Chemiluminescence detection of nine corticosteroids in liver

A method for the determination of nine corticosteroids in bovine liver was developed. The liquid-liquid extraction method consisted in the addition of sodium hydroxide to the tissue sample followed by extraction with ethyl acetate. After centrifugation, the extract was evaporated to dryness and the residue redissolved in acetonitrile. The removal of fats was performed with n-hexane and the acetonitrile layer was evaporated. Afterwards, analysis of the extracts was performed using high-performance liquid chromatography with chemiluminescence detection employing luminol as reagent. The recovery curves, performed at five spiking levels (different for each corticosteroid), showed that recoveries of at least 70.5% could be obtained from liver. The chemiluminescence detection gave satisfactory results with respect to sensitivity, and the LOQ ranged from 0.13 ppb for prednisolone to 8.40 ppb for betamethasone. The maximum mean RSD was 4.8% and 7.3% for intra- and inter-day assay, respectively.

Population genetic implications from sequence variation in four Y chromosome genes

Some insight into human evolution has been gained from the sequencing of four Y chromosome genes. Primary genomic sequencing determined gene SMCY to be composed of 27 exons that comprise 4,620 bp of coding sequence. The unfinished sequencing of the 5' portion of gene UTY1 was completed by primer walking, and a total of 20 exons were found. By using denaturing HPLC, these two genes, as well as DBY and DFFRY, were screened for polymorphic sites in 53-72 representatives of the five continents. A total of 98 variants were found, yielding nucleotide diversity estimates of 2.45 x 10(-5), 5. 07 x 10(-5), and 8.54 x 10(-5) for the coding regions of SMCY, DFFRY, and UTY1, respectively, with no variant having been observed in DBY. In agreement with most autosomal genes, diversity estimates for the noncoding regions were about 2- to 3-fold higher and ranged from 9. 16 x 10(-5) to 14.2 x 10(-5) for the four genes. Analysis of the frequencies of derived alleles for all four genes showed that they more closely fit the expectation of a Luria-Delbrück distribution than a distribution expected under a constant population size model, providing evidence for exponential population growth. Pairwise nucleotide mismatch distributions date the occurrence of population expansion to approximately 28,000 years ago. This estimate is in accord with the spread of Aurignacian technology and the disappearance of the Neanderthals.

Nijmegen breakage syndrome-associated T-cell-rich B-cell lymphoma: case report

In 1981 Weemaes et al. first described the Nijmegen breakage syndrome (NBS), a rare autosomal recessive disorder characterized by stunted growth, microcephaly, immunodeficiency, spontaneous chromosome instability, and a peculiar predisposition to cancer development. Most NBS-related malignancies are lymphomas, but their pathologic features have rarely been specified. We report here the case of a northern Italian 8-year-old child who, 2 years after the diagnosis of NBS, developed a diffuse large B-cell lymphoma (T cell-rich B-cell lymphoma variant). The histological and immunobiological features of the lymphoma population are analyzed and discussed in detail.

[Ovulation induction and the risk of ovarian tumors]

In the last years it has been observed a more and more increasing number of women submitted to therapies for induction of ovulation (disorders of the ovulation represent 33% of the causes of female infertility). In 1998, these therapies had been administrated to approximately two million of USA women. Various Authors have assumed a possible relationship between induction of ovulation and ovarian tumors. Between 1982 and 1997, at least 43 cases of ovarian tumors have been published (among these, there were also 25 cases of epithelial tumors) occurring in women previously treated with ovulation induction. The mean age of patient was 30.3 years, approximately 20 years younger than normal patient population for the same tumors. Among the possible causes of epithelial ovarian tumors, there is the trauma of the ovary surface caused by the continuous repeating of the ovulation phenomenon (incessant ovulation). Gynecologist should be aware of this potential risk for their patients. Multicentric studies should be evaluated in order to establish the risk of ovarian cancer in women treated for infertility problems. A survey of the international literature is made in order to analyse the epidemiological studies and to discuss the relationship between ovulation inducing agents and ovarian tumors.

Dexamethasone-induced changes in FAD-glycerophosphate dehydrogenase mRNA, content and activity, and insulin release in human pancreatic islets

Human pancreatic islets were cultured for 63 hr at 2.8 or 16.7 mM D-glucose in the absence or presence of dexamethasone. In the 1.0 to 10 microM range, dexamethasone caused a concentration-related decrease in the FAD (flavin adenine dinucleotide)-linked mitochondrial glycerophosphate dehydrogenase (mGDH) mRNA content of the islets, and decreased both the mGDH content of the islets and the catalytic activity of the enzyme in islet homogenates, these effects being often more marked in islets cultured at 16.7 mM, rather than 2.8 mM, D-glucose. Even after culture in the presence of no more than 10 nM dexamethasone, namely under conditions in which the mGDH mRNA content and activity were both virtually unaffected, the corticosteroid restored the capacity of the beta-cells to display an increase in insulin output in response to a rise in D-glucose concentration in islets first cultured at 2.8 mM D-glucose but suppressed the insulinotropic action of the hexose in islets first cultured at 16.7 mM D-glucose. Whilst revealing an untoward effect of high concentrations of dexamethasone upon mGDH mRNA, content and activity in human islets, these findings also document a dual effect of a low concentration of the corticosteroid (10 nM) upon the secretory responsiveness of human islets to D-glucose, independently of any significant change in mGDH gene expression. It is proposed that such a dual action may account, in part at least, for both the well known increase in insulin output found in hypercorticism and the more recently discovered unfavourable direct effect of corticosteroid hormones on the secretory activity of islet beta-cells.

