[Laparoscopic training--the guarantee of a future in pediatric surgery]

Laparoscopy is considered today the highlight of modern surgery, the forerunner of the fascinating world of video and robotic surgery, both of them derived from the sophisticated areas of aeronautic industry. Remarkably, Romanian specialists keep up with the pace of worldwide technological developments, assimilating one by one each and every video endoscopic procedure. In the early 90s, the Romanian laparos-copic school was founded with the contribution of many important personalities; their activities and achievements have been an inspiration for the following generation of laparoscopic surgeons. In this last decade, the newest branch of laparoscopic surgery in our country, pediatric laparoscopy, managed to evolve from its "shy" beginnings to become an important method of improving the quality of surgical procedures, to the benefit of our "small patients". The purpose of this article is to encourage and promote minimally invasive video endoscopic surgery training, emphasizing its crucial role in the education and professional development of the next generation of pediatric surgeons, and not only. The modem concept of laparoscopic training includes experimental scientific practices, as well as the newest technical acquisitions such as virtual reality video-electronic simulation.

Female pelvi-abdominal multilocular recurrent fluid collection of uncertain aetiology

Recurrent pelvi-abdominal multilocular fluid collections in female patients may be of various aetiology: infections, haemorrhage, benign or malignant tumours.

PURPOSE

Diagnosis of such fluid collections is complex, imaging examinations (ultrasonography, computed tomography, MRI) and biochemical, cytological and histological examinations must be included. Some cases, however, are difficult to diagnose, and their treatment is uncertain.

MATERIALS AND METHODS

We present the case of a 22-year-old unmarried female patient with minor symptoms, not correlated with a pelvi-peritoneal fluid collection extending into the infra-mesocolic space, revealed by ultrasonography and MRI. The aetiology was uncertain after biological examinations and cytology. The disease course was recurrent during 14 months, under anti-inflammatory treatment and surgical intervention with removal of the fluid (2.5 l), resection of the right ovary (histological examination revealed small ovarian mucinous cysts) and excision of a fibroma of the right utero-sacral ligament. Follow-up sonography was the chosen method for repeated diagnostic and therapeutic echo-guided punctures. Finally, after immuno-stimulating treatment, we observed almost complete remission of the peritoneal fluid collection.

RESULTS

This paper reveals significant discordances between the clinical appearance and the presence of a large peritoneal fluid collection, between locally recurrent appearance and cytological and histopathological "benign" results, between positive intradermal reaction to tuberculin and negative culture of B. Koch from aspirate. There were concordances between immune electrophoresis and some cytological elements and between three dimensional and panoramic SieScape ultrasonography and MRI. We must, however, note the superiority of MRI in the designation of anatomical findings and analysis of the histological structure.

CONCLUSION

The importance of this case is derived from the atypical clinical appearance and course, with uncertain aetiology after complex imaging, biological and surgical explorations.

Atomic structure of As(25)Si(40)Te(35) glass

Glassy As(25)Si(40)Te(35) has been studied by x-ray and neutron diffraction as well as x-ray absorption spectroscopy (EXAFS) at As and Te K-edges. Simultaneous modelling of the four independent measurements by means of the reverse Monte Carlo (RMC) simulation technique allowed the separation of partial pair distribution functions and estimation of the corresponding coordination numbers. It is shown that the atomic structure of As(25)Si(40)Te(35) glass can be presented as a three-dimensional network of twofold coordinated Te, threefold coordinated As and fourfold coordinated Si atoms.

Magnetographic assessment of fetal hiccups and their effect on fetal heart rhythm

Fetal hiccups emerge as early as nine weeks post-conception, being the predominant diaphragmatic movement before 26 weeks of gestation. They are considered as a programmed isometric inspiratory muscle exercise of the fetus in preparation for the post-natal respiratory function, or a manifestation of a reflex circuitry underlying the development of suckling and gasping patterns. The present paper provides the first evidence of non-invasive biomagnetic measurements of the diaphragm spasmodic contractions associated with fetal hiccups. The magnetic field patterns generated by fetal hiccups exhibit well-defined morphological features, consisting of an initial high frequency transient waveform followed by a more prolonged low frequency component. This pattern is consistent across recordings obtained from two fetal subjects, and it is confirmed by signals recorded in a neonatal subject. These results demonstrate that fetal biomagnetometry can provide insights into the electrophysiological mechanisms of diaphragm motor function in the fetus. Additionally, we study the correlation between hiccup events and fetal cardiac rhythm and provide evidence that hiccups may modulate the fetal heart rate during the last trimester of pregnancy.

Predicting response to peginterferon alpha-2a, lamivudine and the two combined for HBeAg-negative chronic hepatitis B

OBJECTIVE

In a trial of patients with hepatitis B e antigen (HBeAg)-negative chronic hepatitis B, 24 week post-treatment biochemical and virological response rates with peginterferon alpha-2a with or without lamivudine were significantly higher than with lamivudine alone. The effect of pre-treatment factors on post-treatment responses was investigated.

