Bladder function associated with posterior urethral valves after primary valve ablation or proximal urinary diversion in children and adolescents

PURPOSE

We retrospectively reviewed 2 series of patients with posterior urethral valves treated initially with valve ablation preceded by bilateral cutaneous ureterostomies or valve ablation alone to evaluate and compare bladder function behavior of each treatment group.

MATERIALS AND METHODS

From 1970 to 1983, 19 males 22 days to 21 months old with posterior urethral valves were treated with 1 of 2 initial surgical approaches, including upper tract diversion, delayed undiversion and ablation in 11 (group 1), and primary valve ablation only in 8 (group 2). Median patient age at the time of cutaneous urinary diversion and primary valve ablation for groups 1 and 2 was 7 and 9 months, respectively. Median duration of bladder defunctionalization was 48 months. All patients were evaluated urodynamically after initial ablation or re-functionalization of the bladder using standard rapid fill cystometry. Median patient age for groups 1 and 2 was 14 and 9.5 years, respectively, at the time of urodynamic testing 16 and 12.6 years, respectively, at followup.

RESULTS

Urodynamic assessment revealed detrusor instability in 5 group 1 patients but in only group 2 1 patient. Group 2 patients had significantly lower median end filling pressure (4 versus 15 cm. water, p <0.03) and higher maximum bladder capacity (1.4 versus 0.8, p <0.005) than those in group 1. Group 1 patients had lower compliance than those in group 2 (median 15 versus 82 cm. water, p <0.05). Further analysis showed no difference between groups 1 and 2 in overall median voiding detrusor pressure at maximum flow (51 versus 52.6 cm. water, respectively). Cystometric detrusor under activity patterns were noted in 5 group 1 and 2 group 2 patients. Residual urine volumes were 17%, 31%, 19% and 8% of bladder capacity, respectively, in 2 group 1 and 2 group 2 patients. At final followup 5 group 1 and 2 group 2 patients had renal function deterioration. Two other group 1 patients and group 2 had progression to end stage renal failure. A higher ureteral reimplantation rate was noted in group 1 (63%) than group 2 (6%).

CONCLUSIONS

This retrospective study revealed that long-term bladder function of patients with posterior urethral valves treated with temporary supravesical diversion is affected more adversely than those treated with valve ablation alone.

[Gynecomastia and testicular tumor in children with Peutz-Jeghers syndrome]

The rarity of both conditions and the precocity of its onset (4 years old) make the case of interest for pediatricians and pediatric surgeons. The finding of a testicular tumor poses same differences of criterium about its management.

Mechanical and enzymatic thrombolysis for massive pulmonary embolism

PURPOSE

To assess the efficacy and safety of mechanical fragmentation combined with intrapulmonary thrombolysis in massive pulmonary thromboembolism (PTE) with hemodynamic impairment.

MATERIALS AND METHODS

Fifty-nine patients diagnosed with massive PTE with hemodynamic impact were treated. The initial clinical symptoms were shock in 23 patients (38.9%), syncope in eight (13.5%), and dyspnea at rest in 28 (47.4%). Mean O2 saturation was 67.8%. Mean pulmonary artery pressure (PAP) was 42.1 mm Hg. During fragmentation, thrombolysis was administered in the form of a urokinase bolus of 200,000-500,000 U in 57 patients and 20 mg of recombinant tissue plasminogen activator (rt-PA) in two patients. The mean urokinase dose used was 2,500,000 IU, whereas the total dose of rt-PA was 100 mg. Heparin sodium infusion was performed to reach activated partial thromboplastin time ratios of 2. The follow-up consisted of clinical assessment, pulmonary scintigraphy, and echocardiography. The patients received treatment with dicoumarin for 6 months after the procedure.

RESULTS

Clinical improvement was seen in 56 patients (94%). Three patients died. The mean PAP after the treatment was 21.8 mm Hg. The mean posttreatment Miller index was 0.35. Technical success was achieved in all cases and clinical symptoms improved in all cases except those in which the patients died. Pulmonary scintigraphy showed improved perfusion in all cases. Echocardiography was performed after 3-6 months, showing a mean pressure of 22.8 mm Hg (corrected values). There were no signs of recurrent PTE or arterial hypertension in the follow-up.

CONCLUSION

The data provided confirm the efficacy and safety of mechanical fragmentation and pharmacologic thrombolysis in the treatment of massive PTE with hemodynamic impairment, showing improvement of symptoms and a decrease in PAP.

Development of cutaneous sarcoidosis in a patient with chronic hepatitis C treated with interferon alpha 2b

BACKGROUND

Sarcoidosis is a multisystemic granulomatous disorder of unknown etiology that most commonly affects young adults. A probable induction of sarcoidosis by interferons (IFN) has been published. To this date, few cases of cutaneous sarcoidosis inpatients with chronic hepatitis C under interferon treatment have been reported.

OBJECTIVE

We describe a 50-year-old woman with chronic hepatitis C who developed lesions of cutaneous sarcoidosis three months after IFN treatment.

CONCLUSIONS

The possible role of INF therapy in the development of cutaneous sarcoidosis in a patient with chronic hepatitis C should be considered.

