Altered blood-brain barrier transport of nanotherapeutics in lysosomal storage diseases

Treatment of neurological lysosomal storage disorders (LSDs) are limited because of impermeability of the blood-brain barrier (BBB) to macromolecules. Nanoformulations targeting BBB transcytosis are being explored, but the status of these routes in LSDs is unknown. We studied nanocarriers (NCs) targeted to the transferrin receptor (TfR), ganglioside GM1 or ICAM1, associated to the clathrin, caveolar or cell adhesion molecule (CAM) routes, respectively. We used brain endothelial cells and mouse models of acid sphingomyelinase-deficient Niemann Pick disease (NPD), and postmortem LSD patients' brains, all compared to respective controls. NC transcytosis across brain endothelial cells and brain distribution in mice were affected, yet through different mechanisms. Reduced TfR and clathrin expression were found, along with decreased transcytosis in cells and mouse brain distribution. Caveolin-1 expression and GM1 transcytosis were also reduced, yet increased GM1 levels seemed to compensate, providing similar NC brain distribution in NPD vs. control mice. A tendency to lower NHE-1 levels was seen, but highly increased ICAM1 expression in cells and human brains correlated with increased transcytosis and brain distribution in mice. Thus, transcytosis-related alterations in NPD and likely other LSDs may impact therapeutic access to the brain, illustrating the need for these mechanistic studies.

Functional outcome and complications after treatment of comminuted tibial fractures or deformities using Ilizarov bone transport: a single-center study at 15- to 30-year follow-up

INTRODUCTION

The aim of this retrospective study was to evaluate long-term outcomes and complications of a single-center and single-surgeon patient series of isolated and comminuted tibial fractures with bone defects or tibial deformities treated by Ilizarov bone transport.

MATERIALS AND METHODS

Data from a consecutive series of patients with isolated comminuted tibial fractures (Fracture Group: FG) or deformities (Deformity Group: DG) treated between 1987 and 2002 were included. For clinical assessment, the Lower Extremities Functional Scale was used; complications were recorded according to the Dindo classification and statistical analysis was performed.

RESULTS

Overall, 72 patients were enrolled with a mean follow-up of 21.6 years (range 15-30) a mean LEFS of 36.4 (range 0-100). In the FG, the mean LEFS was 21.3 (range 0-98.75), and the external fixation time (EFT) lasted 7.6 months (range 3-18 months) months. In the DG, the mean LEFS was 76.7 (range 55-100), and the EFT was 10.6 months (range 3-20 months). Between the two groups, the clinical evaluation was significantly different, while the EFT was not (p = 0.14). In the FG, the worst results were obtained in the cases of open fractures with a higher percentage of complications and the need for further surgical procedures. The cumulative rate of complications was 55.6% during the first 36 months and 66.7% at the minimum follow-up of 180 months.

CONCLUSIONS

Ilizarov bone transport, even at a long follow-up period, proved to be an effective technique for both definitive treatment of comminuted tibial fractures with bone defects or tibial deformities. Although our functional outcomes were lower in patients with exposed fractures, they were in line with the literature, but not influenced by the EFT when properly managed. Most complications occurred during the first 3 years; however, they could also arise much later, even until almost 30 years.

Mobile robotic platforms for the acoustic tracking of deep-sea demersal fishery resources

Knowing the displacement capacity and mobility patterns of industrially exploited (i.e., fished) marine resources is key to establishing effective conservation management strategies in human-impacted marine ecosystems. Acquiring accurate behavioral information of deep-sea fished ecosystems is necessary to establish the sizes of marine protected areas within the framework of large international societal programs (e.g., European Community H2020, as part of the Blue Growth economic strategy). However, such information is currently scarce, and high-frequency and prolonged data collection is rarely available. Here, we report the implementation of autonomous underwater vehicles and remotely operated vehicles as an aid for acoustic long-baseline localization systems for autonomous tracking of Norway lobster (Nephrops norvegicus), one of the key living resources exploited in European waters. In combination with seafloor moored acoustic receivers, we detected and tracked the movements of 33 tagged lobsters at 400-m depth for more than 3 months. We also identified the best procedures to localize both the acoustic receivers and the tagged lobsters, based on algorithms designed for off-the-shelf acoustic tags identification. Autonomous mobile platforms that deliver data on animal behavior beyond traditional fixed platform capabilities represent an advance for prolonged, in situ monitoring of deep-sea benthic animal behavior at meter spatial scales.

Challenging Surgical Treatment of Displaced Articular Tibial Plateau Fractures: Do Early Knee Radiographic Features Have a Predictive Value of the Mid-Term Clinical Functional Outcomes?

Objective

To evaluate mid‐term radiographic and functional outcomes of tibial plateau fracture (TPF) patients treated with the open reduction internal fixation (ORIF) technique and to find predictive factors of clinical outcomes.

