CT Features of an unusual calcified schwannoma of the superior laryngeal nerve

We report the CT findings in a patient with a lateral neck mass histologically diagnosed as a laryngeal schwannoma but presenting some uncommon CT features. CT showed unusual calcified components, very rarely observed and potentially misleading for diagnosis. However, this imaging feature can be found in ancient schwannomas. Our case is, therefore, a very rare one and reviews the main differential diagnoses.

[Schwannomas of the neck. About 3 cases, and literature review]

INTRODUCTION

Schwannomas of the neck are rare. Their diagnosis remains difficult despite the evolution of imaging techniques. The goals of our study were to review the diagnostic and therapeutic approach for these tumors.

MATERIALS AND METHODS

Retrospective study (1998-2005) concerning 3 cases of schwannoma in rare localizations: superior laryngeal nerve, ansa cervicalis and deep cervical plexus. These 3 patients were operated on in our ENT head and neck department. We made a review of the literature using the Medline database.

RESULTS

The mean delay between symptomatology and treatment was 5 years. In all cases, the schwannoma presented with a slowly-growing cervical mass. In only one case, the diagnosis of schwannoma was maded preoperatively. All 3 patients were treated surgically and the involved nerve was sacrificied. There were no postoperative complications. The mean follow-up duration was 3.5 years, with no recurrence.

DISCUSSION-CONCLUSION

To establish a diagnosis of neck schwannoma, ultrasound is the least sensitive imaging tool. Fine needle aspiration is especially useful to rule out other conditions. The most relevant diagnostic tools are CT-scan and especially MRI. Treatment is surgical; it should include sacrifice of the involved nerve. Surgical exploration of the neck and tumor resection could be performed at the same operation in the informed patient aware of the sequelae of nerve sacrifice, or otherwise be performed in two steps in the uninformed patient.

A pilot study in two French medical schools for teaching histology using virtual microscopy

PURPOSE

Glass slides and standard microscopes associated to a brief review of the lectures with projection slides were used during practical training in histology and histopathology for many years. Today it is necessary to develop new tools to improve teaching, and to face a lower number of teachers, as well the increase of the microscope maintenance costs. The goal of this study was to evaluate the feasibility of virtual slide implantation in several medical schools, the feedback from students, and to develop the interest in microscopic histology.

METHODS

We used virtual slides generated by the Samba 2050 system produced by Samba technologies. A collection of all organs for histology training was realized and overviewed by three MD, PhD. A questionnaire was distributed in middle of the year to evaluate the feedback.

RESULTS

The feedback of the students is highly positive. Students works faster, on better resources, interactivity between students is increased, and the fact that this is a new modality of teaching raises the students' interest.

CONCLUSION

Today the teaching program in two French medical schools (Lyon and Grenoble) include virtual slides alone or in addition to microscopic glass slide examination to teach histology or pathology.

Poly(I)-poly(C12U) but not ribavirin prevents death in a hamster model of Nipah virus infection

Clinical nonrandomized trials demonstrate some efficacy for ribavirin in the treatment of patients with severe Nipah virus-induced encephalitis. We report here that EICAR, the 5-ethynyl analogue of ribavirin, and the OMP-decarboxylase inhibitors 6-aza-uridine and pyrazofurin have strong antiviral activity against Nipah virus replication in vitro. Ribavirin and 6-aza-uridine were tested further in hamsters infected with a lethal dose of Nipah virus. The activity of these small-molecule inhibitors was compared with that of the interferon inducer poly(I)-poly(C(12)U). Both ribavirin and 6-aza-uridine were able to delay but not prevent Nipah virus-induced mortality. Poly(I)-poly(C(12)U), at 3 mg/kg of body weight daily from the day of infection to 10 days postinfection, prevented mortality in 5 of 6 infected animals.

[Comparison of two routine screening strategies for gestational diabetes mellitus: the experience of Jean-Verdier Hospital]

OBJECTIVE

Screening strategies for gestational diabetes mellitus are controversial. Thus, we sought to determine the benefits of universal screening.

