Nasal septum perforation as the presenting sign of lupus erythematosus

Nasal septum perforation is an uncommon and not well known feature of lupus erythematosus (LE). In general, it occurs during exacerbations and in a context of systemic vasculitis. Very rarely it can be a presenting sign, accompanying more usual manifestations of LE. We report the case of a 30-year-old woman who presented with a 2-year history of painful, slowly progressive nasal septum perforation. Laboratory study disclosed positive antinuclear antibodies, circulating immune complexes, hypocomplementemia, nuclear epidermal deposition of IgG in normal skin and transitory positive antiphospholipid antibodies. Symmetric peripheral joint arthritis, photosensitivity and diffuse alopecia subsequently developed. This case seems unique in that the nasal septum perforation occurred as an isolated presenting sign; it emphasizes the value of this feature in the diagnosis of LE.

River water quality improvement by natural and constructed wetland systems in the tropical semi-arid region of northeastern Brazil

The efficiencies of a natural Typha spp wetland (Wn) formed on a river bed and its effluent treatment in a constructed wetland (Wc, subsurface horizontal flow) were investigated in northeastern Brazil (Paraiba State). The Wc system (12 tanks with stone gravel, 4.13 m2, 0.22 m3, 20 Typha spp rhizomes, m(-2) each, with 38, 29, and 19 mm x d(-1) hydraulic loadings, and 5, 7, and 10 days HRT) was fed daily with effluent from a Wn. Wn removal presented the highest values after Typha spp were cut during the 5th week. Removal values were (1st and 2nd periods or before and after cutting): 75% and 81% BOD5; 10-53% total phosphorus; 13%-55% ammonia; 89%-91% FC; 90-96% coliphages and bacteriophages. Wc removals increased with time with best results on 10 d HRT. Removals were also higher in the 2nd period: 74%-78% BOD5; 58%-82% ammonia; 90% FC; 94-98% FS; and 92%-96% coliphages and bacteriophages. Despite the high remaining values of FC (1.4 x 10(4) CFU/100 ml) and FX (4 x 10(3) CFU/100 ml), the removals were satisfactory and HRT dependent, suggesting a gradual optimization of the system with time. The Wc exhibited good efficiency for improving water quality from polluted river.

Remodeling of HDL by CETP in vivo and by CETP and hepatic lipase in vitro results in enhanced uptake of HDL CE by cells expressing scavenger receptor B-I

The transport of HDL cholesteryl esters (CE) from plasma to the liver involves a direct uptake pathway, mediated by hepatic scavenger receptor B-I (SR-BI), and an indirect pathway, involving the exchange of HDL CE for triglycerides (TG) of TG-rich lipoproteins by cholesteryl ester transfer protein (CETP). We carried out HDL CE turnover studies in mice expressing human CETP and/or human lecithin:cholesterol acyltransferase (LCAT) transgenes on a background of human apoA-I expression. The fractional clearance of HDL CE by the liver was delayed by LCAT transgene, while the CETP transgene increased it. However, there was no incremental transfer of HDL CE radioactivity to the TG-rich lipoprotein fraction in mice expressing CETP, suggesting increased direct removal of HDL CE in the liver. To evaluate the possibility that this might be mediated by SR-BI, HDL isolated from plasma of the different groups of transgenic mice was incubated with SR-BI transfected or control CHO cells. HDL isolated from mice expressing CETP showed a 2- to 4-fold increase in SR-BI-mediated HDL CE uptake, compared to HDL from mice lacking CETP. The addition of pure CETP to HDL in cell culture did not lead to increased selective uptake of HDL CE by cells. However, when human HDL was enriched with TG by incubation with TG-rich lipoproteins in the presence of CETP, then treated with hepatic lipase, there was a significant enhancement of HDL CE uptake. Thus, the remodeling of human HDL by CETP, involving CE;-TG interchange, followed by the action of hepatic lipase (HL), leads to the enhanced uptake of HDL CE by cellular SR-BI. These observations suggest that in animals such as humans in which both the selective uptake and CETP pathways are active, the two pathways could operate in a synergistic fashion to enhance reverse cholesterol transport.

[Adjuvant therapy with a glycoprotein IIb-IIa inhibitor (abciximab) in coronary angioplasties with a high thrombotic risk]

INTRODUCTION

We retrospectively studied our experience with adjunctive therapy with glycoprotein IIb-IIIa inhibitor (abciximab) on patients with a high risk of thrombotic complications during coronary angioplasty (PTCA).