Trabecular trajectory in the articular processes of the human fourth cervical vertebra

The articular processes (AP) of the neural arch have been implicated in weight transmission through the cervical spine. To analyse the mechanism of weight transmission in the AP, we studied the direction of forces within it, in particular, the pattern of trabecular trajectories. Twenty-two AP from C4 vertebrae were studied in anatomical sections, and corresponding photoelastic models from selected sections were constructed and analysed. Anatomical and photoelastic findings show the subarticular spongiosa of the superior articular process (SAP) to be orthogonally arranged with vertical and oblique trabeculae in the direction of compressive forces and additional trabeculae always oriented perpendicular to the former. Vertical and oblique trabeculae are divided into rostral, middle and posterior groups. Rostral and middle trabeculae end in the anterior wall of the SAP and the transitional zone with the pedicle. Posterior trabeculae end in the subarticular spongiosa of the inferior articular process (IAP). The findings relating to trabecular trajectories in the SAP differ from previous descriptions and instead suggest that a part of the weight forces distributed within the AP transmit to the subchondral zone of the IAP. Knowledge of the trajectorial architecture of the AP may contribute to refining finite element analytical models for investigating its weight-bearing function.

In vitro antibacterial activity of glass-ionomer cements

The in vitro antibacterial activity of the glass-ionomer restorative cements Ketac-Cem, Ketac-Bond, Ketac-Silver and Vitrebond was studied in conjunction with 32 strains of five bacteria involved in the development of caries: Streptococcus spp., Lactobacillus spp., Actinomyces spp., Porphyromonas spp. and Clostridium spp. The agar plate diffusion method was used for the cultures, which included a chlorhexidine positive control. All the glass-ionomer cements tested inhibited bacterial growth, but with considerable differences in the scope of their action. Of the four cements, Vitrebond, a resin-modified glass-ionomer cement, was determined to be the most effective bacterial inhibitor.

Laparoscopic pancreatic surgery in patients with neuroendocrine tumours: indications and limits

Laparoscopic pancreatic procedures are still at an evaluation stage with regard to their indications and techniques. Between January 1998 and December 2000, 13 patients with endocrine pancreatic tumours - 11 insulinomas and 2 non-functioning tumours-underwent laparoscopic surgery, laparoscopic ultrasonography being used in all the patients. Enucleation was performed in five patients. The operative time was 2-3 hours. Distal pancreatectomy was performed in six patients with insulinomas, and spleen preservation with intact splenic vessels was feasible in five. Splenectomy was necessary in one patient for technical reasons. Laparoscopic distal pancreatectomy with splenic vessel preservation was performed in two patients with a large (6 and 8 cm) non-functioning tumour. The mean operative time for all the patients undergoing distal pancreatectomy was 4 hours, ranging from 3 to 5 hours. A pancreatic fistula occurred in three patients after tumour enucleation and in two patients after distal pancreatectomy; the mean hospital stay for all patients was 5 days. Enucleation guided by laparoscopic ultrasonography thus allows safe tumour dissection and excision, laparoscopic distal pancreatectomy also being feasible and safe. Splenic salvage with splenic vessel preservation is technically possible. The laparoscopic approach allows a shorter hospital stay and an earlier return to normal activities.

10-Year experience with artificial urinary sphincter in children and adolescents

PURPOSE

We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence.

MATERIALS AND METHODS

Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5).

RESULTS

There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent.

CONCLUSIONS

This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

10-Year experience with artificial urinary sphincter in children and adolescents

PURPOSE

We evaluate specific indications, patient selection and complications of the AMS800 artificial sphincter in children and adolescents with sphincteric incontinence.

MATERIALS AND METHODS

Between 1987 and 1997, 39 males and 10 females with a mean age of 14 years (range 7 to 20) with sphincter deficiency underwent artificial urinary sphincter placement. The underlying etiology of incontinence was myelodysplasia in 38 patients, exstrophy-epispadias complex in 7 and urethral trauma in 4. All patients underwent preoperatively conventional urodynamic investigations. Augmentation cystoplasty was done in 9 patients before sphincter implantation and both procedures were performed simultaneously in 2 cases. The cuff was adjusted around the bladder neck in 37 patients and around the bulbar urethra in 12. Followup ranged from 2 to 11 years (mean 7.5).

RESULTS

There were 54 sphincter implants in 49 patients. Of the 49 patients 33 (67%) achieved continence, 9 had substantial improvement and 7 remained unchanged after surgery. Erosion occurred in 10 patients due to sphincter infection in 2, mechanical failure in 6 and postoperative changes in bladder behavior in 2. Of these 10 patients with erosion 5 are incontinent and awaiting sphincter replacement, 2 required bladder neck closure and appendicovesicostomy, and 3 are dry without prosthetic replacement. Mean time to erosion was 24.9 months (range 1 month to 9 years), and 3 erosions occurred within 3 months of sphincter placement. Of the 6 patients with mechanical problems 5 regained continence after successful replacement of the sphincter. Only 2 of the 49 cases had postoperative detrusor overactivity requiring augmentation after surgery. Of the 29 patients who performed clean intermittent catheterization preoperatively 3 no longer needed it after implantation of the prosthesis. Finally, 25 (86%) of the 29 patients with a cuff placed around the bladder neck and with no previous surgical repairs at this site achieved continence after implantation whereas only 3 (37.5%) of 8 patients who had undergone prior bladder neck surgical procedures became continent.

CONCLUSIONS

This study supports previous reports that the artificial urinary sphincter is effective therapy for sphincteric incontinence. Additionally, in our study previous surgical procedures on the lower urinary tract before sphincter placement increased significantly the rate of postoperative complications.

Bladder functional outcome after delayed vesicostomy closure and antireflux surgery in young infants with 'primary' vesico-ureteric reflux

OBJECTIVE

To evaluate bladder function by conventional urodynamic investigations in young infants with primary vesico-ureteric reflux (VUR) who had undergone an initial temporary cutaneous vesicostomy followed by later antireflux surgery and vesicostomy closure.

