[Inhalers and nebulizers in the children]

Inhaled way is the most efficient method to deliver drugs for the treatment of respiratory diseases. Pulmonary deposition depends upon the inhalation system and technique. The evaluation of the drug deposition is difficult, particularly in children. Because of irradiation, scintigraphic studies which permit the best approach of the pulmonary deposition are rare in children. Various inhalation systems are available: nebuliser, metered-dose inhaler with or without spacer device, dry powder inhaler. Whatever the system used, the control of asthma will be only possible with the regular evaluation of the child inhalatory technique.

[Evaluation of systematic pulmonary function testing for asthma in children aged three to five years]

Pulmonary function testing is not usually done in the preschool child, despite the recent data showing early deterioration in airway function in asthma.

METHODS

We evaluated feasibility and clinical interest of flow-volume loop by forced expiratory maneuver and measure of airway resistance by interrupter technique (interrupter resistance), before and after inhalation of salbutamol, in 75 children aged three to five years seen in the ambulatory setting for asthma.

RESULTS

Feasibility rate (92%) and reproducibility rate (91%) of those techniques were good, so that 84% of the cases could be exploited (63 children of 75). We found few significant associations between clinical parameters and flow-volume loop. We found a significant association between elevated interrupter resistance at basis and night-symptoms (P = 0.03), between diminished interrupter resistance after salbutamol and exercise-symptoms (P = 0.03), symptoms in the ambulatory setting (P = 0.02) and absence of inhaled corticosteroid treatment (P = 0.046). Pulmonary function testing resulted in treatment modification in 14% of cases.

CONCLUSION

Our study shows that flow-volume loop and measure of airway resistance by interrupter technique can be done with a good reproducibility in the preschool child. Interrupter resistance appears to be better correlated than flow-volume loop with usually evaluated clinical parameters.

[Treatment of cytomegalovirus pneumonia with ganciclovir in an immunocompetent infant]

Cytomegalovirus infection is common in the immunodepressed child, and because of its severity, is usually treated with intravenous ganciclovir. It is also common in the immunocompetent child, but is usually asymptomatic, so that there is no indication for ganciclovir treatment, because of the potential toxicity of the drug.

CASE REPORT

We report a case of symptomatic cytomegalovirus infection in a six-week-old infant, presenting with interstitial pneumonia associated with weight and height growth failure. Cytomegalovirus was found by polymerase chain reaction in the bronchovalveolar lavage fluid and in the blood. This child was successfully treated with 15 days of intravenous ganciclovir, and experienced no adverse effect of this treatment. The child was free of symptoms and free of immunodeficiency after seven months of follow-up.

CONCLUSION

Immunocompetent patients with cytomegalovirus infection, pulmonary involvement and weight and height growth failure, may benefit from intravenous ganciclovir treatment. Further studies, with larger number of cases, are yet needed to define more precisely the indications of such a treatment in the immunocompetent child.

Interventional radiology techniques in the treatment of complications due to videolaparoscopic cholecystectomy

INTRODUCTION

The development of videolaparoscopic cholecystectomy (VLC) has represented an important achievement in the search for minimally invasive surgical procedures, and especially in the surgical management of such a common and costly disease as cholelithiasis. However, the literature shows that, while VLC carries a similar mortality rate to open surgery, it has a greater incidence (2-5 times) of iatrogenic injury to the biliary tract and hepatic hilum [3, 5, 10, 25, 28]; this incidence further increases in cases of so-called "hard cholecystis" [10, 13, 25, 28, 30]. An equally minimally invasive technique is therefore needed to treat these lesions; this technique should be effective and safe, allow for shorter hospital stays and lower costs, and be made available at all the centres where VLC is performed.

MATERIAL AND METHODS

We evaluated 60 patients (28 women and 22 men, age range 41-71) with 24 peritoneal collections (14 bilomas, 10 abscesses), 35 biliary stenosis (clips, chronic-developing lesions), and 2 vascular lesions as direct iatrogenic post-LC injuries. The most frequent clinical symptoms were jaundice, pain, sepsis, abdominal distension, and abdominal colic due to retained common bile duct stones. We carried out 60 percutaneous biliary reconstruction procedures, 44 biliary drainages (4 internal, 4 external), 6 combined radiological-endoscopic approaches with the Rendez-Vous technique, and 2 embolisations.

RESULTS

All procedures had 100% technical success; the biliary reconstruction procedures had a 2% morbidity rate (sepsis, cholangitis). The clinical emergencies (choleperitoneum, haemoperitoneum, severe jaundice) resolved in 72 hours for 55 of the 60 patients (92%). The combined percutaneous-endoscopic procedures with the biliary Rendez-Vous technique were successfully performed in 5 out of 6 cases, allowing reconstruction of bile duct continuity and remission of symptoms, without the need to resort to surgical anastomosis. At a recent follow-up of the patients who had been managed only percutaneously, one showed patency of the bile ducts and had the stent removed after 18 months, and two showed optimal functioning of the stent that was still in place after 5 and 8 months respectively; two patients were lost to follow-up. Primary biliary patency at 60 months from biliary reconstruction was 75%. Maximum and immediate dilatation was obtained at the first attempt in most cases. Reoperation was avoided in 59 out of 60 patients. Only one patient with full transection of the common bile duct was reoperated on after insertion of a biliary drainage catheter. The overall length of hospital stays was between 1 and 4 weeks.

CONCLUSIONS

Interventional radiology carried out according to indications seems to be the most natural way to treat the complications of VLC. It spares the patients, who opted for a minimally invasive technique like VLC, the need to undergo open surgery, and allows for shorter hospital stays and more efficient cost management for the hospital.

Hemoretroperitoneum associated with liver bare area injuries: CT evaluation

In hepatic injury restricted to the postero-superior region of segment VII (bare area), hemoperitoneum may be absent and this condition may be associated with hemoretroperitoneum. The aim of this paper is to present the association between bare area injuries and hemoretroperitoneum evaluated by CT. The CT examinations of 32 patients with blunt liver trauma were reviewed and the number and location of lesions were evaluated. Right lobe involvement was identified, focusing on the bare area lesions. The presence of hemoperitoneum and hemoretroperitoneum were determined. In the 32 patients 44 parenchymal lesions were detected. Segment VII was involved in 16 cases: 5 patients presented an intraparenchymal lesion, 11 patients a lesion emerging to the liver surface. In 8 cases the lesion was localized in the bare area. In the 16 patients presenting a segment-VII lesion, hemoperitoneum was detected in 3 cases, hemoretroperitoneum in 4 cases, and both conditions in 4 cases. A traumatic hepatic lesion may be associated with hemoretroperitoneum rather than hemoperitoneum. This justifies the absence of clinical signals of peritoneal irritation; the negativity of both US scan and peritoneal lavage may cause an inappropriate therapeutic management. Computed tomography yields both the detection of the parenchymal damage and the correct localization of the intraperitoneal and retroperitoneal hemorrhage.

[Isolated blunt hepatic traumas: role of emergency CT in therapeutic choice]

INTRODUCTION

The purpose of the study was to establish the role of score-based CT classification of hepatic lesions, peritoneal and retroperitoneal bleeding in the blunt hepatic trauma.

MATERIAL AND METHODS

CT examinations of 47 haemodynamically stable patients, with isolated traumatic hepatic lesions were reviewed. CT scans were obtained with a spiral CT (thickness mm 10, pitch of 1) before and after 60 seconds after from intravenous administration of 140 cc of contrast medium at a rate of 2 cc/sec). Eleven out of 47 patients underwent surgery immediately after the CT examination, 2/47 patients in 48 hours; 34/47 patients were treated conservatively with CT follow-up on days 3 and 7, and before dimission discharge. The hepatic lesions, and degree of peritoneal and retroperitoneal haemorrhage were classified using the following scale: 1-5 for the hepatic lesions, in according to the Mirvis classification; 0-3 for peritoneal haemorrhage (0=no haemorrhage, 1=minor mild haemorrhage, 2=moderate haemorrhage, 3=major massive haemorrhage); 0-2 for retroperitoneal haemorrhage (0=no haemorrhage, 1=haemorrhage confined to the anterior pararenal space, 2=haemorrhage in 2 or more retroperitoneal spaces). The score was correlated to the treatment decisions (follow-up or surgery).

