[Intramedullary spinal cord metastasis as the first manifestation of a renal carcinoma]

We present the case of a 69 year-old male without known antecedente who presented a clinical loss of distal force in his lower limbs during the last two months. Magnetic resonance imaging (MRI) showed an intramedullary spinal cord mass at the level of the medullaris cone. The patient was operated on; the histological diagnosis was clear cells carcinoma suggestive of metastasis from an unsuspected renal tumor that was later confirmed with an abdominal CT. When the patient's state is good, surgery can correct the neurological deficit produced by an intramedullary spinal cord lesion. The neurological state of our patient improved after the intervention, and 14 months after surgery, he has no neurological deficit in the lower limbs.

Animal welfare and developing countries: opportunities for trade in high-welfare products from developing countries

Discussion on the potential for developing countries to develop trade in niche markets such as higher welfare standards has been highlighted with moves by the World Organisation for Animal Health (OIE) to set internationally agreed standards for animal welfare. This paper examines the existing and potential trade in value-added higher welfare products using case studies in the beef and poultry sectors from three countries in Africa, Asia and Latin America. It shows that at present there is only a small trade in these products but that this can have a major effect at a national level. In the beef export trade from Namibia, the existence of the only assurance scheme in Africa setting standards in hygiene, veterinary care and animal welfare has created a trusted, safe and healthy product and ensured that Namibia has grown into Africa's largest exporter of beef to the European Union. In Thailand, the broiler industry, which has enjoyed annual growth in the past 15 years, is developing value-added products to develop markets to counter competition from other countries. The development and implementation of standards for organic products in both Thailand and Argentina over the past decade have also resulted in growth in the export markets of these products. The paper concludes that there is growth potential for the sectors in all three markets which can be assisted by the development of OIE baseline standards.

Treatment of acute lymphoblastic leukaemia in countries with limited resources; lessons from use of a single protocol in India over a twenty year peroid

In the 1970s, survival rates after treatment for acute lymphoblastic leukaemia (ALL) in children and young adults (less than 25 years) in India were poor, even in specialised cancer centres. The introduction of a standard treatment protocol (MCP841) and improvements in supportive care in three major cancer centres in India led to an increase in the event-free survival rate (EFS) from less than 20% to 45-60% at 4 years. Results of treatment with protocol MCP841 between 1984 and 1990 have been published and are briefly reviewed here. In addition, previously unpublished data from 1048 patients treated between 1990 and 1997 are reported. Significant differences in both patient populations and treatment outcome were noted among the centres. In one centre, a sufficiently large number of patients were treated each year to perform an analysis of patient characteristics and outcome over time. Although steady improvement in outcome was observed, differences in the patient populations in the time periods examined were also noted. Remarkably, prognostic factors common to all three centres could not be defined. Total white blood cell count (WBC) was the only statistically significant risk factor identified in multivariate analyses in two of the centres. Age is strongly associated with outcome in Western series, but was not a risk factor for EFS in any of the centres. Comparison of patient characteristics with published series from Western nations indicated that patients from all three Indian centres had more extensive disease at presentation, as measured by WBC, lymphadenopathy and organomegaly. The proportions of ALLs with precursor T-cell immunophenotypes, particularly in Chennai, were also increased, even when differences in the age distribution were taken into consideration (in <18-year olds, the range was 21.1-42.7%), and in molecular analyses performed on leukaemic cells from over 250 patients less than 21-years-old with precursor B-cell ALL, a lower frequency of TEL-AML1-positive ALL cases than reported in Western series was observed. The worse outcome of treatment in Indian patients compared with recent Western series was probably due to the higher rate of toxic deaths in the Indian patients, and possibly also due to their more extensive disease - which is, at least partly, a consequence of delay in diagnosis. Differences in the spectrum of molecular subtypes may also have played a role. The higher toxic death rates observed are likely to have arisen from a combination of more extensive disease at diagnosis, co-morbidities (e.g., intercurrent infections), differences in the level of hygiene achievable in the average home, poor access to acute care, and more limited supportive care facilities in Indian hospitals. Toxic death was not associated with WBC at presentation, and hence would tend to obscure the importance of this, and, potentially, other risk factors, as prognostic indicators. Since the prevalence of individual risk factors varies in different populations and over time, their relative importance would also be expected to vary in different centres and in different time periods. This was, in fact, observed. These findings have important implications for the treatment of ALL in countries of low socioeconomic status; it cannot be assumed that risk factors defined in Western populations are equally appropriate for patient assignment to risk-adapted therapy groups in less affluent countries. They also demonstrate that heterogeneity in patient populations and resources can result in significant differences in outcome, even when the same treatment protocol is used. This is often overlooked when comparing published patient series.

