[Jugular megabulb as a cause of pulsatile tinnitus]

INTRODUCTION

Pulsatile tinnitus (AP), possibly of vascular origin, may be a sign of various vascular and non-vascular pathological processes. Arteriovenous fistulas and malformations are, perhaps, the commonest cause of AP.

CLINICAL CASE

A 64 year-old woman presented with AP of the right ear for the past 14 years. It was continuous all day and could be observed externally by the examiner. The intensity of the tinnitus diminished on right later-cervical compression and on turning her head to the left. There was bilateral transmission deafness. Neurological examination was normal. Complementary explorations (MR, CT of the base of the skull and cerebral arteriography) showed the presence of a jugular megabulb of the right side.

CONCLUSIONS

The presence of AP may be for many years the only sign of subjacent vascular pathology, such as a megabulb of the jugular vein.

Slow cluster formation of purified human or rhesus T cells requires protein kinase C and LFA-1

Homotropic T cell adhesion, as generally studied, consists of a rapid, transient binding process that is measured over a 15-120 min. period. Here we report a slow type of adhesion process occurring with human or rhesus T cells, purified from peripheral blood, that manifests itself by the formation of rounded, multi-layer clusters which may contain hundreds of cells. The maximal number and size of the clusters peak 1-2 days after the addition of phorbol ester, an absolute requirement. The number of clusters formed is proportional to phorbol ester concentration up to 1.25 ng/mL. Phorbol esters such as phorbol myristate acetate (PMA), phorbol dibutyrate (PDB), and 7-octylindolactam (OIL) induced optimal cluster formation at 1-13 ng/mL, levels slightly higher than that required to induce mitogenesis of purified T cells. Phorbol itself and the alpha-form of the ester were inactive. Both cluster formation and mitogenesis (stimulated by Con A or anti-CD3) are completely inhibited by staurosporin at 12.5 ng/mL. Even at 2.5 ng/mL, 74% of cluster formation was inhibited, which strongly implies a crucial role for protein kinase C. In the presence of accessory cells, T cell clusters were suppressed. Monoclonal Ab such as anti-CD3, mouse anti-CD3 followed by anti-mouse IgG, anti-CD4, anti-CD4A, anti-CD2, anti-CD8, and anti-CD45 did not induce cluster formation. None were inhibitory or stimulatory in the presence of PMA, except for anti-CD3 which enhanced cluster formation by 26%. However, anti-LFA-1 beta-chain (mouse monoclonal) completely blocked cluster formation over the range studied (63-1000 ng/mL) for both human and rhesus cells; rat anti-LFA-1 only blocked human cell adhesion. Anti LFA-1 only partially inhibited T cell mitogenesis. These results show that slow cluster formation shares the LFA-1 and phorbol ester requirements of the rapid adhesion of T cells requiring LFA-1 and ICAM-1. However, cluster occurs at a very low phorbol ester concentration, appears more sensitive to staurosporin inhibition, and is not stimulated via the TCR receptor like the rapid adhesion process. We hypothesize that certain neuronal processes, induced by phorbol ester, and which also show a similar protein kinase C activation time course, may share mechanisms in common with cluster formation.

[Diarrhea and AIDS: more complex diagnostic techniques; better therapeutic results]

During 17 months, 73 HIV-positive patients with diarrhea lasting at least for 14 days, were studied prospectively. The patients had stool specimen examinations negative for enteric pathogens, or positive for one of them, but with no response to specific treatment. All patients were subcomitted to digestive endoscopy and biopsies were taken for microbiological and histological studies. The etiology of the diarrhea could be established in 48 patients (66%). In 45, the cause was an enteric infection. There was association of 2 pathogens in 11 patients, and of 3 in 1 patient. The agents found were: Cryptosporidium (24%), MAI (16%), Giardia lambila (12%), isospora belli (5%), Shigella (5%), Salmonella (5%); Entamoeba histolytica (3%), HSV (3%), tuberculosis (2%), adherent bacteria (2%) and spirochetes (2%). In 3 patients the etiology was not infection, their diagnoses were coeliac disease, lymphoma and idiophatic colonic ulcers, respectively. In 51% of the cases only the examination of endoscopic biopsy specimens could identify the cause of the diarrhea. These results justify the use of these methods to improve diagnosis and therapeutic attempts in these patients.

