Polymorphous low-grade adenocarcinoma of the salivary glands: clinicopathological and immunohistochemical study of a case

Polymorphous low-grade adenocarcinoma (PLGA) is a distinctive salivary gland neoplasm with a predilection for intraoral sites. Histological and immunohistochemical analyses were used to study a case involving the minor salivary glands of the buccal mucosa in a 68-year-old woman. Histologically, the tumor was characterized by unenca-psulated, progressing and focally-infiltrative borders and showed variable growth patterns including solid, tubular, microcystic and cribriform; papillary and papillary-cystic areas of more than focal extent were present. Cytologically the neoplasm was composed of uniform, round to cuboidal cells with bland, round to oval nuclei. Immunohistochemical analysis showed that the tumor cells were positive for cytokeratin, S-100 protein, vimentin, focally-positive for EMA and actin and negative for CEA. The significance of the papillary component and the possible relationship to other salivary gland tumors is discussed.

[The use of laryngeal mask airway in esophagogastroduodenoscopy in children]

BACKGROUND

The use of laryngeal mask airway (LMA) for inducing and maintaining sedation during EGDS has never been reported in the literature but for a brief letter written by Gajraj in 1996. This study proposes the use of sevoflurane administered through LMA.

METHODS

At the Pediatric Clinic of the University of Rome "La Sapienza" 80 children un-derwent EGDS. After premedication, immediate 8% sevoflurane and 60/40% N2O/O2 induction was delivered. Concentration of sevoflurane was reduced to 1% for maintaining general anesthesia. Heart rate (HR), systemic blood pressure (SBP), respiratory rate (RR), EtCO2 and SpO2 were not invasively monitored. Time for induction, time for emergence as well as complications, if any, were also evaluated.

RESULTS

The monitored parameters did not show any significant changes. The time for loss of eyelash reflex and the time for end of induction were of 121+/-15 sec. 3.5+/-1.3 min respectively. The time for emergence was 3.4+/-1.8 min. Only minor complications were reported.

CONCLUSIONS

The results obtained show that the use of LMA associated to sevoflurane as single inhaling agent can be a valid technique for EGDS in pediatric patients.

A novel syndrome with dwarfism, poorly muscled build, absent clavicles, humeroradial fusion, slender bones, oligodactyly and micrognathia

We report on a 15-year-old girl with severe pre- and post-natal growth retardation, poorly muscled build, micrognathia, ulnar ray oligodactyly, absent clavicles, abnormal scapulae, humeroradial fusion, hip dislocation, small iliac wings, slender tubular bones and normal intelligence. An extensive search has failed to ascribe this association to a known condition. This child shared some clinical and radiological features with the Yunis-Varon syndrome but the normal intelligence and the ulnar ray oligodactyly of our patient does not support this diagnosis.

Hormonal factors influencing weight and growth pattern in craniopharyngioma

Patients operated on for craniopharyngioma frequently suffer from hyperphagia and are obese, but their statural growth is normal despite growth hormone (GH) deficiency. We have evaluated the hormonal factors influencing changes in weight and growth in 17 children before and 1, 3-6, 12, and/or 24 months after surgical resection of a craniopharyngioma performed at 7.7 +/- (SE) 1 years of age. Of these, 15 patients had a GH deficiency before surgery, and all had complete pituitary deficiency after it. The plasma fasting insulin concentrations before surgery were positively correlated with body mass index (BMI, kg/m(2); p < 0.05), plasma insulin-like growth factors (IGFI, p = 0.03, and IGFII, p = 0.04), and leptin (p = 0.03). They increased significantly 1 month after surgery and continued to increase thereafter, whereas leptin increased significantly only 3-6 months after surgery, paralleling changes in BMI. The plasma fasting insulin concentrations before surgery were also positively correlated with the weight changes (12.3 +/- 2.3 kg, p < 0.01) during the 12 months after surgery, but not with changes in BMI SDS (3.1 +/- 0.5, p = 0.07). Both expressions of weight change were correlated with the concomitant growth rates (4.8 +/- 0.7 cm, p < 0.01). IGFI was above the 10th percentile for children with idiopathic short stature in 10 of 15 patients with craniopharyngioma-induced GH deficiency and IGF-binding protein 3 in 14 of 15 patients. Craniopharyngioma itself modified the control of insulin secretion, and surgery increased the insulin secretion which continued in the same way in a given patient after surgery. The increased insulin secretion in turn increases weight and keeps IGFI nearly normal. This may explain the normal growth rate despite the complete lack of GH.