RESULTS

Based on the hepatic lesion scores, we classified: 4 patients as grade 1 of grade 1, 9 as grade 2, 22 as grade 3, 11 as grade 4, 1 as grade 5; based on peritoneal haemorrhage, 14 patients as grade 0, 9 as grade 1, 8 as grade 2, and 10 as grade 3; based on retroperitoneal haemorrhage, 36 patients as grade 0 of grade 0, 3 as grade 1, and 8 as grade 2. The overall scores of the 13 patients that who underwent surgery were: 6 in 6 patients, 7 in 4 patients, 8, 9, and 10 in 1 patient.

DISCUSSION AND CONCLUSIONS

CT is the modality of reference for evaluating traumatic hepatic lesions. The selection of patients for surgery requires an accurate classification and grading of the lesions. The classification of hepatic lesions alone, however, is not sufficient, as it does not take into account peritoneal and retroperitoneal haemorrhage, that which often occurs, and are correlated with the need for exploratory laparotomy. Integrated score-based evaluation of the hepatic lesions, peritoneal and retroperitoneal haemorrhage shows a good correlation with treatment decisions and clinical outcome.

Integrated imaging in peripheral nerve lesions in type 1 neurofibromatosis

PURPOSE

Our aim was to evaluate the role of Ultrasonography (US) and Magnetic Resonance (MR) in the staging and follow-up of peripheral nerve lesions in type 1 Neurofibromatosis (NF1).

MATERIAL AND METHODS

We evaluated forty-six NF1 patients (16 males and 30 females, age range 12-65 years, mean age 34 years) affected by 51 soft tissue lesions, clinically diagnosed as subcutaneous (18 cases) and plexiform (33 cases) neurofibromas. The lesions were studied to identify site, size, extension, relationship with surrounding structures, and any features indicating malignant transformation. All patients underwent at least one US examination performed with a 7.5 - 10 MHz linear multi-frequency probe. All subcutaneous neurofibromas larger than 2 cm, all superficial or deep plexiform neurofibromas not clearly defined at US, and all large plexiform neurofibromas with massive involvement of surrounding tissues were studied by MR using 0.2 T magnet (Artoscan) or 1.5 T magnet (Magnetom Vision Plus Siemens). Fifteen patients underwent surgery; the remaining cases (31) were followed up according to the National Institutes of Health (NIH) protocol.

RESULTS

The subcutaneous neurofibromas smaller than 2 cm showed homogeneous hypoechoic echotexture (10 cases), whereas lesions equal to or larger than 2 cm showed a characteristic target pattern (peripheral hypoechoic rim with hyperechoic core). All lesions larger than 2 cm studied by MRI displayed the target pattern in T2-weighted sequences, with peripheral signal hyperintensity and central signal hypointensity. At US, the 33 plexiform neurofibromas had an irregular shape with undefined borders; the patterns were classified as follows: 1) superficial plate-like lesions (14 cases); 2) superficial lesions with deep digitations (8 cases); 3) deep multi-lobulated lesions (5 cases); 4) extensive lesions massively involving soft tissues (6 cases). MRI was performed in 11 cases, showing an isointense or moderately hyperintense signal on T1-weighted sequences, high signal intensity on T2-weighted sequences, and, after intravenous gadolinium administration, variable enhancement on T1-weighted sequences.

CONCLUSIONS

The results obtained in subcutaneous neurofibromas indicate a clear relationship between lesion size and US-MR imaging, with similar local staging. Since MRI failed to provide additional information, US may be considered the first-choice, and sometimes decisive, examination in these cases. As regards plexiform neurofibromas, US only proved useful in staging superficial lesions and partly deep multi-lobulated lesions as it accurately depicted lesion size, but not local extension; MRI is therefore useful in the preoperative staging of lesions. In extensive lesions, US proved unable to provide accurate and complete local staging of the lesions, so that MRI should be systematically used in these cases.

Esophagogram and CT vs endoscopic and surgical specimens in the diagnosis of esophageal carcinoma

PURPOSE

Aim of our study was to assess the accuracy of diagnostic imaging in establishing site, morphology and size of the neoplasm comparing surgical specimens or endoscopic examination with esophagograms and CT in patients with esophageal cancer. CT accuracy in defining TNM staging was also evaluated.

MATERIAL AND METHODS

From 1993 to 2000 we examined 39 patients with esophageal cancer: 30 males (77%) and 9 females (23%), age range 41-85 years. All patients underwent esophagogram, digestive endoscopy, and chest and abdominal CT. In 22 patients who underwent surgery, we evaluated the correlation between diagnostic imaging and surgical specimens. Patients were divided into 3 groups on the basis of discrepancy between pathological and radiological measurements: =/<1 cm (considered as no discrepancy); 1 to 3 cm; > 3 cm.

RESULTS

Esophagogram identified neoplasm in 38 patients out of 39, while CT identified neoplasm in all patients. Location and morphology of the neoplasm established at endoscopy were confirmed in all patients. Lesion length measured at esophagogram corresponded to length of surgical specimens in 13 of the 22 surgically treated patients (59%). In this group there was a dominance of polypoid and stenotic tumor forms. In the remaining 9 cases there was a dominance of ulcerative tumor forms. CT measurement corresponded in 7 patients (32%) with a dominance of polypoid and stenotic tumor forms. T staging performed with CT corresponded to surgical specimens in 12 patients (54%, T3-T4). N staging correlated in 19 patients (86%). CT identified distant metastases in 6 patients (27%).

DISCUSSION AND CONCLUSIONS

Our study proves a high sensitivity of esophagogram and CT in the diagnosis of esophageal carcinoma. Esophagogram presented a higher accuracy in establishing tumor length (59% of cases, as compared to CT 32%). Tumor morphology influenced the accuracy of the esophagogram, and highest accuracy was obtained in polypoid and stenotic tumors. T staging performed with CT corresponded to surgical specimens in advanced stages (T3-T4), while accuracy was poorer in smaller superficial lesions (T1-T2) due to the inability of CT to differentiate the layers of the esophageal wall. N understaging in 14% of cases did not modify surgical management. CT presented a high sensitivity in the identification of loco-regional lymph nodes and identified distant metastases in 6 patients. In conclusion, these techniques are accurate and non-invasive and their role in establishing the correct management is therefore important.

MR evaluation of anterior cruciate ligament reconstruction with quadriceps tendon. Preliminary experience

PURPOSE

Anterior cruciate ligament reconstructions are becoming increasingly frequent, and MRI has been shown to be the best imaging modality for the non-invasive assessment of surgical outcome. Use of the quadriceps tendon as a biological replacement for injured cruciate ligament is a recent innovation. This study evaluated by MRI the results of anterior cruciate reconstruction in 27 consecutive patients who underwent arthroscopic reconstruction with homologous quadriceps tendon.

MATERIAL AND METHODS

MRI was carried out on 27 patients who had undergone anterior cruciate ligament reconstruction with the middle third of the homolateral quadriceps tendon. The examinations were performed on two MRI units: a permanent 0.2-Tesla dedicated magnet (Artoscan, Esaote Italy) and whole-body 1.5-Tesla superconducting magnet (Signa, GE Medical Systems Milwaukee, Winsconsin USA). Axial, sagittal and coronal images were acquired with SE, GE and STIR fat suppression sequences. The examinations were performed 1, 3, and 6 months post-operatively in 16 patients, and 1 and 3 post-operatively in 11 patients. The same arthroscopic surgical technique was employed in all patients, with 20 cases of tibial mono-tunnel femoral semi-tunnel, and 7 cases with tibial bi-tunnel technique. All patients were assessed by arthrometric and clinical tests after surgery. Bioabsorbable interference screws were used for tibial fixation in all patients and metallic interference screws were used for femoral graft fixation in 8 patients.