PATIENTS AND METHODS

Prospective study with 2121 women involved but 1610 really screened (75.9%). According to WHO's recommendations, the strategy implemented was one-step, universal screening with a 75g oral glucose tolerance test. Screening was performed between 24 and 28 weeks of gestation or earlier if risk factors were identified. Results were compared to previous year (2001) then only a selective screening was done.

RESULTS

Application of universal screening increased the prevalence of gestational diabetes mellitus (8.39% to 15.65%). Out of the 252 patients with gestational diabetes, 66 did not display any identified risk factor (26.19%). Some new risk factors have been identified: age>30, Asian, Indian or Pakistan ethnies. If these new risk factors were applied, this super selective screening would have a sensibility of 96%.

DISCUSSION AND CONCLUSION

Universal screening seems to be the most appropriate routine screening strategy because it is difficult to know exactly the specific risk factors of a population to do a super selective screening.

Stability of all-in-one standard formulae for paediatric parenteral nutrition

The Robert Debré Hospital pharmacy unit ensures an annual manufacturing rate of 20,000 parenteral nutrition bags. Until 1999, these bags consisted in binary admixtures, fat emulsions being administered to the patient via a "Y" connexion on the catheter. Since then, all-in-one standard formulae have been established and are manufactured using a Baxa MM23 automated compounder. The aim of this study was to assess the physico-chemical stability of all-in-one admixtures, in order to ensure patient administration safety (mainly avoiding precipitation risks between the nutrients). Three bags of each standard formula were manufactured in monocompartmental bags. Stability assays consisted in the assessment of the admixture's (1) macroscopic aspect, (2) drop size measurement, (3) zeta potential measurement, (4) pH measurement, and (5) osmolality measurement. Tests were conducted between D0 (manufacturing day) and D10 (10 days after manufacture). All-in-one admixtures manufactured according to the established standard formulae were found to be stable for at least 10 days, provided they are kept away from light and at a temperature of +4 degrees C.

102 ANALYSIS OF EARLY EMBRYONIC TRANSCRIPTION IN THE BOVINE EMBRYO USING A DEDICATED cDNA LIBRARY

Early embryonic development is initially dependent on mRNAs that have been transcribed during oocyte growth (maternal transcripts). Newly formed zygotic transcripts then become required during what is called the maternal-to-zygotic transition. In cattle, this transition initiates at the 8-cell stage and ends before the morula stage. Because of its decisive role in the further development of the embryo we are interested in characterizing the regulative functions of those cattle zygotic transcripts that are differentially expressed at the end of this transition. For that reason a subtracted cDNA library corresponding to the first zygotic transcripts was established at the early compacted morula stage using suppressive subtractive hybridization (SSH; Clontech, LePont de Claix, France). Morula derived cDNAs were used as Tester and 4-cell stage cDNAs as Driver materials. Cattle embryos were obtained from slaughterhouse-derived ovaries using standard in vitro maturation and fertilization techniques. Since, in cattle, early cleaving (2-cell-stage) zygotes are more likely to develop to the blastocyst stage than their later-cleaving counterparts, all embryos used to establish the cDNA library were selected from zygotes that were already at the 2-cell stage 32 h post-in vitro fertilization. Total RNA was extracted from batches of 140 (morula) and 200 (4-cell-stage) embryos and the amount of PolyA+ RNAs was estimated according to Duranthon and Renard (in Biology and Pathology of the Oocyte, Trounson and Gosden eds, Cambridge Univ. Press, 2003, p. 96). Double-stranded cDNAs were synthesized with the SMART cDNA amplification kit (Clontech) before SSH was undertaken. Upon RNA extraction, exogenous transcripts obtained from Arabidopsis thaliana (Stratagene, La Jolla, CA, USA) were added either to the Tester only (at three concentrations: 10−3, 5 × 10−3, 5 × 10−2) or to both the Tester and the Driver materials (at two concentrations: 5 × 10−3, 5 × 10−2). These transcripts allowed us to report on the efficiency of our subtraction procedure and on the quality of the bacterial library in terms of tester-specific transcript enrichment. We found the library to be enriched in specific transcripts of the Tester (morula stage) by a factor of 300. Normalization of the library, as determined from the proportion of exogenous transcripts after bacterial transformation, was effective for those added initially at low (10−3) or moderate (5 × 10−3) concentrations but not for abundant ones (5 × 10−2). These conditions are thus beneficial for the isolation of rare zygotic transcripts present at an initial concentration of only 10−3 of the messengers. Ongoing study using various differential screening of this cattle library with morula- and 4-cell-stage probes will now allow us to identify zygotic transcripts specifically expressed at the onset of genome activation and not present in the pool of maternal transcripts up to the 4-cell stage. This work was supported by an INRA CIRAD grant (BioDiva) to LCB.