METHODS

Multivariate analyses were performed using available data from 518 patients treated with peginterferon alpha-2a with or without lamivudine, or with lamivudine alone. A post-treatment response was defined as alanine aminotransferase (ALT) normalisation and hepatitis B virus (HBV) DNA level of <20,000 copies/ml.

RESULTS

In logistic regression analyses across all treatment arms, peginterferon alpha-2a (with or without lamivudine) therapy, younger age, female gender, high baseline ALT, low baseline HBV DNA and HBV genotype were identified as significant predictors of combined response at 24 weeks post-treatment. In the peginterferon alpha-2a and lamivudine monotherapy arms, patients with genotypes B or C had a higher chance of response than genotype D infected patients (p<0.001), the latter responding better to the combination than to peginterferon alpha-2a monotherapy (p = 0.015). At 1 year post-treatment, response rates by intention-to-treat analysis were 19.2% for the peginterferon alpha-2a, 19.0% for the combination, and 10.0% for the lamivudine groups, with genotypes B or C associated with a sustained combined response to peginterferon alpha-2a with or without lamivudine therapy.

CONCLUSIONS

Baseline ALT and HBV DNA levels, patient age, gender, and infecting HBV genotype significantly influenced combined response at 24 weeks post-treatment, in patients treated with peginterferon alpha-2a and/or lamivudine. At 1 year post-treatment HBV genotype was significantly predictive of efficacy for patients treated with peginterferon alpha-2a with or without lamivudine.

Renal inflammatory myofibroblastic tumor - a new case report

Renal inflammatory pseudotumor is uncommon, benign tumor that has been classified into separate group but there is a risk that this lesion could be misdiagnosed. The aim of this work is to report a new case of 57-years-old man presented in our hospital with hematuria, minimal grade fever and right flank pain. Magnetic resonance imaging (MRI) and sonography revealed a tumor of the right mediorenal parenchyma, 2.5 cm in diameter. The patient underwent right nephroureterectomy under the diagnosis of renal cell carcinoma. Macroscopically examination carried out on the removed kidney showed a 2/2/1.5 cm yellowish, gelatinous, well circumscribed, mediorenal and pericaliceal mass. Fragments of the tumor were fixed in 10% formaldehyde, included in paraffin, and the sections were stained with HE, VG and immunohistochemically with vimentin (VIM), MNF116, SyN, smooth muscle actin (ACT), desmin, CD68, S100, HMB45, and CD117. The histological examination revealed a compact spindle cell proliferation, a hypocellular fibrous area in an edematous myxoid background infiltrated by small lymphocytes, histiocytes, some plasma cells and small bone area. The spindle cells were diffuse positive for VIM, ACT, CD68 and negative for desmin, MNF116, SyN, S100, HMB45, and CD117. The pathologic diagnosis was renal inflammatory pseudotumor, raising the problem of differential diagnosis, as the clinical and imagistic aspects are similar to those of a renal carcinoma and the problem in establishing a preoperative correct diagnosis.

[Dextrocardia of post right pneumonectomy]

The negative pressure achieved in the hemi thorax in the case of lung pneumonectomy has consequences on the mediastinum organ statics. This condition results through the other lung expansion. These changes are common, but rare in adult lung pneumonectomy. In the case of right lung pneumonectomy, the mediastinum moves to the operated part and disturbs the function of the vessels and cavities with thin wall or low pressure (vena cava, right atrium). These aspects are not observed in the case of left lung pneumonectomy. Taking this into consideration the authors present the case of a young woman with right lung pneumonectomy, an intervention made in childhood, at ten years old. After sixteen years of evolution a serious mediastinum re-shuffle was discovered, the heart was moved in the right hemi thorax, with a dextrocardia like aspect. This case is interesting because it raises positive and differential diagnosis problems--dextrocardia, associated disorders, serious complications.

Clinico-imaging and anatomopathologic correlations in sarcomas of maxilla

Sarcomas are relatively uncommon tumors, accounting for 1% of all malignancies. Sarcomas are commonly classified according to their site of origin: soft tissues or bone. The purpose of the clinic study was to focus the symptoms and the clinic signs. The radio-imaging study is essential in the evaluation of the maxilla tumors. The histopathologic study was done to determine the histological type, the differentiation level, the invasion level as well as the presence or absence of the metastases in drainage ganglia. The correlation of the findings of this study leads to a clear and correct clinic diagnosis, an adequate local or general therapy and a prognostic. The diagnostic role of imaging is essential and often permits the orientation to benignity or, on the contrary, requires biopsy if the image is an aggressive one or of uncertain nature. Advances in diagnostic imaging have contributed substantially to the management of tumors. The strong collaboration among the physician, imaging personnel and anatomo-pathologist serves the patient's benefit.

Severe hemolytic anemia due to passenger lymphocytes after living-related bowel transplant

BACKGROUND

Hemolytic anemia following solid organ transplant may be caused by 'passenger' lymphocytes producing antibodies against erythrocytes. This phenomenon has never been described after intestinal transplant.