Methods

A retrospective, single‐center study was performed enrolling a consecutive series of patients with diagnosis of TPF. All subjects were treated by ORIF between January 2010 and December 2015 at our level‐1 healthcare trauma center. The inclusion criteria were: age between 18 and 75 years; ORIF technique used for articular TPF, type 41‐B and 41‐C, isolated or with associated injuries. The patients were divided in two groups, according to fracture patterns and compared. Their characteristics, radiographic and clinical outcomes were recorded. Radiographs 12 months after surgery were evaluated for reduction and alignment, and radiographs at 24 months to describe post‐traumatic osteoarthritis (PTOA). Functional outcomes were assessed using the visual analog scale (VAS), the Short Form 36 (SF‐36), the knee injury and osteoarthritis outcome score (KOOS), and the American Knee Society score (AKSS) questionnaires. Return to work and sport activities were also investigated. Univariate and multivariate analysis were performed, and the statistical significance was defined as two‐tailed P < 0.05.

Results

Forty‐five patients were included, 29 males and 16 females; the mean age was 54.5 years. The mean follow‐up was 57.18 months (range, 26–94). There were AO 41‐B fractures (partial articular fractures) in more than half of the patients (66.67%), while the remaining 15 had AO 41‐C fractures (complete articular fractures). The sub‐type AO 41‐B3 was the most common, reported in 62.22% of patients. The mean KOOS score was 69.0. Mean AKSS and SF‐36 PCS scores were 79.0 and 41.4, respectively. There were significant relationships between age and functional results (KOOS ADL, Sport, QoL, and SF‐36 PCS) and between BMI and KOOS Pain, ADL, Sport, and QoL. No differences were found between the two types of fractures regarding quality of reduction and alignment. AO 41‐C TPF tend to develop PTOA more frequently with respect to 41‐B fractures, while type AO 41‐C TPF had the worst clinical outcomes. We found that the presence of an articular step‐off and the malalignment of the tibial axis after surgery were predictive of daily pain felt by patients. PTOA was predictive of a worse AKSS. The overall complication rate was 13.33%: 1 superficial wound infection, 1 deep vein thrombosis, and 4 cases of transitory deficit of the common peroneal nerve.

Conclusion

The present study demonstrates that early radiographic features may be predictive for pain perceived by patients at mid‐term follow‐up.

Salbutamol tolerability and efficacy in patients with spinal muscular atrophy type II

Spinal muscular atrophy (SMA) is an autosomal recessive disease caused by homozygous deletions or loss-of-function mutations in SMN1, which result in a degeneration of motor neurons in the spinal cord and brain stem. Even without a randomized placebo-controlled trial, salbutamol has been offered to patients with SMA in the neuromuscular clinics of most of hospitals for many years. We describe the response to salbutamol in 48 patients with SMA type II who were not taking any other medication. We investigate the changes over an eighteen-month period in motor functional scales and we analyze side effects and subjective response to treatment. Our results suggest that oral administration of salbutamol might be helpful in the maintenance of motor function in patients with SMA type II. An apparent beneficial effect was observed in functional scales of children under the age of 6, especially during the first 6 months of therapy. The majority of patients of all ages referred some kind of subjective positive effect associated with therapy intake. Salbutamol seemed safe and was well tolerated without serious side effects.

A Randomised Trial of Subcutaneous Low Molecular Weight Heparin (CY 216) Compared with lntravenous Unfractionated Heparin in the Treatment of Deep Vein Thrombosis

The standard treatment of deep vein thrombosis is given by continuous intravenous infusion of unfractionated heparin. This entails hospitalisation, nursing care, immobility and repeated laboratory tests (e.g. activated partial thromboplastin time [APTT], platelet count). In addition approximately 10% of patients suffer major haemorrhages. The potential advantages of a low molecular weight heparin (CY 216) given subcutaneously were explored in a randomised trial with blind quantitative evaluation of venograms. The study included 166 patients and both “therapeutic efficacy” and “intention to-treat” analyses showed that subcutaneous CY 216 in fixed doses based only on body weight was more effective on the Arnesen and Marder phlebographic scores than continuous i. v. standard heparin with daily dose adjustment according to results of coagulation tests. There was no increase in the risks of pulmonary embolism, haemorrhage or clot extension.

Failure of Computerized Impedance Plethysmography in the Diagnostic Management of Patients with Clinically Suspected Deep-Vein Thrombosis

Before a new diagnostic modality can be introduced in clinical medicine, the validity of both a normal and abnormal test result have to be assessed prospectively in an appropriate patient group. We have evaluated the clinical validity of. a new computerized impedance plethysmography (CIP) in the diagnostic management of 381 consecutive patients with clinically suspected venous thrombosis. In patients with serially normal CIP results, the diagnosis of venous thrombosis was refuted and, consequently, they were not treated with anticoagulant therapy and all were followed up for a period of 6 months to estimate the occurrence of symptomatic venous thromboembolism.

The study was prematurely terminated by the safety monitoring committee because of an unacceptably high incidence of confirmed venous thromboembolism (10 patients, 3.2%; 95% confidence interval: 1.6% to 6%), including 4 episodes of fatal pulmonary embolism. In a subsequent explanatory study using ultrasonography in 29 other symptomatic patients who had at least 2 repeated normal CIP test results, the failure of CIP to detect proximal vein thrombosis was confirmed in 4 patients (14%). The reasons for this failure are probably related to the use of a modified device to measure impedance in the CIP apparatus, resulting in a lower ability to separate patients without venous thrombosis from those with the disease.