An esophago-atrial vein or fibrous cord in a top fold of the oblique sinus of the pericardial sac

In a previous anatomical study of the oblique sinus of pericardium, we reported on the morphological variations of this recess. We noted a previously undescribed variation of its top in 32.7% of our cases. Here we detail this variation using microscopic and macroscopic mediastinal dissections of 107 adult fresh cadavers. It seems a top fold of the oblique sinus contains a permeable esophago-atrial vein or a fibrous cord. These unique variations of the oblique sinus modify the classical anatomical and embryological descriptions. Abnormal esophago-atrial veins have not been described previously but they are predictable according to embryological knowledge. From a clinical point of view, such a vein, permeable or not, may facilitate extension of esophageal carcinoma to the pericardium and may represent a porto-systemic bypass in cases of portal hypertension.

[Failure to thrive and intestinal diseases in congenital disorders of glycosylation]

Congenital disorders of glycosylation type I (GDG-I) is a class of genetic multisystem disorders characterised by defective glycosylation of glycoproteins. The characteristics and mechanisms of failure to thrive and intestinal diseases present in CDG-I are anectodal.

PATIENTS AND METHODS

The aim of this study was to analyse 7 CDG-I (4 CDG-Ia, 2 CDG-Ib and 1 CDG-Ix) with important digestive symptoms and failure to thrive in order to characterise the mechanisms implied.

RESULTS

Four children had no skin abnormality or dysmorphia (1 CDG-Ia, 2 CDG-Ib, 1 CDG-Ix). An encephalopathy with cerebellar hypoplasia was present only in the 4 CDG-Ia. Failure to thrive and diarrhea were present during the first month of life in 6 and appeared at 5 years in one CDG-Ia associated to mild or severe hepatopathy in all patients. One CDG-Ia, 1 CDG-Ib, 1 CDG-Ix had an exsudative enteropathy. A positive steatorrhea was present in 3 patients. Five patients had an abnormal small bowel biopsy. Abnormalities were variable: moderate inflammation of the chorion without villous atrophy in 2, intra-enterocyte fat accumulation without villous atrophy in 2, and partial villous atrophy with lymphangectasia in 1. In 2 CDG-Ia the intestinal biopsy was normal. Enteral nutrition in 4 and parenteral nutrition in 2 were effective in 4 patients and 1 patient with an exsudative enteropathy respond to a free fat diet (CDG-Ix).

CONCLUSION

The digestive symptoms with failure to thrive is a common feature of CDG-I and could be the first symptoms. The diagnostic should be suspected if no other cause is found. Mechanisms of the intestinal symptoms appear to be multiple such as inflammation, abnormal enterocyte lipid transport or intestinal permeability related to the abnormal glycosylation of intestinal mucosa glycoproteins.

[Rendu-Osler-Weber syndrome. Pulmonary arteriovenous fistulas. A report of three cases]

Hereditary hemorrhagic telangiectasia (HHT), or Rendu-Osler-Weber syndrome, is a rare disorder that is closely linked to the development of pulmonary arteriovenous malformations (PAVM). Diagnosis can be based on clinical signs such as upper respiratory tract changes or recurrent hemorrhagic events. Nevertheless, pulmonary involvement, a prognostic factor, may remain undetected. In the three HTT cases with PAVM we report, the following diagnostic information was obtained non-invasively: shunt fraction measurements (breathing 100% oxygen), echocardiographic contrast studies, and three-dimensional helical computed tomographs. Arteriography demonstrated a single PAVM in one case and the patient underwent successful coil embolization, with clinical and functional improvement.