MATERIALS AND METHODS

We report a case of severe, immune-mediated hemolysis due to symptomatic passenger lymphocyte syndrome (PLS) in a 4-yr-old recipient of living donor small bowel transplant. The Coombs'-positive hemolysis was caused by anti-A,B antibodies derived from donor lymphocytes in an ABO-compatible donor-recipient pair (O into A).

RESULTS

This complication was successfully and efficiently treated by the novel combined use of group O RBC transfusion, plasmapheresis and rituximab (anti-CD20).

CONCLUSIONS

A severe hemolytic anemia due to PLS can occur in bowel transplantation. This complication should be considered when performing ABO-incompatible bowel transplant with a blood group O donor and an A or B recipient. Treatment with plasmapheresis, blood group O transfusion and rituximab has proved successful in our case.

Influence of the cortical electrical activity level during general anaesthesia on the severity of immediate postoperative pain in the morbidly obese

BACKGROUND

The objective of anaesthesia is to provide hypnosis, analgesia and adequate conditions during surgery. It is difficult to establish the appropriate dose of general anaesthetic drugs in the morbidly obese patient. Moreover, there are conflicting data concerning adequate anaesthesia levels and the severity of postoperative pain. The aim of this study was to investigate the relationship between the spectral edge frequency (SEF) during general anaesthesia and the severity of immediate postoperative pain following gastric banding surgery in morbidly obese patients.

METHODS

Seventy-one ASA 2 morbidly obese patients (BMI > 35%) undergoing elective laparoscopic gastric banding procedure were recruited for this study. Anaesthesia consisted of midazolam, fentanyl and thiopental for induction, vecuronium for muscle relaxation, N2O and isoflurane with additional fentanyl administrations, according to the clinical judgement of the anaesthesiologist, for maintenance. Continuous SEF monitoring was added to the standard monitors (SpO2, ETCO2, ECG, NIBP, O2 and isoflurane concentration), but the EEG monitor screen was hidden from the anaesthesiologist's sight. SEF postoperative analysis divided the patients into two groups: group 1, SEF-recommended target range of 8-12 Hz, more than 80% of the surgical time; and group 2, SEF-recommended target range of 8-12 Hz, less than 80% of the surgery duration. Pain intensity was assessed in the post anaesthesia care unit using a standard visual analogue scale (VAS) of 10 cm, when patients were awake enough to correct a deliberately given wrong own telephone or ID number. Intravenous morphine was administered for postoperative analgesia in 2-mg increments, every 3-4 min, until the patient felt comfortable. A recovery room nurse unaware of the SEF range recorded during surgery registered pain severity and morphine requirements.

RESULTS

The end-tidal isoflurane concentration was significantly higher in group 1 than in group 2 (0.83 vs. 0.7 P = 0.016). The intensity of pain at admission into the recovery room and at discharge was significantly lower in group 1 than in group 2 (VAS 6.1 vs. 6.9-P = 0.0049, and 3.9 vs. 4.2-P = 0.00478, respectively).

CONCLUSIONS

Keeping the SEF range between 8 and 12 Hz during anaesthesia for laparoscopic gastric banding for morbid obesity, both the immediate post operative pain intensity and morphine requirement, are significantly reduced.

[Intracranial and intraorbital meningioma ]

AIM OF THE ARTICLE: To discuss the simultaneous presence of intraorbitar and intracranian meningiomas, the origin and the link between these tumors.

MATERIAL AND METHODS

We show 3 cases with intracranian and intraorbitar meningiomas.

RESULTS

Therapeutically attitude and debates about anatomopathological results.

CONCLUSIONS

Difficulty in determine the intracranian or intraorbitar origin of meningiomas.

Pharmacokinetics, food intake requirements and tolerability of once-daily combinations of nelfinavir and low-dose ritonavir in healthy volunteers

AIMS

This study was performed to evaluate the steady-state pharmacokinetics, food intake requirements and short-term tolerability of once-daily combinations of nelfinavir and low-dose ritonavir.

METHODS

Twenty-seven healthy volunteers were randomized over three groups to receive a once-daily regimen of nelfinavir/ritonavir 2,000/200 mg (group 1), 2,000/400 mg (group 2) or 2,500/200 mg (group 3) with food for 14 days. Pharmacokinetic parameters for nelfinavir and its active metabolite M8 were assessed on study days 15 and 16, after administration of the regimens with a full (610 kcal) or light (271 kcal) breakfast, respectively.

