Establishment of Diagnostic Reference Levels in Portuguese Interventional Radiology departments

PURPOSE

To establish Portuguese Diagnostic Reference Levels (DRLs), for six body fluoroscopy guided interventional procedures (FGIP).

METHOD

A retrospective study was conducted in five interventional departments most representative of Interventional Radiology (IR) practice. Dose values, in terms of air kerma area product (PKA in Gy.cm2), air kerma at the patient entrance reference point (Ka,r in mGy), and exposure parameters (fluoroscopy time (FT) and number of cine runs) were collected. Examinations were selected per procedure (at least 20), according to the antero-posterior and lateral diameter mean value (±5 cm), measured on previous Computed Tomography (CT) examinations.

RESULTS

Data of 489 body FGIP show a large variation on dose values per procedure and per department. National DRLs in terms of PKA were 20.2 Gy.cm2 for Percutaneous transhepatic biliary drainage (PTBD), 98.2 Gy.cm2 for Bronchial artery embolisation (BAE), 247.7 Gy.cm2 for Transarterial chemoembolisation (TACE), 331.6 Gy.cm2 for Inferior epigastric arteries embolisation (IEAE), 312.0 Gy.cm2 for Transjugular intrahepatic portosystemic shunt (TIPS) and 19.3 Gy.cm2 for Endovascular treatment of femoral popliteal arteries (ETFPA).

CONCLUSIONS

This is the first study reporting Interventional Radiology DRLs in Portugal and we propose preliminary national estimates for the six more common body FGIP. The results of this study will be presented and discussed with all Portuguese IR departments, to promote procedures optimisation.

Radiation protection measures used in Portuguese interventional radiology departments: A national survey

INTRODUCTION

This study aimed to characterise radiation protection (RP) measures used in interventional radiology (IR) departments in Portugal with respect to European and national recommendations.

METHODS

An online national survey was created to characterise the fluoroscopy technology as well as analyse the frequency of body fluoroscopy-guided intervention procedures (FGIP), RP education and training of the staff, and RP measures used daily.

RESULTS

In Portugal, most equipment for FGIP are single-sourced and have a flat panel detector (70%). The most commonly FGIP are percutaneous biliary drainage, percutaneous arterial and venous thrombolysis/thrombectomy, arteriovenous malformations embolization, and percutaneous transluminal balloon angioplasty for arteriovenous fistulas. Only a few staff members had received postgraduate education and training in RP (30%), with most nurses having not received RP education and training (40%). Some of the recommended RP measures lacked harmonisation. Additionally, >50% of the IR departments do not consider examination dose values to identify patients eligible for tissue reactions follow-up.

CONCLUSION

This is the first study to examine the characteristics of IR departments in Portugal. We observed a lack of RP education and training among staff members; further, there was a need to update some RP measures in some IR departments according to the recommendations.

IMPLICATIONS FOR PRACTICE

Our findings will be presented to the participating IR departments in order to update and promote RP best practices. Moreover, our findings will be presented to the national societies of the different professional groups in order to inform strategies for harmonising RP education and training of the staff.

Paediatric head computed tomography dose values and the impact on image quality

Background

The purpose of this study is to analyse paediatric head Computed Tomography (CT) examination dose values, establish local Diagnostic Reference Levels (DRL), and perform objective image quality assessment per categorisation.

Methods

A total of 100 paediatric head CT examinations divided into 5 paediatric age categorisations were retrospectively selected: 0–3months, 3months to 1 year, 1 to 6 years, and more than 6 years. Computed Tomography Dose Index (CTDIvol - mGy) and Dose Lenght Product (DLP – mGy.cm), acquisition mode and CT scanner were collected per examination. Examinations with lower and higher dose values per categorisation were selected, and 10 Regions of Interest (ROI’s) were defined on supra and infra tentorial regions in order to access image quality, based on signal and noise values. Local DRLs were compare with the literature and with previous studies of this centre.

Results

The obtained DLP values were 580, 570, 700, 754 mGy.cm, for the categorisation of 0–3 months, 3 months to 1 year, 1 to 6 years, and more than 6 years, respectively. No significant differences were founded in dose values and image quality, per paediatric categorisation.

Conclusions

Despise previous local DRLs were defined using a different age categorisation, some paediatric aged categorisation revealed an increase of the dose values. These results must be related with the acquisition of a new CT scanner. Optimisation process is on-going and new protocols are being define.

Early onset gastric cancer no longer presents as an advanced disease with ominous prognosis

BACKGROUND

This study aimed to characterize the clinicopathological features and prognosis of early onset gastric carcinomas (EOGCs) in a sample of young Portuguese adults.

MATERIAL AND METHODS

A subset of 415 patients submitted to gastric resection was divided into 2 groups: A--patients aged 45 years or less (n = 108), and B--patients older than 45 years (n = 307). The groups were compared for several clinicopathological features and the survival of the patients was analyzed by uni- and multivariate analysis.

RESULTS

The surgical resection rate was higher in young patients, in whom tumors more frequently displayed an ulcerative shape (p < 0.001) and diffuse/isolated cell-type histology (p < 0.001). In the elderly, the rate of vascular invasion was significantly higher (p = 0.002). Overall, the survival of young patients was higher than in the elderly (p < 0.001). Survival curves were higher in young patients, except for pT4 and pM1 cases. In the multivariate survival analysis, age (p < 0.001), depth of tumor invasion (p < 0.001), nodal status (p < 0.001), vascular invasion (p = 0.011) and distant metastases (p = 0.007) emerged as independent prognostic factors for gastric carcinoma.