PATIENTS AND METHODS

From 1983 to 1990, nine boys (10-360 days old) with primary VUR were treated with an initial vesicostomy, followed by delayed closure of the vesicostomy and the simultaneous surgical correction of reflux. Severe VUR was detected bilaterally in seven and unilaterally in two infants at the time of the initial diagnosis. The mean (SD, range) age at vesicostomy was 12.4 (8, 3-23) months and the duration of bladder defunctionalization 38.7 (25.5, 18-90) months. All patients were assessed urodynamically after closing the vesicostomy, using rapid-fill cystometry with normal saline solution at room temperature. The mean (range) age at the time of urodynamic testing was 7.3 (5-15) years; the mean (SD, range) follow-up was 10.1 (4.1, 5-17) years.

RESULTS

Six boys with bilateral VUR underwent successful ureteroneocystostomy; nephroureterectomy was required in one patient. In two patients the VUR resolved with time. After re-functionalization, the mean (SD, range) maximum cystometric capacity, expressed as a percentage of the mean bladder capacity for age, was 1.4 (0.5, 0.6-2.2)%. In three patients the bladder capacity was higher (> or = 40%) than expected for age, while one had diminished (< 70%) bladder capacity. The mean (range) end-filling detrusor pressure was 14.5 (5-42) cmH2O and the mean (SD, range) compliance 24 (13.9, 4-44) mL/cmH2O. Two patients had a compliance of < 10 mL/cmH2O, one of whom had associated unstable detrusor contractions of 90 cmH2O. The mean (SD, range) detrusor voiding pressure at peak flow was 47.3 (16.8, 5-76) cmH2O. One patient had a residual urine volume of 8% of bladder capacity. At the follow-up, only one patient (aged 5 years) with detrusor instability had urinary incontinence.

CONCLUSION

This study shows that the bladder of young infants with primary VUR treated with temporary vesicostomy regained normal function after re-functionalization of the lower urinary tract.

[Treatment of non-parasitic splenic cyst with percutaneous injection of alcohol]

We report a case of a 12-years-old girl treated by percuta-neous injection of a splenic epithelial cyst. Indication was due to the gradual cyst's growth and pain in left hypocondrium. A percutaneous drainage under ultrasonographic view was performed with direct puncture technique, inserting a pigtail catheter into the cyst. After the total aspiration of the contrast, we injected sterile absolute alcohol for 20 minutes. Subsecuently, it was aspirated and the catheter was pulled-out. After a follow up period of more than 4 years, the cyst remains collapsed. There were no complications.

[Benign encephalitis of the brain stem]

INTRODUCTION

The secondary encephalitis disorders are due to an immunological mechanism which causes demyelinating lesions of the central and peripheral nervous systems, with very variable clinical features. The pathogenesis and localization of benign encephalitis of the brain stem and the Miller Fisher syndrome (MFS) are still subject to debate. It is suggested that they may both belong to different extremes of the same nosological spectrum known as the ophthalmoplegia-ataxia-areflexia syndrome.

CLINICAL CASE

We report the case of an 11 year old boy with encephalitis of the brain stem who had electromyographic alterations compatible with the Guillain-Barré syndrome, and MR images characteristic of an acute demyelinating disorder of the brainstem.

CONCLUSIONS

The encephalitis of the brain stem is an uncommon condition in children which leads to diagnostic difficulty at its onset, since this is similar in other disorders such as MFS, tumours, cerebrovascular accidents and less often in the initial stages of multiple sclerosis. The clinical course is very useful to distinguish between these conditions. MR is the imaging technique of choice for diagnosis in these patients. Although there is currently no specific treatment for post-infectious encephalitis, the use of high doses of immunoglobulins may be justified in view of the physiopathological origin of the condition.

Main products and kinetics of the thermal degradation of polyamides

The thermal degradation of the polyamides (PA) 6, 12, 66 and 612 was investigated by means of thermal analysis/mass spectrometry (TA-MS) and pyrolysis in a german standard oven. Sample masses were about 20 and 40 mg. The heating rates used in the dynamic studies were 1, 5 and 10 K min(-1). Both air and nitrogen atmospheres were utilized. The kinetic parameters were calculated from the TA-MS measurements and the main decomposition products were registered online. The evolved products from the pyrolysis oven were captured and analyzed off-line by GC/MS.

[Mechanical fragmentation and intrapulmonary fibrinolysis in the treatment of massive pulmonary embolism hemodynamic repercussions]

OBJECTIVE

To evaluate the efficacy and safety of mechanical fragmentation associated with intrapulmonary thrombolysis to treat massive pulmonary thromboembolism (PTE) with altered hemodynamics.

MATERIAL AND METHOD

Fifty-one patients with a diagnosis of acute PTE were enrolled, the criteria being a Miller index over 0.50 and mean pressure of 30 mmHg in the principal superior pulmonary artery. The initial clinical pictures included shock (19 patients), syncope (6) and severe dyspnea at rest (26). Oxygen saturation measured by pulse oxymetry was 71.4%. Mean pulmonary artery pressure was 46.1 mmHg. The main thromboembolisms were fragmented, with one bolus of a fibrinolytic agent administered during the fragmentation procedure. An infusion of the fibrinolytic agent was administered through a catheter. Monitoring included clinical assessment, pulmonary scintigraphy and echocardiography.

RESULTS

After fragmentation and administration of the bolus dose of the fibrinolytic agent, improvement was observed in 49 patients (97.2%). Mean pressure after mechanical and pharmacological treatment was 24.1 mmHg. Technical success was achieved in 100% of the patients.