We concluded that CIP is insensitive for the detection of proximal vein thrombosis and, therefore, not clinically useful in the diagnostic management of patients with suspected venous thrombosis.

The One Health approach for the management of an imported case of rabies in mainland Spain in 2013

After more than 30 years without any reported cases of rabies in terrestrial carnivores in mainland Spain, an imported case was detected in June 2013 in Toledo. Although the infected dog was moved across different locations and had contact with humans and dogs, the incident was controlled within a few days. An epidemiological investigation was performed and rabies-free status in terrestrial carnivores in mainland Spain was restored six months after the incident. Key to the successful management of this case were the previous vaccination of susceptible animals in the affected area before the case was detected, the collaboration of different authorities in decision making, and the application of control measures according to national and international regulations and to the One Health concept.

Peak bone strength is influenced by calcium intake in growing rats

In this study we investigated the effect of supplementing the diet of the growing male rat with different levels of calcium (from low to higher than recommended intakes at constant Ca/P ratio), on multiple factors (bone mass, strength, size, geometry, material properties, turnover) influencing bone strength during the bone accrual period. Rats, age 28days were supplemented for 4weeks with high Ca (1.2%), adequate Ca (0.5%) or low Ca level (0.2%). Bone metabolism and structural parameters were measured. No changes in body weight or food intake were observed among the groups. As anticipated, compared to the adequate Ca intake, low-Ca intake had a detrimental impact on bone growth (33.63 vs. 33.68mm), bone strength (-19.7% for failure load), bone architecture (-58% for BV/TV) and peak bone mass accrual (-29% for BMD) due to the hormonal disruption implied in Ca metabolism. In contrast, novel, surprising results were observed in that higher than adequate Ca intake resulted in improved peak bone strength (106 vs. 184N/mm for the stiffness and 61 vs. 89N for the failure load) and bone material properties (467 vs. 514mPa for tissue hardness) but these effects were not accompanied by changes in bone mass, size, microarchitecture or bone turnover. Hormonal factors, IGF-I and bone modeling were also evaluated. Compared to the adequate level of Ca, IGF-I level was significantly lower in the low-Ca intake group and significantly higher in the high-Ca intake group. No detrimental effects of high Ca were observed on bone modeling (assessed by histomorphometry and bone markers), at least in this short-term intervention. In conclusion, the decrease in failure load in the low calcium group can be explained by the change in bone geometry and bone mass parameters. Thus, improvements in mechanical properties can be explained by the improved quality of intrinsic bone tissue as shown by nanoindentation. These results suggest that supplemental Ca may be beneficial for the attainment of peak bone strength and that multiple factors linked to bone mass and strength should be taken into account when setting dietary levels of adequate mineral intake to support optimal peak bone mass acquisition.

Hammersmith Functional Motor Scale and Motor Function Measure-20 in non ambulant SMA patients

The aim of this prospective longitudinal multi centric study was to evaluate the correlation between the Hammersmith Functional Motor Scale and the 20 item version of the Motor Function Measure in non ambulant SMA children and adults at baseline and over a 12 month period. Seventy-four non-ambulant patients performed both measures at baseline and 49 also had an assessment 12 month later. At baseline the scores ranged between 0 and 40 on the Hammersmith Motor function Scale and between 3 and 45 on the Motor Function Measure 20. The correlation between the two scales was 0.733. The 12 month changes ranged between -11 and 4 for the Hammersmith and between -11 and 7 for the Motor Function Measure 20. The correlation between changes was 0.48. Our results suggest that both scales provide useful information although they appeared to work differently at the two extremes of the spectrum of abilities. The Hammersmith Motor Function Scale appeared to be more suitable in strong non ambulant patients, while the Motor Function Measures appeared to be more sensitive to capture activities and possible changes in the very weak patients, including more items capturing axial and upper limb activities. The choice of these measures in clinical trials should therefore depend on inclusion criteria and magnitude of expected changes.

Six minute walk test in type III spinal muscular atrophy: a 12month longitudinal study

The aim of our longitudinal multicentric study was to establish the changes on the 6min walk test (6MWT) in ambulant SMA type III children and adults over a 12month period. Thirty-eight ambulant type III patients performed the 6MWT at baseline and 12months after baseline. The distance covered in 6min ranged between 75 and 510m (mean 294.91, SD 127) at baseline and between 50 and 611m (mean 293.41m, SD 141) at 12months. The mean change in distance between baseline and 12months was -1.46 (SD 50.1; range: -183 to 131.8m). The changes were not correlated with age or baseline values (p>.05) even though younger patients reaching puberty, had a relatively higher risk of showing deterioration of more than 30m compared to older patients. Our findings provide the first longitudinal data using the 6MWT in ambulant SMA patients.