CONCLUSION

Young gastric cancer patients no longer present with more advanced disease than the elderly and, overall, survival is better in young patients.

Molecular alterations of KIT and PDGFRA in GISTs: evaluation of a Portuguese series

AIM

To assess KIT and PDGFRA mutations frequencies in a Portuguese series of gastrointestinal stromal tumours (GISTs).

METHODS

78 GISTs were evaluated for CD117 expression and screened for mutations in KIT (exons 9, 11, 13, 14 and 17) and PDGFRA (exons 12, 14 and 18) genes.

RESULTS

KIT activating mutations were identified in 44 (56%) of the 78 GISTs. Forty cases (91%) presented a mutation in KIT exon 11, and 4 (9%) in exon 9. One case showed a 4 bp deletion in intron 14. PDGFRA mutations were observed in 5 cases (6%): 2 (3%) in exon 12 and 3 (4%) in exon 18. Survival analysis was performed in 63 of the 78 GISTs. The presence of mutated KIT was significantly correlated with shorter survival of patients (p = 0.0460), and inversely associated with epithelioid histological type of GISTs (p = 0.0064).

CONCLUSIONS

Overall, the incidence of both KIT and PDGFRA mutations in these Portuguese series was 63%, being in agreement with other studies, mainly of Iberian populations. The great majority of mutations were located in KIT exon 11, statistically associated with worse prognosis and indicative of favourable response to imatinib-based therapy in this Portuguese series of GISTs.

Marginal zone lymphoma of both spleen and kidney displaying transformation into large B-cell lymphoma

We report a case of simultaneous involvement of the spleen and the left kidney in a marginal zone lymphoma with a monotypic lymphoplasmacytic cell component, which transformed into a diffuse large B-cell lymphoma of the immunoblastic type. PCR showed that the small and large B-cell populations carried the same type of immunoglobulin heavy chain gene rearrangement. This type of rearrangement was detected in the spleen, the latero-aortic lymphadenopathy and the kidney demonstrating that it is the same lymphoma that affected both organs and the lymph nodes. Primary renal lymphoma is very rare and only a few cases of renal marginal zone lymphoma, MALT type, have been reported. Involvement of simultaneous multiple sites has been described in MALT type lymphoma, but splenic involvement secondary to renal MALT lymphoma seems to have never been observed. Nevertheless, in our case the huge size of the spleen associated with splenic hilar node involvement is consistent with primary splenic marginal zone lymphoma. The extension into latero-aortic lymph nodes of this lymphoma can explain secondary kidney involvement. The nodal Kaposi's sarcoma observed in this patient of Mediterranean origin was probably coincidental.

The CAG repeat within the androgen receptor gene and its relationship to cryptorchidism

PURPOSE

We examined the significance of the CAG repeat polymorphism in the pathogenesis of cryptorchidism.

MATERIALS AND METHODS

Genomic deoxyribonucleic acid (DNA) was extracted from blood samples from 42 cryptorchid boys and from 31 non-cryptorchid control subjects. In the cryptorchid group, 7 had bilateral cryptorchidism and 6 had patent processus vaginalis in the contralateral side. To determine the number of CAG repeats, the DNA was amplified by polymerase chain reaction and sequenced.

RESULTS

The mean CAG repeat length in the AR gene was 22.5 (range 16 to 28) in patients and 21.5 (range 17 to 26) in controls (non-significant). Patients with bilateral cryptorchidism had a mean length of 24.3 (range 21 to 26) and patients with unilateral cryptorchidism and patent processus vaginalis in the contra lateral side had a mean of 25.2 (range 21 to 28), which was statistically different from controls (p = 0.015 and p = 0.005 respectively).

CONCLUSION

CAG repeat length of the AR gene does not seem to play a major role in patients with unilateral cryptorchidism. However, in patients with bilateral undescended testis, a less functional androgen receptor through a longer polyglutamine chain may have a role in its pathogenesis. In the same way, patients with unilateral cryptorchidism a contralateral patent processus vaginalis have longer CAG repeats that might be responsible for a slower testicular descent and incomplete closure of the processus vaginalis.

Clinicopathological significance and survival influence of p53 protein expression in gastric carcinoma

AIMS

Mutations in the gene coding for p53 protein are among the most frequent genetic alterations observed in human cancers. The relevance and biological significance of p53 expression in gastric carcinoma are far from being fully established. The aim of our study was to evaluate the influence of p53 detected by immunohistochemistry in the clinicopathological behaviour of a series of gastric carcinoma cases.

METHODS AND RESULTS

Samples from 163 patients treated by gastric resection for gastric carcinoma between 1988 and 1995 were used. Surgical specimens were evaluated for the presence of p53 protein detected by immunohistochemistry with a monoclonal antibody. Cases were classified as positive or negative for p53. Several clinicopathological parameters and c-erb B-2 expression were analysed in the same series and compared with the expression of p53. Cumulative survival was evaluated using univariate analysis and Cox model regression. p53 expression was identified in 41 carcinomas (25.2%) and was significantly associated with venous invasion (P = 0.049), lymph node metastases (P = 0.01) and c-erb B-2 expression (P = 0.003). All the parameters except gender, tumour size and Laurén's classification influenced survival on univariate analysis. p53 expression correlated with overall survival (P = 0.006) and survival in the subgroup of patients with intestinal type carcinoma (P = 0.04). In the subgroup of patients with carcinomas not expressing c-erb B-2, p53 expression significantly influenced cumulative survival (P = 0.02).

CONCLUSIONS

p53 expression is associated with the aggressive biological behaviour of gastric carcinomas and is related to cumulative survival.