CONCLUSION

The results attest to the efficacy and safety of mechanical fragmentation and medical thrombolysis in treating massive PTE affecting hemodynamics, leading to clinical improvement and lowered pulmonary artery pressure.

Antibacterial activity of four dentin bonding systems

The antibacterial action of bonding systems Gluma 2000, Syntac, Prisma Universal Bond 3, Scotchbond Multipurpose and Prime-Bond was tested against 32 strains of the caries-producing bacteria Streptococcus spp., Lactobacillus spp., Actinomyces spp., Porphyromonas spp. and Clostridium spp. An agar plate diffusion method was used with chlorhexidine as the positive control. Assays were performed in triplicate for each component (primer and adhesive) of the bonding systems. All the adhesives were found to inhibit bacterial growth but with differences in their spectra of action. The sum action of the Scotchbond Multipurpose components were most inhibitory and Prime-Bond was found to be the least effective system.

Relationship between weight at birth and the number and size of renal glomeruli in humans: a histomorphometric study

BACKGROUND

The number of nephrons in humans varies considerably under normal circumstances, and retarded intrauterine growth has been reported to be associated with a significant reduction in nephron number. Low nephron number may be an independent risk factor for the development of hypertension. We therefore decided to evaluate the relationship between body weight at birth and the number and size of nephron units.

METHODS

We examined coronal sections of the kidneys of 35 neonates who died within two weeks of birth because of hyaline membrane, infectious complications, brain hemorrhage, or perinatal hypoxia and had no urinary congenital malformations. Nine of them (5 males and 4 females) were between 36 and 37 weeks of gestation, and the rest had 38 or more weeks of gestation. Eighteen neonates weighed less than 2500 g at birth [low birth weight (LBW); 9 females and 9 males], and 17 had weights above this value [normal birth weight (NBW); 8 females and 9 males]. In each section, glomeruli present in four sequential subcapsular microscopic fields, corresponding to 0.6 mm2, were counted; in addition, the area of each of 65 consecutive glomeruli was determined by a computerized measurement system. Glomerular volume was calculated from the glomerular area. Linear regression analysis was used to test the relationship between glomerular number and size and the weight at birth.

RESULTS

The number of glomeruli per 0.6 mm2 of renal cortex was 92.9 +/- 4.85 in the LBW and 105.8 +/- 3.91 in NBW (P < 0.0001). Glomerular volume (micro(3) x 10(-3)) was 529.1 +/- 187.63 in the LBW group and 158.0 +/- 49.89 in the NBW group (P < 0.0001). The glomeruli occupied 8.59 +/- 1.38% of the kidney area under examination in the LBW group and 14.3 +/- 2.75% in the NBW group (P < 0.0001). There were significant direct correlations between the weight at birth and the number of glomeruli (r = 0.870, P < 0.0001) and area occupied by glomeruli (r = 0.935, P < 0.0001). There were inverse correlations between the number of glomeruli and the volume of the glomeruli (r = -0.816, P < 0.0001) and the weight at birth and glomerular volume (r = -0.848, P < 0.0001). These findings were independent of sex and race (black vs. white). Essential arterial hypertension existed in 38.9% of the mothers of children with LBW and in 5.9% of the mothers of children with NBW (P < 0.05). Smoking habits existed in 50% of the mothers of LBW children and in 11.8% of the mothers of NBW children (P < 0.05).

CONCLUSION

There are strong correlations between glomerular number (direct) and size (inverse) with LBW in this cohort. Endowment with decreased nephron numbers may be a risk factor for hypertension and the rate of progression of renal disease.

Antibacterial activity of resin adhesives, glass ionomer and resin-modified glass ionomer cements and a compomer in contact with dentin caries samples

A total of 103 clinical samples of carious dentin were used to study the antibacterial action of different dental resin adhesive materials (Gluma 2000, Syntac, Prisma Universal Bond 3, Scotchbond Multi-Purpose and Prime&Bond 2.0) glass ionomer cements (Ketac-Cem, Ketac-Bond, Ketac-Silver, Ketac-Fil) resin-modified glass ionomer cements (Fuji II LC, Vitremer and Vitrebond) and a compomer (Dyract). The agar plate diffusion method was used for the microbial cultures and a chlorhexidine control. The growth of the caries-producing microorganisms was effectively inhibited by the Vitremer and Vitrebond cements, and to a lesser extent by the Scotchbond Multi-Purpose adhesive system. Overall, there were statistically significant differences in the antibacterial activity of the products tested.

Developmental expression and molecular characterization of two gap junction channel proteins expressed during embryogenesis in the grasshopper Schistocerca americana

Gap junctions are membrane channels that directly connect the cytoplasm of neighboring cells, allowing the exchange of ions and small molecules. Two analogous families of proteins, the connexins and innexins, are the channel-forming molecules in vertebrates and invertebrates, respectively. In order to study the role of gap junctions in the embryonic development of the nervous system, we searched for innexins in the grasshopper Schistocerca americana. Here we present the molecular cloning and sequence analysis of two novel innexins, G-Inx(1) and G-Inx(2), expressed during grasshopper embryonic development. The analysis of G-Inx(1) and G-Inx(2) proteins suggests they bear four transmembrane domains, which show strong conservation in members of the innexin family. The study of the phylogenetic relationships between members of the innexin family and the new grasshopper proteins suggests that G-Inx(1) is orthologous to the Drosophila 1(1)-ogre. However, G-Inx(2) seems to be a member of a new group of insect innexins. We used in situ hybridization with the G-Inx(1) and G-Inx(2) cDNA clones, and two polyclonal sera raised against different regions of G-Inx(1) to study the mRNA and protein expression patterns and the subcellular localization of the grasshopper innexins. G-Inx(1) is primarily expressed in the embryonic nervous system, in neural precursors and glial cells. In addition, a restricted stripe of epithelial cells in the developing limb, involved in the guidance of sensory growth cones, expresses G-Inx(1). G-Inx(2) expression is more widespread in the grasshopper embryo, but a restricted expression is found in a subset of neural precursors. The generally different but partially overlapping expression patterns of G-Inx(1) and G-Inx(2) supports the combinatorial character of gap junction formation in invertebrates, an essential property to generate specificity in this form of cell-cell communication.