RESULTS

Pharmacokinetic data were evaluable for eight volunteers in group 1, eight in group 2 and four in group 3. Administration of nelfinavir/ritonavir with a full breakfast resulted in geometric mean (GM) nelfinavir AUC(24h) values of 76.8, 51.3, and 61.9 h*mg/l in group 1, 2 and 3, respectively. GM 24-h Cmin concentrations of nelfinavir were 0.76 mg l(-1), 0.43 mg l(-1) and 0.47 mg l(-1), respectively. Co-administration of ritonavir increased M8 concentrations more than nelfinavir concentrations, resulting in GM AUC(24h) and Cmin values for nelfinavir plus M8 that were higher than or comparable to reference values for the approved regimen of nelfinavir (1,250 mg BID without ritonavir). In the 2,000/200 mg group, seven out of eight subjects had a Cmin value of nelfinavir plus M8 above a threshold of 1.0 mg l-1. Administration of the combinations with a light breakfast resulted in significant decreases in the AUC(24h) and Cmin of nelfinavir and nelfinavir plus M8, compared with intake with a full breakfast. For the Cmin of nelfinavir plus M8, the GM ratio (light/full breakfast) was 0.76 (90% confidence interval 0.67-0.86, participants from all groups combined). Short-term tolerability was satisfactory, apart from a higher than expected incidence of mild rash (12%).

CONCLUSIONS

Administration of nelfinavir in a once-daily regimen appears feasible. A nelfinavir/ritonavir 2,000/200 mg combination appears appropriate for further evaluation. Once-daily nelfinavir/ritonavir should be taken with a meal containing at least 600 kcal.

The attitude of Romanian medical trainees towards the eradication of H. pylori

AIM

To evaluate the knowledge of Romanian medical trainees regarding H. pylori infection and its management.

METHODS

A specialized questionnaire used in a US survey with similar purpose was distributed to 57 medical interns and residents. The questionnaire included 17 item concerning the testing and treatment of H. pylori infection as well as information sources.

RESULTS

Romanian medical interns and residents are generally well informed about diagnostic tests and therapeutic recommendations of national and international guidelines. However the decisions are not always appropriate, in respect to the on site practical possibilities.

CONCLUSIONS

Medical faculties should be satisfied with the knowledge of Romanian medical trainees regarding H. pylori infection. However, more emphasis should be given during postgraduate training to the development of practical skills in different specific cases

Limited effect of food composition on the pharmacokinetics of nelfinavir administered twice daily

The objective of the study was to investigate the effect of two different breakfasts on the pharmacokinetics of nelfinavir under steady state conditions.

METHODS

Twenty-four healthy male volunteers were evaluated in a 17 days open labeled one sequence crossover study evaluating the effect of a 'light' breakfast (350 kcal) compared to a standard breakfast (800 kcal) on the pharmacokinetics of nelfinavir at steady state during 1250 mg twice daily (BID) administration.

RESULTS

After administration with a standard breakfast higher concentrations of nelfinavir were observed during the terminal phase than after administration with a 'light' breakfast. The comparison of the log subset 10 transformed parameters C subset 1-hr-postdose, AUC subset 0-12h, C subset max, and C subset 12 hours, showed that the AUC subset 0-12h was decreased by 13% (P = 0.01) after administration with the 'light' breakfast. Nelfinavir 1250 mg BID was well tolerated.

CONCLUSIONS

Although drug intake with a 'light' breakfast' showed a statistically significant decrease for nelfinavir AUC subset 0-12h, this marginal 13% reduction is not considered clinically relevant. No significant effects of the two different breakfasts were found for the remaining three parameters tested C subset 1-hr-postdose, C subset max, and C subset 12 hours.

[Color Doppler ultrasonography of the orbit in the treatment and evolution of the open angle glaucoma with normalized pressure]

The purpose of the paper consists to evaluate the vascular component that it takes part to ethiopatogenie of certain forms of primary open angle glaucomas, as well as to suggest a specific treatment.

MATERIAL AND METHOD

14 patients (28 eyes) with primary open angle glaucomas with average of 64 years were investigated by Color Doppler Imaging. All patients present deteriorations papilo-perimetric or/and visual acuity, in spite of normalized pressure by medical or surgical treatment.

RESULTS

The calculus of the velocimetric indices allowed us to measure the vascular resistance index that is increased at 6 patients in ophthalmic circulation, 4 patients in central retinal artery and 2 patients in whole shaft carotid-ophthalmic. We are found a correlation between papilo-perimetric deteriorations and the value of the vascular resistance index, too. Giving vasodilatative drugs that grow the ocular blood flow by improving the microcirculation at the level of the optic nerve's head, such as calcium channel blockers, could benefit effects for this type of patients.

CONCLUSIONS

Orbitar Color Doppler Imaging allows to evaluate the vascular lesions that have a negative influence in the evolution of primary open angle glaucomas, and, therefore, suggesting a specific treatment.

[Ocular myopathies - cause of exophthalmia]

It presents the "thickenings" of the extraocular muscles that can cause exophthalmos. It makes the difference between myositis limited to the orbit and the systemic myopathies and endocrine myopathies.

Drug resistance mutations in HIV-1-infected subjects during protease inhibitor-containing highly active antiretroviral therapy with nelfinavir or indinavir

OBJECTIVES

The aim of this retrospective study was to evaluate treatment outcome and characterize the pattern of genotype mutations in subjects with treatment failure on highly active antiretroviral therapy (HAART) containing nelfinavir or indinavir.