In vivo expression of the mannose-resistant fimbriae of Photorhabdus temperata K122 during insect infection

Photorhabdus temperata K122 is an entomopathogenic bacterium symbiotically associated with nematodes of the family Heterorhabditidae: Surface fimbriae are important for the colonization of many pathogenic bacteria, and here we report the nucleotide sequence and analysis of the expression of a 12-kbp fragment encoding the mannose-resistant fimbriae of P. temperata (mrf). The mrf gene cluster contains 11 genes with an organization similar to that of the mrp locus from Proteus mirabilis. mrfI (encoding a putative recombinase) and mrfA (encoding pilin), the first gene in an apparent operon of nine other genes, are expressed from divergent promoters. The mrfI-mrfA intergenic region contains inverted repeats flanking the mrfA promoter. This region was shown to be capable of inversion, consistent with an ON/OFF regulation of the operon. In in vitro liquid cultures, both orientations were detected. Nevertheless, when we analyzed the expression of all of the genes in the mrf locus by semiquantitative reverse transcription-PCR during infection of Galleria mellonella (greater wax moth) larvae, expression of mrfA was not detected until 25 h postinfection, preceding the death of the larvae at 32 h. In contrast, mrfJ (a putative inhibitor of flagellar synthesis) was expressed throughout infection. Expression of mrfI was also detected only late in infection (25 to 30 h), indicating a possible increase in inversion frequency at this stage. In both in vitro liquid cultures and in vivo larval infections, the distal genes of the operon were expressed at substantially lower levels than mrfA. These results indicate the complex regulation of the mrf cluster during infection.

MUC5B expression in gastric carcinoma: relationship with clinico-pathological parameters and with expression of mucins MUC1, MUC2, MUC5AC and MUC6

Previous studies have shown that mucin expression can be used to evaluate differentiation patterns of gastric carcinoma: MUC5AC expression is associated with diffuse type and early gastric carcinomas, and MUC2 expression is associated with mucinous gastric carcinomas. The role played by MUC5B in the evaluation of differentiation and biological behaviour of gastric carcinoma is largely unknown. Our aim was to characterise the pattern of expression of mucins MUC1, MUC2, MUC5AC, MUC5B and MUC6 in a series of 50 gastric carcinomas to evaluate whether MUC5B expression was associated with the clinico-pathological characteristics of the cases and/or with the co-expression of other mucins. A panel of six monoclonal antibodies (HMFG1, SM3, PMH1, CLH2, EU-MUC5Ba and CLH5) was used to determine the expression of mucins (MUC1, MUC1 underglycosylated form, MUC2, MUC5B, MUC5AC and MUC6, respectively) using immunohistochemistry. Cases were considered positive if more than 5% of the cells expressed immunoreactivity for the several mucins evaluated. Our results showed that: (a) expression of MUC5B was observed in 11 cases (22.0%) and was associated with the "unclassified" histological type of gastric carcinoma according to Laurén ( P = 0.03) and with the absence of venous invasion ( P = 0.02); (b) in this series, MUC5B expression had no impact on survival of patients with gastric carcinoma; (c) the expression of MUC5B was associated with the co-expression of MUC5AC ( P = 0.02) and (d) none of the cases with the so-called complete intestinal phenotype of mucin expression expressed MUC5B.

Leiomioma de vejiga. análisis de agregación de 90 casos

INTRODUCTION

Bladder leiomyomas (BL) are rare. Most publications regarding these tumours are reports of isolated cases; therefore they don't allow an evaluation of diagnostic and treatment procedures.

MATERIAL & METHODS

We preformed a pooled analysis of 90 cases of BL reported in the literature.

RESULTS

Mean age was 45.3 (19 to 85 years), 68 (75.6%) were women. Filling symptoms were the most frequently reported (50%), followed by voiding symptoms (24.4%). Twenty four patients (26.7%) were asymptomatic. Tumours were endoluminal in 46 patients (51.1%), intramural in 27 (30%) and extravesical in 15 (16.7%). A laparotomy was performed in 56 patients (62.2%), with enucleation in 29 (32.2%), partial cystectomy in 25 (27.8%) and total cystectomy in 2 (2.2%). A transurethral resection was preformed in 27 (30%) and a transvaginal resection in 5 (5.6%). Two patients underwent conservative treatment. In 3 cases there were reports of recurrence and one patient got a vesicovaginal fistula.

CONCLUSIONS

Although BL are rare, when evaluating bladder tumours, imaging techniques can make suspect of this neoplasm. Surgical treatment of these tumours has a very high success rate. Usually an enucleation or a transurethral resection is sufficient to render the patient tumour free, avoiding a more iatrogenic surgery.

[Renal neoplasm with vena cava involvement]

Renal cancer with vena cava tumour thrombus is relatively rare (4 to 10%). Because of the poor results obtained with any kind of alternative therapy (e.g. radiation, hormonal, chemotherapy and immunotherapy) operation with complete removal of the vena cava tumour thrombus continues to be the better method of treatment. The prognostic significance of the cephalic extent of an inferior vena caval tumor thrombus associated with renal cell carcinoma is controversial. Long-term survival after surgical treatment is possible in patients with localized renal cell carcinoma (survival 50% at five years). The authors report a case of vena caval extension of renal cell carcinoma in a 70-years-old man. The patient presented with a history of right lumbar pain and pedal edema. Magnetic Resonance demonstrated the presence and the level of tumoral thrombus. The patient was submitted to a radical nephrectomy and complete removal of tumor thrombus from vena caval.