RESULTS

In all cases MRI correctly visualised the tunnel positions, the articular portion and the bone-portion of the graft inside the tibial and femoral tunnels. The absence of paramagnetic artefacts in the tibia allowed complete visualisation on the axial, sagittal and coronal MRI images with optimal spatial and contrast resolutions. In 6 cases, the presence of metal residues from the surgical cutter prevented correct evaluation of femoral tunnel content. No new graft or articular lesions were found. In 18/27 cases peri-focal marrow edema around the tibial tunnel had disappeared 3 months after surgery. The process of synovial incorporation was judged to be correct in all cases.

DISCUSSION

The use of anterior cruciate ligament reconstruction with the quadriceps tendon is a important innovation given the size of the harvested material and the possibility of completely filling the osseous tunnels, without interposition of synovial proliferation or fluid collection between tendon and bone, as confirmed by MRI. Furthermore, the use of non-metallic screws allows MRI evaluation of tunnel content and oedema in the spongy bone around the tunnel. The study of the double tibial tunnel requires specific obliqueness in the coronal plane scans.

CONCLUSIONS

This arthroscopic technique for anterior cruciate ligament reconstruction allows thorough MRI evaluation of all portions of the transplant, and in particular those coursing within the tibia and femur. The absence of bone oedema around the tunnels and synovial proliferation within the tunnels may be predictive of faster healing and complete bone incorporation of the grafts.

[Comparison between estimates of radiological workload]

OBJECTIVE

To comparise three methods for assessing the productivity of radiological services: a) simple count of radiological examinations, b) method proposed by SNR-SAGO-SIRM, c) method used by Regione Emilia Romagna (RER) to evalutate the characteristics of these methods and to find a common method of estimate.

MATERIAL AND METHODS

On the radiological examinations performed at our unit over a period of 12 months were recorded. The different types of examinations were clustered into five homogenous groups (general radiology, ultrasound, barium examinations, CT, MRI). The data were assessed by a) number of examinations/hour per radiologist, b) score/hour according to the SNR-SAGO-SIRM method and c) score/hour according to the RER method, and then compared for the percentage of the single aggregates.

RESULTS

a) The total number of examinations was 26,776 with 40% being accounted for by general radiology; mean numbers of examinations our ranged from 2.43 (August) to 4.20 (March). b) The total score according to the SNR-SAGO-SIRM method was 67,054. The radiologist weight per hour ranged from 6.37 (August) to 9.67 (May). Ultrasound was the most relevant examination in the unit accounting for 43% of total weight. c) The total score according to the RER method was 1,850,780. The radiologist weight per hour ranged from 159 (August) to 316 (April). CT was the most relevant examination (51% of total weight).

CONCLUSION

According to the simple count of examinations, general radiology and ultrasound were the most relevant examinations together accounting for 75% of examinations, i.e. 40% and 35% respectively, whereas by SNR-SAGO-SIRM standards the two techniques represent 19% and 45% respectively. The simple count method therefore fails to give adequate weight to technologically advanced imaging technique. The SNR-SAGO-SIRM method adequately takes into account the combination of patient-number and patient weight. The RER method gives excessive weight costly technology as it considers the total weight of the examination and not only the radiologist's activity.

[New femoral fixation system for tendon transplantation in ACL reconstruction. Preliminary experience with MR imaging]

INTRODUCTION

The Authors describe the MR aspects of a new femoral fixation technique which has been recently introduced in anterior cruciate ligament recontructive surgery. This fixation device is composed of bioabsorbable material and of a thin thread which measures about 2,8 mm in diameter and 3,5 cm in length. This thread is positioned via the lateral transcondylar approach using the same arthroscopic technique as is used to position the transcondylar interference screw. By means of this technique it is possible to fix all the types of autologous grafts which are presently employed: patellar tendon, flexor tendons and quadriceps tendon. In MR, the absence of paramagnetic artifacts allows to detect also the graft portion inside the femoral bone tunnel and to acquire very accurate images.

MATERIAL AND METHODS

By means of MR examination, we have studied 16 patients of either sex (11 M/ 5 F) with an age ranging from 18 to 37 years (mean age: 28,9 years). All of them underwent an anterior cruciate pro-ligament reconstruction by employing autologous tendons: the patellar tendom (=9), the quadriceps tendon (=4) and the flexor tendons (=3). By means of dedicated MR equipment at low-field intensity and with permanent magnet (Artoscan 0,2 T, Esaote, Genoa, Italy), every patient underwent follow-up controls during a period of time ranging from 1 to 9 months after the operation. We employed T1-weighted and T2-weighted spin-echo, gradient-echo and STIR sequences with fat tissue suppression. Besides the standard axial, sagittal and coronal planes, we employed a coronal plane with doubt obliquity which runs both along the axial plane and along the sagittal one with the aim of visualizing the whole graft on a single scanning plane including completely either the intra-articular portion or the bone tunnel portion.

RESULTS

In none of these cases we did detect para-magnetic artifacts which could prevent us from performing a complete assessment either of the fixation device or of the content of the femoral tunnel. The tendinous graft was studied along the hole intra-articular length and inside the portions of the femoral and tibial bone tunnel. For this purpose the images acquired on oblique plane along the roof of the intercondylar notch were very useful. No patient reported significant complications, apart from two cases of maniscus everlasting pain as regards medial fibrocartilaginous sutures and one case of residual pain which concerns the anterior region of the patellar tendinous donor site. The evaluation form of the International knee Document Committee shows that in clinical terms all the patients achieved good results (=7) or excellent results (=9). Overall, we detected no new grant rupture or any functional limitation of the flexor-extension.

DISCUSSION AND CONCLUSIONS

The advent of small-size bioabsorbable synthetic materials that are compatible with the MR equipment at out disposal, make it easier to obtain a good visualization of all the portions of the anterior cruciate tendinous ligament graft. By employing suitable sequences as well as scanning planes, MR is the only technique which is able to meet any operated patient's requirements and in particular those one which concern the development state of his/her recovery progress as well as the grant-taking. Follow-up studies will be necessary, however, to determine the real evolution as well as the complete integration of these reconstructions.

Identification of 96 single nucleotide polymorphisms in eight genes involved in iron metabolism: efficiency of bioinformatic extraction compared with a systematic sequencing approach

Single nucleotide polymorphisms (SNPs) can significantly contribute to the characterization of the genes predisposing to iron overloads or deficiencies. We report an SNP survey of coding and non-coding regions of eight genes involved in iron metabolism, by two successive methods. First, we made use of the public domain sequence data, by using assembled expressed sequence tags, non-redundant sequences, and SNP database screening. We extracted 77 potential SNPs of which only 31 could be further validated by sequencing DNA from 44 unrelated multi-ethnic individuals. Our results indicate that a bioinformatic approach may be effective only in those cases where candidate SNPs are extracted from two different data sources or in cases of experimentally confirmed SNPs. Second, additional systematic sequencing of DNA from 24 unrelated Breton subjects increased the number of SNPs over a total length of 86 kb to 96. The average distance between the SNPs and minor allele frequencies were higher than reported by others authors; this discrepancy may reflect the nature of the genes studied and the ethnic homogeneity of our test population.