Congenital cytomegalovirus infection in preterm and full-term newborn infants from a population with a high seroprevalence rate

BACKGROUND

Cytomegalovirus (CMV) is the most frequent cause of congenital infections in humans. Prematurity occurs in as many as 34% of infants with symptomatic congenital CMV infection.

OBJECTIVE

To determine the clinical presentation and frequency of congenital CMV infection among preterm infants and full-term infants from a population with a high seroprevalence rate.

DESIGN/METHODS

A total of 289 preterm infants (median gestational age, 34 weeks; median birth weight, 1,757 g) and 163 term infants (median gestational age, 39 weeks; median birth weight, 3,150 g) sequentially born were included in the study. Serum IgG antibodies to CMV were measured in all mothers. One urine sample was collected within the first 7 days of age from all newborns. Virus isolation in urine samples was performed by tissue culture, and viral DNA was detected by a multiplex PCR. CMV infection was diagnosed in infants with virus excretion detected by both methods on at least two occasions within the first 3 weeks of life.

RESULTS

Maternal CMV seropositivity rate was 95.7%. Congenital CMV infection was detected in 6 of 289 (2.1%) (95% confidence interval, 0.84 to 4.68) preterm infants and in 3 of 163 term infants (1.8%) (95% confidence interval, 0.48 to 5.74) (P > 0.05). Four of 6 preterm infants with congenital CMV infection were symptomatic, but none of the term infants was symptomatic (P = 0.16).

CONCLUSION

The frequency of congenital CMV infection in preterm newborn infants from mothers with a high seropositive rate was similar to that found in term infants. No significant difference was found between the proportion of symptomatic infants among preterm and term infants. Our finding of symptomatic congenital CMV infection underscores the need of further evaluation of correlates of congenital symptomatic infection in highly immune populations.

Synthesis and antialgal activity of dihydrophenanthrenes and phenanthrenes II: mimics of naturally occurring compounds in Juncus effusus

9,10-Dihydrophenanthrenes and phenanthrenes, mimics of natural compounds with strong antialgal activity, have been synthesized through cross-coupling by zerovalent Ni of 1-(2-iodo-5-methoxy)-phenylethanol or 2-iodo-5-methoxyacetophenone with iodoxylenes. The synthetic compounds had a hydroxyl or a methoxyl group at C-2 and two methyls in the C ring. Assays on the green alga Selenastrum capricornutum showed that all the compounds, except 2-methoxy-5,7-dimethylphenanthrene, caused strong inhibition of algal growth at 10(-4) M. 2-Hydroxy-7,8-dimethyl-9,10-dihydrophenanthrene and 2-methoxy-5,6-dimethylphenanthrene fully inhibited growth at 10(-5) M.

Pituitary apoplexy in an adolescent with prolactin-secreting adenoma

A 14.8-year-old girl was treated with bromocriptine for a prolactin-secreting adenoma. She suddenly developed headaches, vomiting, fever and meningeal syndrome. This was associated with corticotropin, thyrotropin and gonadotropin deficiencies. Magnetic resonance imaging showed peripheral enhancement and a central hyposignal suggesting intra-adenoma hemorrhage and then disappearance of the adenoma. Hydrocortisone was initiated in emergency to prevent any risk to life.

The use of insulin-like growth factor 1 reference values for the diagnosis of growth hormone deficiency in prepubertal children

OBJECTIVE

This study was done to determine whether the use of reference values obtained in children with idiopathic short stature (ISS) improved the clinical value of serum insulin-like growth factor I (IGF-1) as a tool for diagnosing GH deficiency (GHD) in prepubertal children.

PATIENTS AND METHODS

Serum IGF-1 was measured with a new IRMA kit (IGFI-RIA CT, Cis Bio, Gif sur Yvette, France) in 168 prepubertal normal children and in prepubertal children with ISS (n = 68), organic GHD due to a craniopharyngioma (oGHD, n = 15) and permanent idiopathic GHD (iGHD, n = 28).