[Arterial blood pressure behavior during the administration of intravenous streptokinase, in patients with acute myocardial infarction]

OBJECTIVE

To evaluate the effect on blood pressure (BP) of intravenous (i.v.) streptokinase (SK) in patients (PTS) with acute myocardial infarction (AMI).

DESIGN

Retrospective study with analysis of BP registers ten minutes before and during SK infusion.

SETTING

PTS admitted to the Coronary Care Unit (CCU) of Santo António Hospital, Oporto.

PATIENTS

Thirty-eight male PTS, average ages of 54, ranging from 38 to 67, AMI confirmed, and criteria to thrombolytic therapy. One patient was excluded on account of persistent hypotension since admission.

MATERIAL AND METHODS

I.v. infusion of 1.500.000 U of SK over 60 minutes, preceded by 200 mg i.v. of prednisolone. BP and heart rate (HR) were evaluated with Datascope Accutorr 1A set. The lowest value of the systolic BP (SBP) recorded ten minutes before SK infusion was considered the baseline value. We valued the reduction of SBP above 15%, defining its fall as the difference between the baseline value and the minimum value of SBP recorded during the infusion. Hypertension was defined to SBP values below 90 mmHg.

MAIN RESULTS

The fall was 40.4 +/- 22.1 mmHg (range 9 to 102, having been recorded the minimum value at 22.9 +/- 10.9 minutes. It was accompanied by diastolic BP (DBP) fall of 30.6 +/- 18.9 mmHg (range -2 to 76) and by a HR increasing from 76.2 +/- 13.7 beats/min. to 80.8 +/- 14.1 beats/min. (p < 0.01). In 86% of the PTS this fall was transient, lasting 8.9 +/- 6.3 minutes, and was corrected by slowing or stopping the infusion for a few minutes and placing the patient in Trendelenburg position. Two PTS needed sympaticomimetic amines because of persistent BP reduction despite the previous measures. 92% of the PTS had a SBP fall higher than 15% in relation to the baseline value. The SBP was kept over 90 mmHg in 20 PTS (54%); hypotension was recorded in the remaining 14 PTS (38%), and in 10 (27%) of these the SBP fell below 80 mmHg. We couldn't prove that the infarction and the extension of the ischemic lesion had influenced this BP fall.

CONCLUSIONS

The BP reduction during treatment with high doses of SK deserves some attention because, although transient and easily reversible, it is frequent and sometimes significative. It demands then careful monitoring in order to avoid the hypoperfusion to the ischemic myocardium, that could jeopardize the potential benefits of reperfusion in the reduction of infarction area, the main objective of the thrombolytic treatment.

Neurofilaments consist of distinct populations that can be distinguished by C-terminal phosphorylation, bundling, and axonal transport rate in growing axonal neurites

We examined the steady-state distribution and axonal transport of neurofilament (NF) subunits within growing axonal neurites of NB2a/d1 cells. Ultrastructural analyses demonstrated a longitudinally oriented "bundle" of closely apposed NFs that was surrounded by more widely spaced individual NFs. NF bundles were recovered during fractionation and could be isolated from individual NFs by sedimentation through sucrose. Immunoreactivity toward the restrictive C-terminal phospho-dependent antibody RT97 was significantly more prominent on bundled than on individual NFs. Microinjected biotinylated NF subunits, GFP-tagged NF subunits expressed after transfection, and radiolabeled endogenous subunits all associated with individual NFs before they associated with bundled NFs. Biotinylated and GFP-tagged NF subunits did not accumulate uniformly along bundled NFs; they initially appeared within the proximal portion of the NF bundle and only subsequently were observed along the entire length of bundled NFs. These findings demonstrate that axonal NFs are not homogeneous but, rather, consist of distinct populations. One of these is characterized by less extensive C-terminal phosphorylation and a relative lack of NF-NF interactions. The other is characterized by more extensive C-terminal NF phosphorylation and increased NF-NF interactions and either undergoes markedly slower axonal transport or does not transport and undergoes turnover via subunit and/or filament exchange with individual NFs. Inhibition of phosphatase activities increased NF-NF interactions within living cells. These findings collectively suggest that C-terminal phosphorylation and NF-NF interactions are responsible for slowing NF axonal transport.

Clinicopathologic profiles and prognosis of gastric carcinomas from the cardia, fundus/body and antrum

BACKGROUND/AIMS

The putative influence of tumor location on the biologic behavior of gastric carcinomas remains controversial. The aim of this study was to investigate if carcinomas arising in the three types of gastric mucosa (cardia, fundus/body and antrum) have different clinical and pathologic profiles and carry a different prognosis.

METHODS

Three hundred and two patients with cardia or gastric carcinoma resected between 1984 and 1996 were retrospectively studied. Cases were divided in three groups according to tumor location: cardia (n = 80); fundus/body (n = 60); antrum (n = 162). The three groups were crosstabulated with clinic and pathologic parameters, such as age, sex, macroscopy, histology, desmoplasia, tumor size, depth of tumor wall penetration, nodal status, venous invasion and stage. Survival rates were calculated for the three locations according to the aforementioned parameters. Univariate survival analysis and Cox regression were performed for each location.

RESULTS

Cases from the cardia and fundus/body were similar and distinct from antrum cases according to macroscopy, tumor size, depth of wall penetration, venous invasion, nodal status and stage. Cases from fundus/body were similar to antrum cases and distinct from cardia cases according to gender and Laurén's classification. An overall difference in survival between the three locations was observed (p = 0.006). Cumulative survival was better for patients with carcinomas in the antrum than in the cardia (p = 0.04) and in the fundus/body (p = 0.003); no significant differences were observed in survival between cardia and fundus/body carcinoma cases. Cox regression identified stage and venous invasion as prognostic factors for patients with carcinomas in the three locations. In the group of cardia tumors, older patients had a worse outcome and in the group of fundus/body carcinomas, large tumors were associated with a poorer survival.