Determination of cycloserine in human plasma by high-performance liquid chromatography with fluorescence detection, using derivatization with p-benzoquinone

A new method for determining cycloserine in plasma samples is described. This method is based on the derivatization of cycloserine with p-benzoquinone, a reaction that takes place at the same time as the process of plasma deproteinization due to the presence of ethanol as solvent in the solution of the derivatization reagent. Four derivatives are obtained from this reaction. The main derivative is well correlated with the cycloserine concentration. The ratio between the volumes of the plasma sample and the reagent solution is 1:2 for a p-benzoquinone concentration of 1000 microg/mL. Elution from a C18 column was isocratic, using a mobile phase containing (v/v) 85% aqueous 0.1% formic acid solution, and 15% (v/v) of a mixture of methanol and acetonitrile (1:1), with a flow-rate of 1 mL/min, at 25 degrees C. Determinations by fluorescence detection were achieved with excitation at 381 nm and emission at 450 nm, with a detection limit of 10 ng/mL for an injection volume of 5 microL. This method was validated and applied to the determination of cycloserine in blood plasma samples of several healthy volunteers.

[Spontaneous remission of osteochondritis dissecans in 8 pediatric patients undergoing conservative treatment]

PURPOSE

Ostheocondritis dissecans lesions of the knee has a poor prognosis if certain signs are present at MRI. Clinical course is dependent on the site and extension of the lesions, and the age of the patient. In children, certain MRI findings similar to those found in the adult have a different prognostic significance, and in some case the condition can be cured by conservative treatment. By means of MR follow-up examinations performed at 6, 12 months, and in 2 cases, 24 months, we evaluated up the evolution of 8 osteochondritis dissecans treated conservatively with rest and antinflammatory drugs.

MATERIAL AND METHODS

7 pediatric patients (mean age 13 years) with 8 lesions of osteochondritis dissecans (bilateral in one cases) underwent MR follow-up examinations. In all cases the maximum longitudinal diameter of the lesion focus did not exceed 2 cm and at the first MR control the cartilage was intact. The MR examinations were performed using a dedicated low field magnet and a permanent low field magnet.

RESULTS

MR allowed us to correctly identify both the origin and the extent of the lesion in all the patients. The follow-up examinations performed after 6, 12 and 24 months, showed complete disappearance of the osteochondritis dissecans focus in 6 cases whereas two lesions showed a 50% reduction of their extent.

DISCUSSION AND CONCLUSIONS

Magnetic Resonance currently represents the gold standard for the evaluation of osteochondritis dissecans focus because, unlike other imaging techniques which are not able to identify the lesion it enables to establish an early diagnosis. Although the small number of the lesions examined only allows preliminary conclusions to be drawn, we have shown that in pediatric patients conservatively treated osteochondral lesions may evolve favourably. However, in all the cases examined the cartilage covering the lesion was intact. Favourable prognostic factors at MR are: stability of the transchondrial fragment and infraspongious edema at the adjacent bone. Peripheral hypervascularization may represent an attempt and spontaneous heading, as occurred in our cases.

Infectious spondylodiscitis: magnetic resonance imaging in HIV-infected and HIV-uninfected patients

OBJECTIVE

We retrospectively reviewed 21 infections of the spine to correlate magnetic resonance imaging (MRI) with etiology of spondylodiscitis according to HIV status.

CONCLUSION

MRI allowed the differentiation between tuberculous and pyogenic spondylodiscitis in the chronic stage. Typical findings were not observed in HIV+ as compared with HIV- patients, either concerning etiology or characteristic features of the spondylodiscitis.

Venesection therapy of insulin resistance-associated hepatic iron overload

BACKGROUND/AIMS

The association of hepatic iron overload with metabolic disorders has been coined as the insulin resistance-associated hepatic iron overload syndrome (IR-HIO).

METHODS

Fifty-six IR-HIO patients were phlebotomized either weekly (n = 14) or bimonthly (n = 42) and compared with C282Y homozygotes and with ten IR-HIO patients treated by a low calorie diet alone.

RESULTS

In venesected patients, the median amount of mobilized iron was 0.6 g in 2.8 months in females and 1.8 g in 5 months in males. Mobilized iron did not differ depending on the frequency of venesections or HFE genotype. When compared with C282Y homozygotes, IR-HIO patients had a similar amount of mobilized iron, but three-fold serum ferritin levels. The presenting symptoms (chronic fatigue and/or polyarthralgias) improved in 6/7 patients. Phlebotomies were well tolerated. In patients treated by a low calorie diet, serum ferritin levels remained stable.

CONCLUSIONS

In IR-HIO patients, body iron stores are significantly increased, overestimated by serum ferritin, not modified by a low calorie diet, and safely removed by phlebotomies. Based on these data and on studies indicating that iron excess is associated with increased risk for hepatic fibrosis, cancer and cardiovascular disorders, venesection therapy can be recommended in IR-HIO patients.

[Role of sonography in the evaluation of parotid gland in HIV+ children undergone highly active antiretroviral therapy (HAART)]

PURPOSE

To evaluate the role of sonography (US) in the evaluation of parotid gland alterations in HIV+ children, in order to show their presence, severity, specificity, relationship with clinical and laboratory data and sensitivity to new drugs.

MATERIAL AND METHODS

From June 2000 to December 2000 twenty-two consecutive HIV+ children (12 males and 10 females, mean age 9.7) undergoing HAART were prospectively examined with US. A multi-frequency linear probe (7.5-10 MHz) was used for the examination. The glands were assessed for alterations in gland volume and vasculature, hypoechoic foci, hyperechoic striae, lympho-epithelial cysts and solid nodules and the enlargement of intraparotid and adjacent lympho nodes. The US findings on HIV+ patients were compared with the patients'clinical and laboratory data and with US exams performed on HIV- children. Finally, we made a comparison with US exams performed on the same patients before HAART:

RESULTS

In HIV+ children the most frequent US findings were hypoechoic foci (68.2% of patients), hyperechoic striae (68.2%) and the enlargement of intraparotid and adjacent lympho nodes (86.3% and 95.4%, respectively). No relationship between US outline and clinical and laboratory data was found. In the control group (HIV-negative children) hypoechoic foci and hyperechoic striae were rare (4.7% and 14.3%, respectively), while the enlargement of intraparotid and adjacent lympho nodes was very common (76.2% and 100%, respectively). The comparison with US exams performed on the same patients before HAART showed an improvement in 59.1% of patients, no improvement in 13.6% and a worsening in 13.6% (3 patients were lost to follow-up).

DISCUSSION AND CONCLUSIONS

US is useful in the study of parotid gland alterations in HIV+ children. The most frequent specific US findings were hypoechoic foci and hyperechoic striae, whereas the enlargement of intraparotid and adjacent lympho nodes was frequent but completely aspecific. The analysis of results did not show any relationship between the US findings and clinical and laboratory data. HAART can be correlated to an improvement and/or a stabilization of the US pattern in most patients.

[Osteo-odonto-kerato-prosthesis. Radiographic, CT and MR features]

PURPOSE

Osteo-odonto-keratoprosthesis, a complex eye surgery technique devised by Strampelli, provides a valuable opportunity to restore vision in patients with severe corneal opacification (chemical or thermal burns, bullous keratopathy, severe keratitis, consequences of perforating injuries) in whom corneal transplant or the insertion of synthetic prostheses is contraindicated because of the high risk of rejection. Successful implantation of corneal prostheses in these patients was clearly dependent on the use of perfectly biocompatible materials to support the optic. Strampelli demonstrated that thin autologous tooth sections, complete with alveolar-dental ligament fulfilled these requirements, and integrated perfectly with the eye tissues without any risk of rejection. This study aims to present the radiological aspects and postoperative outcome of 13 patients who received osteo-odonto-keratoprosthesis (bilateral in 11 cases and monolateral in 2) evaluated by plain radiography, CT and MRI.

MATERIAL AND METHODS

Between 1993 and 2001 we evaluated 13 patients who had undergone Strampelli's osteo-odonto-keratoprosthesis, using CT, plain radiography and MRI. All patients were examined by plain radiography; 11 patients were also examined by CT and 8 also by MRI. The time interval between surgery and the radiological evaluation ranged from 3 to 13 years with a mean follow-up of 5 years and 9 months.

