBP-3). In the present work, this mIGFBP-3 inhibited the TGF beta stimulation by about 50%, while the stimulation induced by PDGF or insulin was not inhibited by mIGFBP-3. Furthermore, TGF beta stimulation, in the presence of a high concentration of insulin in conditions which would saturate IGF receptors, was not significantly inhibited by mIGFBP-3. All together these results suggest that a part of the mitogenic effect of TGF beta may be through increasing IGF secretion and eventually other growth factors such as PDGF (as suggested previously).

Synthesis and secretion by mouse 3T3 cells of an inhibitor of cell growth (mIGFBP-3): correlation with cell proliferation

Our results show that stimulation by serum of dense cultures of 3T3 cells rapidly induced increased synthesis of a growth inhibitor (mIGFBP-3) capable of binding IGF. mIGFBP-3 was secreted by stimulated cells immediately after its synthesis, and accumulated in the medium. Accumulation of mIGFBP-3 in the medium increased, as a function of growth factor (bFGF, PDGF, insulin) concentrations and time. bFGF was the best stimulatory factor for both DNA synthesis and accumulation of mIGFBP-3 in the first 24 h of incubation. DNA synthesis was arrested after 48 h of incubation with bFGF when accumulation of mIGFBP-3 was maximal. Since we showed that mIGFBP-3 is able to inhibit bFGF stimulation of DNA synthesis in mouse fibroblasts, it is possible that the accumulation of mIGFBP-3 induces a feedback regulation of cell growth.

Purification from transformed mouse fibroblast of a cell growth inhibitor which is an IGF-binding protein

From medium conditioned by 3T3 cells, we had previously purified an inhibitory factor of Mr 45 kDa which we termed IDF45 (inhibitory diffusible factor). The protein was able to 100% inhibit stimulation induced in CEF by 1% calf serum and to reversibly prevent cell growth. We then demonstrated that IDF45 was an IGF-binding protein. Our results suggested that IDF45 was a bifunctional molecule able to bind IGF and to inhibit DNA synthesis stimulated by this hormone, but also to inhibit stimulation of DNA synthesis induced by another growth factor in serum. Indeed, its N terminal amino acid sequence has great homology with that of IGFBP-3 and IDF45 is now proposed to be named IGFBP-3 (mouse IGF binding protein). Present results show that Ha-ras transfected 3T3 cells (EJ cells), like 3T3 cells, secrete a mIGFBP-3 molecule. In addition, transfected cells secrete a doublet of an IGF-binding protein (IGFBP-28) of Mr 28 kDa which is not secreted by untransformed 3T3 cells. IGFBP-28 has been purified and characterized in this work. Various results suggest that IGFBP-28 is not a degradation product of mIGFBP-3. Its N terminal amino acid sequence was different from that of mIGFBP-3. IGFBP-28 inhibited DNA synthesis stimulated by IGF-I, but much more IGFBP-28 protein than mIGFBP-3 was required to prevent this stimulation. In agreement with this result, IGFBP-28 has low affinity for IGF-I. In contrast, IGFBP-28 has high affinity for IGF-II. Like mIGFBP-3, IGFBP-28 was able to inhibit the stimulation induced by serum in CEF and to reversibly prevent growth, though with a specific activity lower than that of mIGFBP-3. It has also the capacity to inhibit stimulation of DNA synthesis induced by high molecular weight serum proteins depleted in IGF-I and II. In conclusion we have shown that transformation of 3T3 cells with Ha-ras induced the synthesis of a new IGF binding protein in medium conditioned by normal 3T3 cells. Our results suggest that IGFBP-28 like mIGFBP-3 is a bifunctional protein able to inhibit stimulation induced by IGF and by serum proteins different from IGFs.