Heterologous expression of Trypanosoma cruzi trans-sialidase in Leishmania major enhances virulence

Earlier studies showed that mice primed for a few hours with the trans-sialidase (TS) of Trypanosoma cruzi, the agent of Chagas' disease, become highly susceptible to trypanosomal infection. These studies suggest that TS affects parasite virulence independent of antigenic stimulation. Potentially, TS could enhance or reduce the virulence of heterologous microbes depending on the mechanism of TS action and on the type of immune response elicited by the particular parasite. We tested this hypothesis by expressing heterologous TS in Leishmania major, a protozoan parasite that causes cutaneous leishmaniasis and lacks TS and the TS product alpha2-3-linked sialic acid. Leishmania cells transfected with a T. cruzi TS expression construct made high levels of active enzyme, which was present in the promastigotes and shed into the extracellular milieu. TS expression did not affect L. major binding to and entry into cultured macrophages or its tropism for macrophage infection in vivo. However, TS-expressing L. major exhibited elevated virulence in BALB/c mice, as determined by lesion progression, parasite numbers, and macro- and microscopic examination of cutaneous lesions. Several genetic tests proved that the enhanced virulence was directly attributable to TS expression. The results are consistent with TS functioning to sabotage the mouse immune system to confer a growth advantage on T. cruzi and transgenic L. major. These data suggest that heterologous expression of T. cruzi virulence factors in Leishmania may provide a new approach for dissecting their function in vivo.

A novel frameshift mutation (2436insT) produces an immediate stop codon in the autosomal dominant polycystic kidney disease 2 (PKD2) gene

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is a genetically heterogeneous disorder that can be caused by mutations in at least three different genes. Several mutations have been identified in PKD1 and PKD2 genes. Most of the mutations found in PKD2 gene are predicted to cause premature termination of the protein.

METHODS

We analysed an Argentinian family characterized previously as PKD2. The PKD2 gene was amplified from genomic DNA using 17 primer pairs and the products were analysed by heteroduplex analysis. PCR products that showed a variation by heteroduplex analysis were sequenced directly. The mutation was confirmed by sequencing relatives. The segregation of the mutation in this family was verified by restriction endonuclease digestion of PCR products obtained from genomic DNA of all family members. Results and conclusions. Here, we report a novel mutation present in an Argentinian family characterized as PKD2 by linkage analysis. The mutation, shared by all affected members of the family, is a thymidine insertion at position 2436 of the gene, which results in a translation frameshift and creates an immediate stop codon. This mutation is expected to lead to a truncated protein that lacks the interacting domain with the PKD1 gene product. The thymidine insertion abolished a Ddel restriction site, allowing a rapid test for detection of PKD2 carriers in the family.

Treatment of unstable distal radius fractures with cancellous allograft and external fixation

Unstable fractures of the distal radius continue to pose a challenge to the hand surgeon. Adjunctive bone grafting is often required to augment structural integrity and aid healing. Because of the risks inherent to bone autograft harvest, however, freeze-dried, irradiated cancellous bone allograft has been used to treat unstable distal radius fractures with severe metaphyseal comminution. Seventeen patients with such fractures (mean age, 70 years; 2 males and 15 females) were treated with bone allograft and external fixation with or without internal fixation. The outcome was evaluated using the modified Mayo wrist score, demonstrating 3 excellent, 8 good, 6 fair, and no poor results on follow-up examination (mean follow-up period, 23 months; range, 7-43 months). The patients were requested to return for follow-up review between 1997 and 1998. These results show that cancellous bone allograft is a useful adjunct to external fixation in the treatment of unstable distal radius fractures.

Antibacterial activity of glass-ionomer restorative cements exposed to cavity-producing microorganisms

The antibacterial activity of the glass-ionomer restorative cements Ketac-Fil, Ketac-Silver, Fuji II LC, and Vitremer was studied in vitro, in conjunction with a total of 32 strains of five bacterial genera that may be associated with dental caries: Streptococcus spp, Lactobacillus spp, Actinomyces spp, Porphyromonas spp, and Clostridium spp. Agar plate diffusion was the method used for the bacterial cultures, which included a chlorhexidine control. All four glass-ionomer cements were found to inhibit bacterial growth, though with noteworthy differences in their spheres of action. Vitremer was the cement determined to have the greatest antibacterial effects, whereas Ketac-Silver presented the least inhibitory action.

[Life-threatening hemoptysis. Treatment with transcatheter embolization]

OBJECTIVE

To evaluate the immediate and long-term efficacy of transcatheter embolization of bronchial, systemic and pulmonary arteries to treat life-threatening hemoptysis. Likewise, we propose the systematic treatment of life-threatening hemoptysis by means of transcatheter embolization.