Occult Vascular Lesions in Patients with Atherothrombotic Events: The AIRVAG Cohort

OBJECTIVES

To determine clinical parameters that could predict occult vascular lesions (OVL) in patients with symptomatic atherosclerosis.

PATIENTS AND METHODS

Prospective evaluation of 269 consecutive patients with symptomatic atherosclerosis (cerebral 32%, peripheral vascular 15%, and coronary 53%): complete laboratory, ultrasound exams (carotids, aorta, heart), ankle-brachial index. OVL were defined as: abdominal aortic aneurysm, carotid artery stenosis > 50%, or left ventricular segmental contraction abnormalities when affecting a different vascular bed from the symptomatic. Clinical predictors of OVL were evaluated by logistic regression analysis.

RESULTS

OVL were found in 35 patients (13%): 12 abdominal aortic aneurysms, 21 carotid artery stenosis and 15 segmental left ventricular contraction abnormalities. OVL were associated with peripheral vascular disease (intermittent claudication or reduced ankle-brachial index), cigarette smoking, increased pulse pressure, microalbuminuria and hyperhomocysteinemia. By multivariate analysis, intermittent claudication (odds ratio 5.8; 95% CI 2.6-12.8) and microalbuminuria (OR 4.2; 95% CI 1.7-10.5) were strong independent predictors of OVL. Similar results were obtained when peripheral vascular disease was defined as reduced ankle-brachial index (OR 5.3; 95% CI 2.4-11.7).

CONCLUSIONS

Clinical and subclinical peripheral vascular disease, as well as microalbuminuria are strong independent predictors of OVL in atherosclerotic patients. A screening study of OVL may be warranted in these patients.

New tetrachromic VOF stain (Type III-G.S) for normal and pathological fish tissues

A new VOF Type III-G.S stain was applied to histological sections of different organs and tissues of healthy and pathological larvae, juvenile and adult fish species (Solea senegalensis; Sparus aurata; Diplodus sargo; Pagrus auriga; Argyrosomus regius and Halobatrachus didactylus). In comparison to the original Gutiérrez VOF stain, more acid dyes of contrasting colours and polychromatic/metachromatic properties were incorporated as essential constituents of the tetrachromic VOF stain. This facilitates the selective staining of different basic tissues and improves the morphological analysis of histochemical approaches of the cell components. The VOF Type III -6.5 stain is composed of a mixture of several dyes of varying size and molecular weight (Orange G<acid Fuchsin<Light green<Methyl Blue<Fast Green), which are used simultaneously, and it enables the individual tissues to be selectively differentiated and stained. Muscle fibers, collagen, reticulin and elastin fibers, erythrocytes, cartilage, bone, mucous cells, oocytes and larvae were selectively stained and differentiated. Dyes with small size and molecular weight (i.e Orange G), penetrate all tissue structures rapidly, but are only tightly retained in densely textured tissues (i.e erythrocytes). Methyl Blue is an interesting triarylmethane dye (large size and molecular weight), which is incorporated in this new VOF tetrachrome stain, and acquires histochemical significance when used at acid pH (2.8) because collagen and reticulin fibers, as well basophilic and metachromatic substances (strongly ionized sulphated glycoconjugates) can be identified. Muscle tissues show an evident green colour (Fast Green or Light Green affinities), even those isolated and/or diffuse muscle fibers present in the digestive submucosa layer. Connective tissues showed a specific and strong blue colour (Methyl Blue affinity) or mixed blue-red staining (Methyl Blue and Acid Fucshin affinities). Very noticeable is the staining of the mucous cells, as well as the hyaline capsule of the viral lymphocystic cells, which were stained blue-purple (carboxylated and/or strongly ionized sulphated groups). Cartilaginous tissues showed a blue or purple (Methyl Blue affinity) staining, and a specific red colour (Acid Fucshin affinity) was evident during calcification or in bone structures (i.e skeleton, fins, gills, teeth).

