Temporomandibular joint ankylosis after condylar dislocation into the middle cranial fossa: A case report

INTRODUCTION

Dislocation of the mandibular condyle into the middle cranial fossa after a trauma is a rare event. The lack of appropriate treatment can lead to ankylosis of the temporomandibular joint (TMJ). We report about a case of TMJ ankylosis following intracranial dislocation of the mandibular condyle through the roof of the articular fossa.

CASE REPORT

A 9-year-old patient was referred for a severe limitation of mouth opening that began progressively one year before. A history of chin injury due to an accidental fall was found. Preoperative CT scan showed a TMJ ankylosis on the right side combined with a dislocation of the mandibular condyle into the middle cranial fossa. Treatment consisted in an intracranial resection of the mandibular condyle, partial removal of the ankylosis block and TMJ arthroplasty.

DISCUSSION

Our case is the second case of TMJ ankylosis following intracranial dislocation of the mandibular condyle and treated with arthroplasty alone published in the English literature. There is no consensus regarding the pathophysiology of TMJ ankylosis and regarding the attitude towards the ankylosis block. In our case, no recurrence was noticed after a one-year follow-up. An interdisciplinary approach is needed, including maxillofacial surgeon, neurosurgeon, physiotherapist and orthodontist.

Genetic characterization of local Criollo pig breeds from the Americas using microsatellite markers

Little is known about local Criollo pig genetic resources and relationships among the various populations. In this paper, genetic diversity and relationships among 17 Criollo pig populations from 11 American countries were assessed with 24 microsatellite markers. Heterozygosities, F-statistics, and genetic distances were estimated, and multivariate, genetic structure and admixture analyses were performed. The overall means for genetic variability parameters based on the 24 microsatellite markers were the following: mean number of alleles per locus of 6.25 ± 2.3; effective number of alleles per locus of 3.33 ± 1.56; allelic richness per locus of 4.61 ± 1.37; expected and observed heterozygosity of 0.62 ± 0.04 and 0.57 ± 0.02, respectively; within-population inbreeding coefficient of 0.089; and proportion of genetic variability accounted for by differences among breeds of 0.11 ± 0.01. Genetic differences were not significantly associated with the geographical location to which breeds were assigned or their country of origin. Still, the NeighborNet dendrogram depicted the clustering by geographic origin of several South American breeds (Criollo Boliviano, Criollo of northeastern Argentina wet, and Criollo of northeastern Argentina dry), but some unexpected results were also observed, such as the grouping of breeds from countries as distant as El Salvador, Mexico, Ecuador, and Cuba. The results of genetic structure and admixture analyses indicated that the most likely number of ancestral populations was 11, and most breeds clustered separately when this was the number of predefined populations, with the exception of some closely related breeds that shared the same cluster and others that were admixed. These results indicate that Criollo pigs represent important reservoirs of pig genetic diversity useful for local development as well as for the pig industry.

Porcine colonization of the Americas: a 60k SNP story

The pig, Sus scrofa, is a foreign species to the American continent. Although pigs originally introduced in the Americas should be related to those from the Iberian Peninsula and Canary islands, the phylogeny of current creole pigs that now populate the continent is likely to be very complex. Because of the extreme climates that America harbors, these populations also provide a unique example of a fast evolutionary phenomenon of adaptation. Here, we provide a genome wide study of these issues by genotyping, with a 60k SNP chip, 206 village pigs sampled across 14 countries and 183 pigs from outgroup breeds that are potential founders of the American populations, including wild boar, Iberian, international and Chinese breeds. Results show that American village pigs are primarily of European ancestry, although the observed genetic landscape is that of a complex conglomerate. There was no correlation between genetic and geographical distances, neither continent wide nor when analyzing specific areas. Most populations showed a clear admixed structure where the Iberian pig was not necessarily the main component, illustrating how international breeds, but also Chinese pigs, have contributed to extant genetic composition of American village pigs. We also observe that many genes related to the cardiovascular system show an increased differentiation between altiplano and genetically related pigs living near sea level.

The Perfect Stage of Powdery Mildew of Grapevine Caused by Erysiphe necator Found in Peru