[Somatosensory focal seizures as an onset form in adult Moyamoya syndrome]

Moya-Moya disease is a chronic infrequent vasculopathy. Occasionally such abnormalities are found in association with one of many conditions, in these cases the angiographic abnormality should be termed Moya-Moya syndrome rather than Moya-Moya disease. Although in children the usual manifestations are ischemic events and seizures. This clinical presentation is infrequent in adults. We present a 42-years-old man with a 1-month history of recurrent right sided partial somatosensorial seizures, later he presented a left parietal infarction, the angiographic findings were compatible with moyamoya syndrome.

Trace determination of herbicides in estuarine waters by liquid chromatography-high-flow pneumatically assisted electrospray mass spectrometry

High-flow pneumatically assisted electrospray (ESP) was applied to the characterization of triazine (atrazine, simazine, ametryne, cyanazine, deethylatrazine and deisopropylatrazine), phenylurea (chlortoluron++, isoproturon, diuron, linuron and diflubenzuron) and other priority herbicides (alachlor, metolachlor). In LC-ESP-MS the [M+Na]+ ion was used as the base peak in most cases, with the exception of chlorotriazines, which showed [M+H]+ as the base peak. When LC-TSP-MS was used, [M+H]+ was the base peak for many of the pesticides, with the exception of linuron and diflubenzuron, which showed [M+NH4]+ as the base peak. The ESP results were compared with those obtained with thermospray (TSP). LC-TSP-MS offered greater sensitivity for triazines than phenylurea herbicides, whereas the use of LC-ESP-MS offered an enhancement in sensitivity for phenylurea herbicides. As regards the fragmentation obtained using both techniques, ESP offered a considerable amount of structural information for the different chlorotriazines studied when the extraction voltage was increased from 20 to 40 V. Liquid-liquid extraction with dichloromethane was used for the trace enrichment of the different herbicides in estaurine water samples from the Elorn river (France). The presence of the different triazine metabolites, atrazine, simazine, metolachlor, isoproturon and diuron was confirmed by both LC-MS techniques.

Prognostic implications of clinical, electrocardiographic and hemodynamic findings in chronic Chagas' disease

To evaluate the prognostic importance of 19 clinical, electrocardiographic and hemodynamic variables, 556 chronic chagasic patients were submitted to an extensive protocol, including left cineventriculogram and Holter monitoring, and followed for up to 15 years. The protagonist role of the magnitude of the myocardial compromise in the evolution of chagasic patients is underscored by our results, which indicated the independent prognostic value of an ejection fraction below 0.30 (P < 0.001), a heart rate higher than 89 beats/min (P < 0.01), grade IV functional capacity (P < 0.05), end systolic stress > 120 g/cm2 (P < 0.05), and end diastolic volume index > 200 ml/m2 (P < 0.05). When only patients with an ejection fraction over 0.29 were considered, variables with independent prognostic value were: the cardio-thoracic ratio (P < 0.01), functional capacity (P < 0.05) and heart rate (P < 0.05). Survival analysis demonstrated that the presence of complex (Lown III, IV) ventricular arrhythmias increased mortality significantly (P < 0.01) only in patients with an ejection fraction over 0.29. Therefore, preservation of myocardial function is the capital measure in the treatment of chronic chagasic patients.

[Air quality of premises and public health]

Indoor air quality is gaining increasing prominence as a public health problem in developed and developing countries. Its pollution brings about diseases (infectious, allergic, toxic, carcinogenic) or benign symptoms (without clear definition) grouped in the so-called Sick Building Syndrome. On the basis of 2 large surveys in air conditioned buildings the authors describe the main factors of this syndrome which is prominently observed in women and is multifactorial. The improvement of indoor air quality needs interaction among the diverse disciplines: architects, engineers, biologists and clinically oriented physicians.