Analysis of conserved and non-conserved amino acids critical for ALSV (Avian leukemia and sarcoma viruses) integrase functions in vitro

Retroviral integrase (IN) is the viral enzyme responsible for the integration of viral DNA into host cellular DNA. In vitro, recombinant IN protein is able to catalyze the 3'-processing, strand transfer and disintegration activities. In order to analyze the importance of specific residues of ALSV (Avian leukemia and sarcoma viruses) IN protein, we introduced 31 amino acid substitutions either in residues previously shown by others to be involved in IN oligomerization or in selected conserved and non-conserved residues through the IN sequence. We tested, in vitro, the three catalytic activities of these mutants as well as their capacity to bind DNA. We found that (i) 88% of the substitutions occurring on well-conserved residues have an effect on IN activities (ii) two mutants (S85T in the central catalytic domain and N197C in the C-terminal domain) present a reduced efficiency of DNA binding compared to the wild type protein. Moreover, all mutations made on the dimer interface of C-terminal domain present reduced activities, suggesting an important role of this part of the protein. Finally, for some mutations, we observed differences between the ALSV and HIV (Human immunodeficiency virus) IN corresponding residues.

Axillary lymph-node dissection for positive sentinel nodes in breast cancer patients

AIM

The aim was to identify a subset of breast cancer patient with positive sentinel nodes (SNs) for whom secondary axillary clearance would be unnecessary.

METHODS

Between March 1999 and May 2001, 288 patients with T0-T2 breast cancer less than 3cm in diameter had SN detection either by a colorimetric method or using a combined technique. SNs were stained with haematoxylin and eosin (H&E). For all negative SNs, serial sections and immunochemistry (IHC) were performed. All patients with positive SNs underwent a complete axillary lymph node dissection. One hundred and twenty patients were SN positve.

RESULTS

Non-sentinel node positivity (NSNP) was closely associated with the size of the tumour (14.3%, 54.1% and 51.8% for pT1a-b, pT1c and pT2 tumours respectively) and with the size of the SN metastasis: 15.9% IHC detected micrometastasis, 33.3% and 78.8% micro- and macrometastasis detected with H&E staining respectively. NSNP was found in 24.0% and 42.8% of patients with pT1c breast cancer and with micrometastasis detected by IHC and H&E staining. The node positivity rate reached 81.1% for pT1c lesions with macrometastasis in the SN. For the patients with pT2 breast cancer, these rates were 12.5% (IHC), 28.5% (H&E) 91.1% (macrometastasis).

CONCLUSIONS

We are unable to isolate precisely a subset of patients for whom total axillary lymph node dissection would be unnecessary. A subset of 14 small tumours (<1cm diameter) demonstrated micrometastases in the SN without NSNP.

[Pancreatic involvement in inflammatory bowel diseases in children]

Pancreatitis in inflammatory bowel disease (IBD) in children is anecdotal. In adults, symptomatic pancreatitis occurs in 2% and asymptomatic in 8 to 21%.

PATIENTS AND METHODS

The aim of our study was to review retrospectively the frequency of pancreatitis in 124 pediatric patients (54.8% boys, 45.2% girls; 97 with Crohn disease, 16 with ulcerative colitis and 11 with undetermined colitis). Diagnostic criterion of pancreatitis was an increase of amylasemia > or = +2 SD of the normal with or without evocative clinical symptoms.

RESULTS

Symptomatic or asymptomatic pancreatitis was found in 27% (respectively 14.5 and 12.5%). Pancreatitis was significantly more frequent in girls as compared to boys (P = 0.04). Symptomatic pancreatitis was moderate and non complicated, often recurrent. It occurred mainly during active and severe diseases (P = 0.006). The localizations of IBD were not discriminant. Strong relation with drug was found in 25% of pancreatitis mainly due to azathioprine or 5-aminosalicylic acid, and salazopyrin. Duodenal localisation of Crohn disease or hepatobiliary complications were found associated with pancreatitis in 18% and 15% respectively.

CONCLUSION

These data suggest the high incidence of symptomatic and asymptomatic pancreatitis in children with IBD, the importance of its regular monitoring but also its multifactorial causes. Precise diagnosis of pancreatitis in pediatric IBD has to be done in order to avoid inappropriate drug pancreatitis diagnosis.