STUDY DESIGN AND METHODS

The database of the Swiss HIV Cohort Study was screened for all subjects naive to protease inhibitor (PI) treatment who started HAART with nelfinavir or indinavir, responded initially (HIV-RNA <400 copies/ml) and received >24 weeks of treatment. Responders with subsequent treatment failure (HIV-RNA >1000 copies/ml, bordered by HIV-RNA >400 copies/ml) were selected for genotypic analysis.

RESULTS

Initial treatment response, maintenance of response and subsequent virological failure were observed at a comparable frequency in 1143 nelfinavir and 1555 indinavir subjects. Of the treatment-naive patients, 13% who took nelfinavir and 16% who took indinavir had HIV-RNA >1000 copies/ml at least once. These values increased to 24 and 27%, respectively, for reverse transcriptase inhibitor-experienced subjects. Genotypic analysis in a subset of subjects with virological failure identified 30N as the only primary mutation in the nelfinavir subjects (8 out of 21, 38%) whereas isolated or combined 82A/T and 461/L mutations were detected in the indinavir subjects (9 out of 20, 45%).

CONCLUSIONS

In this population of previously PI-naive subjects, the rate of virological failure and the frequency of resistance mutations at the time of virological failure were comparable in subjects receiving nelfinavir- or indinavir-containing HAART. In nelfinavir subjects, 30N was the only primary mutation whereas isolated or combined 82A/T and 461/L mutations were detected in indinavir subjects.

[Glial hamartoma of the papilla]

There are shown two cases of glial hamartoma of the optic nerve head. In both cases the retinal vessels are tortuous around the optic nerve disc, and the choroid shows a brown colour, like a choroidal naevus. Histologically this kind of tumors of the optic nerve head are astrocytomas and they are met specially under the age of twenty. The glial hamartoma of the optic nerve head is a rare disease.

[Reconstruction of mediastinal veins in same side dialysis shunt]

Centralvenous obstruction is a rare however typical lesion with patients on chronic hemodialysis. A still functional arteriovenous shunt in its run-in can cause serious disorder, especially painful congestion and an insufficient dialysis. Should the shunt be maintained, a run-off reconstruction is required. 13 patients were treated with a centralvenous obstruction combined with a complication of the shunt. In 8 patients the intervention was either impossible from the beginning or finally proved to be not successful after repeated recanalisations. 6 out of these patients underwent a transsternal reconstruction of their bypass (a total of 7 interventions). 2 patients died perioperatively, 2 patients died 1 year, respectively 1 1/2 years later with a still intact reconstruction, 2 patients are still alive. Their reconstruction has been working for two, respectively three years. The bypass material was large-calibrated e-PTFE with external support. Compared to conventional indications the catheter techniques proved to be less effective in the treatment of central venous obstruction. One year after the first intervention only three out of seven shunts could still be used for the dialysis. The longest symptom-free period was 12 months. The operative reconstruction is indeed very effective but it implies considerable risks and effort. This method cannot be recommended to patients on chronic dialysis who are in a poor condition.

Automatic karyotyping of metaphase cells with overlapping chromosomes

Image analysis research aimed at analyzing images of banded, human chromosomes is described. An experimental automated karyotyping system (AKS) has been assembled. The goal of the system is to label the chromosomes from a metaphase image with minimal human intervention. The AKS is unique in that it is designed to automatically process cells containing overlapping chromosomes. It also has four novel algorithmic features: the use of cross section sequence graphs, an over-segmentation-based segmentation strategy, the use of the 'pale path' concept for banded chromosomes and the application of mathematical programming for cell-level chromosome classification in cells with overlapping chromosomes. System performance was analyzed using a variety of metaphase images exhibiting various levels of overlapping chromosomes.

Adaptive denoising and multiscale detection of the V wave in brainstem auditory evoked potentials

This paper describes a wavelet-transform-based system for the V wave identification in brainstem auditory evoked potentials (BAEP). The system combines signal denoising and rule-based localization modules. The signal denoising module has the potential of effective noise reduction after signal averaging. It analyses adaptively the evolution of the wavelet transform maxima across scales. The singularities of the signal create wavelet maxima with different properties from those of the induced noise. A non-linear filtering process implemented with a neural network extracts out the noise-induced maxima. The filtered wavelet details are subsequently analysed by the rule-based localization module for the automatic identification of the V wave. In the first phase, it implements a set of statistical observations as well as heuristic criteria used by human experts in order to classify the IV-V complex. At the second phase, using a multiscale focusing algorithm, the IV and V waves are positioned on the BAEP signal. Our experiments revealed that the system provides accurate results even for signals exhibiting unclear IV-V complexes.

Peripheral leukocytes activation in aortic aneurysmal disease

The pathogenesis of aneurysmal disease involves factors acting over time. A sustained chronic inflammatory reaction is observed in association with initiations, maintenance, rapid growth and rupture of aortic aneurysms. This study was designed to identify the possible pathogenic role of the inflammatory cells in the outcome of aneurysmal disease, testing the activation state of peripheral lymphocytes and neutrophils. Circulating activated lymphocytes and repeated peaks of neutrophils activation in sequential follow-up is associated with larger aneurysms, mural thrombosis, tendency to aneurysm extension and rupture.