[The anti-arrhythmia effect of carbamazepine in chagasic patients with advanced myocardial damage]

Oral administration of 600 mg/day of carbamazepine to 14 arrhythmic chagasic patients with advanced myocardial damage and no signs of congestive heart failure did not alter the frequency of ventricular extrasystoles, but reduced the total number of supraventricular ectopic beats in 7/14 patients and the episodes of complex ventricular arrhythmias in up to 43% of patients. This assessment was made from 24 hour continuous Holter recording during the course of this double-blind, placebo controlled, randomized crossover study. Serum levels of carbamazepine were also determined and found within therapeutic limits. Six patients complained of minor side effects. One patient presented with iatrogenic complete AV block, another case had proarrhythmic effect and one patient had to be withdrawn from the study because of gastric irritation. No instance of contractile depression was observed. Accordingly, carbamazepine is a therapeutic alternative for treatment of symptomatic complex ventricular or supraventricular arrhythmias in chronic chagasic patients without evidence of conduction system involvement or with intolerance to other antiarrhythmic drugs.

Anti-CD2-induced tyrosine phosphorylation of T cell polypeptides is independent of the PMA-induced modification of p56lck

The molecular basis for T cell activation involves the phosphorylation of of polypeptides at both serines and tyrosines. We find that with human peripheral T cells the serine phosphorylation of p56lck is independent of the more rapid tyrosine phosphorylation of other polypeptides via stimulation of the CD2 receptor with anti-CD2 (anti-T11(2) and anti-T11(3) mAb's). Triton X-100 soluble polypeptides were analyzed by Western blotting with the subsequent immunodetection by anti-phosphotyrosine or anti-lck antibodies. While polypeptides from resting T cells showed very low levels of endogenous tyrosine phosphorylation, incubation with anti-CD2 for periods as short as 30 sec resulted in the tyrosine phosphorylation of a 75-kDa polypeptide (p75). Polypeptide bands were also observed at 27 and 54 kDa, but these were artifacts from the reaction of anti-CD2 with the horse anti-mouse secondary antibody used in our detection system. Preincubation of T cells with phenylarsine oxide amplified the anti-CD2-induced tyrosine phosphorylation of the p75 and revealed additional phosphotyrosine polypeptides of 120, 100, and 33 kDa. The mitogenic combination of phorbol 12-myristate 13-acetate (PMA) with anti-CD2 changed neither the intensity nor the pattern of the tyrosine phosphorylation observed with anti-CD2 alone. The tyrosine phosphorylation of the p75 was not induced by concanavalin A (Con A) or PMA. While PMA alone failed to stimulate tyrosine phosphorylation above resting levels, PMA induced the nearly complete conversion of p56lck into p60lck (the lck-shift) at 30 min; no lck-shift was observed at 30 and 90 sec. Neither anti-CD2 nor Con A induced the lck-shift. Whereas PMA with either anti-CD2 or Con A was required for mitogenesis, only anti-CD2 led to tyrosine phosphorylation, and only PMA induced the lck-shift.

N-acetylcysteine enhances T cell functions and T cell growth in culture

N-Acetylcysteine (NAC) is highly nontoxic for peripheral blood T cells and immunostimulatory enhancing T cell functions such as mitogenesis, interleukin-2 (IL-2) production, and growth in culture. NAC has been proposed for the treatment of AIDS based on its inhibition of human immunodeficiency virus (HIV) replication in cultured cells. Therefore its effect on normal T cells from 10 young donors and one elderly donor has been investigated as a prelude to clinical consideration. T cell function was evaluated in the presence and absence of accessory cells. With concanavalin A and anti-CD3 activation, NAC enhanced mitogenesis by approximately 2- to 2.5-fold at 5-10 mM. Mitogenesis of purified T cells with anti-CD2 was not affected by NAC; in the presence of accessory cells, NAC enhanced mitogenesis by approximately 2-fold at 1-10 mM. Importantly, NAC levels above 10 mM completely inhibited activation of peripheral blood mononuclear cells by anti-CD2. IL-2 secreted by T cells was also enhanced by NAC, approximately 1.5-fold, but IL-2 secreted by cells from old donors was enhanced by 3-fold. In cultures of peripheral blood T cells, NAC (10 mM) stimulated growth by at least 4- to 6-fold after two passages. These results show that NAC, nontoxic even at 20 mM, is an effective enhancer of T cell function and a remarkable enhancer of growth. Results from other laboratories show that NAC, which increases glutathione levels, suppresses HIV replication presumably via suppression of the activation of transcriptional factor NF-kappa B.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in the plasma concentrations of lipids and lipoprotein fractions in dogs infected with Leishmania infantum