Determination of dexamethasone in bovine liver by chemiluminescence high-performance liquid chromatography

A new method for the determination of dexamethasone (9alpha-fluoro-11beta,17alpha,21-trihydroxy-16alpha -methylpregna-1, 4-diene-3,20-dione) in bovine liver was developed. This new liquid-liquid extraction method comprises the addition of sodium hydroxide to the tissue sample followed by extraction with ethyl acetate. After centrifugation, the extract is evaporated to dryness and the residue dissolved in acetonitrile. The cleaning of the fat is performed with n-hexane, and the acetonitrile layer is evaporated. Analysis of the extracts is performed using high-performance liquid chromatography with chemiluminescence detection employing luminol as CL reagent. A series of recovery curves performed at spiking levels of 50, 30, 10, 5, and 2.5 ppb show that at least 80% of DEX can be recovered from liver and that the chemiluminescence detection yields satisfactory results with respect to sensitivity (LOD 0.2 ppb), reproducibility (CV% 10.7) and repeatability (CV% 6.2-8.9).

[Hürthle cell carcinoma of the thyroid. A 41 years experience]

BACKGROUND

Hürthle cells can be found in non malignant thyroidal diseases such as Basedow Graves and Hashimoto diseases. When Hürthle cells comprise more the 75% of cellularity, they become a neoplasm. There are malignant variants of these neoplasms, constituted by follicular and papillary Hürthle cell carcinomas.

AIM

To report a 41 years experience with Hürthle cell carcinomas of the thyroid.

MATERIAL AND METHODS

A retrospective review of all patients operated for a thyroid carcinoma and selection of those patients with Hürthle cell carcinoma of the thyroid.

RESULTS

Twenty two patients (21 female, mean age 48 years old) with Hürthle cell carcinoma of the thyroid were selected. Total or near total thyroidectomy was the treatment of choice in 20 and 19 received 131I. Metastatic involvement of cervical lymph nodes was found in five patients and they underwent modified cervical lymph node dissection. During follow up, only one patient died of the disease. We did not find higher incidences of local recurrences, distant metastases or mortality rates, compared to well differentiated thyroid carcinomas.

CONCLUSIONS

Hürthle cell carcinomas of the thyroid and well differentiated thyroid carcinomas have similar biological behaviors. Their treatment should be similar, including total or near total thyroidectomy plus modified cervical node dissection when there is lymph node involvement. Radioactive iodine therapy and suppressive levothyroxin therapy should follow.

Inhibition of erythrocyte aminolevulinate dehydratase by a 56.2-kD peptide from uremic plasma

Among the abnormalities in erythrocyte porphyrin metabolism already described in patients with chronic renal failure on hemodialysis, a decrease in blood aminolevulinate dehydratase activity has been reported, suggesting the presence in uremic plasma of an inhibitor of the enzyme. The aim of this work has been to isolate and characterize such an inhibitor. Blood samples from 105 patients with chronic uremia were collected; plasma was applied to Sephadex G-100 columns and the fraction with the highest inhibiting capacity was identified and purified by subsequent SDS-polyacrylamide gel electrophoresis, followed by electroelution and electroblotting. It was demonstrated that the factor present in plasma of uremic patients inhibited blood aminolevulinate dehydratase in a concentration-dependent manner; its inhibitory properties were abolished after heat, trypsin and TCA treatment indicating its peptidic nature. The purified inhibitor has an apparent molecular mass of 56.2 kD, it inhibits blood aminolevulinate dehydratase in a competitive way and the Ki value is 12x10(-6) M. The amino acid composition of the inhibitor has been determined and it has been found that its N-terminal amino acid is blocked. The isolated peptide may play a role in heme biosynthesis disturbances and in the pathogenesis of uremic anemia.

Determination of clenbuterol residues in bovine hair by using diphasic dialysis and gas chromatography-mass spectrometry

A method for the determination of clenbuterol (4-amino-3,5-dichloro-alpha[(tert.-butylamino)methyl]-benzyl alcohol hydrochloride) in hair of living cows has been developed. Hair samples were digested in an alkaline medium. The diphasic dialysis technique is a semi-permeable membrane technology developed for the direct extraction of relatively low-molecular-mass analytes such as clenbuterol. In this case, we used sodium citrate buffer to homogenize the digested hair, dichloromethane was used as the extraction solvent at 37 degrees C, and stirring was applied at 150 rpm for 4 h. The analysis was carried out using gas chromatography-mass spectrometry. The calibration curve for clenbuterol in hair was linear in the range from 12.5 to 400 ng g(-1). The detection limit of clenbuterol was 5 ng g(-1) and the quantification limit was 12.5 ng g(-1), in hair. A good inter-day reproducibility was obtained (R.S.D. = 7.08%). The repeatability and intra-day reproducibility (50 ng g(-1) of hair, n = 10) show R.S.D.s of 7.1 and 9.5%, respectively.

[Insular carcinoma of the thyroid]

We report 5 cases of insular carcinoma of the thyroid. Most patients were females (80%) with an age range of 28 to 75 years. Treatment consisted of total or near total thyroidectomy plus modified cervical lymph node dissection in cases with lymph node metastasis. This was followed by radioiodine therapy and external radiation therapy in patients with residual disease. None of the patients had distant metastasis. However, three patients with involvement of the perithyroid soft tissue died within 4 years of the diagnosis. The other two patients are alive without evidence of disease. This type of thyroid carcinoma has an aggresive clinical course with frequent extension to the adjacent soft tissue associated to poor outcomes.