Magnesium enrichment and distribution in plants

Food products enriched with stable isotopes are used in nutrition to study the metabolic fate of nutrients in humans. This study reports on the labeling of green beans, white beans, soybeans and wheat with a stable isotope of magnesium (25Mg) obtained in greenhouse conditions for further studies on magnesium bioavailability. Soybean and green bean are the most efficient plant species to obtain large amounts of edible parts rapidly with a minimum loss of labeled Mg in other parts of the plants. The results obtained showed that a relatively high percentage of the magnesium found in seeds (grains/beans) can come from the redistribution of magnesium previously accumulated in other organs.

European Lymnaeidae (Mollusca: Gastropoda), intermediate hosts of trematodiases, based on nuclear ribosomal DNA ITS-2 sequences

Freshwater snails of the family Lymnaeidae are of a great parasitological importance because of the very numerous helminth species they transmit, mainly trematodiases of large medical and veterinary impact. The present knowledge on the genetics of lymnaeids and on their parasite-host inter-relationships is far from being sufficient. The family is immersed in a systematic-taxonomic confusion. The necessity for a tool which enables species distinction and population characterization is evident. This paper aims to review the European Lymnaeidae basing on the second internal transcribed spacer ITS-2 of the nuclear ribosomal DNA. The ITS-2 sequences of 66 populations of 13 European and 1 North American lymnaeid species, including the five generic (or subgeneric) taxa Lymnaea sensu stricto, Stagnicola, Omphiscola, Radix and Galba, have been obtained. The ITS-2 proves to be a useful marker for resolving supraspecific, specific and population relationships in Lymnaeidae. Three different groupings according to their ITS-2 length could be distinguished: Radix and Galba may be considered the oldest taxa (370-406 bp lengths), and Lymnaea s. str., European Stagnicola and Omphiscola (468-491 bp lengths) the most recent, American Stagnicola and Hinkleyia being intermediate (434-450 bp lengths). This hypothesis agrees with the phylogeny of lymnaeids based on palaeontological data, chromosome numbers and radular dentition. ITS-2 sequences present a conserved central region flanked by two variable lateral regions corresponding to the 5' and 3' ends. The number of repeats of two microsatellites found in this conserved central region allows to differentiate Radix from all other lymnaeids. Phylogenetic trees showed four clades: (A) Lymnaea s. str., European Stagnicola and Omphiscola; (B) Radix species; (C) Galba truncatula; and (D) North American stagnicolines. ITS-2 results suggest that retaining Stagnicola as a subgenus of Lymnaea may be the most appropriate and that genus status for Omphiscola is justified. Radix shows a complexity suggesting different evolutionary lines, whereas G. truncatula appears to be very homogeneous. North American and European stagnicolines do not belong to the same supraspecific taxon; the genus Hinkleyia may be used for the American stagnicolines. Genetic distances and sequence differences allowed us to distinguish the upper limit to be expected within a single species and to how different sister species may be. S. palustris, S. fuscus and S. corvus proved to be valid species, but S. turricula may not be considered a species independent from S. palustris. Marked nucleotide divergences and genetic distances detected between different S. fuscus populations may be interpreted as a process of geographic differentiation developping in the present. Among Radix, six valid species could be distinguished: R. auricularia, R. ampla, R. peregra (=R. ovata;=R. balthica), R. labiata, R. lagotis and Radix sp. The information which the ITS-2 marker furnishes is of applied interest concerning the molluscan host specificity of the different trematode species. The phylogenetic trees inferred from the ITS-2 sequences are able to differentiate between lymnaeids transmitting and those non-transmitting fasciolids, as well as between those transmitting F. hepatica and those transmitting F. gigantica. The Fasciola specificity is linked to the two oldest genera which moreover cluster together in the phylogenetic trees, suggesting an origin of the Fasciola ancestors related to the origin of this branch. European Trichobilharzia species causing human dermatitis are transmitted only by lymnaeids of the Radix and Lymnaea s. str.-Stagnicola groups. Results suggest the convenience of reinvestigating compatibility differences after accurate lymnaeid species classification by ITS-2 sequencing. Similarly, ITS-2 sequencing would allow a step forward in the appropriate rearrangement of the actual systematic confusion among echinostomatids.

[Evaluation of tracheobronchial lesions with spiral CT: comparison between virtual endoscopy and bronchoscopy]

INTRODUCTION

The aim of this study is to describe the scanning parameters for virtual bronchoscopy in the evaluation of the tracheobronchial tree and to compare the results of this examination with the endoscopic findings.

MATERIAL AND METHODS

27 patients with tracheobronchial neoplasms suspected at preliminary clinical and chest film findings or postoperative follow-up for malignant disease were evaluated with spiral CT of the chest and bronchoscopy. Virtual endoscopy was performed on the pulmonary volume involved by the lesion, using narrow axial images (thickness 2 mm, table index 3 mm, reconstruction index 1 mm.) so as to obtain MPR, MIP and 3D reconstructions with 3D Endo Vew program (Philips Medical System, Eindhoven, Holland). We compared these reconstructions and the findings the normal spiral CT scanning with the corresponding endoscopic examinations.