Grapevine (Vitis vinifera L.) has been cultivated in Peru since the sixteenth century to produce wine and grape brandy called "Pisco". Grapevine powdery mildew caused by Erysiphe necator (Schwein.) (formerly Uncinula necator [Schw.] Burr.; anamorph Oidium tuckeri) is currently the most important disease of grapevine in Peru. Table grape producers rely heavily on fungicide applications to manage powdery mildew infections. In Peru, the pathogen is normally found in the anamorphic state, except for one report of the teleomorphic state in 1972 (2) on wine grape varieties. In July 2011, ascomata were observed on table grapevine leaves cv. Sugraone in a commercial field near Huaral in the central coast of Peru. Abundant, mature (black) and immature (brown), globose ascocarps were visible on the abaxial leaf surfaces covered by the anamorphic state of the fungus. The chasmothecia were epiphyllous and ranged from 93.3 to 157.5 μm in diameter. The appendages were hyaline, variable in number (9 to 17), septate, with the apex helicoid when mature, and measuring 310 to 480 μm long. Each ascocarp contained four to seven subglobose asci (55.3 to 76.7 × 36.3 to 52.0 μm) with two to six (mostly three) ascospores. The ascospores were elliptical, hyaline, and measured 20.2 to 25.0 μm long by 11.1 to 17.3 μm wide. The pathogen was identified as E. necator on the basis of the host genus and morphology of the teleomorph (1). The teleomorphic state of E. necator could be a source of primary inoculum before infection by anamorphic conidia occurs, provide the basis for genetic recombination, and lead to more frequent appearance of new races. This could have serious implications for managing fungicide resistance in the pathogen population and may also result in the development of virulence to the resistance of some grape varieties tolerant to powdery mildew infections. In South America, the teleomorph of E. necator has been recently detected in Chile (3), and has caused great concern among grape producers. To our knowledge, this finding represents a first record of the presence of the ascigenous state of the pathogen on table grapes in Peru. References: (1) U. Braun. A Monograph of the Erysiphales (powdery mildews). J. Cramer, Berlin-Stuttgart, 1987. (2) S. L. Dongo and M. E. Arestegui. Fitopatologia 8:35, 1973. (3) F. Riveros et al. Aconex 83:24, 2004.

Genetic characterization of Latin-American Creole cattle using microsatellite markers

Genetic diversity in and relationships among 26 Creole cattle breeds from 10 American countries were assessed using 19 microsatellites. Heterozygosities, F-statistics estimates, genetic distances, multivariate analyses and assignment tests were performed. The levels of within-breed diversity detected in Creole cattle were considerable and higher than those previously reported for European breeds, but similar to those found in other Latin American breeds. Differences among breeds accounted for 8.4% of the total genetic variability. Most breeds clustered separately when the number of pre-defined populations was 21 (the most probable K value), with the exception of some closely related breeds that shared the same cluster and others that were admixed. Despite the high genetic diversity detected, significant inbreeding was also observed within some breeds, and heterozygote excess was detected in others. These results indicate that Creoles represent important reservoirs of cattle genetic diversity and that appropriate conservation measures should be implemented for these native breeds in order to minimize inbreeding and uncontrolled crossbreeding.

First Report of Neofusicoccum parvum Associated with Dieback of Mango Trees in Peru

Mango (Mangifera indica L) is one of the most important cash crops of northern Peru. Since 2003, adult mango trees (cvs. Criollo and Kent) located in Piura Province developed symptoms of dieback characterized by the death of twigs and branches in the tree canopy. Additional disease symptoms involved darkened, elongated lesions on the peduncle, causing an early maturation of the fruit, and in advanced symptoms, stem-end rot of fruits. Symptoms were frequent in the spring months (September to November) when the lesions expand rapidly. Diseased tissues from branches and fruits were collected and small pieces of necrotic tissues were surface disinfected and plated onto potato dextrose agar (PDA) with 0.5 g L^-1 streptomycin sulfate. Plates were incubated at 25°C in the dark. All affected tissues consistently developed colonies with a white mycelium, moderately dense, and becoming olivaceous gray after 5 to 6 days. Pycnidia were produced on sterile mango twigs placed on the surface of potato carrot agar (PCA) after 10 days. Conidia were hyaline, guttulate, aseptate, measuring (15-) 18.5 (-22.5) × (4-) 5.2 (-7.5) μm. Conidia became olivaceous and developed one or two septa before germination. Isolates were identified as Neofusicoccum parvum (Pennycook & Samuels) Crous, Slippers, & A.J.L. Phillips (1). DNA sequences of the rDNA internal transcribed spacer region (ITS) and part of the translation elongation factor 1-alpha (EF1-α) genes were used to confirm the identification through BLAST searches in GenBank (ITS: 99% identity to Accession No. EU080928; EF1-α: 98% identity to Accession No. AY343367). Representative sequences of the studied DNA regions were deposited at GenBank (ITS: Accession No. FJ528596; EF1-α: Accession No. FJ528597). Pathogenicity tests were conducted on 18-month-old potted mango plants cv. Kent with two N. parvum strains (A4 and A5). A mycelial plug (3 cm in diameter) taken from the margin of an actively growing colony of each isolate was put in a wound made with a cork borer of the same diameter on the stem of each plant. Inoculation wounds were wrapped with Parafilm. Controls were inoculated with sterile PDA plugs. Ten replicates for each isolate were used with an equal number of control plants. Plants were maintained in a greenhouse with a temperature range of 22 to 28°C. After 4 weeks, mango plants showed necrotic stem lesions originating from the inoculation point affecting also the branches of the inoculated plants. No differences in lesion area between strains were obtained. No lesions developed in the control plants. Reisolations from necrotic tissues were successful and both isolates were morphologically identical to those used for inoculations. N. parvum was isolated from all symptomatic trees in all surveyed areas. This pathogen has already been reported on mango (2) and currently represents a serious problem in the mango-producing areas of Peru. To our knowledge, this is the first report of N. parvum affecting mango in Peru. References: (1) P. W. Crous et al. Stud. Mycol. 55:235, 2006. (2) B. Slippers et al. Mycologia 97:99, 2005.