Tratamiento artroscópico de las lesiones tipo 1B del fibrocartílago triangular

El complejo del fibrocartílago triangular (CFCT) desempeña un papel fundamental en la biomecánica de la muñeca. Actúa absorbiendo y transmitiendo cargas, y sirve como punto de pivote para la rotación del radio y del carpo alrededor del cúbito, por lo que funciona como centro de rotación del antebrazo. Además constituye el principal elemento estabilizador de la articulación radiocubital distal. Estudios histológicos han demostrado que la parte central del CFCT, también denominada disco articular, es avascular, mientras que su periferia está bien vascularizada, por lo que las lesiones de esta porción tienen mayor capacidad de regeneración. Las lesiones del CFCT constituyen una causa primaria de dolor en el lado cubital de la muñeca y de inestabilidad de la articulación radiocubital distal. Su tratamiento ha incluido una serie de medidas conservadoras así como un número variable de técnicas quirúrgicas, entre las que destacan en los últimos años el desbridamiento artroscópico en las lesiones centrales, y la reinserción artroscópica en las lesiones periféricas. Presentamos un estudio retrospectivo sobre los resultados del tratamiento artroscópico de las lesiones periféricas tipo 1B, realizado en 10 pacientes que fueron intervenidos quirúrgicamente en nuestro departamento entre los meses de febrero de 1999 y enero de 2002. Se realizó una reinserción artroscópica mediante técnica dentro-afuera y sutura en pull-out, obteniéndose resultados excelentes en 7 casos, buenos en 2 y malos en 1.

The triangular fibrocartilage complex (TFCC) plays an important role in the biomechanics of the wrist. It acts by absorbing and transmitting loads, and serves as a pivot point for the rotation of the radiocarpal unit around the ulnar axis, and so it works as a centre of rotation for the forearm. It is also the main stabilising element of the distal radioulnar joint. Histological studies have shown that the central part of the TFCC, also known as the articular disc, is avascular, while its periphery is well vascularised, and so lesions in this section have a greater regeneration ability. TFCC lesions are a primary cause of pain in the ulnar side of the wrist and instability of the distal radioulnar joint. Treatment for this has included a series of conservative measures as well as a variable number of surgical techniques, particularly in recent years arthroscopic debridement in central lesions and athroscopic reinsertion in peripheral lesions. We present a retrospective study of the results of arthroscopic treatment of type 1B lesions, carried out on 10 patients who were operated on in our department between February 1999 and January 2002. Arthroscopic reinsertion was carried out using the internal-external and pull-out suture technique, with excellent results being obtained in 7 cases, good results in 2, and an unfavourable result in 1 case.

Liver transplantation in Medellin, Colombia: Initial experience

OBJECTIVE

The goal of this article is to present the experience of a new liver transplant team.

MATERIALS AND METHODS

This review includes all patients who received a liver transplant between March 15, 2000 and March 15, 2003.

RESULTS

We performed 87 transplantations on 84 patients; 39 were females and 45 were males of average age 43.6 years, including 6 children. The majority of the patients were from Colombia with time on the waiting list of less than 1 month. The average donor age was 26.7 years. The preservation solutions included Wisconsin, HTK-Brettschneider (Custodiol), and Corpaúl (similar to Henn-Ross). In this study, 95.4% were whole livers, with 97.7% using the piggyback method. We placed 23 arterial grafts and 2 venous grafts for vascular reconstructions; 95.4% were duct-to-duct anastomosis (95.4%). Among the cohort, 8.3% experienced acute rejection and 1.2% experienced chronic rejection. Two patients required retransplantation due to hepatic artery thrombosis with biliary tree necrosis.