RESULTS

In all patients we were able to study the lobar and segmental bronchi in all patients and in 2 we also evaluated the subsegmental bronchi. 25 lesions in 23 patients were shown by virtual endoscopy (8 occlusions, 8 stenosis, 5 compressions, 3 flogosis with endobronchial mucus, 1 bronchocele) and in 4 patients the examinations were negative. The bronchoscopy was negative in 4 patients and positive in 23 patients with 25 lesions, but we had agreement in 23/27 patients (85,1%). In 2 patients virtual endoscopy showed the lesions in a different bronchus compared to bronchoscopy. In one patient we interpreted the obstruction as neoplastic instead of mucus inside the bronchi and in the last patient bronchoscopy was not performed due to his old age and the virtual endoscopy showed total obstruction of a segmental bronchus.

DISCUSSION AND CONCLUSIONS

The results show that virtual endoscopy can study the tracheobronchial tree as far as the segmental bronchi, and sometimes also the subsegmental bronchi and the bronchi below a closed obstruction. In addition, it can evaluate the extraluminal location of the lesions. For these reasons virtual endoscopy provides a road map for bronchoscopy as a guide for transbronchial biopsy and for endobronchial treatment planning. The limitation of this technique is its inability to evaluate the mucosal surface and distinguish flogosis from neoplastic lesions by biopsy. It can be used however in the postoperative follow-up both for cancer and transplant, when immediate biopsy is not necessary.

[Pleural and parenchymal lung diseases from asbestos exposure. CT diagnosis]

INTRODUCTION

We report the CT findings of parenchymal and pleural diseases in a group of patients with a history of asbestos exposure, excluding lung cancer (which is not typical in this subjects) and asbestosis (which is a parenchymal fibrosis).

MATERIAL AND METHODS

We retrospectively reviewed a series of CT examinations (conventional, helical and high resolution scans) of 21 patients examined from 1995 to 1999. They had pleural plaques (10), round atelectasis (2) and malignant pleural mesothelioma (9). All patients had a history of direct or indirect asbestos exposure, except one with malignant pleural mesothelioma. We evaluated the following CT findings: nodular, plaque or uniform pleural thickening; pleural calcifications; pleural thickening less or greater than 1 cm; pleural margins (regular, polycyclic, spiculated); localization (uni/bilateral hemithorax); distribution (upper, medium or lower region); pulmonary, mediastinal and diaphragmatic involvement; fissural involvement; pleural effusion; lymph node enlargement; lung mass with the comet-tail sign; lung volume (normal, reduced, increased).

RESULTS

Pleural plaques were always bilateral and less than 1 cm thick, with calcifications in 80% of the cases. Margins were always regular, polycyclic in 40% of the patients and never irregular. The pulmonary pleura in the mid-chest was involved in cell cases the diaphragmatic pleura in the 50% of the cases and the upper and lower regions in 60% and 80% of the patients, respectively. Round atelectasis (3 cases in 2 patients) was always shown as a parenchymal mass in the lower lobes, posteriorly or posteromedially, with adjacent pleural thickening; its diameter ranged 4.4-6 cm and there was the comet-tail sign. In malignant pleural mesothelioma we always found pleural effusion, with unilateral pleural effusion being the only sign in 2 patients. Other findings were pleural nodules (77.7%), with spiculated (22.2%) and polycyclic (77.7%) margins, more than 1 cm in diameter. The disease was always unilateral. The parenchymal pleural was involved in 77.7% of the cases while the mediastinal and diaphagmatic pleura were involved in 44.4% of the patients. Fissural involvement was demonstrated in 66.6% of the patients. Lymph nodes were enlarged in 66.6% of the cases. The volume of the affected hemithorax was increased (22.2%), decreased (44.4%) or normal (33.3%).

DISCUSSION AND CONCLUSIONS

The presence of pleural plaques is a specific sign of asbestos exposure. Round atelectasis may also indicate asbestos exposure, but it can be found in many diseases with pleural inflammation, such as tuberculous effusion, trauma, pulmonary infarct, congestive heart failure, coronary artery bypass. The CT patterns of these two diseases are typical and no other finding is necessary to confirm the diagnosis. CT-guided needle biopsy is needed only if the round atelectasis has an atypical appearance on CT images, that is without the comet-tail sign. Malignant pleural mesothelioma is strongly associated with previous occupational exposure and presents typical CT findings only in an advanced stage (irregular and nodular pleural thickening, pleural effusion, mediastinal and pulmonary contraction for tumor encasement, parenchymal and lymph node metastases), but the differential diagnosis with pleural metastatic disease can be difficult. CT plays an important role in tumor assessment but biopsy is necessary for lesion characterization.

Seasonality of marriages in Spanish and French parishes in the Cerdanya valley, eastern Pyrenees

The Cerdanya valley in the eastern Pyrenees has a physical unity into which a political frontier has been imposed to divide it. The social and cultural repercussions of this Franco-Spanish border have created obstacles to marriage which are not due to topography. Choice of month of marriage is under cultural control and the study of seasonality in marriages recorded in the registers of all the Cerdan parishes on both sides of the border demonstrated differences over time and between French and Spanish sectors. It is suggested that these changes demonstrate the process of distancing of the two populations. Cluster and correspondence analysis showed progressive differentiation of the seasonality patterns of the French and Spanish Cerdans despite the geographic unity of the valley. Sociocultural factors are presumed responsible.