Mobilization of peripheral blood stem cells with docetaxel and cyclophosphamide (CY) in patients with metastatic breast cancer: a randomized trial of 3 vs 4 g/m2 of CY

The purpose of this study was to develop a regimen of docetaxel, cyclophosphamide (CY) and filgrastim for mobilization of peripheral blood stem cells (PBSC) in patients with metastatic breast cancer (n = 66). A phase I trial of CY 2, 3 or 4 g/m2 with docetaxel 100 mg/m2, in consecutive cohorts of four patients each, did not reveal any dose-limiting toxicities and subsequent patients were randomized to receive 3 or 4 g/m2 of CY. The median yield of CD34+ cells from all patients was 11.06x10(6)/kg (range, 0.03-84.77) from a median of two aphereses (range, 1-7); 6.52x10(6) CD34+ cells/kg/apheresis (range, 0.01-52.07). Target CD34+ cell doses > or =2.5 and > or =5.0x10(6)/kg were achieved in 89% and 79%, respectively. There were no statistically significant differences in CD34+ cell yields or target CD34+ cell doses achieved following 3 or 4 g/m2 of CY. Patients with only one prior chemotherapy regimen yielded a median of 12.82x10(6) CD34+ cells/kg/apheresis compared to 5.85 for those receiving > or =2 regimens (P = 0.03). It was concluded that the combination of docetaxel, 100 mg/m2, CY 3 g/m2 without mesna could be administered with acceptable toxicity with collection of adequate quantities of PBSC from the majority of patients.

Site-directed mutations of the FAD-linked glycerophosphate dehydrogenase gene impairs the mitochondrial anchoring of the enzyme in transfected COS-7 cells

COS-7 cells were transfected with the green fluorescent protein (GFP) of Aequorea victoria, human mitochondrial FAD-linked glycerophosphate dehydrogenase (mGDH), a mGDHwt-EGFP construct, or two mutant mGDH-proteins fused with EGFP. The site of mutation was selected to affect cationic amino acids in the peptide signal sequence currently believed to play a key role in the subcellular distribution of mitochondrial proteins. All proteins were suitably expressed in the COS-7 cells. However, an increase in mGDH enzymatic activity above the control value in non-transfected COS-7 cell homogenates was only observed in cells transfected with mGDH, indicating that the catalytic activity of mGDH was masked in fused proteins. Confocal microscopy documented that, in the cells transfected with the mGDHwt-EGFP construct, the fusion protein was located exclusively in mitochondria, this contrasting with the nuclear labelling of cells expressing the green fluorescent protein alone. The mitochondrial anchoring of the mutated mGDH fused protein was altered, this alteration being most obvious in the mGDH313233-EGFP mutant. These findings raise the idea that a conformation change of the mGDH protein, as resulting from either an inherited or acquired alteration of its amino acid sequence, may affect its subcellular distribution and, hence, modify its immunogenic potential.

[Carpal tunnel syndrome: clinical and neurophysiological correlation: review of 100 cases]

INTRODUCTION

The diagnosis of carpal tunnel syndrome (CTS) continues to be neurophysiologically and clinically controversial. This study attempts to find the correlation between the subjective symptomatology and the neurophysiological affectation, establishing a diagnostic guide for the family doctor in order to recognize early CTS for referral to the specialist doctor.

PATIENTS AND METHODS

After a sample of 100 cases with clinical suspicion of CTS, a clinical evaluation was made with the symptoms (paresthesias, pain, loss of strength), signs (Tinel, Phalen), and the neurophysiological evaluation with electroneurography (ENG) of the median and cubital nerve (sensory velocity (SV), motor distal latency (MDL)), and electromyography (EMG) of tenar eminence muscles. With this data an epidemiological study was made with correlation between the clinical and neurophysiological parameters.

RESULTS

The patients with pain, loss of strength and Tinel's sign had significant alteration of the parameters of ENG and EMG. Tinel's sign had a sensitivity (SE) = 30.1% and a specificity (SP) = 73% for MDL, a SE = 32.5% and a SP = 88.2% for SV. Phalen's sign had a SE = 22.2% and a SP = 94.6% for MDL, a SE = 18.1% and a SP = 94.1% for SV.

CONCLUSIONS

The guide to recognize clinically the patients which must be studied neurophysiologically that have a high probability to suffer CTS is: diagnosis for motor alteration, pain (SE = 79%), loss of strength (SP = 86%) and Phalen's sign (SP = 94.6%). Sensory alteration: paresthesias (SE = 97%), Tinel's sign (SP = 88.2%) and Phalen's sign (SP = 94.1%).

Reduction of islet amylin expression and basal secretion by adenovirus-mediated delivery of amylin antisense cDNA

Reduction of amylin content and secretion in rat islets was attempted by transduction with an adenovirus bearing a 0.2-kb fragment of rat amylin cDNA inserted in the antisense orientation (AdCMV-alpha amylin). Exposure of islets to AdCMV-alpha amylin at a multiplicity of infection (moi) of 200 (1.2 x 10(7) pfu/ml) reduced amylin mRNA levels by 37 +/- 5% (p < 0.005), whereas infection with an adenovirus expressing the reporter gene of beta-galactosidase (AdCMV-lacz) did not modify amylin expression. Transduction with the antisense construct was specifically associated with the decrease (30 +/- 6%; p < 0.001) in the amylin content. Insulin content was unaltered in AdCMV-alpha amylin islets compared to AdCMV-lacz-transduced or untransduced cells. Basal amylin secretion (2.8 mM glucose) was 36 +/- 3% (p < 0.005) lower in AdCMV-alpha amylin islets than in untransduced or AdCMV-lacz-transduced islets. In contrast, no difference in amylin secretion in response to high glucose concentrations (16.7 mM) was detected in AdCMV-alpha amylin-transduced islets. Thus, a reduction of amylin content and basal secretion in islet cells can be achieved by the adenovirus-mediated expression of antisense RNA.

Presence of the 918 mutation in the RET proto-oncogene in a Mexican patient with multiple endocrine neoplasia type 2B

The dominantly inherited Multiple Endocrine Neoplasia cancer syndrome type 2B (MEN2B) is characterized by the presence of medullary thyroid carcinoma (MTC), phaechromocytoma (PHAEO), mucosal neuromas, ganglioneuromas of the intestinal tract, skeletal and ophthalmic abnormalities. MEN2B has been associated with a specific point mutation in the tyrosine kinase domain of the RET proto-oncogene (918RET mutation). We investigated a Mexican patient MEN2B for the presence of the 918RET mutation using the polymerase chain reaction followed by restriction endonuclease digestion. We have detected this mutation in DNA from the patient's MTC, PHAEO, and peripheral blood cells, but not in DNA from the patient's mother, suggesting that this mutation arose de novo. Our results are in agreement with the suggestion that the 918RET mutation is present in a vast majority of MEN2B cases around the world.