Pulmonary function in children with initial low birth weight

The objective of this analysis was to examine the effect of low birth weight and prematurity on bronchial air-flow, bronchial reactivity, airway symptoms and asthma diagnosis at school age. A cross-sectional epidemiological study was performed in three small towns in the eastern part of Germany on 2470 school children aged 5-14 (89.1% of eligible children). A 78 item questionnaire to determine risk factors at birth and in early childhood was employed. 7.8% of the children were born before completing 38 gestational weeks; 6.6% had a birth weight less than 2500 g. Pulmonary function analysis were done by a mobile plethysmography at the school. There were only weak restrictions in lung volume in term low birth weight (LBW) children (100 ml lower TLC, p = 0.107), and flow (257 ml lower PEFR, p = 0.108), were low. However, bronchial hyper-responsiveness indicated by 292 ml lower FEV1.0 after cold air bronchial provocation, was significantly increased compared to term normal birth weight children (p < 0.001). The effect of LBW was less in older children, only slightly stronger in girls and increased in children mechanically ventilated during the postnatal period. Correspondingly, there was a higher prevalence of diagnosed asthma in term LBW children (OR 1.6, 95%-confidence interval 1.0-2.6), however these were without an increased risk for any allergic sensitization. LBW, therefore, seems to be a risk factor for smaller lungs and hyperreactive airways primarily in term born children, whereas in preterm children the immature bronchial system seems to be recover by school age.

Beat-to-beat wavelet variance of the QRS complex as a marker of arrhythmogenic substrate in ventricular tachycardia patients

This study proposes a wavelet transform based technique to assess the beat-to-beat variation of the QRS signal in post-myocardial infarction patients with sustained monomorphic ventricular tachycardia. Recent electrophysiological investigations suggested that the diminished synchrony between the normal myocardium and the scarred arrhythmogenic tissue bordering a myocardial infarction area gives rise to beat-variable ECG signal components. Using a mathematical model of small variations in a largely repetitive waveform, we show that the inherent alignment errors (trigger jitter) of the high-resolution ECG (HRECG) can artificially increase the value of the time-domain beat-to-beat variance, making it less valuable as a marker of beat-variable signal components. To overcome this drawback, we propose the wavelet based approach which discriminates between the different factors responsible for the beat variability (the alignment error and the beat-variable signal components). The Morlet wavelet transform is performed on HRECG signals from normal individuals (control group) and postmyocardial infarction patients with documented ventricular tachycardia. Electrical variability is quantitatively assessed via the beat-to-beat wavelet variance measurements. A marker of arrhythmogenic induced variance which achieves a good performance in discrimination of ventricular tachycardia patients from normal subjects was found between 200 Hz and 300 Hz. This finding is in agreement with the proposed mathematical model which states that the useful part of the time-frequency map is shifted upward in a precise mathematical way, as the variance induced by the beat-variable arrhythmogenic signals depend on the frequency characteristics of the first derivative of these signals. We conclude that the dynamics of the arrhythmogenic substrate as revealed by the beat-to-beat wavelet variance can be a new estimator of ventricular tachycardia risk.

Effect of exercise training upon left ventricular systolic performance and effort capacity in patients with old myocardial infarction

Recent studies suggested an improving of left ventricular (LV) systolic function during exercise training in patients with old myocardial infarction. Twenty patients with old myocardial infarction (3-6 weeks) were included in an exercise training programme (mainly cycloergometer) for 2 to 8 weeks. Before and after the exercise training programme, the effort capacity and LV systolic function were determined through exercise testing on cycloergometer and echocardiography. The peak effort raised from 4.39 to 5.27 METs (p < 0.05) and the difference DAF-DAM was reduced from 25% to 12% (p < 0.05). The double product (DP) at peak effort raised nonsignificantly (4.91%, p > > 0.05), but at submaximal effort levels DP decreased significantly on each effort step (12.16%, p < < 0.05). In turn, LV systolic function calculated parameters were practically the same before and after the exercise training programme. (EDD 54.3 vs 5.3 mm, ESD 39.3 vs 38 mm, EDV 160 vs 169 ml, ESV 60.6 vs 54.8 ml, EF 54.1% vs 57.8%, SF 27.6% vs 31.2%). It is concluded that exercise training raised the effort capacity in patients with old myocardial infarction, mainly through peripheral mechanisms, LV systolic function being unchanged. It is also important that exercise training have not any detrimental effect upon LV systolic function and consequently exercise training programmes can be applied and can be useful also in patients with old myocardial infarction and impaired LV systolic function.