Comparison of Application Methods of Systemic Fungicides to Suppress Branch Cankers in Clementine Trees Caused by Phytophthora citrophthora

Since 2002, considerable losses of Clementine trees (Citrus clementina) have been observed in Spain due to Phytophthora branch canker of citrus caused by Phytophthora citrophthora. Due to the low efficiency of the available cultural and genetic control measures, application of fungicides is required for economic management of the disease. Fosetyl-Al, metalaxyl, and its enantiomer mefenoxam are the only systemic fungicides registered for control of Phytophthora diseases in Spain. However, their efficacy has not been tested against Phytophthora branch canker. Greenhouse and field experiments were conducted for 3 years in Spain to evaluate the ability of these fungicides and application methods to reduce lesion expansion. Nevertheless, with the inoculation technique used, it was not possible to evaluate the protective activity of fungicides, which can play an important role in their performance under field conditions. None of the fungicide treatments inhibited lesion expansion when applications were made on a curative basis. The residual effect was better on young than on mature trees. Paint treatments were generally more effective in reducing lesion expansion that drip chemigation or foliar sprays. However, this application method is laborious and becomes uneconomical in Spain. Trunk and branch sprays as well as long-term programs of foliar sprays or drip chemigation for control of spring and autumn infections are proposed as targets for future research.

Intravenous valproate dosing in neonates

The loading dosage of intravenous valproate required to achieve a desired serum concentration in neonates is not known. Two neonates with seizures received loading doses of intravenous valproate over 30 minutes. Serum valproate concentrations were measured 45 minutes and 3 hours after initiation of the infusion. Both neonates had received phenobarbital and phenytoin before the loading infusions. In the first patient, a loading dose of intravenous valproate of 10 mg/kg increased the 45-minute postinfusion serum valproate concentration to 41 microg/mL with a 3-hour postinfusion serum valproate concentration of 33 microg/mL. In the second patient, a loading dose of 25 mg/kg increased the 45-minute postinfusion serum valproic acid concentration to 100 microg/mL with a 3-hour postinfusion serum valproic acid concentration of 78 microg/mL. We found that each 1 mg/kg of intravenous valproate increased the 45-minute and 3-hour postinfusion serum valproic acid concentrations by approximately 4 microg/mL and 3 microg/mL, respectively. We suggest that these figures be used to calculate the desirable loading dose of intravenous valproate in neonates until larger studies are conducted. The volume of distribution and the serum clearance of valproate were approximately 0.245 L/kg and 25 mL/h/kg, respectively.

Epilepsy surgery in children with tuberous sclerosis complex: presurgical evaluation and outcome

PURPOSE

Children with tuberous sclerosis complex (TSC) benefit from excisional surgery if seizures can be localized to a single tuber. We evaluated the role of noninvasive studies to localize the epileptogenic tuber/region (ET/R) and the outcome of focal resection.

METHODS

We identified 21 children with TSC, ages 3 months to 15 years (mean 4.8 years). All had video-(electroencephalogram) EEG and magnetic resonance imaging (MRI) scans, and 18 also had ictal single photon emission-computed tomography (SPECT) studies. An ET/R was localized in 17 patients. Thirteen patients underwent resection guided by intraoperative electrocorticography (n = 7) or subdural monitoring (n = 6).

RESULTS

Interictal EEG revealed a principal spike focus (PSF) that corresponded to the ET/R in 14 children. In seven, PSFs occurred in rhythmic runs. PSFs were not observed remote from the ET/R. Focal polymorphic slowing and attenuation occurred in the region of the PSF in 11 patients. Sixteen patients demonstrated an ictal focus corresponding to the ET/R. Ictal SPECT revealed focal hyperperfusion correlating with the ET/R in 10 patients. Although the MRIs in all children revealed multiple tubers, the ET/R corresponded to a large discrete tuber in 8 patients and a calcified tuber in 13 patients. Patchy calcified tubers were also seen elsewhere in six patients. At a mean follow-up of 26 months, 9 of the 13 children who underwent surgery were seizure-free, one had greater than 75% reduction in seizures, two were unchanged, and one was lost to follow-up. New seizures developed in one child from a contralateral tuber.

CONCLUSIONS

Surgical resection of an ET/R alleviates seizures in most children with TSC and intractable epilepsy. The scalp EEG and MRI help define the ET/R and improve case selection when ictal SPECT is nonlocalizing.