Nucleotide sequence of cDNA fragments coding for the FAD-,glycerophosphate- and calcium-binding domains of human islet mitochondrial glycerophosphate dehydrogenase

The cDNA fragments coding for the FAD-, glycerophosphate- and calcium-binding domains of mitochondrial glycerophosphate dehydrogenase (mGDH) were synthetized using RNA extracted from freshly isolated pancreatic islets of a normal subject and two-non-insulin-dependent diabetic patients. Single strand conformation polymorphism analysis of the PCR products yielded the same mobility as control cDNA probes. Likewise, the nucleotide sequence and corresponding amino acid sequence were identical to the normal gene bank sequence. These findings argue against the presence, in pancreatic islets, of an mGDH isoform distinct from that previously characterized in extrapancreatic organs.

Determination of residues of the beta-agonist clenbuterol in liver of medicated farm animals by gas chromatography-mass spectrometry using diphasic dialysis as an extraction procedure

A method has been developed for the rapid confirmation of clenbuterol in cow liver using gas chromatography coupled with detection by mass spectrometry of the trimethylsilyl derivatives of clenbuterol. The technique used for the extraction was diphasic dialysis. It was observed that the best suitable solution to homogenize the liver the barium hydroxide-barium chloride buffer, the optimal extraction solvent was tert.-butylmethyl ether at an extraction temperature of 37 degrees C, and stirring should be applied at 150 rpm for 4 h. This extraction method improves clenbuterol recovery up to values of 99.3%. With the use of the barium buffer, derivatization is performed more efficiently and the detection and quantification limits can be decreased to values close to 250 ppt and 500 ppt, respectively.

Long-term prognosis for atypical and malignant meningiomas: a study of 71 surgical cases

To contribute to a better understanding of the prognostic differences between atypical and malignant meningiomas as defined by the World Health Organization (WHO) and the influence of the grade of initial surgical excision on postoperative course, 42 cases of atypical and 29 of malignant meningioma were studied, along with long-term follow up. The two groups were compared with respect to long-term survival, recurrence-free survival, and median time to recurrence. The prognostic significance of the Simpson grade of surgical resection and tumor location was also considered. Survival at 5 and 10 years was recorded in 95% and 79%, respectively, of patients with atypical meningioma and in 64.3% and 34.5% of patients with malignant meningioma (p = 0.001). Recurrence-free survival and median time to recurrence were also significantly longer in patients with atypical than in those with malignant meningiomas: 11.9 versus 2 years (p = 0.001) and 5 versus 2 years (p < 0.0041), respectively. Six (26%) of the 23 recurring atypical meningiomas became malignant. Simpson Grade I resection and location in the cerebral convexity, which were closely related, were found to be associated with a significantly better clinical course in the entire series (p < or = 0.0016). Patients with atypical meningiomas fared better than those with malignant meningiomas after incomplete surgical excision (Simpson Grades II-III), but the difference was not statistically significant. Multivariate analysis using the Cox model indicated that radical extirpation (Simpson Grade I vs. II-III) and histological findings (atypical meningioma vs. malignant meningioma) were significantly related to prolonged survival (p < 0.0003 and p < 0.0388, respectively). In conclusion, the current study shows that for most patients with atypical meningioma the prognosis was less severe than for those with malignant meningioma, but the risk of a downhill course resulting from malignancy after incomplete resection and recurrence was not negligible (26%). In addition, the WHO classification was found to be inadequate for a minority of the atypical meningioma cases, which currently have the same unfavorable course as cases of malignant meningioma. The results also indicate that objective Simpson Grade I extirpation of convexity meningiomas can be successful despite histological findings of malignancy.

Long-term prognosis for atypical and malignant meningiomas: a study of 71 surgical cases

To contribute to a better understanding of the prognostic differences between atypical and malignant meningiomas as defined by the World Health Organization (WHO) and the influence of the grade of initial surgical excision on postoperative course, 42 cases of atypical and 29 of malignant meningioma were studied, along with long-term follow up. The two groups were compared with respect to long-term survival, recurrence-free survival, and median time to recurrence. The prognostic significance of the Simpson grade of surgical resection and tumor location was also considered. Survival at 5 and 10 years was recorded in 95% and 79%, respectively, of patients with atypical meningioma and in 64.3% and 34.5% of patients with malignant meningioma (p = 0.001). Recurrence-free survival and median time to recurrence were also significantly longer in patients with atypical than in those with malignant meningiomas: 11.9 versus 2 years (p = 0.001) and 5 versus 2 years (p < 0.0041), respectively. Six (26%) of the 23 recurring atypical meningiomas became malignant. Simpson Grade I resection and location in the cerebral convexity, which were closely related, were found to be associated with a significantly better clinical course in the entire series (p ¾ 0.0016). Patients with atypical meningiomas fared better than those with malignant meningiomas after incomplete surgical excision (Simpson Grades II-III), but the difference was not statistically significant. Multivariate analysis using the Cox model indicated that radical extirpation (Simpson Grade I vs. II-III) and histological findings (atypical meningioma vs. malignant meningioma) were significantly related to prolonged survival (p < 0.0003 and p < 0.0388, respectively). In conclusion, the current study shows that for most patients with atypical meningioma the prognosis was less severe than for those with malignant meningioma, but the risk of a downhill course resulting from malignancy after incomplete resection and recurrence was not negligible (26%). In addition, the WHO classification was found to be inadequate for a minority of the atypical meningioma cases, which currently have the same unfavorable course as cases of malignant meningioma. The results also indicate that objective Simpson Grade I extirpation of convexity meningiomas can be successful despite histological findings of malignancy.