A study was made of serum concentrations of cholesterol, phospholipids, triglycerides, cholesterol bound to high-density lipoproteins (HDL), HDL1-cholesterol, HDL2-cholesterol and cholesterol bound to low-density lipoproteins (LDL) in 16 dogs naturally infected with Leishmania infantum (ZMON-1) taken from an endemic focus. Results were compared with those of a control group of ten healthy dogs. Statistically significant increases in cholesterol, triglyceride and LDL-cholesterol levels were observed. There was, however, a statistically significant decrease in HDL-cholesterol level, mainly at the expense of the HDL2-cholesterol subfraction. Cholesterol transport is therefore shown to undergo changes which may be attributed to the consumptive evolution of the disease, immunocomplex deposits in cells, hepatic disorders and interactions between the parasite and the normal cholesterol metabolism of the host.

Effects of ursodeoxycholic acid in patients with intrahepatic cholestasis of pregnancy

The efficacy and safety of ursodeoxycholic acid in the treatment of intrahepatic cholestasis of pregnancy was investigated in an open pilot study. Five patients received 1 gm/day of ursodeoxycholic acid during 20 days and another three patients received two identical periods of treatment separated by a 14-day interval free of the drug. Pruritus and serum levels of total bile salts and glutamic-pyruvic transaminase improved significantly during treatment with ursodeoxycholic acid. In the three patients who received two periods of treatment with ursodeoxycholic acid, pruritus and the laboratory alterations relapsed in the second week after the drug was discontinued, but they improved again when ursodeoxycholic acid was readministered. No adverse reactions were detected in the mothers or in their babies. All newborns were thriving normally during a follow-up period that lasted 5 mo after delivery. It is concluded that UDCA appears to be safe when administered in late pregnancy; its promising efficacy in the treatment of intrahepatic cholestasis of pregnancy should now be confirmed in controlled clinical trials.

[Symptomatic effect of epomediol in patients with cholestasis of pregnancy]

Epomediol is a terpenoid that prevents and reverses cholestasis induced by ethinylestradiol in the rat, apparently by improving liver cell membrane fluidity. Assuming that the pathogenesis of intrahepatic cholestasis of pregnancy (ICP) is related with increased estrogen levels, we studied the effects of epomediol in this disease. Patients hospitalized due to ICP received epomediol 900 mg/day (n = 7), or 1,200 mg/day (n = 4) orally, during 15 days. Biochemical parameters of liver dysfunction (serum bilirubin, bile salts, aminotransferase, alkaline phosphatases) were not modified during nor after epomediol administration. The severity of pruritus was significantly reduced in comparison to pretreatment status, with both doses of epomediol. A greater amelioration of pruritus was observed in patients treated with epomediol 1,200 mg/day than in patients who received 900 mg/day (to 20.7 +/- 6.2, as percent of pre-treatment severity score, versus 48.8 +/- 7.5 respectively; p < 0.05). After epomediol administration was stopped, pruritus relapsed in 6 patients; 3 of them had received the higher drug dose. After delivery, pruritus vanished and liver function tests returned to normal, in all patients. No adverse effects attributable to the drug were observed in the mothers or in their babies. The beneficial effect of epomediol on pruritus in patients with ICP appeared greater in this study than that observed recently in similar patients who received a placebo.