RESULTS

IGF-1 was lower (P < 0.001) in iGHD than in either ISS or oGHD and was below the fifth percentile of the normal range in 29/68 ISS (43%), 8/15 oGHD (53%) and 28/28 (100%) iGHD patients. Three oGHD (20%) and two iGHD (7%) patients had a serum IGF-1 below the fifth percentile of the normal group but above the fifth percentile of the ISS group. Thus, a serum IGF-1 below the fifth percentile of the normal group distinguished between normal children and iGHD with 100% sensitivity, between normal and oGHD with 53% sensitivity and between normal and all GHD (idiopathic + organic) with 84% sensitivity; the overall specificity was only 57%. Conversely, a serum IGF-1 below the fifth percentile of the ISS population distinguished between ISS and iGHD with 93% sensitivity, between ISS and oGHD with 33% sensitivity and between ISS and all GHD with 72% sensitivity; the overall specificity was then 95%.

CONCLUSIONS

A serum IGF-1 within the normal range virtually excludes idiopathic GHD but does not rule out organic GHD, whereas an IGF-1 below the ISS range is strongly in favour of GHD, after exclusion of poor nutritional status and/or liver disease. An IGF-1 below the normal range but in the idiopathic short stature range gives no definitive conclusion even when it is associated with a low GH peak. Thus, whereas reference values obtained in normal children must be used to interpret serum IGF-1 in short prepubertal children, reference data obtained in idiopathic short stature children should also be taken into account.

[The use of alfentanil for short duration surgery in pediatric anesthesia]

BACKGROUND

In the present paper, the effectiveness of the alfentanyl-propofol combination versus fentanyl-propofol association in pediatric anesthesia during short surgical procedures was investigated.

METHODS

EXPERIMENTAL DESIGN

randomized study.

SETTING

This study was carried out at the Surgical-Division of the Pediatric Clinic of the University "La Sapienza", Rome.

PATIENT

100 children (age 4.95 +/- 0.26 yr, body weight 21.13 +/- 0.86 kg) undergone to short anesthesia (50 +/- 0.01 min), were examined. PATIENTs were divided randomly into two groups, A and B, each composed of 50 children. PATIENTs in group A received an alfentanyl bolus dose of 50 micrograms.kg-1 and a continuous infusion of 0.50 microgram.kg-1.min-1, whereas patients in group B received a fentanyl bolus dose of 5 micrograms.kg-1 and a continuous infusion of 0.16 microgram.kg-1.min-1. In all patients, propofol was given in the same dose (bolus dose 1 mg.kg-1; continuous infusion 0.1 mg.kg-1.min-1) in association with opioid analgesic.

MEASUREMENTS

non-invasive arterial pressure, EKG, heart rate, rectal temperature, oxygen saturation, capnography; during the postoperative course, we evaluated the motor activity response, the degree of weakfulness and consciousness.

RESULTS

No significant differences between two groups in the systolic, diastolic and mean arterial pressure were pointed out whereas a decrease in heart rate in the group B and a better and more rapid restoration of breathing in group A was observed. Children of group A, after awakening, were more quiet and answered more readily to simple orders (64%). In group B 50% of children showed psychomotor unrest and 10% of them cried. The group that received alfentanyl answered more readily than group B (42% versus 26%).

CONCLUSIONS

The present study shows that alfentanyl allows a better control of the surgical analgesia and it assures a good analgesic cover for all short surgical procedures without risk of early respiratory depression in postoperative period. Furthermore alfentanyl assures an early postoperative recovery due to the minimal pool, minimal undesired effects, and a cardiocirculatory stability.

[Laryngeal mask as alternative to facial mask in the newborn]

OBJECTIVE

The present study demonstrates that the use of laryngeal mask airway (LMA) is an alternative to face-mask (FM) during induction of general anesthesia with halothane. In all patient the induction of general anesthesia is carried out by halotane and N2O/O2 50%, using only the LMA, preceding topical anesthesia of pharynx.

METHODS

EXPERIMENTAL DESIGN

prospective study.

SETTING

this study was carried out at the surgical-division of the Pediatric Clinic, of University "La Sapienza", Rome.

PATIENTS

a total of 80 newborns, average age 14.8 +/- 2.4 days and average body weight 2280 +/- 110 g were examined.