A new meatless diet for adult screwworm (Diptera: Calliphoridae)

Screwworm flies, Cochliomyia hominivorax (Coquerel), were fed on honey and spray dried egg product; honey, molasses, and spray dried egg product; honey and spray dried meat protein; as well as on a control diet of honey and horsemeat, which is the standard diet used for screwworm adult colony in the mass-rearing facility. In general, the weight of eggs laid by females fed on the diet of spray dried egg product was significantly higher than that laid by females fed on the standard horsemeat diet. Egg production declined when spray dried meat protein replaced the egg product. Partial replacement of honey with molasses in the egg diet did not decrease egg production, compared with the control diet. The use of spray dried egg diet has advantages over the horsemeat diet, such as storage, handling, preparation, feeding, and expense. A cost analysis suggests that replacing the horsemeat with spray dried egg product, and half of the honey with molasses, would reduce the cost of the diet by more than US $100,000 annually.

[Epilepsy treatment by vagal stimulation]

INTRODUCTION

Vagal nerve stimulation is the latest therapeutic modality for the treatment of epilepsy. It consists of a lead implanted in the left vagal nerve which is connected to a subcutaneous stimulator implanted in the left axillary or pectorial region.

DEVELOPMENT

The stimulator is programmed to intermittently stimulate the vagal nerve throughout the day and a magnet also allows the patient to control the stimulation from the outside. This treatment has been used in patients with intractable partial seizures who are not candidates for epilepsy surgery. The results reported have varied but in general the procedure appears promising with at least 50% of the implanted having over 50% improvement in their seizure frequency and many having complete control without significant side effects.

CONCLUSION

Further review of the results are still needed to fully determine the true value of this treatment and to identify the subgroups of patients which will benefit the most.

An alternative source of blood protein for screwworm (Diptera: Calliphoridae) larval diet

Larvae of screwworm, Cochliomyia hominivorax (Coquerel), were reared on diets with varying concentrations of spray dried animal blood cells, spray dried inedible egg product, and powdered milk substitute, and compared with those reared on spray dried whole bovine blood-based diet currently used for mass rearing. Mean larval weight, pupal weight, number of pupae, adult emergence, sex ratio, longevity, fecundity, and fertility obtained from the tests with animal blood cell based diets were similar to those from tests with whole bovine blood based diet. The animal blood cell based diet has potential for use in the mass production of screwworm larvae.

[Epilepsy centers: classification and basic requirements]

Over the last two decades the surgical treatment of epilepsies has become a commonly used and effective method for the treatment of intractable epilepsy. However, because of its wide use in various types of centers throughout the world the methodology involved varies significantly throughout the centers. With this article we propose the bases from which a multidisciplinary team of numerous centers can eventually develop an effective and acceptable international protocol for the surgical treatment of the epilepsies and the classifications of the centers.

[Neuropathology of refractory epilepsy in children]

INTRODUCTION AND OBJECTIVES

The pathological findings in surgical material from children with refractory epilepsy has not offered yet a clear understanding of its role in this condition. The objective of this paper is to report our findings to further expand our knowledge about refractory epilepsy in children.

MATERIAL AND METHODS

Results of microscopic examination of the surgical specimen obtained from 80 children, ages 12 or younger, who had surgery for intractable epilepsy at Miami Children's Hospital between 1990 and 1996 were reviewed.

RESULTS

Examination was normal only in one. The rest revealed ectopic neurons (1), dysplastic cells with ectopic neurons (2), dyslamination with large neurons (7), dyslamination with ectopic neurons (18), dyslamination with dysplastic cells (10), pachygyria (2), encephalomalacia (9), gliosis with ectopic neurons (10), gliosis without ectopic neurons (3), developmental ectodermal tumor (6), ganglioglioma (2), tumors (3), and Rasmussen encephalitis (4). Lesions were located to the temporal lobe in 34 children. CONCLUSIONS. Extratemporal lesions are more frequent than temporal one, including hyppocampal sclerosis. Ectopic neurons, the most frequent pathological findings, rather than a cause of seizure may be a marker other highly epileptogenic cortical malformations.

[Single photon emission computer tomography in the differential diagnosis of the paroxysmal clinical events in newborns]

Conventional computerized cranial tomography by single photon emission (TLCESF) is a nuclear medicine technique which makes use of a radioactive chemical complex to obtain a qualitative image of cerebral, cerebellar and brain-stem vascularization. This technique shows the changes in vascularization which occur between (decrease) and during (increase) the clinical events of paroxysmal epilepsy (ECP) in the area of origin. This technique is indicated in neonates with ECP which does not disappear on etiological treatment, where a non-epileptic cause cannot be ruled out on clinical grounds and where there are no associated encephalographic epileptic changes during the ECP.