Mutation in the calcium-binding domain of the mitochondrial glycerophosphate dehydrogenase gene in a family of diabetic subjects

The Ca(2+)-sensitive and mitochondrial enzyme FAD-linked glycerophosphate dehydrogenase (m-GDH) represents an essential component of the pancreatic B-cell glucose-sensing device. This report deals with the first identified case of mutation in the calcium-binding domain of the m-GDH gene in a patient with type-2 diabetes and his glucose-intolerant half sister. Single strand conformation polymorphism analysis indeed revealed an abnormal mobility of the 32P-labelled polymerase chain reaction product in these two subjects. The corresponding base pair mutations and amino acid changes were documented. In the diabetic proband, the relative extent of the Ca(2+)-induced activation of m-GDH in CD3+ T-lymphocytes was lower than in his brother with a normal m-GDH gene sequence.

[Homograft replacement of aortic valve and ascending aorta]

From May 1990 through December 1994, integral valved aortic homografts were implanted for replacement of the aortic valve and of part or the whole of the ascending aorta in 24 patients with a mean age of 45.5 years (17-66 years). Ten patients (41.7%) had infective endocarditis of the aortic valve (4 of the native valve and 6 prosthetic). Seven of these had root abscesses (70%), one with a fistula to the right atrium, resulting in a variable degree of discontinuity between the left ventricle and the aorta. Twelve patients (50%) had ascending aortic aneurysms and the remaining two (8.3%) had aortic dissection. Three patients (12.5%) also had mitral pathology, one had triple vessel coronary disease, one had aortic coarctation and another one had a sub-aortic membrane. Two thirds of the patients were in NYHA class III/IV and 10 (41.7%) had moderate or severe left ventricular dysfunction. A modified Bentall technique utilising fresh aortic homografts was used in all patients. The homografts were harvested aseptically from donors with a mean age of 30 years (16-54 years) and preserved at 4 degrees C for a period of 1-43 days (median-13 days). Six patients (25%) had associated surgery: mitral valve replacement; mitral valvuloplasty with a ring; closure of aortic- atrial fistula, resection of sub-aortic membrane; triple coronary artery bypass; and mitral and tricuspid annuloplasty and closure of ASD (one patient each). Postoperatively three patients (12.5%) required reexploration for excessive blood drainage in the first hours and one patient with complete A-V block required a pacemaker (4.2%). Hospital mortality was 4.2% (one patient). At the time of discharge, no patient had significant Doppler or echocardiographic aortic gradient or regurgitation. All patients were followed for a mean period of 31 months (7-62 months). One patient died of a non cardiac death and the remainder are in NYHA class I without thromboembolic or haemorrhagic accidents and with echocardiographic findings similar to those observed at discharge. These results suggest that aortic homografts constitute an effective and safe method of reestablishing the continuity between left ventricle and aorta, especially in the presence of an infective process with root abscesses.

Clinical algorithm for treatment of Plasmodium falciparum malaria in children

BACKGROUND

Identification of children who need antimalarial treatment is difficult in settings where confirmatory laboratory testing is not available, as in much of sub-Saharan Africa. The current national policy in Malawi is to treat all children with fever, usually defined as the mother's report of fever in the child, for presumed malaria. To assess this policy and to find out whether a better clinical case definition could be devised, we studied acutely ill children presenting to two hospital outpatient departments in Malawi.

METHODS

The parent or guardian of each enrolled child (n = 1124) was asked a standard series of questions about the symptoms and duration of the child's illness. Each child was examined, axillary and rectal temperatures and blood haemoglobin concentrations were measured, and a giemsastained thick smear was examined for malaria parasites. Logistic regression procedures were used to identify clinical predictors of parasitaemia.

FINDINGS

High temperature (37.7 degrees C or above), nailbed pallor, enlarged spleen, and being seen at one of the clinics rather than the other were associated with an increased risk of malaria parasitaemia in univariate analyses. A revised malaria case definition of rectal temperature of 37.7 degrees C or higher, splenomegaly, or nailbed pallor was 85% sensitive in identifying parasitaemic children and 41% specific; the corresponding sensitivity and specificity for the nationally recommended definition that equates mother's history of fever with malaria were 93% and 21%. The revised case definition had 89% sensitivity in identifying parasitaemic children with haemoglobin concentration below 80 g/L and 89% sensitivity in identifying children with parasite density greater than 10,000/microL, characteristics that indicate a clear need for antimalarial treatment.

INTERPRETATION

These results suggest that better clinical definitions are feasible, that splenomegaly and pallor are helpful in identifying children with malaria, and that much overtreatment of children without parasitaemia could be avoided.

Validity of mother's history regarding antimalarial drug use in Malawian children under five years old

History obtained from parents and carers is an important, and often the only, source of information for health workers treating children for malaria, but its validity has not been well evaluated. At 2 hospitals in Malawi, we obtained malaria treatment histories from mothers of 973 ill children reported to have had fever as part of the illness. Urine samples were collected from 755 of the 973 children (78%). Of the 755, 457 (61%) were reported to have received some kind of treatment. Among those who reportedly received treatment, 79 (17%) were said to have received chloroquine and 23 (5%) a sulphonamide-containing medicine; however, when urine specimens were tested for antimalarial drugs, chloroquine was found in 182 specimens (40%) and a sulphonamide in 148 (32%). Among urine specimens collected from 291 children who were reported to have received no treatment (no report was recorded for 7 children), chloroquine was detected in 56 (19%) and a sulphonamide in 44 (15%). Although not statistically significant, mothers often reported a child as not having received an antimalarial drug if the child was younger than 12 months or had been sick for more than 3 d. The mothers' information regarding home treatment of fever in children was highly inaccurate. Malaria treatment histories, whether collected at health facilities or in surveys of knowledge, attitudes, and practices, must be interpreted with caution.