PATIENTS AND METHODS

From September 1996 to November 1997, we performed PTCA in 210 patients, and abciximab was given to 38 (18%) of them. The interventions were urgent (primary PTCA in acute myocardial infarction) in 55% of the cases. The mean age of patients was 68.6 +/- 12 years and 71% were male. The reasons for coronary intervention were: acute myocardial infarction in 21 patients (55.3%), unstable angina in 9 (23.7%) and stable angina in 8 (21%). Coronary stents were implanted in 13 patients (34%) and an intra aortic balloon pump was used in 4 (11%). The reasons for using abciximab were: thrombus containing lesion: 22 (57.9%); other type B2/C lesion characteristics: 6 (15.9%); acute closure post balloon PTCA: 9 (23.7%), sub-acute stent thrombosis: 1 (2.6%). Oral acetilsalicilic acid and intravenous heparin were given to all patients at the beginning of the intervention. The mean APTT was 124 +/- 32 seconds at the end of the procedure.

RESULTS

The arterial sheaths (8 French) were removed six hours after procedure, according to the normalisation of APTT values. Angiographic success in this group of patients was 100%. One patient died during hospitalisation due to left ventricular failure. There was no need for repeated angioplasty or coronary bypass grafting during hospital stay. The main complications related to the use of abciximab were: bleeding (requiring transfusion) in four patients 10.5%); severe thrombocytopenia (< 50,000 platelets/mm3): 1 (2.6%): cardiac tamponade (requiring pericardiocentesis): 1 (2.6%) and pseudo-aneurysm of femoral artery (requiring vascular surgery): 1 (2.6%).

CONCLUSIONS

The use of abciximab as adjunctive therapy in this small group of patients undergoing coronary interventions with high risk of thrombotic complications is associated with high procedural success, but at the expense of high rates of bleeding complications. Therefore, special care must be applied during and after the procedure to enhance the safety of the patients treated with this drug.

Endothelial nitric oxide synthase in hypoxic newborn porcine pulmonary vessels

AIMS

To determine if the failure of neonatal pulmonary arteries to dilate is due to a lack of nitric oxide synthase (NOS).

METHODS

A monoclonal antibody to endothelial NOS was used to demonstrate the distribution and density of NOS in the developing porcine lung after a period in hypobaric hypoxia. Newborn piglets were made hypertensive by exposure to hypobaric hypoxia (50.8 kPa) from < 5 minutes of age to 2.5 days of age, 3-6 days of age or 14-17 days of age. A semiquantitative scoring system was used to assess the distribution of endothelial NOS by light microscopy.

RESULTS

NOS was present in the arteries in all hypoxic animals. However, hypoxia from birth caused a reduction in NOS compared with those lungs normal at birth and those normal at 3 days. Hypoxia from 3-6 days led to a high density of NOS compared with normal lungs at 6 days. Hypoxia from 14-17 days had little effect on the amount of NOS. On recovery in room air after exposure to hypoxia from birth there was a transient increase in endothelial NOS after three days of recovery, mirroring that seen at three days in normal animals.

CONCLUSIONS

Suppression of NOS production in the first few days of life may contribute to pulmonary hypertension in neonates.

Early abundance of nerves containing NO synthase in the airways of newborn pigs and subsequent decrease with age

We have localized by immunocytochemistry, and quantified by intercept counting, NO-synthase-containing nerves in newborn pig intrapulmonary airways and maturational changes in their density in juvenile and adult lung. NO-synthase-containing nerves supplying airway smooth muscle and epithelium were evident at all ages (< 2 h, 1-2 days, 3-5 days, 6-10 days, 10 and 16 weeks). They were most abundant in neonates, and their density decreased with age (intercepts/mm2 +/- SEM: newborn, 94 +/- 3.3; 16 weeks, 7 +/- 0.3; P < 0.001), as did their percentage of the total nerves defined by the general neuronal marker PGP 9.5 (newborn, 38 +/- 2.7%; 16 weeks, 18 +/- 2.3%; P < 0.01). Neural-derived NO may be important in pulmonary adaptation to extra-uterine life.