INTERVENTIONS

newborns were submitted to surgery for congenital malformations, diagnostic research and positioning of a central venous catheter (CVC).

MEASUREMENTS

Heart rate, non-invasive arterial pressure through cardiomonitor Hewlett Packard 78352A, oxygen saturation through Nellcor N3000, time of induction of general anesthesia and respiratory rate were assessed.

RESULTS

Blood pressure and heart rate were increased during the positioning of LMA; oxygen saturation remained > or = 94% and respiratory rate was constant during the whole observation. Muscular relaxing, as an index of anesthesia, was observed after 33 +/- 1.5 sec after positioning of LMA.

CONCLUSIONS

In the light of the results obtained, the use of the LMA for airway ventilation during the induction period of pediatric anesthesia is suggested.

Idiopathic growth hormone deficiency: presentation, diagnostic and treatment during childhood

The clinical and biological presentation of idiopathic growth hormone (GH) deficiency (GHD) varies greatly, demonstrating the variety of its pathogenic features and explaining why it is difficult to diagnose. We examined 48 patients (26 males) with certain idiopathic GHD diagnosed at 4.8 +/- 0.7 yr. The symptoms that led to the diagnosis of GHD were low growth rate (33 cases), hypoglycemia (12 cases), microphallus (1 case) and in 2 cases the GHD was diagnosed from magnetic resonance imaging (MRI) performed for delayed mental development (1 case), or congenital blindness (1 case). The 2 other cases were diagnosed from routine GH evaluation performed at birth because of idiopathic GHD in siblings. Thirteen had congenital malformation. Twenty three cases (48%) had features suggesting that the GHD was of antenatal origin. Six of them were born by breech delivery. Twenty one cases (44%) had features suggesting a hypothalamic origin. The decrease in growth rate occurred before 0.5 year in 21 (55%), before 1 year in 27 (71%) and before 2 years in 30 (79%): 8 patients (21%) maintained a normal growth rate after this age. Among these 8 patients, 5 had signs suggesting an antenatal origin and 4 had severe episodes of hypoglycemia from birth. The mean GH peak after the pharmacological stimulation test was 3.6 +/- 0.5 micrograms/l. The mean plasma insulin-like growth factor 1 (IGFI) was 0.1 +/- 0.02 U/ml. The GH deficiency was associated with deficiencies of thyrotropin in 26 (54%) and of adrenocorticotrophic hormone in 17 (35%) patients. Among the 15 patients of pubertal age, 9 (60%) had gonadotrophin deficiency. No patient had diabetes insipidus. The MRI showed pituitary stalk interruption syndrome in 39 patients and normal pituitary anatomy in 6 patients. GH treatment reduced the difference between target and actual heights from 3.5 SD (before) to I SD (after 3 years) in the 39 more recently seen patients given 0.5-0.6 U/kg/w GH in 6 or 7 weekly injections. Height gain during the first year and cumulative height gain over 3 years (SD) was correlated negatively with height (SD) at the start of treatment (p < 0.01). We conclude that most of the patients with GHD have features suggesting an antenatal origin. Despite this early origin, the decreased growth rate may occur after 2 years.

[Use of the laryngeal mask for airway control in difficult intubations in children]

LMA was introduced in clinical practice by Arthur Brain in 1983 as a valuable substitute of tracheal tube in adult who underwent general anaesthesia; since then its applications have been extensively studied. LMA is a relatively new non-invasive ventilatory device which has allowed a radical change in the management of modern general anaesthesia. In this study, the application of LMA is assessed during induction and maintenance of general anaesthesia in children affected by severe facial deformities that could render the placement of the tracheal tube difficult. Three patients were affected by complex malformative syndromes involving the maxillo-facial skeleton and one patient presented a massive teratoma, originating from the orbit. In all these cases, LMA provided a patient airway and a satisfactory ventilation during both induction and the repeated attempts of inserting the tracheal tube; in one case, since the orotracheal intubation failed, LMA has proved to be as effective as the tracheal tube during the maintenance of general anaesthesia. Therefore, LMA is recommended as an essential ventilatory device in the hands of paediatric anaesthesiologists.