MATERIAL AND METHODS

One hundred seven angiographies were performed on the same number of patients experiencing life-threatening hemoptysis with bleeding exceeding 150 ml in 24 hours. Before angiography, we rinsed the vessels with cold saline solution and adrenalin through the catheter. Thirty-three patients were female and 74 were male. Mean age was 52.3 years (range 12 to 75 years). Embolization was performed in 104 (3 in patients with recurrent hemoptysis) using polyvinyl alcohol and micro-coils. Bronchial and systemic arteries of the affected hemithorax (mammary and lateral thoracic arteries) were checked in all patients. If findings were negative or bleeding was recurrent, we also performed pulmonary arteriography.

RESULTS

In two cases we were unable to catheterize the artery theoretically responsible for bleeding. Examination of both arterial and systemic vessels proved normal in one patient. The embolization technique was successful in 99% (103/104) of the cases and the rate of immediate clinical success was 95.1% (99/104). The mean time of follow-up was 43.2 months (range 3 to 66 months). Hemoptysis recurred in 15.3% (16 cases) within a mean 8.3 months (range 15 days to 48 months); embolization was repeated in 14 of these patients with satisfactory results, while two underwent surgery. In five patients (4.8%) we observed complications requiring no additional medical treatment: one instance of coil migration to the deep femoral artery, from which the coil was removed in a basket; two cases of bronchial artery extravasation with small mediastinal hematomas; and two hematomas at the points of puncture.

CONCLUSION

Selective or supra-selective embolization of the arteries that feed the bronchi provides effective management of life-threatening hemoptysis. No additional medical treatment is usually required.

[Autosomal dominant polycystic kidney disease: detection of a new mutation in the PKD1 gene]

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder characterized by genetic heterogeneity. Up to three loci are involved in this disease, PKD1 on chromosome 16p13.3, PKD2 on 4q21, and a third locus of unknown location. Since the identification of the PKD1 gene, the interest was centered in the characterization of the mutations responsible for the disease. Most mutations found were diverse and situated throughout the gene with no phenotypic correlation. Here we describe a new mutation in exon 44 from PKD1 gene in a family previously characterized as PKD1 by linkage analysis. The mutation is a single base substitution from a C to a T at position 12220 originating a stop codon at the mutation site. This would lead to premature termination and the formation of a truncated protein lacking part of the carboxi-terminus.

Pheochromocytoma and clear-cell renal carcinoma in a child with von Hippel-Lindau disease: a patient report

A 6 year-old boy with von Hippel-Lindau (VHL) disease presented with hypertension due to bilateral pheochromocytomas. At age 13 he developed a renal carcinoma and bilateral paragangliomas. His mother had retinal angiomas, bilateral pheochromocytomas and a cerebellar hemangioblastoma. This unusual presentation illustrates the complexity and difficulties associated with the management of VHL disease.

Isolated polycystic liver disease not linked to polycystic kidney disease 1 and 2

Autosomal dominant polycystic liver disease occurs commonly in association with autosomal dominant polycystic kidney disease, types 1 and 2. It may also exist as a separate entity, genetically distinct from autosomal dominant polycystic kidney disease types 1 and 2, as has been recently established to exist in a Belgian family. We report here a large Argentinian family of Spanish-Belgian ancestry with autosomal dominant polycystic liver disease, where proximal and distal markers for both polycystic kidney disease 1 and 2 failed to demonstrate genetic linkage. The data support the notion that polycystic liver disease and autosomal dominant polycystic kidney disease may have separate chromosomal loci.

Acute colorectal obstruction: treatment with self-expandable metallic stents before scheduled surgery--results of a multicenter study

PURPOSE

To evaluate the efficacy of treatment with self-expandable metallic stents for acute colonic obstruction before elective surgical resection.

MATERIALS AND METHODS

In 71 patients with malignant obstruction seen from October 1993 through December 1996, lesions were located in the transverse colon in one patient, in the descending colon in 22 patients, and in the rectosigmoid region in 48. A total of 72 self-expandable metallic stents were implanted within 24 hours of diagnosis.

RESULTS

Technical success was obtained in 64 patients (90%). In two cases (3%), it was not possible to advance across the obstructing mass. In five cases (7%), the prostheses were poorly positioned at the site of obstruction, requiring placement of a new stent in three cases. Clinical improvement and resolution of the obstruction were confirmed in 66 patients (93%) within 96 hours. Minor complications developed in nine cases (13%). One patient (1%) underwent surgery to resolve a colonic perforation caused by wires at the ends of the stent. The mean time between stent placement and surgery was 8.6 days (range, 6-16 days).

CONCLUSION

Implantation of colorectal stents is a safe treatment of acute malignant colonic obstruction before resection.

[Caudal regression syndrome]

INTRODUCTION

The regression caudal syndrome includes a spectrum of malformations which vary from the symptomless coccygeal agenesis until thoracic vertebrae and sacrococcygeal agenesis with severe neurological deficit; it is associated sometimes with malformations in other organs and systems. We present a case of partial agenesis of sacro and coccix with neuromuscular, sphincter and orthopedist alterations.

CLINICAL CASE

A 4-year-old patient consults because of walk alterations, with daytime and nocturnal enuresis and urinary incontinence, constipation/encopresis and rectal prolapse. Familiar and personnel precedents are uninteresting. She began to walk at normal age, referring only rectal prolapse with constipation from nursing and urinary tract infections and encopresis when she was 3 years old, with normal complementary explorations (digestive and nephrourologyc). She presents in lumbosacral X-rays four lumbar vertebrae, a dysplasic sacro and absence of coccix. Hypoplasy of sacro with bilateral stenosis of the pelvis and coxa vara in both femurs are seen in the lumbar CT. In RMI is observed agenesis of sacro and coccix vertebrae.