[Results of surgery treatment of epilepsy]

The recent advances in the surgical treatment of epilepsy have resulted in great improvement in the overall outcome of these patients. The pediatric group has probably benefited the most as patients who previously were not candidate for this form of treatment are now able to undergo epilepsy surgery with results which are as good as those of adults. In fact, children may now benefit the most, as the control of their epilepsy and our ability to stop their anticonvulsants may allow them to better develop from a psychosocial aspect. Also, because of their plasticity, young children may tolerate surgery involving loss of eloquent cortex without subsequent permanent deficits. The most recent reported results from different centers indicate that 68-90% of patients undergoing temporal lobectomy remain seizure free while the percentage of patients remaining seizure free after extratemporal resections is approximately 50-66%. However, one of the problems with these results is that they vary significantly from one center to another because of the methodology used to evaluate results and the selection of patients depending on the strength of the centers. At present we do not have an optimal method to evaluate results of epilepsy surgery that takes in consideration not only seizure control but also psychosocial outcome. It is our goal to develop such method which will ultimately help us identify the best surgical candidates and predict their outcome.

Altered responsiveness during hyperventilation-induced EEG slowing: a non-epileptic phenomenon in normal children

The relation between hyperventilation (HV)-induced high-amplitude rhythmical slowing (HIHARS) and altered responsiveness without generalized spike and wave activity has not been clearly defined. To test whether altered responsiveness is a nonspecific physiologic response rather than a symptom of generalized epilepsy, we assessed verbal recall ability and motor response testing in 12 healthy nonepileptic children (mean age 9.6 years). Both tasks were administered as a baseline before HV, during HV but before onset of EEG slowing, and during HIHARS. Verbal recall and motor responsiveness remained unchanged during baseline and HV before onset of slowing. During HIHARS, all children exhibited impaired verbal recall (p < 0.005) and 8 of 12 failed to respond to repeated auditory clicks (p < 0.005). Our findings indicate that in a normal setting, responsiveness may be impaired during HV in healthy nonepileptic children.

Carbamazepine toxicity resulting from generic substitution

Generic substitution is practiced widely in both hospital and community settings. There have been several reports of reduced serum concentrations and seizure exacerbation following generic substitution of Tegretol. We describe the first 2 cases of carbamazepine toxicity resulting from the substitution of Tegretol with Epitol. Two 6-year-old children experienced increases in the maximum serum carbamazepine concentration, one of 22% and one of 41%. Both became asymptomatic when their serum concentrations were lowered and had no residual effects.

A safe and effective paradigm to functionally map the cortex in childhood

Conventional cortical stimulation based on pulses of fixed duration briefer than the chronaxie rarely elicit responses in infants and young children. We developed a stimulation paradigm that relies on increments in both stimulus intensity and pulse duration. This approach ensures that stimulation parameters converge to the chronaxie by mathematically minimizing the energy required to elicit a response. In six patients, this paradigm successfully elicited clinical responses and/or afterdischarges at thresholds 5-8 mA below the standard paradigm and at up to 64% lower energy levels. Furthermore, three patients under age 5 years who did not respond to maximal fixed duration stimulation demonstrated afterdischarges and clinical responses when longer pulse durations were utilized. These findings indicate that a paradigm based on dual increments is effective for cortical mapping in children. Furthermore, by ensuring responses at lower energy levels, it may be more efficient for mapping the cortex at all ages.

Placement of intracerebral depth electrodes during excisional surgery for epilepsy: value of intraoperative ultrasound

The authors describe the use of intraoperative US for directing placement of depth electrodes for the localization of seizure foci prior to temporal lobectomy. They used this technique in seven patients (six undergoing temporal and one frontal resection), and encountered no complications.

Localization of seizure foci: pitfalls and caveats

The pitfalls and difficulties in accurately localizing seizure foci are reviewed. Basic issues regarding modeling, volume conduction, inhomogeneities, and corticocortical propagation are discussed, and the limitations of scalp and intracranial recordings are outlined. The ambiguities in interpreting patterns and their significance are highlighted with a concluding commentary on pitfalls in defining the epileptogenic region.

Advanced colorectal carcinoma. A prospective randomized trial of sequential methotrexate, 5-fluorouracil, and leucovorin versus 5-fluorouracil alone

One hundred and twenty-five previously untreated patients bearing metastatic or advanced recurrent (inoperable) colorectal carcinoma and measurable disease were prospectively randomized. Those in arm A received 5-fluorouracil (5-FU), 1,200 mg/m2 i.v. infusion over 2 h, while those in arm B received methotrexate (MTX), 200 mg/m2 i.v. (push injection), followed 20 h later by 5-FU, 1,200 mg/m2 i.v. infusion over 2 h, plus calcium leucovorin (LV), 25 mg i.m. every 6 h for eight doses beginning 24 h after MTX administration. Cycles were repeated every 15 days. All patients receiving treatment were evaluable for toxicity and survival, and 118 patients were evaluable for response. The objective regression rate (complete plus partial response) was 12% (7 of 58) in arm A and 28% (17 of 60) in arm B (p = 0.049). No change was observed in 24% (14 of 58) in arm A and in 35% (21 of 60) in arm B (p = 0.28), while progressive disease was registered in 64% (37 of 58) and 37% (22 of 60) in arms A and B, respectively (p = 0.006). Median duration of response was 3 months in arm A and 5 months in arm B (p = 0.39). The median survival was 8.3 months in arm A and 11.2 months in arm B (p = 0.25). No statistically significant differences were found when objective regression and survival were related to site of primary tumor, performance status, and number of involved organs. There were two drug-related deaths in arm B due to severe myelosuppression followed by mucositis and sepsis. Of nonhematologic toxicities, diarrhea was more frequently observed in arm B, as were mucositis and infectious complications. Our results indicate that the sequential schedule MTX-5-FU-LV with 20-h intervals between MTX and 5-FU is superior in terms of objective regression to 5-FU alone given at the dose and schedule used in the present study. However, MTX-5-FU-LV did not have a significant impact on survival.