Helicobacter pylori and plasma ammonia levels in cirrhotics: role of urease inhibition by acetohydroxamic acid

BACKGROUND AND AIMS

The role of Helicobacter pylori as a cause of hyperammonaemia in cirrhotics has still not been fully clarified. This study was aimed at evaluating the effect of acute Helicobacter pylori urease inhibition by oral acetohydroxamic acid administration on blood ammonia levels in cirrhotic patients.

METHODS

Twenty-nine cirrhotics (14 males, 15 females; mean age: 63 years; Child-Pugh class: 14 A, 9 B, and 6 C) undergoing upper gastrointestinal endoscopy were enrolled in the study. The presence of Helicobacter pylori infection was assessed by rapid urease test and histology. A semi-quantitative grading of bacterial density was also performed at histology. All patients received oral acetohydroxamic acid 750 mg, and blood samples for assessment of ammonia levels were taken before and at 15, 30, 60 and 90 minutes after administration.

RESULTS

Helicobacter pylori infection was detected in 20 patients, while 9 patients were uninfected. Acetohydroxamic acid administration led to a significant reduction in blood ammonia levels at 15 and 30 minutes (mean +/- SD, 113 +/- 44 vs 101 +/- 43 and 93 +/- 38 micrograms/dl, respectively; p = 0.002) only in patients with Helicobacter pylori infection. Moreover, the reduction was statistically significant only in Child-Pugh B/C class patients and in those with moderate/marked Helicobacter pylori density in gastric mucosa. Basal ammonia levels did not differ between Helicobacter pylori positive and negative patients, nor in patients with mild and moderate/marked Helicobacter pylori density in gastric mucosa, while Child-Pugh class B/C cirrhotics had higher basal ammonia levels than class A cirrhotics, in both Helicobacter pylori positive and negative groups.

CONCLUSIONS

Our data showed that Helicobacter pylori urease inhibition by acetohydroxamic acid administration significantly reduces blood ammonia levels in patients with more advanced liver cirrhosis and in those with a high bacterial density in gastric mucosa.

Pituitary stalk interruption syndrome: a clinical-biological-genetic assessment of its pathogenesis

The detection of pituitary stalk interruption syndrome (PSIS) by magnetic resonance imaging is a diagnostic marker of permanent GH deficiency (GHD), but the pathogenesis of PSIS is unknown. Fifty-one patients (27 males) with GHD and PSIS were classified according to whether the GHD was isolated (group 1, 16 cases) or associated with other anterior pituitary abnormalities (group 2, 35 cases). The 2 groups had similar characteristics (frequencies of perinatal abnormalities, ages at occurrence of first signs and at diagnosis, height, GH peak response to stimuli other than GHRH), but associated malformations were less frequent in group 1 (12%) than in group 2 (54%; P < 0.01), hypoglycemia occurred in 25% of group 1 and 70% of group 2 (P < 0.01), and the GH peak response to GHRH was less than 10 micrograms/L in 0% of group 1 (4 cases evaluated) and 57% of group 2 (21 cases; P < 0.05). Thirty-one cases (61%; 25 from group 2) had features suggesting an antenatal origin: familial form (4 cases), microphallus (10 boys), and/or associated malformations (50%; 21 cases). Twenty-seven cases (53%, 22 from group 2) had features suggesting a hypothalamic origin. The three group 1 patients with a GH peak of 1 microgram/L or less had no large GH-N gene deletion. One familial form had no linkage between the GHD phenotype and abnormal GH-N locus, and the only mutation described to date in the GHRH receptor gene was absent. The two patients with low plasma PRL levels had no Pit-1 gene abnormality. Thus, most of the patients with GHD associated with multiple anterior pituitary abnormalities and PSIS have features suggesting an antenatal origin. The GH-N, GHRH receptor, and Pit-1 genes do not seem to be implicated in PSIS.