[Fine needle aspiration biopsy of thyroid nodules. Analysis of results obtained using a new method with histological examination of the sample]

Fine needle aspiration biopsy (FNAB) is the most useful preoperative work up method for patients with nodular goiter. We analyze 173 patients that underwent FNAB and were subsequently operated. The sample with FNAB was processed both for cytological and histological study, using methods developed at the hospital. The preoperative diagnosis reached was compared with that obtained with the surgical piece. Results showed that the histological analysis of the FNAB sample improved the sensitivity of the method, when compared with the cytological study, from 68.5% to 87.8% (p < 0.035) without modifying specificity (100% for both methods). It is concluded that FNAB with histological study of the sample has a high diagnostic yield and is exempt of complications.

A double-blind, placebo controlled study of Alpare mite D. pteronyssinus immunotherapy in asthmatic patients

Results from one immunotherapy study can be difficult to extrapolate when physicians use products or dose schedules that differ from the ones used in that particular study. The purpose of this study was to determine if an alum absorbed Alpare D. pteronyssinus extract administered in a maintenance dose of 10,000-12,500 BU's could be shown to improve symptoms in asthmatic patients allergic to D. pteronyssinus. Previous studies using higher doses of extracts suggested efficacy but frequent side effects were noted. A double blind placebo controlled study was performed which included 24 active and 25 placebo patients. We measured skin reactivity, methacholine challenge changes, symptoms by visual analog score, specific IgE levels, and end of study assessment. The results showed significantly greater improvement in actively treated patients versus those given placebo in specific IgE levels, symptoms by visual analog score, and end of study status. We saw no significant differences in skin reactivity, methacholine challenge, or diary medication scores. In addition, no difference in side effects was noted between the two groups. We conclude that the dose administered in this study was safe and well tolerated. Some clinical improvement did seem to occur but the study suggests that higher doses may be indicted in certain patients.

Spinal tumors and subarachnoid hemorrhage: pathogenetic and diagnostic aspects in 5 cases

The authors report 5 cases of spinal tumor associated with subarachnoid hemorrhage. Histologically, the tumor was an ependymoma in 2 cases, a neurinoma in 2 cases and a hemangioblastoma in 1 case. The pathogenetic and diagnostic characteristics of these 5 cases are analyzed in the light of other published reports.

Using clinical signs to diagnose anaemia in African children

Anaemia is a serious and common problem among young children in sub-Saharan Africa. As a first step towards developing guidelines for its recognition and treatment, we conducted a study to evaluate the ability of health workers to use clinical findings to identify children with anaemia. Health care workers examined a total of 1104 children under 5 years of age at two hospital-based outpatient clinics in rural Malawi. Blood samples were taken to determine haemoglobin concentrations. Pallor of the conjunctiva, tongue, palm or nail beds was 66% sensitive and 68% specific in distinguishing children with moderate a anaemia (haemoglobin concentration, 5-8 g/dl) and 93% sensitive and 57% specific in distinguishing those with severe anaemia (haemoglobin concentration, < 5 g/dl). Even without laboratory support, which is often unavailable in rural Africa, clinical findings can identify the majority of children with anaemia.

[Papillary cystic tumor of the pancreas: an infrequent carcinoma of good prognosis]

Papillary cystic tumor of the pancreas is a rare low grade carcinoma, with only 130 cases reported in the English literature. We report a 22 years old female presenting with a palpable mass and abdominal pain. Abdominal ultrasound and CAT scan showed a solid-cystic lesion in the head of the pancreas. The patient was subjected to a partial pancreatoduodenectomy and the histological study of the surgical specimen disclosed a papillary cystic carcinoma. Post op course was uneventful and the patient is well at 8 months follow up.

Epileptic seizures in intracerebral hemorrhage: a clinical and prognostic study of 55 cases

Fifty-five cases of epileptic siezures associated with spontaneous intracerebral hemorrhage are reported. Seizures appeared as the first symptom in 23 patients, early (within two weeks after HI) in 18 and late (later than 2 weeks after HI) in 14. From the analysis of the observed cases we noticed that: 1) partial seizures were most frequent type (63%). These appeared mainly in cases with lobar hemorrhage above all; 2) development chronic epilepsy occurred frequently in the case of patients affected by late seizures. We compare our data with those reported in literature in order to highlight main factors which affect the onset and development of seizures associated with spontaneous intracerebral haemorrhage.

Plasma exchange in systemic lupus erythematosus. Experience in thirty-seven patients

Thirty-seven (37) SLE patients submitted to therapeutic plasmapheresis were examined. The results were good in the active stage of the disease. Various types of antibody, anti-DNA, anti nucleus, anti-cardiolipine, I.C. (Clq and C3d) were removed. The values of IgG, coagulation factors, creatinine and proteinuria were assessed. Close collaboration with the clinicians is urged, with the aim of applying immunosuppressive therapy immediately after P.E. to consolidate the results obtained.

Angiomatosis at the Saphenofemoral Junction

Objective:

To describe 12 patients with a vascular malformation found at the saphenofemoral junction during dissection of the inguinal region for surgery of varicose veins.

Design:

Retrospective study of cases found during the period from 1986 to 1991.

Setting:

University Hospital of the Military School of Medicine, Bogota, Colombia.

Patients:

Twelve patients, 11 unilateral and one bilateral, representing 0.5% of our total experience in surgery of varicose veins in 5 years.

Interventions:

Surgical resection of the angiomatous malformation.

Main outcome measures:

Clinical assessment of patients and histological examination of excised tissue.

Results:

The excised angiomatous tissue was found to contain irregular venous vessels, associated with lymphatic nodular structures and surrounded by adipose tissue. A satisfactory clinical outcome was obtained in patients where the angiomatous tissue could be excised.