CONCLUSIONS

There are a wide variety of sacrococcygeal agenesis, which are classified by Renshaw and modified by Pang. As etiologics factors we find the gestational diabetes, in addition to genetic factors. The clinic exploration guides us toward a flaccid paraparesia/areflexia, with orthopaedist alterations, sometimes of artrogripotyc type. With image techniques (X-rays, CT, MRI) we can accomplish the diagnosis and we can discard or demonstrate associated medullary anomalies. We concluded that in all patient with alterations of walk and/or lack of sphincters control we should explore the lumbosacral region searching for medulodiysplasic or vertebral alterations.

Acute colorectal obstruction: stent placement for palliative treatment--results of a multicenter study

PURPOSE

To evaluate the usefulness of stent implantation as a palliative treatment in patients with acute colonic obstruction who are not surgical candidates.

MATERIALS AND METHODS

Twenty-four patients (eight women, 16 men; age range, 60-98 years) with acute colonic obstruction underwent colonic stent placement. In nine patients, the procedure was considered a primary palliative treatment; seven patients had a previous diagnosis of disseminated neoplastic disease, and two were not surgical candidates because of their poor general condition. In the remaining 15 patients, stent placement was considered the definitive palliative treatment after tumor staging. The mean time of follow-up was 8.4 months (range, 1-24 months) for patients who lived and 6.3 months (range, 1-12 months) for those who died.

RESULTS

Stent placement was successful in all patients. Clinical and radiographic findings of bowel obstruction resolved within 24 hours after stent placement in 23 (96%) patients. None of the patients required colostomy for bowel decompression after immediate stent placement. Complications developed in 10 (42%) patients: Two (8%) patients had mild rectal bleeding; three (12%), abdominal pain; two (8%), malpositioning of the stent; two (8%), pseudo-obstructive episodes due to fecal impaction; and one (4%), occlusive tumor ingrowth into the stent lumen. One (4%) patient underwent surgery to resolve stent malfunction due to poor positioning. Two (8.3%) patients--one with malpositioning of the prosthesis and the other with stent occlusion--required a new stent. The remaining complications required no further treatment. The mortality rate at 6 months was 24%. Eight patients were alive at the time this article was written.

CONCLUSION

Colorectal stent placement resulted in successful palliation of acute colonic obstruction in patients with disseminated neoplastic disease.

Prenatal diagnosis of intra-atrial cardiac echogenic foci

Intra-atrial echogenic foci were detected in 3 out of 15,706 fetuses (prevalence 0.019 per cent). In all cases, they were located in the right atrium. Normal chromosomes and negative TORCH titres were observed in all affected cases. Fetuses with intra-atrial echogenic foci demonstrated adequate intra-uterine growth and had normal neonatal outcome. Intra-atrial echogenic foci seem to represent a normal variant of fetal cardiac development.

Microbiology of acute otitis media in Costa Rican children

BACKGROUND

Because of the increasing number of resistant middle ear pathogens reported from different centers worldwide, an active surveillance of the microbiology and susceptibility pattern of middle ear pathogens is required for proper antimicrobial recommendations among different regions of the world.

OBJECTIVE

To study the microbiology and susceptibility pattern of middle ear pathogens obtained from Costa Rican children with acute otitis media.

METHODS

Between 1992 and 1997 a diagnostic tympanocentesis was performed in 398 Costa Rican patients with acute otitis media. Middle ear fluid was obtained for culture and minimal inhibitory concentrations were determined by the E-test technique in those isolates obtained between October, 1995, and January, 1997.

RESULTS

The most common pathogens cultured were Streptococcus pneumoniae (30%), Haemophilus influenzae (14%), Staphylococcus aureus (4%) and Streptococcus pyogenes (4%). Moraxella catarrhalis was uncommon. Beta-lactamase production was low (3.7%) among the H. influenzae isolates but frequent among the Staphylococcus aureus (57.1%) and M. catarrhalis (100%) strains. Overall 9 of 46 S. pneumoniae isolates (19.6%) exhibited decreased susceptibility to penicillin of which 8 isolates (17.4%) showed intermediate and one strain (2.2%) high level resistance. Among the penicillin-susceptible S. pneumoniae isolates, susceptibility to the following antimicrobials was: 81%, azithromycin; 89%, clarithromycin; and 100%, ceftriaxone and trimethoprim-sulfamethoxazole (TMP-SMX). Among the penicillin-resistant S. pneumoniae isolates the percentage of susceptible strains was 89% for azithromycin, clarithromycin and ceftriaxone and 67% for TMP-SMX.

CONCLUSIONS

Based on this microbiologic information the agents considered first line drugs in the treatment of acute otitis media in Costa Rica remain amoxicillin or TMP-SMX.

Deletion patterns in Argentine patients with Duchenne and Becker muscular dystrophy

The identification of mutations in Duchenne or Becker muscular dystrophy (DMD/BMD) patients is important for carrier detection in these families. We present the patterns of deletions of the dystrophin gene in Argentine population. DNA from 75 patients with DMD/BMD was analyzed by multiplex PCR and, in some cases, cDNA/Southern. Deletions were detected in 24 patients (32%) and were mainly clustered in two areas of the dystrophin gene: the 5' end (exons 3-12) and the central part (exons 44-53). 64% of the deletion endpoints lay in the middle region and 34% in the 5' end of the gene. The most frequent sites for deletion-endpoints were in the introns 47 (13.6%), 44 (11%), 2 (9%) and 12 (7%). Thus, the proportion and distribution of deletions in our DMD/BMD patients differ from those reported for other populations. Furthermore, a higher proportion of deletions was observed in familial cases (40%) than in isolated ones (30%), in contrast to previously reported data. The effect of the deletion on the reading frame agree with the phenotype in almost all the patients studied. This study will be useful in prenatal diagnosis and diagnosis of other Argentine DMD patients.