Localization of epileptogenic foci using a simple reference-subtraction montage to document small interchannel time differences

We present a modified EEG montage that detects small interchannel time differences and assists in localizing the epileptogenic focus. Regions with apparently synchronous epileptic discharges are displayed simultaneously in referential and subtraction derivations. The subtraction derivation is a bipolar configuration of two regions of interest that are not necessarily adjacent. The referential derivation reveals the polarity, voltage, and morphology of the two discharges, and the subtraction derivation detects asynchrony; the combined reference-subtraction derivation thus indicates the region that is activated first.

Bone-only versus visceral-only metastatic pattern in breast cancer: analysis of 150 patients. A GOCS study. Grupo Oncológico Cooperativo del Sur

The medical records of 510 patients with metastatic breast cancer were retrospectively reviewed. Seventy-seven patients with metastases confined to skeleton and 73 patients bearing visceral-only disease were identified. All patients had a disease-free interval greater than or equal to 6 months and received systemic therapy with any of the following modalities: chemotherapy, hormonotherapy, or chemohormonotherapy. The clinical features, response to treatment, and survival were analyzed and compared for both groups. Median survival of patients with osseous metastases was 28 months, while it was 13 months for those patients with a visceral pattern (p less than 0.001). Response rates to first and second line systemic therapy for both metastatic patterns showed no significant differences, suggesting a similar degree of sensitivity or resistance in both groups. Objective regression to first therapy was 45% in the group with bony disease and 41% among patients with visceral involvement; median duration of response was 16 months and 13 months, respectively. In both groups progressive disease conserved the original metastatic pattern in most patients. We conclude that although a superiority in survival was evident for the osseous metastatic pattern, for these patients efforts should be made to select the least aggressive therapy in order to avoid excessive toxicity. Further studies are needed to confirm our findings.

Focal resection for malignant partial seizures in infancy

There is little experience with excisional surgery for drug-resistant partial seizures in very young patients. We describe our experience with 5 infants under 1 year of age with malignant partial seizures and deteriorating developmental status. All were experiencing frequent daily seizures that did not respond to 1st-line antiepileptic medications at high therapeutic serum levels and considerable medication toxicity. Three infants had complete resection of epileptic tissue (frontal corticectomy and prefrontal lobectomy) and are seizure-free. Two underwent partial resection (lateral temporal lobectomy, frontal corticectomy with anterior callosotomy) and have experienced a significant reduction in seizure frequency. Surgery did not result in any significant neurologic deficit or lead to compromise of developmental status. From these data, we tentatively conclude that excisional surgery can be performed safely in selected infants with medically uncontrolled malignant partial seizures and may significantly improve long-term seizure status. Referral to a tertiary center specializing in early childhood epilepsy surgical evaluation may be considered in these circumstances.

Phase II Trial of Cytarabine, Cisplatin and Vindesine for Advanced Non-Small Cell Lung Cancer

Thirty-two patients with advanced non-small cell lung cancer (NSCLC) were entered in this study to evaluate the efficacy and toxicity of a chemotherapy schedule including cisplatin (C) 40 mg/m2 intravenously (i.v.) on days 1–3; vindesine (V) 3 mg/m2 i.v. on day 1, and cytarabine (ara-C) 15 mg/m2 subcutaneously every 12 hours on days 1–3 (total dose: 90 mg/m2). Cisplatin was administered simultaneously with one dose of ara-C. Cycles were repeated every 28 days. Five patients out of 28 (18 %) fully evaluable for response presented partial remissions. No complete response was observed. Median survival was 8 months and median duration of response was 4 months. Hematologic toxicity was severe in 3 patients. There were no toxicity-related deaths. Other adverse reactions included nausea and vomiting, alopecia and peripheral neuropathy. We conclude that this chemotherapy combination is marginally effective against NSCLC showing in this group of patients a low number of responses of short duration without a significant impact on survival.

Opsoclonus-myoclonus syndrome: correlation of radiographic and pathological observations

We report a case of a child with opsoclonus-myoclonus syndrome. Neuroradiological studies indicated a lesion in the cerebellar vermis. A cerebellar biopsy revealed changes consisting of Purkinje and granular cell loss with gliosis. This case report documents the correlation of radiologic and pathological findings in a patient with opsoclonus-myoclonus syndrome.