RESULTS

All patients underwent periodic clinical and imaging examinations in the post-operative period to evaluate the osteo-dental implant and to study trophism of the transplant. No post-operative complications, either cicatricial, inflammatory or of any other nature, were clinically suspected. Only two patients showed partial reabsorption of the osteo-dental lamina - evident both on plain film and CT - 10 and 12 years after surgery. Vision was restored in all the patients, with visual acuity of 10/10 in 7 cases.

DISCUSSION AND CONCLUSIONS

Plain radiography allows to correctly evaluate the position of the prosthesis and detect possible displacements or variations in thickness, but it fails to visualize intraocular soft tissues. Besides allowing visualization and study of the prosthesis, CT also allows optimal evaluation of the intra-orbital structures and early detection of the presence and extension of inflammatory complications that may undermine outcome of the procedure. MRI is similar to CT in its capacity to evaluate intra-orbital tissues, but has the advantage of allowing greater contrast resolution thanks to the use of different types of sequences. However, because of the long image acquisition times, this method is subject to movement artifacts that are less evident in the CT examination which, especially if performed using the spiral technique, has very short image acquisition times.

[Symptomatic treatment of cough in children]

Treatment of chronic cough should always be etiologic. Recurrent viral infections are the most frequent problem. Utilisation of antitussive drugs must be limited, of short duration and without contraindications. Antitussive medications are classified in opiate and nonopiate, with central or peripheral action.

A new mutation of E-cadherin gene in familial gastric linitis plastica cancer with extra-digestive dissemination

Over a 12-month period, we diagnosed poorly differentiated infiltrative independent-cell gastric adenocarcinoma in two brothers and one sister aged 41 to 47 years. Their father had died from antral cancer at the age of 34 years. These cancers had two characteristic clinical features: rapid course and distant malignant dissemination. In all three patients, polymerase chain reaction-sequencing of the E-cadherin (CDH1) gene of white blood cells identified a heterozygous nonsense mutation of exon 3, producing a stop codon at position 95 (Q95X), resulting in a truncated protein. The alteration of this protein, which plays a crucial role in epithelial cell adhesion, probably explains the clinical expression in this type of familial diffuse gastric cancer.

Non-hyperfunctioning nodules from multinodular goiters: a minor role in pathogenesis for somatic activating mutations in the TSH-receptor and Gsalpha subunit genes

Constitutive activation of the cAMP pathway stimulates thyrocyte proliferation. Gain-of-function mutations in Gsalpha protein have already been identified in thyroid nodules which have lost the ability to trap iodine. In contrast, most of the studies failed to detect somatic activating mutations in the thyrotropin receptor (TSH-R) in non-hyperfunctioning thyroid tumors. The aim of this study was to screen for mutations TSH-R exon 10, encoding the whole intracytoplasmic area involved in signal transduction, and Gsalpha exons 8 and 9, containing the two hot-spot codons 201 and 227, in a subset of non-hyperfunctioning nodules from multinodular goiter. Identified by matching ultrasonography and scintiscan, 22 eufunctioning (normal 99Tc uptake) and 15 nonfunctioning (decreased 99Tc uptake) nodules from 27 non-toxic multinodular goiters were isolated. After DNA extraction, TSH-R exon 10 was analyzed by direct sequencing of the PCR products and Gsalpha exons 8 and 9 by Denaturing Gradient Gel Electrophoresis. No mutation of TSH-R or Gsalpha was detected in the 37 nodules analyzed. This absence of mutation, despite the use of two sensitive screening methods associated with the analysis of the TSH-R whole intracytoplasmic area and Gsalpha two hot-spot codons, suggests that TSH-R and Gsalpha play a minor role in the pathogenesis of non-toxic nodules from multinodular goiters.

Holoprosencephaly due to mutations in ZIC2: alanine tract expansion mutations may be caused by parental somatic recombination

We report on the prevalence of mutations in the zinc finger transcription factor gene, ZIC2, in a group of 509 unrelated individuals with isolated holoprosencephaly (HPE) and normal chromosomes. Overall, we encountered 16 HPE patients (from 15 unrelated families) with ZIC2 mutations. Thus, ZIC2 mutation was the apparent cause of HPE in 3-4% of cases. Seven mutations were frameshifts that were predicted to result in loss of function, further supporting the idea that ZIC2 haploinsufficiency can result in HPE. One mutation, an alanine tract expansion which is caused by the expansion of an imperfect trinucleotide repeat, occurred in seven patients from six different families. In three of those families, the father was found to be apparently mosaic for the mutation. We hypothesize that this mutation can arise through errors in somatic recombination, an extremely unusual mutation mechanism. In addition, one mutation resulted in a single amino acid change and one mutation was an in-frame deletion of 12 amino acids. The central nervous system malformations seen in patients with ZIC2 mutations ranged from alobar HPE (most common) to middle interhemispheric fusion defect (one case). Although severe facial anomalies are common in HPE, all of the patients with ZIC2 mutations had relatively normal faces, suggesting that ZIC2 mutations represent a large proportion of HPE cases without facial malformation.

[US and CT findings in complicated Meckel diverticulum]

AIM

Meckel s diverticulum is the most common congenital abnormality of the small bowel. It may be silent or symptomatic when complicated by hemorrage, intestinal occlusion, diverticulitis and umbilical fistulas. Radiologic diagnosis is often difficult because abdominal plain radiography and ultrasound are not sufficiently specific; CT is most accurate in differential diagnosis. MATERIAL AND METHODS. 11 patients (age 5-69 ys) were studied. Clinical symptoms included acute abdomen (4 pts), intestinal occlusion (3 pts), abdominal pain (4 pts), fever (5 pts). Radiological studies were abdominal plain radiography (8 pts), ultrasound (5 pts), CT (9 pts).

RESULTS

Abdominal plain radiography depicted signs of intestinal occlusion (4 pts) and perforation (1 pts); in 4 pts the signs were non diagnostic. Ultrasound showed an abscess in the pelvis (2 pts), dilatation and wall-thickening of an intestinal loop (2 pts), intestinal invagination (1 pts); it was not diagnostic in 3 pts. CT was not diagnostic in 3 pts; in 2 pts it showed an abscessual fluid collection in the pelvis, adherent to intestinal loops, with flogosis of the perivisceral fat; in 1 pt it revealed perforation; in 4 cases it was specific showing inversion of the diverticulum in an intestinal loop (2 pts) or a tubular fluid-filled structure, with thickened walls and contrast enhancement, which was interpreted as a inflammatory diverticulum (2 pts).

DISCUSSION

Our series confirms the difficulty of diagnosing Meckel s diverticulum in an acute setting. Abdominal plain radiography only allowed to diagnose intestinal occlusion or perforation. Ultrasound revealed abscessual collections in the pelvis, fluid distention of the diverticulum, segmental thickening of the intestinal walls and invagination. CT proved to be more specific showing signs suggestive of correct diagnosis in 6 pts. In particular, evidence of an intraluminal prolonged mass with central area of fat density and peripherral collar was considered suggestive of intraluminal invagination of Meckel s diverticulum. Another diagnostic sign is the evidence of a tubular fluid-filled structure, with thickened, enhanced walls. In 2 cases CT showed an abscessual collection with gas-fluid level (complication of perforation) confirming the need for surgery.

CONCLUSION

Meckel s diverticulum is a not uncommon condition that in some cases is complicated, resulting in acute abdomen. Preoperative radiological diagnosis can be suspected in the presence of suggestive signs, more often depicted by CT.