An IGF binding protein is an inhibitor of FGF stimulation

We purified to homogeneity a growth inhibiting diffusible factor (IDF45) secreted by dense cultures of mouse 3T3 cells and which was able to inhibit 100% of DNA synthesis stimulated by serum in chick embryo fibroblasts (CEF) (Blat et al., 1989a). We then demonstrated that this factor was an IGF-binding protein (Blat et al., 1989b). Indeed, its N-terminal amino acid sequence was homologous to that of rat IGFBP-3. Our present results show that basic fibroblast growth factor (bFGF) induced, respectively, a fivefold and threefold increase in DNA synthesis in mouse embryo fibroblasts (MEF) and CEF. IDF-45 inhibited the stimulation induced by bFGF by about 65%, while stimulation induced by insulin, PDGF, or EGF was only weakly or not at all inhibited by IDF45. When bFGF stimulation was determined in the presence of a high concentration of insulin in conditions which minimize the effect of endogenous IGF-I or -II, this stimulation was decreased by about 50% in the presence of IDF45. This result suggests that addition of bFGF stimulates IGF secretion, thereby resulting in partial loss of inhibition, by IDF45, of bFGF stimulation.

Presence of IDF45 (mlGFBP-3) binding sites on chick embryo fibroblasts

IDF45 (inhibitory diffusible factor) a mouse insulin-like growth factor binding protein (mlGFBP-3) has been shown to 100 percent inhibit DNA synthesis stimulated by serum in chick embryo fibroblasts (CEF). Our previous results suggested that this large inhibition by IDF45 of serum stimulation was not just the result of its inhibitory activity toward IGF present in serum. The addition of Mn2+ (10(-3)M) in the incubation medium enables us to show the presence of numerous binding sites per cells (about 60,000) of mlGFBP-3. However the dissociation constant (10(-8)M) indicated that this mouse IGFBP-3 bound to the membrane with low affinity. These findings lend new support to the assumption of the bifunctional property of IGFBP-3, which would have an effect outside the cell (binding of IGF in the medium) and another effect within cells or on the surface.

IGFBP-1, an insulin like growth factor binding protein, is a cell growth inhibitor

A novel cell growth inhibitor, IDF45 (inhibitory diffusible factor), was recently purified to apparent homogeneity. It is a bifunctional molecule: able to bind Insulin like growth factor (IGF) and to 100% inhibit DNA synthesis stimulated by serum in fibroblasts. It was of interest to verify whether other members of the IGF-binding protein (IGFBP) family show the same bifunctional growth inhibitory properties. In this paper we show that purified IGFBP-1 derived from amniotic fluid is a cell growth inhibitor. In chick embryo fibroblasts, it inhibited DNA synthesis stimulated by serum. However the stimulation was maximally 60% inhibited and half of the inhibition was observed with 100ng/ml IGFBP-1. So the specific activity of IGFBP-1 is lower than that of IDF45. IGFBP-1 also reversibly prevented the CEF growth. In the same cells IGFBP-1 inhibited DNA synthesis stimulated by IGF-I. We demonstrated that the same protein IGFBP-1 is able to inhibit DNA synthesis stimulated by serum and by IGF-I. The possibility that IGFBP-1 is a bifunctional molecule is discussed.

IGF-I and IGF-binding proteins: stimulatory and inhibitory factors secreted by human prostatic adenocarcinoma cells

Deregulation of growth observed in malignant cell cultures has been assumed to be the result of increased secretion by these cells of autocrine growth factors, as well as the decreased sensitivity of these cells to inhibitory molecules which are diffused from normal or transformed cells. Our results show that PC-3 cells secreted into the medium, factors having stimulatory and inhibitory activities. We found an IGF-like molecule in medium conditioned by PC-3 cells. Its concentration was less than 1 ng/ml of conditioned medium. We demonstrated that PC-3 cells have receptors for IGF-I and are stimulated by this growth factor. However, the dose response curve shows that 1 ng/ml of IGF-I is not sufficient to indicate autocrine growth regulation by IGF of prostatic carcinoma cells. IGF-binding proteins of 90,000, 45,000, 34,000 and 28,000 molecular weight were also secreted by PC-3 cells. It is noteworthy that the secreted proteins which had the greatest inhibitory effect on chick embryo fibroblast growth also has the strongest IGF-binding activity. The probability that the IGF-binding protein secreted by PC-3 cells inhibited serum stimulation of DNA synthesis by preventing stimulation induced by IGF present in the serum is discussed. It is of interest that these IGF-binding proteins inhibited chick embryo fibroblast proliferation but did not inhibit PC-3 cells. This is in agreement with the assumption that IGF present in the medium is not an autocrine growth factor for these cells.