Low morbidity and mortality of status epilepticus in children

In an ongoing study of status epilepticus, 193 children with status epilepticus of varying causes have been followed up for a mean period of 13.2 months. Of these, 97 patients were recruited prospectively. The patients' ages ranged from 1 month to 18 years (mean, 5.0 years). The cause of the status epilepticus was classified as idiopathic in 46 cases, remote symptomatic in 45, febrile in 46, acute symptomatic in 45, and progressive neurologic in 11. The mortality and incidence of sequelae following status epilepticus was low and primarily a function of etiology. Seven children died within 3 months of having the seizure. New neurologic deficits were found in 17 (9.1%) of the 186 survivors. All of the deaths and 15 of the 17 sequelae occurred in the 56 children with acute or progressive neurologic insults. Only two of the 137 children with other causes sustained any new deficits (P less than .001). Duration of the status epilepticus affected outcome only within the acute symptomatic group (P less than .05). Neurologic sequelae occurred in 29% of infants younger than 1 year of age, 11% of children 1 to 3 years of age, and 6% of children older than 3 years of age. However, this was a reflection of the greater incidence of acute neurologic disease in the younger age groups. Within each cause, age did not affect outcome. Of the 193 children, 61 (32%) had a history of prior unprovoked seizures. Of the 125 surviving children with no history of prior unprovoked seizures, 37 (30%) had subsequent unprovoked seizures.(ABSTRACT TRUNCATED AT 250 WORDS)

Stage IV breast cancer: clinical course and survival of patients with osseous versus extraosseous metastases at initial diagnosis. The GOCS (Grupo Oncológico Cooperativo del Sur) experience

The medical records of 414 patients with metastatic breast carcinoma treated between 1978 and 1986 were reviewed and 44 women were identified as having stage IV disease when the primary breast lesion was detected. Of these 44 women, 25 had metastatic disease limited to the skeleton while 19 had extraosseous lesions only. The clinical features, response to therapy, and survival were analyzed and compared for both groups. The median survival of those patients with bone-only metastases was 52 months as compared with 13 months for those with extraskeletal lesions (p = 0.0025). The response rate to first-line systemic therapy was similar for both groups (47% for bone metastases and 44% for extraosseous metastases). The median duration of response was 14 months (range, 3-55 months) for patients with bone disease and 8 months (range, 4-43 months) for those with extraskeletal lesions. We conclude that patients with metastatic breast cancer confined to the skeleton at initial diagnosis tend to follow an indolent, chronic course with prolonged survival. Therefore the increase in response rate with aggressive chemotherapy should be balanced against its higher morbidity. Further studies are needed to confirm whether the better prognosis of these patients is determined by the anatomical confinement of the disease to the skeleton or merely reflects the influence of other prognostic factors.

Video EEG diagnosis of repetitive behavior in early childhood and its relationship to seizures

Differentiating seizures from pseudoseizures frequently is challenging in very young children manifesting repetitive, stereotypic behavior. Using video electroencephalographic recording, we evaluated 60 patients, younger than 10 years of age, with episodic signs and symptoms believed to be seizures despite repeatedly normal routine electroencephalograms. Nine patients (15%) had simple partial and atypical absence seizures. Twenty-four patients (40%) had pseudoseizures presenting as rhythmic movements or staring. Pseudoseizure frequency was greater than the frequency of true seizures; brief staring episodes were common. Motor pseudoseizures usually were of longer duration than true seizures and could be brought on with verbal encouragement. Furthermore, the stereotypic motor presentations were quite different from those of true motor seizures but were difficult to recognize from historic, clinical, and routine electroencephalographic data. Symptomatic patients can be clinically diagnosed by analyzing confirmed episodes with video electroencephalography.

Fatigue in multiple sclerosis

Fatigue is a frequent symptom in multiple sclerosis (MS) that can interfere with a patient's daily functioning. The cause of MS fatigue, its clinical characteristics, and its relationship to other symptoms remain poorly understood. Structured interviews were conducted with 32 patients with MS and 33 normal healthy adults. Fatigue proved to be both more frequent and more severe among the patients with MS. Multiple sclerosis fatigue was unrelated to either depression or global impairment. Multiple sclerosis fatigue appears to be a distinct clinical entity, often disabling, that can be distinguished from normal fatigue, affective disturbance, and neurologic impairment.

Brain death determination by angiography in the setting of a skull defect

The absence of cerebral blood flow is presently considered the most reliable ancillary test in diagnosing brain death. A patient with an open skull fracture who met all criteria for brain death, including confirmatory postmortem studies, had a cerebral angiogram that showed unilateral preservation of cerebral circulation with diffuse extravasation of contrast material. We conclude that a skull defect may result in pressure reduction within the cranial cavity and persistent ipsilateral cerebral circulation, even after brain death. In this setting, diffuse extravasation of contrast material on angiography may reflect diffuse autolysis and suggest the diagnosis of brain death.