CONCLUSIONS

Our results show that cardia carcinoma and antrum carcinoma are distinct gastric carcinoma entities whereas fundus/body carcinoma shares some characteristics from both entities.

Kinesin-mediated transport of neurofilament protein oligomers in growing axons

We examined cytoskeleton-associated forms of NF proteins during axonal neuritogenesis in cultured dorsal root ganglion (DRG) neurons and NB2a/d1 neuroblastoma. In addition to filamentous immunoreactivity, we observed punctate NF immunoreactivity throughout perikarya and neurites. Immuno-electron microscopy revealed this punctate immunoreactivity to consist of non-membrane-bound 75 nm round/ovoid structures consisting of amorphous, fibrous material. Endogenous and microinjected NF subunits incorporated into dots prior to their accumulation within filaments. A transfected GFP-conjugated NF-M incorporated into dots and translocated at a rate consistent with slow axonal transport in real-time video analyses. Some dots converted into a filamentous form or exuded filamentous material during transport. Dots contained conventional kinesin immunoreactivity, associated with microtubules, and their transport into axons was blocked by anti-kinesin antibodies and nocodazole. These oligomeric structures apparently represent one form in which NF subunits are transported in growing axons and may utilize kinesin as a transport motor.

[Cryptorchidism. The clinical implications]

This paper briefly reviews the literature on testicular descent and management implications for cryptorchidism. At present, we believe that descent of the testes in humans is a complex event mediated by both hormonal and mechanical factors. There is now good evidence that testicular descent occurs in two morphologic and hormonally distinct phases. Relative "transabdominal migration", which occurs in the 8th and 15th week of gestation, and "inguinoscrotal" migration, which occurs in the 28th and 35th week of gestation. The first phase is controlled by the Mullerian inhibiting factor (MIF), although this remains controversial. The second phase is androgen--dependent and mediated through the release nerve of the neuropeptide calcitonin gene-related peptide from the genitofemoral. Cryptorchidism can therefore result when any one or more of the involved factors malfunction. The therapeutic use of hCG has, however, been disappointing, and its role is confined to helping to distinguish the undescended testis. The demonstration of the pathological changes after one year of age has recently dictated much earlier surgical correction, but long-term follow-up is needed to prove the clinical benefit of this practice.

Membrane-associated molecules guide limbic and nonlimbic thalamocortical projections

Membrane-associated signals expressed in restricted domains of the developing cerebral cortex may mediate axon target recognition during the establishment of thalamocortical projections, which form in a highly precise manner during development. To test this hypothesis, we first analyzed the outgrowth of thalamic explants from limbic and nonlimbic nuclei on membrane substrates prepared from limbic cortex and neocortex. The results show that different thalamic fiber populations are able to discriminate between membrane substrates prepared from target and nontarget cortical regions. A candidate molecule that could mediate selective choice in the thalamocortical system is the limbic system-associated membrane protein (LAMP), which is an early marker of cortical and subcortical limbic regions (Pimenta et al.,1995) that can promote outgrowth of limbic axons. Limbic thalamic and cortical axons showed preferences for recombinant LAMP (rLAMP) in a stripe assay. Incubation of cortical membranes with an antibody against LAMP prevented the ability of limbic thalamic fibers to distinguish between membranes from limbic cortex and neocortex. Strikingly, nonlimbic thalamic fibers also responded to LAMP, but in contrast to limbic thalamic fibers, rLAMP inhibited branch formation and acted as a repulsive axonal guidance signal for nonlimbic thalamic axons. The present studies indicate that LAMP fulfills a role as a selective guidance cue in the developing thalamocortical system.

[Left ventricular pseudoaneurysm: a rare complication of acute myocardial infarction diagnosed by echocardiography]

Postmyocardial infarction left ventricular pseudoaneurysm resulting from free wall rupture is a very rare finding. Its recognition during life is even rarer. Definitive preoperative diagnosis is difficult, implying, in a great number of cases, the use of multiple imaging modalities. A case of a left ventricular pseudoaneurysm as a mechanical complication of acute myocardial infarction, which was diagnosed by transthoracic echocardiography, is reported. The authors emphasize its rarity, the diagnostic difficulties involved and the contribution of echocardiography to the characterization of that lesion, allowing a definitive diagnosis prior surgery in this case.

Limbic system-associated membrane protein (LAMP) induces neurite outgrowth and intracellular Ca2+ increase in primary fetal neurons

The ability of cell adhesion molecules (CAMs) to transduce cell surface signals into intracellular responses is critical for developing neurons, particularly during axonal pathfinding and targeting. It has been suggested that different CAMs can promote neuronal outgrowth via activation of common neuronal CAM-specific second-messenger pathways, although the elements involved in this cascade could differ. Limbic system-associated membrane protein (LAMP), a member of the Ig superfamily, is a molecule that promotes cell adhesion and neurite outgrowth from specific populations of fetal neurons. In the present study, we show that LAMP can induce several types of calcium (Ca2+) signals. Neurite outgrowth is promoted if fetal hippocampal neurons are grown on lamp-transfected CHO cells. This LAMP-induced outgrowth of neurons is mediated in part through activation of L-type Ca channels. Application of soluble LAMP to cultures of fetal hippocampal neurons caused a sustained (up to 60 min) elevation of intracellular Ca2+ as measured by fluo-3 fluorescence on a confocal microscope. The number of responding hippocampal neurons was initially low, but increased with age in culture and the [Ca2+]i elevation was only partially decreased by an L-type Ca(2+)-channel blocker. In contrast, at all times in culture, only a small fraction of neurons from visual cortex responded to LAMP application and only with transient elevation of cytosolic Ca2+ (< 15 min). Based on these observations, LAMP appears to function primarily through homophilic interactions and acts in part by modulating intracellular Ca2+ levels during neurite outgrowth by increasing the Ca2+ influx through L-type calcium channels, but has additional effects on intracellular Ca2+ signaling at later developmental stages.