Low penetrant hemochromatosis phenotype in eight families: no evidence of modifiers in the MHC region

The gene responsible for hemochromatosis (HFE) has been identified on the short arm of chromosome 6, 4.5 Mb telomeric to HLA-A. A major mutation C282Y is closely correlated with the disease, as it accounts for 68 to 100\% of the cases of hemochromatosis. Nevertheless, some C282Y homozygotes subjects have no clinical or biological expression of the disease. Moreover, in Northern European populations a large discrepancy is observed between the number of C282Y homozygotes and the number of diagnosed hemochromatosis patients, suggesting incomplete penetrance of the mutation. To localize and identify the modifying genes, we investigated eight families including C282Y homozygous relatives showing no clinical signs of the disease, in addition to the hemochromatosis patients. Genomic DNA from 20 C282Y homozygotes (10 patients and 10 siblings presenting no or minor biological abnormalities) were studied. Five polymorphisms from the HFE gene were determined by PCR restriction. Extended haplotypes of the 6p21.3 region were constructed with 10 microsatellite markers. All the C282Y homozygotes shared the same HFE polymorphism. The haplotypes presented no significant difference between the probands and their unaffected relatives. These studies suggest that neither HFE polymorphism nor genes surrounding HFE are able to modulate HFE expression.

Anxiogenic-like effects limit rewarding effects of cocaine in balb/cbyj mice

Previous studies have reported intravenous cocaine self-administration behavior in several strains of mice with the exception of BALB/cByJ, a strain considered a mouse model of high emotional reactivity. The present experiments further investigated acquisition of self-administration in BALB/cByJ mice using a low dose and a habituation session. Following evidence of an initial drug-seeking behavior, we observed a progressive decline of intravenous self-administration. Pretreatment with diazepam (0.5 mg/kg, IP), reinstated cocaine-maintained responding. To test the hypothesis that injections directly into a reward-relevant brain region might support consistent cocaine-seeking behavior, BALB/cByJ mice implanted in the nucleus accumbens (NAc) or the caudate-putamen nucleus (CPu) were trained to discriminate between the arm enabling a microinjection of cocaine (30 pmol/50 nl or 150 pmol/50 nl) and the neutral arm of a Y-maze. Only NAc subjects exhibited a spatial discrimination toward the cocaine-reinforced arm and the D2 antagonist, sulpiride (50 mg/kg, IP) eliminated intra-NAc cocaine self-administration. However, after several days of cocaine self-injection, animals developed an approach/avoidance-like behavior between the start box and the reinforced arm. This behavior was suppressed by systemic diazepam (1 mg/kg, IP) pretreatment. We conclude that: (1) medio-ventral NAc is involved both in the rewarding (via a D2 dopaminergic mechanism) and aversive effects of cocaine in mice; and (2) anxiolytic pretreatment (diazepam) indirectly enhanced the reinforcing properties of cocaine in BALB/cByJ, suggesting that emotionality can act as a protective mechanism against stimulant abuse.

Transient visual symptoms in systemic lupus erythematosus and antiphospholipid syndrome

PURPOSE

To review the potential pathogenic mechanisms of transient visual symptoms (TVS) in the course of systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS), to discuss the most common clinical features associated with the occurrence of TVS, and to explore possible treatment options for these patients.

METHODS

The literature regarding the clinical and laboratory characteristics of SLE and APS patients experiencing TVS is reviewed from 1979 onward. A brief review of the wide spectrum of ophthalmologic features occurring in SLE and APS is also provided.

RESULTS

Data emerging from the review process point to thromboembolism as the most probable cause of TVS in SLE and APS. Thromboembolisms are likely induced by cardiac valve abnormalities and should be treated with anticoagulant drugs.

CONCLUSION

While progress has been made in understanding the association of TVS with SLE and APS, further investigation is needed to clarify this interesting relationship.

Non-hodgkin's lymphoma of the liver in patients with AIDS: sonographic, CT, and MRI findings

PURPOSE

We analyzed the sonographic, CT, and MRI findings in acquired immune deficiency syndrome (AIDS)-related non-Hodgkin's lymphoma (NHL) of the liver to evaluate the role of sonography in the diagnosis of this disease.

METHODS

We retrospectively reviewed sonograms and CT scans on 26 patients who had human immunodeficiency virus with liver lymphoma, either primary (10 cases) or secondary (16 cases), from 1992 to 1999. We also reviewed MR images on 12 of the patients. All patients had pathologically proven NHL; all imaging studies were obtained within 2 weeks of sonographically guided fine-needle aspiration biopsies. Lymphoma was the initial AIDS-defining illness in 38% of the patients.

RESULTS

NHL occurred as multiple lesions in most cases of both primary (7 of 10 cases) and secondary (15 of 16 cases) liver lymphoma. No imaging finding was specific for the diagnosis of hepatic lymphoma. The hepatic lesions were hypoechoic in 25 of 26 cases; in the remaining case, there was a large isoechoic mass. On unenhanced and contrast-enhanced CT, the lesions were hypodense in all cases, with a thin enhancing rim in 6 patients. On MRI, the lesions were hypointense on T1-weighted images and hyperintense on T2-weighted images.

CONCLUSIONS

Sonography may be helpful in the diagnosis of focal hepatic lymphoma in patients with human immunodeficiency virus. Sonographically guided fine-needle aspiration biopsy provides a definitive diagnosis. CT was crucial in the staging of lymphoma. MRI appears appropriate for studying liver NHL in selected cases.

[Recommended algorithms of prescription in the diagnosis of iron deficiency and overload]

In view of the recent development of new tests of biochemistry and molecular biology the assessment of iron status should be reconsidered and updated. The French Society of Clinical Biology (SFBC) and the French Society of Hematology (Cellular Hematology Group) recommend algorithms in the diagnosis of iron deficiency and iron overload bearing in mind the best efficiency and health economy. These recommendations are based on the known sensibility and specificity of each test. The analytical requirements for the determination of the tests as well as the clinical and biological signs evoking an iron deficiency or overload are recalled.

[Vertebral morphometry: evaluation of osteoporosis-caused fractures]

PURPOSE

To compare visual reading of spine radiographs and quantitative morphometric approach for assessing the prevalence of vertebral fractures in postmenopausal osteoporosis.

MATERIAL AND METHODS

In 473 postmenopausal women afferent to our Centre of Osteoporosis under-went lateral thoracic and lumbar spine radiograph to identify vertebral fractures and dual energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD) of the lumbar spine (L1-L4). Osteoporosis was defined according to the World Health Organization (WHO) guidelines. To identify vertebral fractures the radiographs were visually analyzed by two radiologists; a woman was judged as fractured only if both readers independently found at least one vertebral fracture on her films. Then the spine radiographs were digitized by means of a scanner to perform quantitative vertebral morphometry (QVM) using specific software. An expert operator manually located the calipers on the vertebral bodies from T4 to L5 and the computer automatically calculated the anterior, middle and posterior vertebral heights and their ratios. A vertebral fracture was defined by morphometry as a reduction by at least 20%, with an absolute decrease of at least 4 mm, in one of three height ratios of any vertebral body compared to the corresponding reference ratio for fertile women.

RESULTS

Visual reading by radiologists detected 9.5% (45/473) women with vertebral fractures and QVM detected 13.7% (65/473) with statistical significance (p < 0.001). In the 75-80 years age group the prevalence of vertebral fractures reaches the maximum value, 26.3% by visual reading and 36.8% by QVM. Among fractured women, 34 were osteoporotic by DXA; 11 women found fractured by visual reading and 21 by QVM were osteopenic women, with bone mineral densities between -1 and -2.5 SD of the T-score.

CONCLUSION

This study showed that quantitative assessment of spine radiographs by vertebral morphometry is an objective method that allows to identify a larger number of vertebral fractures compared to visual inspection. This is very important not only for epidemiological studies, but also for clinical use because a previous vertebral fracture increases the risk of subsequent fractures significantly. Therefore, to improve the risk assessment of vertebral fractures for osteoporotic patients it is necessary to combine the use of QVM and BMD.