Conclusions:

Vascular surgeons treating varicose veins should be aware of the possibility of finding vascular angiomatous malformation of the saphenofemoral junction. Surgical resection of these benign lesions results in a satisfactory clinical outcome.

[Value of bronchoalveolar lavage in the diagnosis of pulmonary involvement in storage diseases]

A 17 years old female with hepatosplenomegaly and pulmonary infiltrates since the age of four is presented. Sea-blue histiocyte disease, a sphingolipidosis, was diagnosed by liver biopsy, bone marrow aspirate and bronchoalveolar lavage. The relevance of bronchoalveolar lavage as a diagnostic method in cases of systemic diseases with pulmonary involvement is emphasized.

Total Bacterial Count in Raw Milk Using the BactoScan 8000

The BactoScan 8000 (Foss Electric) automatically performs a total count of bacteria in raw milk. It was designed for fast, repeatable counting. The apparatus counts the individual bacteria (IBC) instead of colony forming units (CFU). IBC provides more information on the state of milk hygiene than the CFU count. The repeatability, sr, was 0.033 log (IBC/μL), which is equivalent to a coefficient of variation of 7.9% (IBC/μL). The carryover, which is the contamination one sample imposes on the next, was 0.19%. The BactoScan 8000 was calibrated against the reference method of counting colonies on a Petri dish. The correlation coefficient for 429 milk samples was r= 0.88, and the standard deviation of the residuals, syx, was 0.259. The detection limit was 15 CFU/μL. We recommend establishing a system of payment to farmers based on the bacteriological quality of their milk as determined by the BactoScan 8000. Because results are obtained in IBC/μL, analytical differences resulting from conversion to CFU/|iL are eliminated.

[Effectiveness and tolerability of simvastatin in subjects with primary hypercholesterolemia. Multicenter study]

The efficacy and safety of simvastatin were evaluated in an open multicenter study over a 24-week period. One hundred seventy-two patients (91 men, 81 women) with primary hypercholesterolemia (mostly polygenic) were enrolled in 14 Centers in Northern Italy. The mean age was 55.8 +/- 9.7 years and the mean baseline total cholesterol level was 305 +/- 59 mg/dL. After 4 weeks on an AHA step 1 diet, patients who met the inclusion criterion (total cholesterol > or = 250 mg/dL) were given simvastatin 10 or 20 mg in the evening. The dose could be titrated up to a maximum of 40 mg o.d. at week 6 and 12. No dose titration was allowed after week 12. One hundred forty-nine patients (86.6%) completed the study according to the protocol, 2 (1.2%) were withdrawn from the study because of adverse events not related to the drug, 21 (12.2%) were unavailable for follow-up. Simvastatin treatment was associated with a sustained dose-related reduction in total and LDL cholesterol (-28% and -39% respectively at the end of the study). Triglycerides showed a significant descending trend (-16% at week 24) and HDL-C increased by 9%. Apolipoproteins were measured in only 25 patients: apo B was reduced by 30% and apo A1 increased by 9%. Clinical side effects were not relevant. Mean levels of GOT, GPT and CPK significantly increased after 6 weeks on simvastatin, but remained stable and at any rate ioitlin the normal range thereafter. Eight patients (5.4%) experienced small transaminase level elevations (< 3ULN) and six (4%) small CPK elevations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Heart surgery without previous heart catheterization, in pediatric cardiology]

STUDY OBJECTIVE

To determine the influence of echocardiography in the preoperative diagnosis of heart diseases in children.

DESIGN

Retrospective study.

SETTING

Hospitalized children admitted in Departments of Pediatric Cardiology and Cardiothoracic Surgery.

PATIENTS

Children of both sexes, aged from neonate to 14 years old, with heart disease who underwent cardiac surgery.

MATERIAL AND METHODS

From January 1989 to July 1990, 220 consecutive cardiac surgeries were performed in children with heart disease. The initial diagnosis was based on data from clinical examination, electrocardiogram, thorax X-Ray and echocardiogram (M-mode, 2D, conventional and colour Doppler). Patients were separated in three groups according to their ages: newborn infants less than 28 days old; infants less than 12 months old; children more than 1 year old and less than 14 years old. Patients were separated according to the investigations used further for preoperative diagnosis: whether they had or not cardiac catheterization performed prior to surgery.

RESULTS

From 220 surgical interventions performed, 124 were "open heart" surgeries (9 neonates, 28 infants and 87 children) and the remaining had "closed heart" operations (14 neonates, 37 infants and 45 children). Preoperative diagnosis was mainly dependent on echocardiography, dispensing catheterization in 90 cardiac interventions. The diagnosis was confirmed at surgery or at autopsy. There were 9 deaths, 3 of which occurred in patients not submitted to cardiac catheterization.

CONCLUSIONS

Echocardiography is a reliable method for investigation and establishment of the preoperative diagnosis of heart diseases in children. Its use may further reduce the need for diagnostic catheterization in children, particularly in risk groups.

Cefaclor in the treatment of infective exacerbations of chronic bronchitis in cigarette smokers

There is a direct correlation between number of cigarettes smoked and the incidence of lower respiratory tract infection in humans. In studies with smokers suffering from exacerbations of chronic bronchitis, the most common bacterial pathogens found were Haemophilus influenzae, Streptococcus pneumoniae, Staphylococcus aureus and Branhamella catarrhalis. Antibiotics should be effective against such possible pathogens. Cefaclor has demonstrated in vitro activity against all these pathogens. We designed the present study to evaluate the efficacy and safety of cefaclor in the treatment of acute exacerbations of chronic bronchitis in cigarette smokers. A total of 106 patients were enrolled in the study. H. influenzae was the most common bacterial species isolated in the sputum (in 23.6% of the total sample), followed by S. pneumoniae (18.9%), S. aureus (17.0%), K. pneumoniae (7.5%) and B. catarrhalis (5.7%), while mixed forms were present in 22.6% of cases and other pathogens in 4.7%. Cefaclor (500 mg) was given orally every 8h for 7 to 16 days (mean 10.73 +/- 2.11). Analysis of clinical response data indicates that 75.5% of patients were cured and 17.0% improved. This finding is important because it demonstrates that cefaclor's spectrum of activity encompasses all the most likely pathogens encountered in smokers. Because of its excellent response rate, cefaclor is of particular value in the treatment of lower respiratory tract infections in cigarette smokers.