Efficient design of pulses with trapezoidal magnitude and linear phase response profiles

A variation of the Shinnar-Le Roux (SLR) method of pulse envelope design that allows for control of the phase of the frequency response profile has been developed. The method makes use of the fact that a knowledge of one of the SLR polynomials in combination with a root inversion pattern for the other polynomial is sufficient to fully define the second polynomial. Optimization of the first polynomial, when cast in this form, remains nonlinear. However, it was demonstrated that the relationship between the SLR polynomials and the frequency response profile may be used to generate an initial guess for the SLR polynomials that is sufficiently accurate to allow for the application of linear optimization techniques in most cases. In practice several pulse envelopes having different root inversion patterns are investigated for each target profile. The resulting collection of pulses allows the user to trade off pulse power for profile accuracy. The proposed technique was used to design a large number of amplitude modulated excitation pulses having trapezoidal magnitude and linear phase frequency response profiles. A few examples of the resulting pulses and their response profiles are presented.

[The anatomico-radio-clinical forms of onset in pulmonary tuberculosis]

The aim of the study was to analyze the frequency of various radio-clinical forms of onset in newly discovered TB cases, in the area of the Sibiu dispensary on a period of 3 years (1992-1994). In the 327 cases included in the study, there was an equal sex ratio, with a symptomatic period of at least 3 months before the diagnosis. There was an increased percentage of unilateral cavitary forms, with an equal distribution in city and rural area. The severe forms were more frequent in villages and in male patients. The young patients (under 24) had mostly cavitary forms. The cavitary forms were more frequently associated with other illnesses than the caseous forms.

Factors affecting internal mercury burdens among eastern German children

Internal burdens of mercury were evaluated among 5- to 14-y-old eastern German children in the heavily polluted areas of Bitterfeld, a center of chemical production and coal mining, and Hettstedt, a region of nonferrous metal smelting and mining. We compared blood and urine mercury concentrations in these children with mercury burdens in children who lived in a control area. The unadjusted geometric means of mercury levels in the total group were 0.25 microg/l (95% confidence interval = 0.24, 0.27) in blood and 0.36 microg mercury/g creatinine (95% confidence interval = 0.33, 0.39) in urine. Mercury levels in blood and urine were not significantly higher in children who occupied the two polluted areas, compared with children in the control area. The most significant factor that affected urinary mercury levels was the number of dental amalgam fillings; 27% of the variance in the regression model was explained by the presence of these fillings.

Cardiac electrical instability of the arrhythmogenic tissue substrate assessed by means of wavelet transform

The unstable activation wavefront from the tissue responsible for the production of ventricular tachycardia (VT) gives rise to beat-variable signals components that are eluded during the averaging step of high resolution ECG (HRECG). We used a mathematical model of small variations in a largely repetitive waveform to evaluate the beat-to-beat variance of the HRECG signal. The ability of the Morlet Wavelet Transform to discriminate the different factors responsible for the beat-variability (the alignment error and the beat-variable signal component) has been assessed on simulated signals. The performance evaluation on real ECG signals from normal subjects and patients with a documented history of ventricular tachycardia showed that the dynamics of the arrhythmogenic substrate as revealed by wavelet transform offers a significant improvement in ventricular tachycardia risk assessment.

Disseminated Langerhans cell histiocytosis: a case report with a light microscopic and ultrastructural study

A case of disseminated Langerhans cell histiocytosis (L.C.H.) in a 9 month-old boy is reported. The clinical picture was characterized by severe multivisceral involvement with cutaneous and bone lesions. Histological examination of the skin biopsy revealed diffuse infiltration of large mononucleated histiocytes admixed with a small number of inflammatory cells. Ultrastructural examination confirmed the Langerhans cell (L.C.) phenotype by showing intracytoplasmic Birbeck granules in the proliferating histiocytes. We report the histological and ultrastructural characteristics of our case and review the diagnostic features of L.C.H. in the light of the criteria established by the Writing Group of the Histiocytic Society in 1987.

Arsenic burden among children in industrial areas of eastern Germany

The internal burden of arsenic among 5- to 14-year-old eastern German children in the heavily polluted areas of Hettstedt, a region of smelting and copper mining, and Bitterfeld, a center of chemical production and coal mining, was compared with that in a control area (Zerbst) by means of urinary arsenic concentrations in 1992-94. The unadjusted geometric mean among the 950 children was significantly higher in Hettstedt (5.1 micrograms/l; 95% C.I. 4.8-5.5) but not in Bitterfeld (4.3 micrograms/l; 95% C.I. 3.7-4.9) compared with the control area (4.0 micrograms/l; 95% C.I. 3.5-4.5). This difference persisted after adjustment for relevant confounders. Despite these regional differences, recent fish consumption was as strongly associated with urinary arsenic levels (42% increase, 95% C.I. 18-71%). Additionally, although the geometric mean among the children in Hettstedt (4.8 micrograms As/g creatinine; 95% C.I. 4.5-5.1) was higher than that found in an environmental survey of eastern German children (3.60 micrograms As/g creatinine; 95% C.I. 3.06-4.24), it was similar to that found among western German children (4.59 micrograms As/g creatinine; 95% C.I. 4.20-5.02). This suggests that the arsenic contamination in Hettstedt is not substantially increasing the internal burden of arsenic among children above that found in other German children.