[Vesico-scrotal hernia. Report of a clinical case]

Incidental discovery of vesical hernias during herniorrhaphy is quite common. In such cases, patients are usually asymptomatic since the hernia portion is small and easily repairable. On the other hand, vesical solid protrusion to the scrotum is quite unusual, and is generally found associated to obstructive urinary symptoms. Management involves basically the correction of any associated obstructive conditions, correction of the vesical hernia and herniorrhaphy.

[The echocardiographic diagnosis of a rare complication of an aneurysm of the sinus of Valsalva]

We report the case of a patient with complete heart block caused by extension of a congenital aneurysm of the sinus of Valsalva into the upper interventricular septum, which was diagnosed by transthoracic and transesophageal echocardiography. We emphasize the rarity of this pathology and the value of transesophageal echocardiography in its assessment, providing a complete anatomicofunctional characterization and allowing surgical repair without previous cardiac catheterization.

Granular cell tumour and leiomyomatosis of the esophagus--a non-coincidental association?

One case of esophageal granular cell tumour (GCT) associated with diffuse leiomyomatosis of the distal esophagus is presented. The rarity of each of the lesions per se raises the possibility that the association between GCT and diffuse leiomyomatosis, a previously unreported finding, is not coincidental. In view of the present knowledge on both conditions we suggest that an underlying genetic alteration may be responsible for the hereby described association.

[Value of transesophageal echocardiography in the diagnosis of acute aortic dissection]

We describe our experience of six patients with clinical suspicion of acute aortic dissection (AAD) who were studied consecutively by transesophageal echocardiography (TEE) from April to July of 1991. All of them were previously submitted to transthoracic echocardiogram. The diagnosis was correctly established by TEE in five cases, confirmed by aortography and/or surgery (four cases), or by autopsy (one case). In one patient the diagnosis of AAD was excluded by TEE, and posteriorly by nuclear magnetic resonance. Four patients had a Stanford type A, and one patient a type B dissection. The site of entry was identified in three cases; the intimal entry tear of the type B dissection, not observed by TEE, was localized in the aortic arch by aortography. In three of the four type A dissection cases, a thrombus in the false lumen and an aortic regurgitation were found. No other noninvasive methods were used after the diagnosis of AAD by TEE. The surgical repair was successful in three cases, one of which, without previous necessity of aortography. In our experience, TEE increased extraordinarily the diagnosis efficacy of AAD, making possible an earlier therapeutic approach, and probably contributing to the improvement of the prognosis of this pathology.

[Asymptomatic aortic dissection with large aneurysm of the ascending and the transverse aorta. Report of a case]

The authors present a cae of asymptomatic type I of the DeBakey aortic dissection with a voluminous aneurysm of the false channel. In the absence of suggestive symptoms, the diagnosis was established by chance through two dimensional echocardiography and later confirmed by magnetic resonance imaging. They ignore the period of time between the beginning of the dissection and the diagnosis, but they consider that it could have exceeded five years. During that time, besides as well tolerated aortic incompetence and aneurysmatic enlargement of the false channel, no other problems were detected. Based on this case, the authors are going through the literature and are discussing the importance of some noninvasive imaging techniques in the diagnosis and follow-up of this patients.

[Transcutaneous pacemaker in cardiovascular emergencies]

OBJECTIVES AND DESIGN OF THE STUDY: Retrospective study to evaluate the efficacy and tolerance of the transcutaneous cardiac pacemaker in the urgent treatment of asystole or severe bradycardia.

SETTING

Coronary Care Unit (CCU) and emergency area of the central reference Hospital.

PATIENTS

24 patients, 20 males and four females, aged between 57 and 84 years (mean 70.4 +/- 7.9). Five pts were in asystole and 19 in severe bradycardia.

INTERVENTIONS

The transcutaneous pacemaker used, was the "Cardio Aid Zoll NTP" model. The intensity of the electrical stimulation was increased progressively, until electrical capture or intolerable discomfort by the patients was achieved. We defined by electric efficacy, the visualization of pacing spike followed by a deflection due to ventricular depolarization; and by hemodynamic efficacy, the evidence of myocardial contraction, defined as a palpable pulse, synchronous with the pacing artefact.

MAIN RESULTS

Stimulation threshold ranged from 30 to 140 mA (mean 67.7 +/- 23.4). The duration of pacing was from 15 minutes to 13 hours, being more than one hour in only four situations. From the 20 conscious patients, or the ones who got conscious, 15 (75%) tolerated well the stimulation. It was intolerable in five pts (25%). No significative side effects due to the use of transcutaneous pacemaker were observed.

CONCLUSIONS

The transcutaneous pacemaker was efficient in the electric and hemodynamic stabilization in the majority of patients. It was generally well tolerated and without important side effects. We think that it may be a valid alternative to transvenous pacing technics in the treatment of asystole and severe bradycardia situations.