Cerdanya: mountain valley, genetic highway

In this paper the records of 7844 marriages in the parishes of French and Spanish sectors of the Cerdanya Valley have been analysed. The Cerdanya is an eastern Pyrenean valley, today divided by the Franco-Spanish border, but once united within Catalonia. The results have been reported on the one hand on a small scale using local place names, and on the other hand on a wider scale across France and Spain, because interest lies both in the geographic range from which some marital partners have come and in the relative proportions of brides and grooms from the French and Spanish parts of Cerdanya and from adjacent districts. Both mountains and the Franco-Spanish border are shown to have reduced the likelihood of marriage. Inaccessible mountain barriers appear to have been a greater obstacle to marital movement than the border. Adjacent districts and local provinces have provided a greater proportion of brides and grooms than more distant ones, but thereafter frequencies from the further regions do not decrease with greater distance. More marital partners have moved from Spain to France than vice-versa, and mobility of grooms exceeded mobility of brides. Results are relevant to genetics and the current European interest in nationality and ethnicity.

Calcium bioavailability from a calcium- and sulfate-rich mineral water, compared with milk, in young adult women

Some mineral waters have a high calcium content and may contribute a significant part of the human daily requirements. Calcium bioavailability from a calcium- and sulfate-rich mineral water (CS-W) containing 11.2 mmol Ca/L (467 mg/L) was compared with that from milk in nine healthy young women. Calcium absorption was measured in the fasting state with a dual-label stable-isotope technique. Fractional absorption rates from milk and CS-W were 25.0 +/- 6.7% and 23.8 +/- 4.8% (means +/- SD), respectively, and did not differ significantly (P = 0.05). Urine was collected for 36 h after the administration of the oral stable isotope while the subjects consumed a controlled diet and a quantity of milk or CS-W providing 25 mmol (1000 mg) Ca. No significant difference was found in the excretion of calcium, nor in the excretion of the two stable isotopes. Mean urinary sulfate excretion was significantly increased by 35% when the CS-W was consumed. No significant correlation was found between 36-h urinary excretion of the intravenous calcium tracer and sulfate, sodium, or urine volume. Therefore, calcium from the CS-W was as well absorbed and retained as that from milk, and no calciuric effect of sulfate was found, showing that such mineral waters can be valuable dietary sources of calcium.

Changing features of proximal vein thrombosis over time

Recently, the sensitivity of impedance plethysmography (IPG) for the diagnosis of acute deep-vein thrombosis (DVT) in symptomatic outpatients has been questioned. In order to verify whether a change in the venographic pattern of DVT has occurred over years, accounting for the decreased sensitivity of IPG, the authors compared two series of consecutive venograms demonstrating proximal DVT, performed between 1984-1988 (166 patients) and 1990-1992 (140 patients). They evaluated both the extension and the occlusiveness of deep-vein thrombi in the two series. Moreover, changes in the referral characteristics of patients were investigated. In the second series of venograms a significant decrease in thrombi extension, expressed by a lower prevalence of iliac vein thrombosis (29% versus 43%; P = 0.0074) was observed; moreover, a significant increase in the prevalence of nonocclusive thrombi (22% versus 8%; P = 0.0004) was also recorded in the second series when compared with the first. During the study period, among the referral characteristics of patients, the authors observed both a significant decrease in the prevalence of proximal DVT (from 31% to 24%; P < 0.01) and a slight and not statistically significant decrease in the median time elapsed between onset of symptoms and referral for objective testing (from eight and a half to seven days). In conclusion, proximal deep-vein thrombi are currently less extensive and occlusive than observed in the past. These results might depend on earlier referral of less symptomatic patients and might explain the recently reported decrease in IPG sensitivity for proximal DVT.

[Role of echography and phlebography in the assessment of patients with clinically suspected deep venous thrombosis of the legs]

The roles of US and venography in the evaluation of the patients with clinical suspicion of deep venous thrombosis are discussed relative to personal and literature data. The patients were divided into three groups: outpatients with previous history of venous thrombosis (group I), inpatients without previous history of venous thrombosis (group II) and patients with suspected recurrent venous thrombosis (group III). In group I, compression US yielded very good results: so much so that it can replace venography. In this group of patients, pulsed Doppler added no significant information, while color-Doppler appeared to be a valuable technique. As for the other two groups, venography was confirmed as the most useful technique, even though MR imaging is likely to play, in the future, an important role, since it allows better demonstration of the central thrombus, especially in diffuse occlusive thromboses.

Primary rhabdomyosarcoma of the diaphragm. Report of a case presenting with hemothorax

A rare case of embryonal rhabdomyosarcoma of the diaphragm occurring in an adult male and presenting with hemothorax is reported. The unusual clinical features of this patient underline the need for an accurate preoperative evaluation. The surgical procedure consisted of left thoracotomy with resection of the neoplasm, including a portion of the diaphragm muscle, and then reconstruction. One month after discharge chemo- and radiotherapy were carried out. The immunohistochemical study proved to be very helpful for the pathological diagnosis. A three years follow-up with patient alive and disease-free confirms that a multimodal approach may prove effective in the long term.