EEG and brain death determination in children

In a retrospective study involving several medical centers we identified 52 patients under age 5 years who met the adult clinical criteria for brain death and had at least one EEG with electrocerebral silence. Of the 52 patients, 31 died spontaneously and 21 were disconnected from the respirator. Repeat EEGs were obtained in 28 patients, and in all electrocerebral silence persisted. The study suggests that clinical criteria similar to those used for adults in the determination of brain death can also be applied to children above age 3 months and that a single EEG with electrocerebral silence is sufficient to confirm brain death in this age group.

Computed tomography of the brain in the Smith-Lemli-Opitz syndrome

Computed tomographic (CT) scans of the brain in a child with Smith-Lemli-Opitz syndrome revealed enlargement of the ventricular system, hypoplasia of the cerebellum, and abnormal thickening of the gray matter, consistent with pachygyria. These findings have been previously noted in autopsies performed on patients with this disorder. We conclude that CT scanning is a valuable tool in the evaluation of children suspected of having the Smith-Lemli-Opitz syndrome.

External hydrocephalus: radiologic spectrum and differentiation from cerebral atrophy

External hydrocephalus (EH) is a condition in which infants with rapidly enlarging heads are found to have a CT scan that shows widening of the subarachnoid space with mild or no ventricular dilation. In this study, 74 infants with EH associated with a variety of conditions were examined clinically and with CT scans to identify the radiologic features of the condition as well as to understand its clinical and radiologic evolution. Some of these CT scans were compared with those of patients with cerebral atrophy. The characteristic CT findings in EH were bifrontal widening of the subarachnoid space and widened interhemispheric fissure frontally with only mild enlargement of the rest of the subarachnoid space. Occasional mild to moderate ventriculomegaly was also present. In most cases the radiologic findings could be distinguished from those seen in cerebral atrophy, even without the clinical history of an enlarging head. The cases of cerebral atrophy showed prominent sulci throughout without disproportionate bifrontal widening of the subarachnoid space. Two major groups of infants are identified. The largest group (47) consisted of infants with primary megaloencephaly. Megaloencephaly was idiopathic in 40 infants, many of whom (19) met the criteria for benign familial macrocephaly. Others (7) had a clearly defined genetic syndrome. The radiologic abnormalities in these infants usually disappear by 2 years of age. The other major group (14) consisted of infants who sustained CNS or systemic insults such as subdural hematomas (8) or meningitis (3), which cause impaired CSF absorption. Thirteen premature infants with EH were also identified. It is concluded that EH is an age-related self-limited condition occurring in infants with open cranial sutures and that usually resolves without intervention by 2-3 years of age.

Ependymal foldings and other related ependymal structures in the cerebral aqueduct and fourth ventricle of man

The ependymal lining of the cerebral aqueduct and fourth ventricle of 100 normal humans was studied with the light microscope. Ependymal foldings with normal morphology and a constant distribution pattern were detected in all. The most common sites were the median sulcus and sulcus limitans in the fourth ventricle, and the ventral and lateral walls in the cerebral aqueduct. Rows, islands and rosettes of ependymal cells embedded in normal subependyma were present in 25/82 adults (30%) and in 3/18 children (16%) in a similar distribution pattern as that of the ependymal foldings. We illustrate these normal structures which probably result from fusion between the walls of the ependymal foldings and distinguish them from granular ependymitis and postmortem artifact.

Diagnosis of brain death in children

During the last two decades, criteria have been developed for the diagnosis of brain death that are applicable to adults and children over 5 years of age. To identify brain death, EEG and evoked potentials (EPs) have been extensively used as diagnostic tools in conjunction with the clinical examination and other laboratory procedures such as four-vessel cerebral angiograms or radionuclide scans. In this report, we review the criteria for the determination of brain death. In addition, the question of applying these criteria to children under 5 years of age is critically assessed, with special emphasis on the role of EEG and EPs in confirming the cessation of all brain activities. We propose that the criteria that pertain to adults may be appropriate for children under 5 years of age as well; however, this premise needs to be validated by a large nationwide multi-institutional study.

Miller-Dieker syndrome: a disorder affecting specific pathways of neuronal migration

A patient with the typical craniofacial features and clinical course of Miller-Dieker syndrome (MDS) was found on autopsy to have focal pachygyria rather than lissencephaly. The brainstem and cerebellum were hypoplastic, but thalami and basal ganglia were normal. We believe that MDS is a syndrome in which multiple specific pathways of neuronal migration are affected selectively, such as migration to the neocortex, migration via corpus pontobulbare, and cerebellar migration. However, another migration pathway (via corpus gangliothalamicum) is spared.

Valproic acid in the treatment of Sydenham chorea

Severe cases of Sydenham chorea are still difficult to manage because optimal therapy has not been found. In this report severe chorea responded to valproic acid therapy after trials with diazepam and haloperidol had failed. The literature is reviewed and the possible mechanism of action of valproate in this movement disorder is discussed. Valproic acid is proposed as an effective treatment for severe cases of Sydenham chorea.