[Spinal anesthesia. Repercussions on childbirth]

A study was carried out to discover the action of epidural anesthesia on pain, on the evolution of dilation and expulsion intervals, on the number of surgically assisted births, and on perinatal morbidity. Some of the most significant results indicated that with good techniques, pain disappears in all cases; that the dilating period is significantly shortened with epidural anesthesia, although there is an increase in instrumental-assisted childbirths. Even though epidural anesthesia is, as of this writing, the best method available, the ideal pain reduction method has yet to be discovered. Part of this study was presented before the National Congress of Midwives and received the "Nuk" Prize.

bcl-2 expression in plasma cells from neoplastic gammopathies and reactive plasmacytosis: a comparative study

BACKGROUND AND OBJECTIVE

bcl-2 oncoprotein plays a major physiological role in hemopoietic and non-hemopoietic cells by preventing apoptosis (programmed cell death). Disregulation of this process may be important in oncogenesis and the response to treatment of patients with different hematological malignancies. We have investigated the levels of bcl-2 expression in plasma cells from patients with reactive plasmacytosis (RP), monoclonal gammopathy of unknown significance (MGUS) and multiple myeloma (MM), correlating the bcl-2 expression and clinico-biological features in MM patients.

DESIGN AND METHODS

The percentage of bcl-2 (+) plasma cells and levels of bcl-2 protein expression were investigated in 73 patients at diagnosis. Immunofluorescence and immunoenzymatic methods were applied using McAb against bcl-2 protein, and the intensity of protein expression was assessed by both the mean channel fluorescence intensity (MFI) and semiquantitative methods. To evaluate the intensity of bcl-2 expression in proliferating plasma cells, sequential double immunoenzymatic staining with McAb Ki-67 and bcl-2 was applied in 10 patients with MM. Correlations between bcl-2 expression and the clinico-biological features in MM patients were also studied.

RESULTS

The proportion of bcl-2 (+) plasma cells was significantly higher in MGUS and MM than in RP (p < 0.001). The intensity of bcl-2 expression in plasma cells (assessed by MFI) was significantly different between all groups studied (p < 0.0001). RP showed lower expression than MGUS and MM patients. MM stage III patients demonstrated higher bcl-2 expression values than MGUS (p < 0.01). According to the proportion of plasma cells expressing Ki-67, patients with a proliferative index (Ki-67+) > 4% showed lower bcl-2 expression than patients with proliferative index < 4% (p < 0.05). Immunocytochemistry showed that plasma cells from RP had a lower intensity of bcl-2 expression than MM (p < 0.001), and double immunostaining Ki-67/bcl-2 demonstrated that the majority of proliferating plasma cells had weak bcl-2 expression. There was no correlation between bcl-2 expression and clinico-biological parameters, response to therapy or overall survival in MM patients.

INTERPRETATION AND CONCLUSIONS

Globally, the number of bcl-2 (+) plasma cells and the intensity of protein expression in neoplastic gammopathies are significantly higher than in reactive plasmacytosis and bcl-2 levels tend to increase with disease stage. bcl-2 may be relevant to the pathogenesis of malignant gammopathies, prolonging the survival of plasma cells by preventing apoptosis and increasing the chance of acquiring additional gene defects. bcl-2 expression could also contribute to the resistance to chemotherapy observed in MM disease.

Morphology of the articular processes of the sixth cervical vertebra in humans

With the exception of the 7th vertebra, both past and recent literature describe the lower cervical vertebrae as possessing similar morphological characteristics (Soemmering, 1794; Cruveilhier, 1862; Luschka, 1862; Henle, 1871; Braus-Elze, 1954; Romanes, 1981; Williams et al. 1989; Benninghof, 1994). Gross anatomical differences from the 3rd to the 7th cervical vertebrae comprise the shapes of the vertebral body and uncinate and spinous processes (Putz, 1976; Penning, 1988; Lang, 1990) and the more developed anterior tubercle and anterior root of the transverse process of the 6th cervical vertebra (C6) (Paturet, 1951). During routine examination of a series of dried skeletons, the articular processes (AP) of C6 were found to be distinct from the rest of the cervical vertebrae. The aim of this study was to confirm this unusual appearance of the C6 process by inspecting a sample of dried skeletons. We report the morphology of the AP of C6 in 76 well preserved complete adult skeletons (58 males, 18 females; age 31–77 y) and 5 young specimens from the Anatomical Institutes of Alicante, Valencia and Murcia (Spain) and Munich (Germany). Another 12 skeletons were excluded from the study due to arthritic changes in their cervical APs.

Genetic heterogeneity of autosomal dominant polycystic kidney disease in Argentina

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder with genetic heterogeneity. Up to three loci are involved in this disease, PKD1 on chromosome 16p13.3, PKD2 on 4q21, and a third locus of unknown location. Here we report the existence of locus heterogeneity for this disease in the Argentinian population by performing linkage analysis on 12 families of Caucasian origin. Eleven families showed linkage to PKD 1 and one family showed linkage to PKD2. Two recombinants in the latter family placed the locus PKD2 proximal to D4S1563, in agreement with data recently published on the cloning of this gene. Analysis of clinical data suggests a milder ADPKD phenotype for the PKD2 family.