Comparison of subcutaneous low-molecular-weight heparin with intravenous standard heparin in proximal deep-vein thrombosis

In view of the potential of low-molecular-weight heparins (LMWH) to simplify initial therapy and allow outpatient treatment of proximal deep-vein thrombosis, we undertook a randomised comparison of fixed-dose subcutaneous LMWH with adjusted-dose intravenous standard heparin in the initial treatment of this disorder. Our main objectives were to compare the efficacy of these regimens for 6 months of follow-up and to assess the risk of clinically important bleeding. Of 170 consecutive symptomatic patients with venographically proven proximal deep-venous thrombosis, 85 received standard heparin (to achieve an activated partial thromboplastin time of 1.5 to 2.0 times the pretreatment value) and 85 LMWH (adjusted only for body weight) for 10 days. Oral coumarin was started on day 7 and continued for at least 3 months. The frequency of recurrent venous thromboembolism diagnosed objectively did not differ significantly between the standard-heparin and LMWH groups (12 [14%] vs 6 [7%]; difference 7% [95% confidence interval -3% to 15%]; p = 0.13). Clinically important bleeding was infrequent in both groups (3.5% for standard heparin vs 1.1% for LMWH; p greater than 0.2). We conclude that fixed-dose subcutaneous LMWH is at least as effective and safe as intravenous adjusted-dose heparin in the initial treatment of symptomatic proximal-vein thrombosis. Since there is no need for laboratory monitoring with the LMWH regimen, patients with venous thrombosis can be treated at home.

Contrast venography, the gold standard for the diagnosis of deep-vein thrombosis: improvement in observer agreement

To determine whether the Rabinov-Paulin or the long-leg venography technique should be preferred in the diagnostic management of patients with clinically suspected deep-vein thrombosis, two independent experienced radiologists blindly assessed two different series of venograms of consecutive outpatients with clinically suspected deep-vein thrombosis. Venograms were obtained from two outpatient clinics of primary referral centres. In one centre the venograms were performed according to the technique of Rabinov and Paulin with the use of 100 ml of radiographic material and spot films of the calf, popliteal and more proximal veins. In the other centre, long-leg films were obtained after the administration of 150 ml of contrast material. The percentage venograms adjudicated as inadequate by at least one radiologist and inter-observer disagreement for both series were used as the main study outcome measures. Prior to the study, both radiologists agreed on the standardized criteria for a normal, abnormal and inadequate test result using a separate set of films. An inadequacy rate of 20% was found for the Rabinov-Paulin venography series (n = 123), whereas only 2% of the 126 long-leg films were inadequate for interpretation (p less than 0.001). The inter-observer diagreement for inadequacy, presence or absence of deep-vein thrombosis was 21% for the Rabinov and Paulin venograms and 4% for the long-leg films (kappa, 0.65 and 0.92; 95% confidence intervals: 0.53 to 0.77 and 0.84 to 0.99, respectively; p less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)

A new computerized impedance plethysmograph: accuracy in the detection of proximal deep-vein thrombosis in symptomatic outpatients

Because of the lack of specificity of the clinical diagnosis it is appropriate in patients with clinically suspected deep-vein thrombosis to apply an objective test before starting anticoagulant treatment. Impedance plethysmography is a highly accurate technique for the detection of proximal-vein thrombosis with a reported sensitivity and specificity of 93 and 97%, respectively. In all previous reported evaluations of impedance plethysmography an apparatus which was developed in 1971 was used. A new computerized impedance plethysmography, using a novel device to measure impedance, was blindly compared against venography in 443 consecutive outpatients with clinically suspected deep-vein thrombosis. In the first phase of the study the computerized impedance plethysmography test results of 242 symptomatic patients were used to develop a discriminant line. Subsequently, this discriminant line was validated in the second phase of the study in another 201 symptomatic patients. The combined sensitivity and specificity of these two phases for proximal-vein thrombosis was 91% [95% confidence interval (CI), 86 to 94%] and 94% and (95% CI, 90 to 96%), respectively, which compares favourably with impedance plethysmography. It is concluded that computerized impedance plethysmography is a simple, portable, non-invasive technique with a high accuracy for the detection of proximal vein thrombosis. However, before computerized impedance plethysmography can be used as the only test in the diagnosis of deep-vein thrombosis, the safety of withholding anticoagulant treatment to patients with repeated normal computerized test results should be assessed during long-term follow-up studies.