Intravenous self-administration of heroin/cocaine combinations (speedball) using nose-poke or lever-press operant responding in mice

Acquisition and dose-related self-administration of heroin (H)/cocaine (C) combinations in C57BL/6 x SJL mice were studied in nose-poke or lever-press operant responding procedures. C57BL/6 x SJL mice readily acquired self-administration in both operant procedures with a combination of doses known to be ineffective when each drug was used alone (H: 15 microg/kg and C: 150 microg/kg per injection). Similar numbers of infusions were obtained under conditions of fixed-ratio (FR) 3 versus 1 for the nose-poke and lever-press responses, respectively. Dose-effect curves for heroin:cocaine combinations revealed a pattern corresponding to a leftward shift of the dose-response for intravenous cocaine self-administration. Curves were similar whether generated with 1 or 3 days of availability per dose, or including subjects that did not respond preferentially (> 70% responses) to the hole or lever associated with drug delivery, along with those that did. Motor activity induced by a combination of low doses for each drug was examined (H: 0.375 mg/kg and C: 3.75 mg/kg, i.p.). Under these conditions, the combination of both drugs induced an initial cocaine-like stimulation of horizontal activity, in contrast to the tendency of heroin to decrease activity. It is concluded that heroin:cocaine combinations used in the present study had reinforcing effects in C57BL/6 x SJL mice, and produced a cocaine-like effect in the early part of drug-induced activity sessions, followed by a locomotor profile corresponding to the average of both drugs.

US and CT findings in splenic focal lesions in AIDS

PURPOSE

To evaluate the role of US and CT in focal splenic lesions in AIDS patients in relation to etiology. MATERIAL AND METHODS; A total of 66 patients with AIDS and focal splenic lesions were examined with sonography. CT with administration of contrast medium was performed in 12 cases.

RESULTS

Of the focal splenic lesions, 67% were correlated with an infective pathology with prevalence of Mycobacteria tuberculosis (75%), 26% were neoplastic and 6% splenic infarcts. The lesions were hypoechoic in 60% of the cases, while 10% were hypoanechoic and 1% anechoic. At CT, all lesions appeared hypodense, even after i.v. administration of contrast medium.

CONCLUSION

The combination of echographic reports and clinical and laboratory data allows for a diagnosis that can be confirmed, and making a decision for effective therapy of AIDS is possible. CT does not provide any additional information.

Molecular screening of the CFTR gene in men with anomalies of the vas deferens: identification of three novel mutations

Many studies have shown that congenital absence of the vas deferens (CAVD) is a genital cystic fibrosis transmembrane conductance regulator (CFTR)-mediated phenotype, with a broad spectrum of abnormalities causing male infertility. The genotype of these patients includes mutations in the CFTR gene, e.g. DeltaDeltaF508, R117H and the T5 allele; all of which are commonly found in CAVD. In this study we have screened the entirety of CFTR gene in 47 males with anomalies of the vas deferens: 37 cases of congenital bilateral absence of the vas deferens, three cases of congenital unilateral absence of the vas deferens and seven cases of obstructive azoospermia with hypoplastic vas deferens. Among the 94 chromosomes studied, 65 mutations, of which three are novel (2789+2insA, L1227S, 4428insGA), were identified. The majority of patients (63.8%) had two detectable CFTR gene mutations. Furthermore, high frequencies of the DeltaDeltaF508 mutation (44.7%), the T5 allele (36.2%) and R117H mutation (19.1%) were observed.

US and CT findings in splenic focal lesions in AIDS

PURPOSE

To evaluate the role of US and CT in focal splenic lesions in AIDS patients in relation to etiology. MATERIAL AND METHODS; A total of 66 patients with AIDS and focal splenic lesions were examined with sonography. CT with administration of contrast medium was performed in 12 cases.

RESULTS

Of the focal splenic lesions, 67% were correlated with an infective pathology with prevalence of Mycobacteria tuberculosis (75%), 26% were neoplastic and 6% splenic infarcts. The lesions were hypoechoic in 60% of the cases, while 10% were hypoanechoic and 1% anechoic. At CT, all lesions appeared hypodense, even after i.v. administration of contrast medium.

CONCLUSION

The combination of echographic reports and clinical and laboratory data allows for a diagnosis that can be confirmed, and making a decision for effective therapy of AIDS is possible. CT does not provide any additional information.

[Does neonatal screening of cystic fibrosis affect outcome? Comparative study of two cohorts in Britanny and Loire-Atlantique with follow-up after ten years]

Neonatal screening for cystic fibrosis was started in Brittany in 1989 but not in the adjacent department of Loire-Atlantique. This study compares the outcome from the children of both populations nine years after the beginning of the screening. Those children were seen in different centers but with the same following guidelines.

POPULATION AND METHODS

All children with cystic fibrosis born between 01/01/89 and 31/12/97 in Brittany and the Loire-Atlantique, excluding the meconium ileus, were compared for their initial characteristics and their outcome after nine years of follow-up.

RESULTS

There was no significant difference between both populations for sex ratio, gestational age, birth biometry, percentage of homozygotes delta F508, and mean age of children. Age at diagnosis was lower in Brittany (37 vs 372 days, P < 10(-7)), as was the delay for starting pancreatic supplementation (1.5 vs 14.3 months, P < 10(-7)). Percentage of children hospitalized at least once was higher in Loire-Atlantique (84.4 vs 40.3%, P < 10(-4)). There was no significant difference for colonization with Pseudomonas aeruginosa. Z-scores for weight and height were better in Brittany, as were Shwachman's and Brasfield's scores.

CONCLUSION

The homogeneity of both populations and their follow-up points out that even if the numbers of children are small and the study is retrospective, some benefits of neonatal screening appear, which are already found in other countries where it is partly practiced. This leads us recommend its general use in our populations, which should be associated with the follow-up of the screened children in cystic fibrosis centers to achieve the most of its benefits.

Effect of aspirin on the contractility of aortic smooth muscle and the course of blood pressure development in male spontaneously hypertensive rats

The effects of acetylsalicylic acid (ASA) on aortic smooth muscle contractility were studied in aortic rings of male SHR and WKY rats. The rats were administered two intraperitoneal injections of 10 mg/kg of ASA per week for ten weeks. Blood pressure of each rat was monitored twice weekly prior to the i.p. injections. Twenty four hours after the last injection the aortic smooth muscles were evaluated for generation of active tension in response to KCl, Phenylephrine (PE), Clonidine and Norepinephrine (NE). In another set of experiments calcium conductance was evaluated in the presence or absence of endothelium both in ASA treated and non treated animals. We report that aortic rings from ASA-treated SHR animals were more responsive to contractile agents than rings from non-treated SHR male rats. Also, the Ca2+ conductance in vitro was enhanced appreciably in SHR aortic rings denuded of their monolayer of endothelium in response to ASA treatment. No decrease in systolic blood pressure was observed in response to ASA treatment in SHR male rats. These results suggest that acetylsalicylic acid not only may modulate aortic smooth muscle contractility through the metabolites of arachidonic acid but may repair to a great extent the hypertension associated plasma membrane permeability defect of vascular myocytes.

A new mutation in the six-domain of SIX3 gene causes holoprosencephaly

Holoprosencephaly (HPE) is a severe brain malformation which results from incomplete cleavage of the forebrain during early embryogenesis. The aetiology of HPE is very heterogeneous. Among the genetic factors, SIX3, which is considered to be the functional orthologue of Drosophila genes sine oculis (so) and optix, has been found to be mutated in the homeodomain, in some patients with HPE (HPE2 on chromosome 2p21). We report a new HPE family, presenting a wide spectrum of clinical features, ranging from cyclopia to hypotelorism, in which a mutation was found for the first time in the SIX domain of SIX3: a GG insertion creates a frameshift leading to a nonsense mutation downstream in the homeodomain region.