[Long-term followup of primary intestinal lymphangiectasia in the child. Six case reports]

Primary intestinal lymphangiectasia induce symptoms of protein-losing gastroenteropathy. Only very few studies evaluate the long term follow up of such patients. We reviewed six children diagnosed at 17 +/- 12 months and followed for 11 +/- 4.9 years.

CASE REPORTS

As soon as the diagnosis was made the patients were submitted to a strict low fat diet with added medium chain triglycerides and intermittent liposoluble vitamins perfusions. The diet allowed the disappearance of symptoms for all the patients but laboratory findings indicated continuing chyle leak for most of the children. Only one child who had normal biological parameters tolerates a normal diet since four years. Relaxation of the diet by two patients who had moderate hypoalbuminemia and lymphopenia led to severe clinical relapses 14 and 17 years after the diagnosis period with therapeutic difficulties. Three patients with long term strict low fat diet remain asymptomatic.

CONCLUSION

In most asymptomatic patients, the underlying lymphatic defect remains with permanent biological abnormalities. Clinical relapses may be severe and difficult to treat; thus the need for dietary treatment appears to be permanent.

Do prognostic factors exist for total colonic aganglionosis with ileal involvement?

BACKGROUND/PURPOSE

Total colonic aganglionosis with ileal involvement is estimated at 1 case in 50,000 living births. This pathology has a very variable prognosis, and patients often need long-term parenteral nutrition. The aim of this study is to define prognostic factors for this disease.

METHODS

This is a retrospective study from 1980 to 1999, based on 26 cases of total colonic aganglionosis with ileal involvement. The authors analyzed birth term, sex, birth weight, ileal involvement in centimeters, delay to correct level enterostomy, the total parenteral nutrition duration, and the need for constant rate nutritional assistance. The authors studied the following items: Weight, height, complications, clinical state, and nutritional issues. The statistic test is: LOG RANK (analysis of censored data and comparison of survival diagram).

RESULTS

The only prognostic factor is the length of ileal involvement. All the children with ileal involvement less than 50 cm, except for 2, did not need long-term nutritional assistance; for those with ileal resection over 50 cm, long-term nutritional assistance was needed. Total colonic aganglionosis is a very serious illness (2 children had a small bowel transplantation, and 2 are waiting for one). The prognosis is even worse when associated with a polymalformation syndrome (50% of the children died).

CONCLUSION

The major prognostic factor is the length of small bowel not involved in the total colonic aganglionosis.

[Pediatric gastrointestinal endoscopy: which sedation?]

Through an analysis of the French experience of digestive endoscopists in adult patients and of their own 25 years practice of pediatric digestive endoscopy, the authors militate in favour of anesthetic sedation in order to reduce painfulness and to obtain better acceptation of these procedures by children and their parents.

Lansoprazole in children: pharmacokinetics and efficacy in reflux oesophagitis

BACKGROUND

Data on the proton pump inhibitor lansoprazole in paediatric patients are limited.

AIM

To investigate the pharmacokinetics, optimal dosage and efficacy of lansoprazole in paediatric patients.

METHODS

A 24-h gastric pH recording and a pharmacokinetic study were performed after 7 days of lansoprazole, 17 mg/m2, in 23 patients with reflux oesophagitis (median age, 3.5 years). Response was defined as pH > 3 for > 65% of the recording. The dosage was doubled in non-responders. Patients with no response on day 14 were excluded. Responders underwent endoscopy after 4 weeks on the response-inducing dosage; abnormal findings led to a repeat endoscopy after four additional weeks.

RESULTS

Nine patients responded to 17 mg/m2 and six to 30.3 mg/m2. On day 7, time with pH > 3 was significantly correlated with the area under the plasma concentration-time curve (P=0.003). The area under the plasma concentration-time curve was significantly greater in the nine responders to 17 mg/m2 than in the 14 other patients. Pharmacokinetic parameters were similar in responders and non-responders to the higher dose. After 4 weeks, oesophagitis was healed in 80% of responders. Adverse events occurred in three patients and required treatment discontinuation in one.

CONCLUSIONS

Lansoprazole is effective and safe in children. The optimal starting dosage is 30 mg/m2 or 1.4 mg/kg.