[The atypical ophthalmologic onset of acute Devic neuromyelitis]

A case of Devic's acute neuromyelitis with an atypical ophthalmic debut is presented. Usually, the Devic's neuromyelitis starts by concomitant alteration of both eyes. In the described case, the condition debut has been monocular (OD), as a juxtabulbar optic neuritis, after a respiratory viral infection. The neurological syndrome (paraplegia) and the acute renal failure appeared one week after the viral debut, the patient having been transferred to the neurology department, where, under cortisone treatment the ophthalmological phenomena disappeared completely, remaining only the neurological condition (tetraplegia).

[Rubella pigmentary pseudoretinopathy]

Two cases of rubeolic pigmentary retinopathy with multiples anomalies at congener eye are presented. Both two cases present at congener eye microphthalmos and congenital cataract with uveitis in the first case and convergent strabismus and retard psychomotor in the second case. The retinal lesions are disseminated in all retinal surface in one observation, and only in the temporal retinal area in the second one. These retinal lesions associated with other ocular anomalies are characteristic for rubeolic etiology.

Serum neopterin level predicts HIV-related mortality but not progression to AIDS or development of neurological disease in gay men and parenteral drug users

OBJECTIVE

To investigate the ability of elevated serum neopterin levels to predict independently mortality, progression to acquired immunodeficiency syndrome, and development of neurological disease.

DESIGN

Cross-sectional and longitudinal study of gay and/or bisexual men and parenteral drug users.

SETTING AND PATIENTS

Patients included human immunodeficiency virus (HIV)-negative and -positive gay and/or bisexual men and parenteral drug-using men and women who volunteered for an outpatient study of the natural history of HIV infection.

RESULTS

Serum neopterin levels were significantly elevated in HIV-positive patients (mean, 18.0 nmol/L; SD, 19.2 nmol/L), compared with those in HIV-negative patients (mean, 7.5 nmol/L; SD, 5.5 nmol/L) (P < .001). No differences in the serum neopterin levels could be detected between gay men and parenteral drug users. In HIV-positive patients, women had a higher serum neopterin level than did men (P = .03). The elevated serum neopterin levels were associated with an advanced clinical stage of HIV infection. After adjusting for the CD4 lymphocyte count and other potential confounders, the serum neopterin level was a significant independent predictor of mortality. The elevated serum neopterin levels did not predict progression to acquired immunodeficiency syndrome or development of clinically significant neurological disease.

CONCLUSION

An elevated serum neopterin level predicts mortality, but it does not predict progression to acquired immunodeficiency syndrome or development of neurological disease among HIV-infected individuals.

[Ocular lesions due to plant foreign bodies]

The results of a survey done during the period 1988-1993, regarding the cases of ocular lesions due to vegetal foreign bodies, are presented in 51.1% of the 156 cases involved patients over 50-years-old, especially from country-side, originating in accidents during agricultural labour (79.2%). The main clinical forms of the ocular lesions as well as the nature of the vegetal foreign bodies are described. Some rare clinical aspects, involving toxic-allergic mechanisms of the ocular lesions are also mentioned. Three observations of corneal ulcerations due to vegetal foreign bodies are presented, the therapeutical methods and the evolution of visual acuity during hospitalization are also described.

Pathogenesis aspects of arthrosis in histopathological and electronmicroscopical studies of articular cartilage, correlated to some immunological parameters

Twenty-five biopsies of arthrosic cartilage with radiological correspondence, arthro, sic cartilage under study for Rheumatoid Arthritis (RA) and posttrauma cartilage as control-were examined using histopathological (HE, VG, PAS-Alcian, Gömöri, Safranine O) and electronmicroscopical techniques. The arthrosic cartilage with radiological correspondence shows superficial and deep fissures, perichondrocytic gaps and modified reticulino-collagenic network at the histopathological examination. At the level of synovia-cartilage junction, we found some villous aspects of the synovia desquamating in the proximity of the affected cartilage. The investigated arthroses for RA presented some destructive fibrous modifications of the synovia similar to rheumatoid synovitis and associated with some dystrophic chondrocytic alterations. The ultrastructural affection was severe leading to cellular degeneration. The immunologically-studied arthroses for RA had seric pathologic values regarding: circulating immune complexes (CIC) (mean = 67.08 +/- 1.45 U), Ig.M(mean = 358 +/- 3.02 UI/ml) and anti collagen antibodies (mean = 409.9 +/- 0.42 U). The synovial depletion of complementary fraction C3(mean = 42.3-1 mg%) as against the normal seric level (mean = 63.07 +/- 0.49 mg%) suggests an immune synovitis. Correlation of immunomorphopathological data emphasize that arthrosis coexists with a secondary synovitis following a primitive degenerative process and allows arthroses under study for RA to be separated from other degenerative rheumatism diseases.