Neonatal screening for cystic fibrosis in Brittany, France: assessment of 10 years' experience and impact on prenatal diagnosis

BACKGROUND

Neonatal screening for cystic fibrosis has been a subject of debate over the past few years. This study assesses 10 years of neonatal screening in Brittany, France, and examines its impact on prenatal screening of subsequent pregnancies in couples with an affected child.

METHODS

The study included all the neonates screened for cystic fibrosis in Brittany from Jan 1, 1989, to Dec 31, 1998. The screening consisted of an immunoreactive trypsinogen assay from dried blood spots, plus, from 1993, mutation analysis. Data were collected on incidence of cystic fibrosis, and genotypic and biochemical characteristics. The use of prenatal screening of subsequent pregnancies in affected families was also investigated.

FINDINGS

Of the 343,756 neonates screened, 118 children with cystic fibrosis were identified, giving an incidence of one in 2913. All mutated alleles were characterised: 34 different mutations resulting in 36 genotypes were detected. The introduction of DNA analysis into the protocol greatly reduced the recall rate and increased the sensitivity of the test. The mean cost of the screening programme was US$2.32 per screened child. 39 (34%) of the families identified by neonatal screening opted for subsequent prenatal diagnosis at least once. 12 couples would have benefited from this procedure while their first child was still symptom-free. 42 healthy children were born, and 18 pregnancies were terminated (therapeutic abortion rate of 100%).

INTERPRETATION

We have shown the feasibility of neonatal screening for cystic fibrosis in Brittany. Through the detection of a large range of mutations, neonatal screening provides the opportunity for more reliable prenatal diagnosis and cascade screening. The neonatal screening programme described here could provide a good model for other countries intending to initiate such a scheme.

Enhanced chemiluminescent determination of chloramphenicol and related nitro compounds by 'on-line' photochemical reaction

The viability of tandem photochemical reaction-chemiluminescence detection was studied for a heterogeneous family of nitro compounds using chloramphenicol as a test substance. The 'on-line' chemical photodegradation of chloramphenicol was performed in a flow injection assembly by using a photoreactor consisting of a 725 cm x 0.5 mm id piece of PTFE tubing coiled around an 8 W low-pressure mercury lamp. Photodegraded chloramphenicol was detected by oxidizing photo-fragments from the parent compound and their subsequent reaction with a luminol-Co(II) system. The calibration graph was linear up to 3 x 10(-5) mol l-1 chloramphenicol, the limit of detection was 3 x 10(-9) mol l-1, the relative standard deviation was 1.8% for 2 x 10(-6) mol l-1 of the drug and the sample throughput was 60 h-1. The proposed method was used to determine chloramphenicol in pharmaceutical formulations and its application to other related nitro compounds was studied.

Identification of three novel mutations in the dystrophin gene detected by the heteroduplex/SSCA screening procedure. Mutations in brief no. 222. Online

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are X-linked neuromuscular disorders associated with alterations in the dystrophin gene. Analysis of 45 DMD/BMD patients has identified 18 patients with no deletion in the dystrophin gene. Heteroduplex analysis (HD), single strand conformation analysis (SSCA), and subsequent sequencing, identified five mutations and nine polymorphisms. Three out of the 5 mutations (780C>G, 2501-1g-->t, 9812 9813ins9800-9812) are first reported here. Furthermore we compare the relative efficiencies of the two alternatives methods (HD and SSCA) for screening sequence alterations.

Eukaryotic translation termination factor gene (ETF1/eRF1) maps at D5S500 in a commonly deleted region of chromosome 5q31 in malignant myeloid diseases

The human genome contains four ETF1 (eukaryotic translation termination factor 1) homologous sequences, localized on chromosomes 5, 6, 7 and X, and corresponding to a functional gene on chromosome 5 and three processed pseudogenes on the other chromosomes. ETF1 genomic or cDNA probes were mapped by fluorescence in situ hybridization to 5q31, 6p21, 7q11 and Xp11.4-->p11.1. A microsatellite marker (D5S500) was identified in intron 7 of the functional ETF1 gene providing its exact position in the 5q31 band. Thus, the ETF1 gene is located in a 5q region which contains unidentified genes responsible for genetic or malignant disorders, and it might be considered as a candidate gene involved in the pathogenesis of these diseases.

Anatomical and pharmacological specificity of the rewarding effect elicited by microinjections of morphine into the nucleus accumbens of mice

RATIONALE

The involvement of nucleus accumbens (NAc) in initiating opiate-induced reward has been difficult to demonstrate in rats, and has not been studied in mice.

OBJECTIVES

To determine whether a reward-sensitive strain of mice (BALB/c) would self-administer morphine directly into the NAc or sub-regions of the dorsal striatum.

METHODS

BALB/c mice were unilaterally implanted with a guide-cannula above either the NAc, the anterior caudate putamen, or the posterior caudate putamen. On each experimental day, a stainless-steel injection cannula was inserted into the guide cannula to test the capacity for morphine self-administration (6.5 pmol or 65 pmol/50 nl) using a spatial discrimination task in a Y maze.

RESULTS

Only the ventro-medial NAc group discriminated between the arm enabling a microinjection of morphine and the neutral arm. Once self-administration had been acquired, the effects of a pretreatment with two doses of the opiate antagonist naloxone (0.4 mg/kg or 4 mg/kg) were tested. Both doses slightly disrupted self-administration on the first 2 days. Only subjects receiving the 4-mg/kg dose exhibited an extinction of self-administration, related to an increasing number of jump attempts; none of the other opiate withdrawal-associated signs were observed. Self-administration was reinstated when naloxone was replaced with saline.

CONCLUSIONS

(1) Medio-ventral NAc is involved in acute rewarding effects of opiates in mice. (2) Neither anterior nor posterior dorsal striatum seem to participate in these effects. (3) NAc is involved in jumping caused by naloxone-induced extinction, a behavior presumably revealing an aversive state associated with the unexpected suppression of reward.

The HFE gene undergoes alternate splicing processes

The MHC class I-related HFE gene appears to be involved in iron metabolism, but its pathogenic mechanism in hemochromatosis remains unknown. Furthermore, very little is known about the regulation of its expression. Hybridization of human tissue Northern blots revealed five different HFE mRNAs, indicating that HFE gene transcription is subject to alternative processes. cDNA selection and RT-PCR performed on HeLa cells clearly demonstrated the occurrence of either differential termination or splicing in HFE transcription. Among the numerous molecules identified, two may have a genuine biological significance.

Liquid extraction and HPLC-DAD assay of hydrochlorothiazide from plasma for a bioequivalence study at the lowest therapeutic dose

The main parameters considered in optimizing the liquid extraction and quantitative assay were the yield, precision, limit of quantification, time required for extraction and concentration, and quantity of solvent. The influence on these parameters of the following factors was examined: nature of the extracting solvent, quantity of solvent, co-extraction solvent, and duration of stirring. Instead of equilibrium parameters of the involved thermodynamic system, a kinetic approach was preferred in terms of the effective partition 'constant', which is not really constant but a function of time and extraction conditions. The final selected method, considered to be rapid and simple, was applied to determine the pharmacokinetics of hydrochlorotiazide (HCT) after administration of Capozide (Bristol-Myers Squibb) tablets containing 50 mg Captopril and 25 mg HCT, to 4 healthy volunteers. The results obtained were in accordance with the pharmacokinetic parameters of HCT reported in the literature.

[Management of children in respiratory distress]

Conditioning in respiratory distress in childhood requires a rapid evaluation of severity based on clinical examination in order to immediately start helpful care to improve respiratory status. Oximetry measurement is now integrated in this initial evaluation determining oxygen therapy. Etiologic orientation, quick and clinic, is precised by family questions. Adapted therapeutic will begin and we know that most frequently etiologies are: croup, bronchiolitis and asthma attack.