CONCLUSIONS

We consider that we have passed the crisis of beginning a new program with a reduction in postoperative complications and improving patient and graft survival. At present, we are a center that performs liver transplantations in adults and children, with a good organ donation culture in our city that allows us to offer a waiting time on the list less than one month. Neither a veno-venous bypass nor a T-tube were necessary for our cases. We also have developed a new, less expensive form of perfusing the liver in the donor.

Neonatal spinal muscular atrophy with multiple contractures, bone fractures, respiratory insufficiency and 5q13 deletion

We present the case of a floppy neonate with marked and generalized weakness, respiratory insufficiency and fetal akinesia deformation sequence. The infant showed multiple joint contractures, two bone fractures and needed mechanical ventilation from birth to death at 16 days of age. Electrophysiological assessment showed electrically unexcitable motor and sensory nerves. Muscle biopsy showed diffuse atrophy of type I and type II fibers. Necropsy confirmed the diagnosis of infantile spinal muscular atrophy (SMA) with severe loss of motor neurons in anterior horns and motor nuclei of brainstem. There were also neuronal loss, gliosis, chromatolysis, ballooned cells, empty cell beds and neuronophagia figures in other brainstem and brain nuclei. Genetic analysis of the patient revealed homozygous deletions of survival motor neuron gene 1 (SMN1) and a single copy of SMN2 in region 5q13. This case confirms that the loss of spinal motor neurons underlies the muscular atrophy in severe cases of 5q SMA. This case also shows that the presence of multiple joint contractures, bone fractures and respiratory insufficiency in SMA in the neonatal period does not necessarily exclude the occurrence of classical deletions in the SMA 5q13 region. Rather, these atypical clinical findings show the extreme severity and prenatal onset of the disease in these SMA cases, which may be related with the occurrence of a single copy of SMN2 gene. More reports of clinically, pathologically and genetically well-documented cases are essential to define the different types of this disease.

The role of age in the development of Schneiderian symptoms in patients with a first psychotic episode

OBJECTIVE

The likelihood of developing psychotic symptoms greatly increases after puberty. In acute psychotic disorders, first rank symptoms (FRS) are prevalent and considered useful for the diagnostic process. The aim of this study was to test for a linear association between age and the probability of occurrence of FRS in patients with a first psychotic episode (FPE).

METHOD

A total of 112 patients, consecutively admitted with an FPE, were included at baseline and evaluated yearly over a 3-year period using SCID-I and a checklist of 11 items of FRS.

RESULTS

FRS were documented for 65.2% patients at baseline. There was a dose-response relationship in the association between age and FRS. There was no interaction with sex or with final diagnostic category.

CONCLUSION

Variation in the expression of the core positive symptoms of psychosis is subject to the influence of underlying age-dependent maturational processes both in terms of occurrence and level of severity.

Paragangliomas de la cauda equina: a propósito de dos casos

Extraadrenal paragangliomas involving the spinal cord are not common and usually take the compression of the cauda equine. Two cases of paraganglioma of the cauda equina with a different presentation are reported, and the clinical and histopathology findings of this tumor, as well as diagnosis, treatment and prognosis are review. We stress the importance of the high tumor vascularization form of intradural that can make impossible achieve a complete resection. Laminotomy and intraoperatory echography are very useful in the approach to intradural tumors, such as paraganglioma.

[Severe polymyositis with simvastatin use]

INTRODUCTION

Myotoxicity is the most common adverse reaction of statins, being its frequency less than 0.5%. Mild myopathy reversible after statin withdrawal is the most common event. We present a case of severe polymyositis which was likely to be induced by simvastatin.

CASE REPORT

75 years old man with hypercholesterolemia treated with simvastatin 20 mg/day for 6 months started previous 2 months with proximal limb weakness, dysphagia and myalgias during exercise that did not release after simvastatin withdrawal. Laboratory findings showed increased creatinin kinase (6,010 UI/L), raised aldolase (51 UI/L) and lactic acid dehydrogenase (1,406 UI/L). Muscular biopsy showed abundant inflammatory cell infiltration in perivascular areas, muscle fibre necrosis with miofagocitosis and considerable variation in fibre size, some of them reaching 210 mm. Treatment with cortico esteroids was started and 4 months later clinical remission and nomalization of creatinin kinase was observed.