[Left ventricular mechanics in Chagas' disease and primary dilated myocardiopathies. A hemodynamic study]

The evolution of several mechanical parameters of left ventricular function was studied in 32 control subjects, 171 chronic chagasic and 60 primary dilated cardiomyopathy patients, which were submitted to an extensive invasive and non-invasive protocol. Preload and afterload (end-diastolic and end-systolic stress), contractile status (ejection fraction), the magnitude (mass/index) and adequacy of hypertrophy (mass/volume ratio) and afterload (systolic stress/volume ratio) were derived from the invasive explorations. There was an increased afterload in 25% of chronic chagasic patients without other evidence of early myocardial damage, which was accompanied by signs of inadequate hypertrophy. Both findings increased further with the progression of the disease. Systolic performance was initially preserved, but showed a progressive depression paralleling the clinical evolution. Patients with dilated cardiomyopathy showed a mechanical profile similar to chagasic patients with advanced degree of myocardial damage. The hemodynamic determination of mass index, mass/volume ratio, end-systolic and end-diastolic stress seem to be the best parameters for detection of early abnormalities in loading conditions of the heart in chronic Chagas, disease, and for indication and evaluation of the results of vasodilator therapy in both groups of patients.

S-adenosyl-L-methionine in the treatment of patients with intrahepatic cholestasis of pregnancy: a randomized, double-blind, placebo-controlled study with negative results

S-Adenosyl-L-methionine has been reported to induce beneficial effects in intrahepatic cholestasis of pregnancy. Because cholestasis of pregnancy has a high prevalence in Chile and a deleterious effect on fetal prognosis, we decided to verify the efficacy of S-adenosyl-L-methionine in this disease. Eighteen patients with pruritus that appeared during pregnancy and with elevated serum levels of bile salts (68.1 +/- 15.9 mumol/L; mean +/- S.E.M.) and ALT (226 +/- 50 KU/L) were enrolled in a prospective double-blind study comparing the effects of the drug with a placebo. S-Adenosyl-L-methionine, 900 mg, or placebo was administered in daily intravenous infusions for 20 days. Every 5 days liver function tests were done and pruritus was assessed using a preestablished score. No significant differences in pruritus or in serum levels of bile salts, ALT, bilirubin and alkaline phosphatases were seen during or after treatment between patients who received S-adenosyl-L-methionine (n = 9) or placebo (n = 9). No relevant adverse reactions were detected. Most patients had cesarean sections because of reasons unrelated to the therapeutic trial. All newborns had Apgar scores greater than 7 and normal postnatal development. Our patients had moderately severe to severe cholestasis of pregnancy as indicated by the onset of pruritus before wk 32 of pregnancy. Seven of nine multiparous patients had a past history of recurrent cholestasis of pregnancy. In this study, the administration of S-adenosyl-L-methionine during 20 days did not improve intrahepatic cholestasis of pregnancy.

[Ventricular mechanics and cardiac arrhythmias in patients with chagasic and primary dilated cardiomyopathy. Echo-electrocardiographic follow-up]

PURPOSE

To determine the prognostic significance of several parameters of left ventricular mechanics and of complex ventricular arrhythmias.

PATIENTS AND METHODS

184 chronic chagasic and 85 primary dilated cardiomyopathy patients were submitted to non-invasive and invasive studies, including Holter monitoring and "M" mode echocardiogram and followed for a maximum of 8 years.

RESULTS

Finding of a depressed left ventricle (LV) systolic function (% AC) was the most important independent prognostic factor in both groups of patients. The presence of complex ventricular arrhythmias had an additional, but very limited, independent prognostic importance, observed only in chagasic patients with depressed LV systolic function. When patients with similar degrees of left ventricular systolic dysfunction, inadequate hypertrophy or increased afterload were compared, chagasic patients had significantly worse prognosis than those with primary dilated cardiomyopathy. This is partly attributed to higher prevalence of complex ventricular arrhythmias.

CONCLUSION

The higher prevalence of complex ventricular arrhythmias in patients with chronic Chagas' disease may explain the prognostic differences between the groups.