Differences in inhibition by IDF45 (an inhibitory diffusible factor) of early RNA synthesis stimulation induced by pp60 v-src and various mitogens

Factors inhibiting cell growth have been isolated from different cell types. However, little information is available concerning their mode of action. A novel growth inhibitory factor of 45 kDa (IDF45) was recently purified to homogeneity from medium conditioned by 3T3 cells. This molecule was able to inhibit DNA synthesis and the growth of chick embryo fibroblasts (CEF) in a reversible manner. By contrast, DNA synthesis stimulated by v-src expression in CEF was poorly inhibited by IDF45. In order to gain further insight into the IDF45 mode of action in normal and transformed CEF, we compared the effects of IDF45 on early stimulation of RNA synthesis induced in CEF by different mitogenic factors and by v-src gene expression. Stimulation, by serum, of RNA synthesis was inhibited by IDF45; however, inhibition increased when cells were preincubated with IDF45 before addition of serum and cell labeling for 2 h. IDF45 was also able to inhibit partially the stimulation of RNA synthesis induced by PMA and PDGF but was unable to inhibit stimulation of RNA synthesis induced by insulin and v-src expression. By contrast, stimulation of RNA synthesis induced by IGF-I was rapidly 100% inhibited by IDF45. The effect of IDF45 on DNA synthesis stimulated by the different mitogens was also determined and was correlated with the effect of IDF45 on RNA synthesis. These results suggest that the modes of action of IDF45 on stimulation of RNA synthesis by v-src and by insulin are similar. Our present results agree with others showing the bifunctional activity of IDF45 as an IGF-binding protein and as an inhibitory molecule in DNA stimulation induced by serum.

Inhibitory diffusible factor 45 bifunctional activity. As a cell growth inhibitor and as an insulin-like growth factor I-binding protein

From medium conditioned by 3T3 cells, we had previously purified to apparent homogeneity a novel inhibitory diffusible factor of 45 kDa (IDF45), and then determined the amino-terminal sequence. IDF45 prevented reversibly the growth of chick embryo fibroblast (CEF). In these cells, DNA synthesis stimulated by 1% serum was 50% inhibited in the presence of 45 ng/ml (1 nM) IDF45. In the present article, we show that, in CEF, DNA synthesis stimulated by IGF-I was 100% inhibited in the presence of purified IDF45. Furthermore, the 45-kDa protein (IDF45) was, after Western blotting, able to bind IGF-I. The inhibitory effect of IDF45 upon serum stimulation did not seem to be the result of its inhibitory activity upon IGF-I stimulation, since stimulation by IGF-I and serum were additive. Moreover, it was possible to dissociate the two inhibitory effects: when added to v-src transformed CEF, IDF45 was able to 100% inhibit stimulation induced by IGF-I and was unable to significantly decrease stimulation induced by serum, as was previously observed. Taken together, our results strongly suggest that IDF45 has two distinct functions, one of which was to bind IGF-I and the other to inhibit serum stimulation. Indeed, it was impossible to separate the two functions when IDF45 was purified by cation exchange fast protein liquid chromatography, a method very different from reverse-phase fast protein liquid chromatography previously used for purification to apparent homogeneity of IDF45. On the other hand, if the IGF binding activity and inhibitory activity effect upon serum stimulation were carried by two different proteins, the presence of IGF-I (in conditions where most of the 45-kDa proteins were bound to IGF-I) should not have affected the activity of the molecule inhibiting serum stimulation. However, we observed the contrary: when IDF45 was bound to IGF-I, it lost its inhibitory effect upon stimulation induced by serum. This suggests that the two activities occurred on the same protein and that IDF45 is a bifunctional protein.