Gallstones and diabetes: a case-control study in a free-living population sample

Data on the association between cholelithiasis and diabetes often are controversial and are mostly based on autopsies or on hospital series. Therefore, we designed a case-control study to determine the prevalence of diabetes mellitus in a group of subjects with gallstones or having undergone cholecystectomy (cases) and compared these with a control group of subjects without gallstones, selected during an epidemiological study performed on a free-living population sample. The subjects were matched for sex, age, and body mass index. We enlisted 336 cases and 336 controls, aged 30 to 69 years. All subjects with fasting glycemic levels of < 140 mg/dL and without a documented history of diabetes were submitted to a simplified oral glucose tolerance test (OGTT). All subjects who underwent OGTT were classified according to the National Diabetes Data Group (NDDG) criteria. The prevalence of diabetes in the subjects affected by gallstone disease was significantly higher than that in controls (11.6% vs. 4.8%; odds ratio [OR], 2.55; 95% confidence interval [CI], 1.39-4.67). Diabetes was more frequent in subjects with gallstone disease than in the control group, even according to sex (18.3% vs. 9.9% for men: OR, 2.03; 95% CI, 0.99-4.2; 9.3% vs. 2.6% for women: OR, 3.85; 95% CI, 1.4-10.6). We conclude that an altered glucose metabolism may increase the risk of developing cholelithiasis in certain subjects.

Anaesthesia for caesarean section in a Marfan patient with recurrent aortic dissection

PURPOSE

We report the anaesthetic management of a 34-yr-old pregnant woman with recurrent aortic dissection and Marfan syndrome for Caesarean section.

CLINICAL FEATURES

She presented at 28 wk gestation with recurrent aortic dissection and had undergone aortic valve replacement and coronary ostia reimplantation (Bentall procedure) in the first trimester of pregnancy. She was treated in hospital with labetalol, anticoagulants and steroids and daily echocardiographic examination until 34 wk when caesarean section was planned. After positioning radial artery and CVP catheters and a transoesophageal echocardiographic probe, general anaesthesia was induced with thiopentone and maintained with isoflurane, and endotracheal intubation was facilitated with vecuronium. The site of incision was infiltrated with lidocaine before surgery which was uneventful. The patient was discharged at 10 days.

CONCLUSIONS

With appropriate preoperative care and monitoring, uneventful general anaesthesia for caesarean section was achieved in a patient with Marfan syndrome in the presence of recurrent aortic dissection.

[Non-operable malignant neoplasm of the esophagus. A case of necessary palliative oncologic surgery]

The authors examine the clinical evolution of a patient with an oesophageal neoplasm with intraperitoneal liver metastases unnoticed in preoperative phase. Some months after the explorative operation, the patient first underwent a thoracotomy + a cervicostomy with monopolar exclusion of oesophagus because of a mediastinitis caused by a iatrogenic perforation during the attempt to place an oesophageal endoprosthesis; then he underwent a recanalization by presternal subcutaneous oesophago-colonplasty, stimulated by the good result of the surgical operation and by the patient's excellent clinical conditions after the mediastinitis event.

[Plasma levels of beta-endorphins and ACTH in labor with continuous peridural analgesia]

In order to investigate whether continuous lumbar epidural analgesia is associated with alterations of plasma levels of beta-endorphins and ACTH, we have studied a group (A) of patients under epidural analgesia and a matched group of control (B) at different stages of labour. Plasma levels of beta-endorphins and ACTH in group A did not significantly change during the labour, while in group B beta-endorphins and ACTH increased in the second stage of labour and decreased thereafter one hour after delivery. The levels of beta-endorphins and ACTH in umbilical cord mix blood were elevated in both groups.

[Medium- and long-term use of central venous catheters in pediatrics. Personal experience]

From January 1992 to October 1994, 74 central venous catheters were inserted, in the University Hospital of Rome: Polyclinic Umberto I - "La Sapienza", in 62 paediatric patients (15.17 +/- 1.64 years old), admitted to the paediatric surgery division. The authors used a large amount of CVC: totally implanted devices (34 Groshong, 7 Broviac, 2 Hickman, 3 Port) and percutaneous catheters (28 Arrow). The choice of the infusional devices has been influenced by the length of the treatment, the primitive disease, the age and the size of the patient. The authors used totally implanted devices in paediatric patients undergoing chemotherapeutic and nutritional therapies. External central venous access devices were used in patients undergoing central catheterization lasting less than two months. The subclavian vein has been used as venous access in patients weighing > 5 kg, the internal jugular vein in < 5, kg patients. This work reports the early (PNX, hematomas, arterial access) and the long term complications (infections, accidental unthreading, occlusions and dislocations). We can say that the medium and long last term CVC is well tolerated and accepted in paediatric patients too, for antineoplastic, nutritional and infusion therapies.