[Morphologic course of the left ventricle after renal transplantation. Echocardiographic study]

OBJECTIVE

To characterize and to quantitate the morphologic changes in left ventricle, in renal transplant patients (Pts) treated with cyclosporine, through sequential echocardiographic examinations.

DESIGN

A prospective study of renal transplant patients, between October/88 and May/89, who maintained good function of the renal graft during the follow-up.

SETTING

Cardiology and Nephrology departments of Santo António Hospital.

MATERIAL AND METHODS

20 patients, 13 men and 7 women, mean age of 33 +/- 10, ranging from 20 to 56, constitute the final group of the study. These patients have been receiving dialysis during 3.8 +/- 2.3 years (0.4-8). Seven patients were excluded, five by echocardiographic criteria and another two because of chronic renal graft disfunction (creatinine greater than 2.0 mg%). The echocardiographic examinations were performed during the first week, and 1, 2, 3, 6 and 12 months after renal transplantation. The following measurements were performed: left ventricular end-diastole diameter (LVED), interventricular septal thickness (IVST), posterior wall thickness (PWT) and left ventricular mass index (LVMI). The measurements were obtained in M-mode following the conventional recommendations. Average values of at least 3 cardiac cycles were used. Heart rate, blood pressure, creatinine, hematocrit, body surface area and fistula patency, were determined at the time of each echocardiogram.

MAIN RESULTS

The LVED decreased progressively until the third month, from 51.9 +/- 7 mm to 47.8 +/- 6 mm (p less than 0.001), remaining stable thereafter. The baseline value of IVST, 13.6 +/- 5 mm, was similar at the twelfth month, 13.8 +/- 2 mm (ns). The baseline value of PWT, 13.7 +/- 4 mm, decreased gradually since the second month, having reached 12.7 +/- 2 mm at the twelfth month (ns). The LVMI (g/m2) reduced progressively, from 243 +/- 82 to 190 +/- 38 at the end of the study (p less than 0.05. A high incidence of arterial hypertension was detected during the follow-up period; at the twelfth month, 18 patients (90%) were on antihypertensive drug therapy, 11 of which had blood pressure greater than or equal to 160/95 mmHg.

CONCLUSIONS

We verified, one year after the renal transplantation, a significant decrease of LVMI, that was mainly determined by the LVED reduction. Left ventricular walls thickness had no significant variation; we think that the high incidence of hypertension during the follow-up period, in part due to the pressure effect of cyclosporine, may have been responsible for this fact.

[Fistula of the right coronary artery near the right ventricle. An echocardiographic study]

A case of a 42-year-old woman with a right coronary artery fistula into the right ventricle is reported; she was asymptomatic and a continuous precordial murmur was found on physical examination. We discuss the usefulness and limitation of the Echo 2-D/Doppler findings, concerning this diagnosis, which was only definitively established by angiocardiography.

[Pulmonary embolism. A propos of a case treated with APSAC]

One describes the clinical case of a patient suffering from massive pulmonary embolism under a state of shock who was successfully treated with APSAC 30 units in one single bolus. Thrombolytic agents provoke a rapid destruction of thrombi which lead to a very important and fast hemodynamic improvement. These agents have a great improving action, compared to heparin, in the alterations of pulmonary diffusion provoked by embolism. Most of the times, they also avoid surgery and the appearance of cor pulmonale. APSAC seems to be effective and secure.

[Indirect criteria of coronary reperfusion and permeability in patients with acute myocardial infarction who have received thrombolytic therapy]

OBJECTIVE

To evaluate the value of some indirect reperfusion signs (IRS) as markers of coronary artery patency in patients (PTS) with acute myocardial infarction (AMI) submitted to intravenous (IV) thrombolytic therapy (TT).

DESIGN

Retrospective study, with analysis of the sensibility (S), specificity (SP) and predictive value (PV) of three IRS: 1. Pain and ST resolution in the first three hours; 2. Peak CK in the first 13 hours; 3. accelerated idioventricular rhythm (AIVR) in the first three hours.

SETTING

Coronary Care Unit (CCU) of the Santo António Hospital and Hemodynamic Laboratory of the S. João Hospital, Oporto.

PATIENTS

Sixty seven PTS (mean age 53.4 +/- 10.6 years) with confirmed AMI, 62 male and five female, 34 with anterior and 33 with inferior infarction, TT started in the first three hours of the beginning of symptoms in 34 PTS and from three to six hours in 33 PTS, all submitted to coronary angiography in the hospital setting (7.6 +/- 5.9 days after AMI).

INTERVENTIONS

IV administration of 1,500,000 U of streptokinase (SK) in 47 PTS and 30 U of APSAC in 20 PTS, preceded by 200 mg IV prednisolone and oral 100 mg acetilsalicylic acid, and followed by IV heparin therapy. Continuous electrocardiographic monitoring, and serial 12 leads ECG and enzymatic assays (at start and 1, 3, 7, 13 and 25 hours of TT). Analysis of the correlation of the three IRS (isolated and in association) with coronary artery patency (TIMI 2 or 3).

MEASUREMENTS AND RESULTS

The total patency rate was 79.1%; there was no statistically significant difference with regard to AMI location, time of symptoms onset (0-3 vs 3-6 hours) or thrombolytic agent (SK vs APSAC). The first and second IRS had a high S and a low SP; together S = 79.2%, SP = 64.3% and PV = 89.4%. The third IRS with the first and/or the second one had a low S (about 25%) but SP and PV of 100%. The coronary patency rate of PTS without IRS was always greater than 50%.

CONCLUSIONS

The analysed IRS although not very reliable are useful when considered in association. It is possible to assess PTA with high probability of reperfusion if AIVR is present. The absence of IRS does not exclude coronary artery patency. There is still missing more reliable no-invasive reperfusion markers.