[Acquired immunodeficiency syndrome associated with infection by HTLV-1 virus: a clinical case]

A 51 year old man with acquired immune deficiency syndrome for 2 years developed a chronic leukemia/T cell lymphoma. Anti HTLV-1 antibodies were confirmed by Western Blot. In the last months he developed hypercalcemia and leukocytosis of 130,000. Necropsy confirmed the diagnosis of Leukemia/T cell lymphoma without cutaneous involvement.

[Primary cutaneous lymphoma: experience with 10 cases]

We report 10 patients with cutaneous lymphoma along with their clinical findings, staging, histopathologic characteristics by light microscopy, and results of anti-HTLV antibody screening. The immunotype was T cell in all. Three patients were diagnosed as having Lymphomatoid papulosis: one of them evolved to Mycosis fungoides, another showed progression to Immunoblastic lymphoma and a third remains as such. Two patients had a long standing Mycosis fungoides and, finally, 5 cases had peripheral T-cell lymphoma. Of the latter, 2 progressed rapidly to death.

Rett's syndrome: a neurophysiological study

Thirteen girls with Rett's syndrome were evaluated with wakefulness and sleep polygraphic records and EMG studies. The main EEG findings were paroxysmal activity during sleep, multifocal in younger and unifocal in older girls, and "pseudorhythmic flattening". In the opinion of the authors, the changes with age are related to evolution of the disease or maturational changes of CNS. The affectation of the peripheral nervous system was demonstrated in almost half the patients.

Effects of plasma exchange (PE) in primary biliary cirrhosis (PBC). A pilot study

Six patients were studied to evaluate the efficacy and safety of plasma exchange (PE) in the treatment of primary biliary cirrhosis (PBC). All patients were affected by PBC at stage III-IV and presented symptoms refractory to pharmacologic therapy. Patients underwent PE for a mean period of 40 weeks (range 10-88). A mean of 33 liters (range 17-64) of plasma per patients was removed. Patients reported less fatigue (4/6), pruritus (5/5), nausea (3/3), Sjogren's syndrome (2/6), and painful neuropathy (2/3). A reduction of xanthomata was noted in one of the three affected patients. Definitive improvement was seen in the patient with Raynaud's phenomenon. A significant reduction was noted for serum cholesterol and gammaglobulins. ALT, AST, gamma-GT, alkaline phosphatase, bilirubin, prothrombin activity, AMA titers were not affected by PE. All patients suffered some mild adverse effects during PE. Two patients (IV stage) developed late edema and ascites after 34 and 44 weeks of treatment. We conclude that PE can be considered effective chronic treatment for advanced symptomatic PBC refractory to pharmacological therapy.

Anaphylactoid reactions to protamine: an often lethal complication in insulin-dependent diabetic patients undergoing vascular surgery

Protamine is used routinely at our institution during arterial surgery to reverse the anticoagulant effect of heparin. Adverse fatal reactions to protamine are generally believed to be rare. However, major anaphylactoid reactions occurred in 11 of the last 1150 patients receiving this drug at our institution. Nine of these reactions occurred in 325 insulin-dependent diabetic patients (incidence, 3%), whereas only two occurred in the 825 patients not receiving insulin (incidence, 0.2%) (p less than 0.001). Ten of these reactions occurred within 10 minutes of protamine administration (15 to 35 mg), whereas one reaction occurred immediately after administration of a 5 mg test dose of protamine. Systolic blood pressure fell below 60 mm Hg in all of the 11 patients, and three patients had to be resuscitated with closed-chest massage. Initial treatment with epinephrine and steroids was successful in seven cases. Four patients required further resuscitative measures, including closed-chest massage. However, one of the patients died as a result of ventricular fibrillation resistant to treatment. Ten of the 11 patients, including the patient who died, had significant preexisting cardiac disease; six of the surviving 10 patients (60%) had perioperative myocardial infarctions and three died. Thus the total mortality rate was 36% (4/11). These data support the implication that neutral protamine Hagedorn (NPH) insulin produces an adverse reaction through immunologic presensitization of the patient. These data also show that, in the older vascular surgery population with a high incidence of significant cardiac disease, protamine reactions can be potentially lethal. Thus routine use of protamine should be avoided in diabetic patients receiving insulin.

Natural killer cells in children with acute leukemia. The effect of interleukin-2

The purpose of this study was to determine (1) the number and activity of natural killer (NK) cells in children with acute leukemia at different stages of their disease; and (2) the effect of interleukin-2 (IL-2) in enhancing NK activity of these patients' cells. The mean percentage of Leu 11+ NK cells in patients at diagnosis (5% of peripheral blood (PB) mononuclear cells) was significantly lower than for patients on maintenance (23%), post-treatment (21%) and for normal children (20%). The mean PB NK cell cytotoxicity for patients at diagnosis (16% lysis versus K562) and during maintenance (20%) was significantly lower than for post-treatment (41%) and normal controls (40%). After NK cells were incubated for 5 days with IL-2, NK cells from 82% (36/44) of patients showed enhanced cytotoxicity toward K562 and several acute leukemia cell lines as well as toward autologous leukemic cells. Cytotoxicity toward autologous cells was very low (0% to 5%, 16 hour assay) before IL-2 stimulation, and significantly increased (23% to 69%) after stimulation, suggesting that IL-2 may be a useful agent for enhancing the antileukemic immune response.