DISCUSSION

Mechanisms of statins induced myotoxicity are not well known. Studies in rats suggest a muscle membrane defect (increased membrane fluidity) and abundant signs of damage (fiber necrosis, hipercontraction) but no cellular infiltrates were seen, pointing to a non inflammatory myopathy which was dose dependent. In our case, and Giordano s et al, the remission of the disease with cortico esteroid therapy and the finding of abundant inflammatory cell infiltration suggest the implication of immunological mechanism and not only a muscle membrane defect.

Interactions of acute morphine with chronic imipramine and fluvoxamine treatment on the antinociceptive effect in arthritic rats

This study was undertaken to investigate the effects induced by chronic systemic administration of two different antidepressants: imipramine (IMI), a dual serotonin-noradrenaline reuptake inhibitor, and fluvoxamine (FVX), a selective serotonin reuptake inhibitor, on the antinociceptive effect of morphine (MOR) in a paw pressure test in adjuvant-induced arthritic rats. For 30 days rats were administered with IMI, FVX or saline (SAL). On days 15 and 30, animals were tested in the paw pressure test 20 min after MOR or SAL administration. MOR induced a significant antinociceptive effect in IMI, FVX and SAL treated rats. But, at 30 days, this increase in pain threshold was significatively higher in IMI than SAL rats. This increase was not seen in FVX rats. These results suggest that a combination of opioid and mixed monoaminergic activities is effective in enhancing the antinociceptive effect of MOR in arthritic rats while only opioid and serotonergic activities have no enhancer effect.

Age-dependence of Schneiderian psychotic symptoms in bipolar patients

Psychotic symptoms frequently occur in bipolar disorder, especially in younger patients. However, whether the association with younger age also extends to psychotic symptoms that have traditionally been associated with schizophrenia, such as Schneiderian first-rank symptoms (FRSs), is unclear. This study examined FRSs in bipolar I patients and their relationship to age and gender. The sample comprised 103 consecutive inpatients who met DSM IV criteria for bipolar disorder, manic or mixed. FRSs were rated with the Scale for the Assessment of Positive Symptoms (SAPS). Interaction between FRSs and gender and FRSs and age was assessed using logistic regression. A high rate of FRSs in manic and mixed patients was found with a higher frequency in men (31%) than in women (14%; P=0.038). A monotonic increase in the association between FRSs and younger age was apparent (odds ratios (OR) over five levels: 1.42; 1.00-2.01). These results confirm previous findings that FRSs are not specific to schizophrenia and suggest in addition that a dimension of nuclear psychotic experiences of developmental origin extends across categorically defined psychotic disorders.

Treatment of severely psychotic inpatients with schizophrenia: olanzapine versus other antipsychotic drugs

Nine hundred and ten schizophrenic inpatients suffering from acute psychotic episodes were included in a naturalistic study. Patients were prescribed treatment with olanzapine (OLZ) or with typical antipsychotic (TYP) drugs. Patients receiving another atypical antipsychotic were excluded. Of the whole sample, 483 (53.4%) were treated with olanzapine and 421 (46.6%) with typical antipsychotics. Three specific subpopulations of greater severity were defined: patients with prominent psychotic symptoms, agitated patients, and patients initially treated with intramuscular (i.m.) medication because of their acute clinical condition. Severity of illness was assessed using the Clinical Global Impression (CGI) scale for severity, the Brief Psychiatric Rating Scale (BPRS) and the Nursing Observational Scale for Inpatient Evaluation. Baseline differences were adjusted per data analysis. The mean change from baseline to endpoint of overall symptomatology (total BPRS score) was significantly greater in the olanzapine group compared to the typical antipsychotic-treated group, both in the sample of patients with prominent positive symptoms (P < 0.001) and in the sample of agitated patients (P =0.015). Significant differences were also found in BPRS positive scores, BPRS negative scores and CGI scores in these two populations. Patients who had received previous i.m. drugs showed no statistically significant differences in symptomatic improvement between both treatments groups, except for a more favourable response of BPRS negative subscores in the olanzapine group (P =0.015). The results suggest that olanzapine may be considered as a first line treatment for severely psychotic inpatients with schizophrenia.