[Cerebral metastasis as the form of presentation of a basaloid carcinoma of the esophagus]

A case of oesophageal basaloid carcinoma is reported. The disease was revealed as a brain metastasis and was found ad initium to be in an advanced stage, with evidence of brain, lung and liver metastasis. The treatment performed was palliative subtotal oesophagectomy followed by roentgen therapy. A year and a half later, the patient is still alive and in home care follow up. The authors end stressing this uncommon presentation for an oesophageal neoplasm and the rarity of its histologic type. They also stress the role of surgery, although palliative, in long survival, very unlike the rapid evolution of the few published cases.

[A fatal intraoperative cerebral ischemia following kinking of the internal carotid artery?]

Postoperative neurological deficit may result from ischaemic or hypoxic hypoxaemia. Postural cerebral hypoperfusion may ensue when a pre-existing asymptomatic vascular anomaly in combination with rotation of the head for surgical positioning compromises cerebral blood flow. CASE REPORT. A 30-year-old man was referred for recraniotomy for glioblastoma. Following uneventful induction of anaesthesia, increased diuresis and progressive hypothermia were observed. The postoperative period was complicated by a seizure, followed by apnoea requiring reintubation of the trachea. A CAT scan revealed global cerebral oedema with subtotal compression of the third ventricle. Intracranial pressure was 60 mm Hg as measured by an epidural probe. On the 1st postoperative day clinical and electroneurophysical signs of brain death were observed; the patient underwent organ explantation the next day. PATHOLOGY. Pathological examination revealed pronounced global hypoxaemic lesions and an S-shaped internal carotid artery with intimal proliferation (Fig. 1). The diagnostic conclusion was cerebral ischaemia following carotid occlusion caused by carotid kinking and completed by surgical positioning (rotation of the head). CONCLUSION. Carotid kinking is a rare abnormality, and patients at risk may not be identified preoperatively. Though it is questionable whether this disaster could have been prevented at all, electroneurophysiological monitoring would have been the only early monitoring system capable of detecting diminishing cerebral blood flow. Although a request for routine intraoperative neurophysiological monitoring seems unrealistic at present, it has to be acknowledged that only such monitoring could have provided the information needed to save this patient.

[Myocardial infarct in a young man with normal coronary vessels: apropos of a clinical case treated with streptokinase]

The authors report a case of a 31 year old young man who suffered acute myocardial infarction and was subjected to early treatment with streptokinase. The immediate follow-up showed a complete recanalization of the infarct-related vessel, without any identifiable obstructive lesion on coronary arteriography. Related to this angiographic finding, common in myocardial infarction in the young adult, the authors debate the implicated mechanisms, focusing essentially in the relation endothelium-platelets-vasomotricity. The issue of cigarette smoking as a risk factor and its possible pathogenic implication, even in the absence of atherosclerotic plaque, is also approached.

Retrograde tracing shows that CGRP-immunoreactive nerves of rat trachea and lung originate from vagal and dorsal root ganglia

The origins of sensory innervation of the lower respiratory tract are thought to be principally the nodose and jugular ganglia of the vagus nerve. It has been suggested and partially demonstrated that there is also a component arising from dorsal root ganglia, but the segmental levels involved are not known precisely. We have therefore investigated the origins of sensory nerves within the rat respiratory tract, particularly those containing calcitonin gene-related peptide (CGRP), using the technique of retrograde axonal tracing combined with immunohistochemistry. Injections of True blue were made into extra-thoracic trachea (n = 4 rats) and percutaneously into the right and left lung (n = 4 each). Retrogradely labelled neuronal perikarya were detected in vagal and dorsal root ganglia, and sympathetic chain ganglia. CGRP-immunoreactive cells were seen only in vagal and dorsal root ganglia. Tracheal innervation arose bilaterally in the vagal sensory ganglia but those on the right side represented the principal source; the majority of CGRP-containing neurons occurred in the jugular ganglion. A very small component of labelling occurred in spinal ganglia at levels C2-C6. The sensory innervation of the lungs was seen to arise predominantly from the ipsilateral dorsal root ganglia (45% of cells CGRP-immunoreactive) at levels T1-T6. In contrast to the trachea, the contribution of vagal sensory neurones to the lungs appeared to be less than that of the spinal ganglia. These results show that the sensory innervation of the rat lungs has a major origin in the dorsal root ganglia, in which almost half of the involved neurons contain CGRP, and confirm that most CGRP-immunoreactive nerves in the trachea arise in the right jugular ganglion.