[Ruptured aneurysm of the sinus of Valsalva into the right ventricle--apropos of a case]

A 37 year old man was referred to our institution because of a cardiac murmur, exertional dyspnea and fatigue, symptoms that began since 18 years of age. He reported a cardiac murmur since childhood, with no past history of rheumatic fever or infectious endocarditis. On clinic examination there was a systolic-diastolic murmur louder in the third and fourth left intercostal space, just at the sternal left border. The 2 D-echo revealed a small disruption in the aorto-septal continuity. Right heart catheterisation was performed, showing an increased pressure in the pulmonary artery and right ventricle; an increase in the oxygen saturation on the right heart chambers, suggested the presence of a left-to-right shunt, nevertheless the exact location of the defect was not possible to recognise. The study was complemented with Doppler color flow imaging that revealed a turbulent flow through the defect, with blood flowing from the aortic root into the right ventricular outflow tract. The diagnosis of ruptured aneurysm of sinus of Valsalva was made, being confirmed later by aortic angiography. A rare case is reported in which an aneurysm of the right coronary sinus ruptured into the right ventricle; we emphasize the important contribution of the Doppler color flow imaging to the correct diagnosis, technique rarely described in this type of complication.

[Pericarditis caused by cholesterol. Apropos of a clinical case]

A case of a 76 year-old woman with a large pericardial effusion is described. The microscopic examination of the scintillating, yellow-greenish fluid obtained by the first pericardiocentesis, showed numerous crystals of cholesterol. In search of the underlying diseases there were found values of T3, T4 and TSH diagnostic of hypothyroidism. Considering the rapid relapse of the effusion and after a second pericardiocentesis, it was decided to open a pleuro-pericardial window. The biopsy of the pericardium showed deposits of cholesterol on electronics microscopy. She was discharged from hospital two weeks after surgery, showing an evident clinical improvement. Six months later she was feeling well, keeping a normal activity for her age. The values of T3, T4 and TSH were normal, and there were no echocardiographic signs of pericardial effusion. It is presented a rare case of cholesterol pericarditis associated to sub-clinical hypothyroidism, showing the presence of cholesterol, as crystals in the pericardial effusion and, we think for the first time in this pathology, in vesicles of pinocytosis, in the pericardial biopsy. The six months period of follow-up showed a good clinical improvement with the selected therapeutic attitude.

[Behavior of arterial pressure during administration of intravenous streptokinase, in patients with acute myocardial infarct]

OBJECTIVE

To evaluate the effect on blood pressure (BP) of intravenous (IV) streptokinase (SK) in patients (PTS) with acute myocardial infarction (AMI).

DESIGN

Retrospective study with analysis of BP registers ten minutes before and during SK infusion.

SETTING

PTS admitted to the Coronary Care Unit (CCU) of Santo António Hospital, Oporto.

PATIENTS

Thirty-eight male PTS, average ages of 54, ranging from 38 to 67, AMI confirmed, and criteria to thrombolytic therapy. One patient was excluded on account of persistent hypotension since admission.

MATERIAL AND METHODS

IV infusion of 1,500,000 U of SK over 60 minutes, preceded by 200 mg IV of prednisolone. BP and heart rate (HR) were evaluated with a Datascope Accutorr 1A set. The lowest value of the systolic BP (SBP) recorded ten minutes before SK infusion was considered the baseline value. We valued the reduction of SBP above 15%, defining its fall as the difference between the baseline value and the minimum value of SBP recorded during the infusion. Hypotension was defined to SBP values below 90 mmHg.

MAIN RESULTS

The SBP fall was 40.4 +/- 22.1 mmHg (range 9 to 102), having been recorded the minimum value at 22.9 +/- 10.9 minutes. It was accompanied by diastolic BP (DBP) fall of 30.6 +/- 18.9 mmHg (range -2 to 76) and by a HR increasing from 76.2 +/- 13.7 beats/min. to 80.8 +/- 14.1 beats/min. (p less than 0.01). In 86% of the PTS this fall was transient, lasting 8.9 +/- 6.3 minutes, and was corrected by slowing or stopping the infusion for a few minutes and placing the patient in Trendelenburg position. Two PTS needed sympaticomimetic amines because of persistent BP reduction despite the previous measures. 92% of the PTS had a SBP fall higher than 15% in relation to the baseline value. The SBP was kept over 90 mmHg in 20 PTS (54%); hypotension was recorded in the remaining 14 PTS (38%), and in 10 (27%) of these the SBP fell below 80 mmHg. We couldn't prove that the infarction location and the extension of the ischemic lesion had influenced this BP fall.

CONCLUSION

The BP reduction during treatment with high doses of SK deserves some attention because, although transient and easily reversible, it is frequent and sometimes significative. It demands then careful monitoring in order to avoid the hypoperfusion to the ischemic myocardium, that could jeopardize the potential benefits of reperfusion in the reduction of infarction area, the main objective of the thrombolytic treatment.

Persistent atrial standstill with atrial inexcitability

Electrophysiologic studies including His bundle recording, atrial, and ventricular stimulation, were performed in three symptomatic patients with persistent atrial standstill of unknown etiology. The rhythm was junctional in two cases and ventricular in one. In two cases, evidence suggestive of associated impairment of the His bundle conduction system was found. The atria were inexcitable at multiple sites and no retrograde conduction to the right atrium could be elicited by ventricular pacing. Follow-up in the three cases, respectively for 48, 42 and 12 months after pacemaker implantation, revealed no return of spontaneous atrial electrical activity.