Failure of computerized impedance plethysmography in the diagnostic management of patients with clinically suspected deep-vein thrombosis

Before a new diagnostic modality can be introduced in clinical medicine, the validity of both a normal and abnormal test result have to be assessed prospectively in an appropriate patient group. We have evaluated the clinical validity of a new computerized impedance plethysmography (CIP) in the diagnostic management of 381 consecutive patients with clinically suspected venous thrombosis. In patients with serially normal CIP results, the diagnosis of venous thrombosis was refuted and, consequently, they were not treated with anticoagulant therapy and all were followed up for a period of 6 months to estimate the occurrence of symptomatic venous thromboembolism. The study was prematurely terminated by the safety monitoring committee because of an unacceptably high incidence of confirmed venous thromboembolism (10 patients, 3.2%; 95% confidence interval: 1.6% to 6%), including 4 episodes of fatal pulmonary embolism. In a subsequent explanatory study using ultrasonography in 29 other symptomatic patients who had at least 2 repeated normal CIP test results, the failure of CIP to detect proximal vein thrombosis was confirmed in 4 patients (14%). The reasons for this failure are probably related to the use of a modified device to measure impedance in the CIP apparatus, resulting in a lower ability to separate patients without venous thrombosis from those with the disease. We concluded that CIP is insensitive for the detection of proximal vein thrombosis and, therefore, not clinically useful in the diagnostic management of patients with suspected venous thrombosis.

[Diagnosis of deep venous thrombosis of the legs: accuracy of ultrasonography using vein compression]

We prospectively compared real-time US findings with venographic results in the legs of 171 consecutive outpatients with clinically suspected deep venous thrombosis (DVT). In each leg the common femoral and the popliteal veins were evaluated with venography and US. The two examinations were independently performed and reviewed. Vein compressibility (VC), intraluminal echogenicity and response to Valsalva maneuver were evaluated with US. Venography detected DVT in 54/171 legs. 10/54 legs had isolated distal DVT. With VC, US was 100% specific, 87% sensitive and 96% accurate. 6/7 false negative US studies were due to isolated distal DVT; therefore US sensitivity for proximal DVT was 98%. The other two US diagnostic criteria were much less accurate than VC. VC-US is an accurate, cheap and reproducible test for the detection of DVT in symptomatic outpatients.

Diagnosis of deep-vein thrombosis using an objective Doppler method

STUDY OBJECTIVE

To determine the diagnostic criteria (phase I) and to assess the accuracy (phase II) of an objective Doppler-Valsalva pressure method as compared with contrast venography for the diagnosis of acute deep-leg-vein thrombosis in symptomatic outpatients.

DESIGN

A two-phase prospective study in consecutive patients. Doppler ultrasound strip-chart recordings and venograms were independently analyzed by experienced observers.

SETTING

Referral-based medical clinics at university medical centers.

PATIENTS

One hundred and ten (phase I) and one hundred and fifty-five (phase II) patients who had clinically suspected venous thrombosis and were referred by their general practitioners were included.

METHODS AND MEASUREMENTS

A normal Doppler test result was defined as a cyclic spontaneous signal (S-signal), a continuous S-signal with a Valsalva pressure of less than 6.5 mm Hg, or an absent S-signal with flow after cessation of the Valsalva maneuver. A continuous S-signal with a Valsalva pressure of 6.5 mm Hg or more or an absent S-signal without flow after cessation of the Valsalva maneuver were defined as abnormal test results. The accuracy indices for proximal vein thrombosis in phase II (155 patients; prevalence, 31%) were sensitivity, 91% (95% CI, 79% to 98%), and specificity, 99% (CI, 97% to 100%). All 3 patients with isolated calf-vein thrombosis had normal Doppler test results.

CONCLUSIONS

The objective Doppler method is an accurate, reproducible, and simple method for detection of venous thrombosis in symptomatic outpatients.

Treatment of deep venous thrombosis by fixed doses of a low-molecular-weight heparin (CY216)

Ninety consecutive outpatients with acute proximal and/or distal deep-vein thrombosis (DVT), as shown by phlebography, were entered into a prospective randomized trial comparing intravenous adjusted unfractionated heparin (UFH) with subcutaneous fixed doses of a low-molecular-weight heparin (CY216; 225 IC anti-Xa U/kg 12 hourly) for 10 days. The incidence of pulmonary embolism did not differ in the two groups (one episode per group). The comparison between pre- and posttreatment venograms and perfusion lung scans showed a statistically significant improvement (p less than 0.01 and p less than 0.05, respectively) only in the CY216-treated group. The incidence of major adverse reactions (major hemorrhages, relevant hemoglobin fall, and serious thrombocytopenia) was significantly higher (22 vs. 4.5%; p = 0.01) in the UFH-treated group. After a mean follow-up period of 2 years, the incidence of thromboembolic recurrences and that of post-thrombotic manifestations did not differ in the two groups. It is concluded that subcutaneous fixed doses of CY216 are more effective and safer than intravenous adjusted UFH in the treatment of acute DVT.

CT diagnosis of spontaneous dissection of the superior mesenteric artery

We report two cases of spontaneous superior mesenteric artery dissection diagnosed by CT. In both cases lamination of the arterial wall and enhancement of both true and false lumina were the key to the diagnosis.

[The side effects of phlebography of the lower extremities using iohexol. A prospective study]

In this prospective study 463 consecutive outpatients, who had undergone phlebography because of clinically suspected deep venous thrombosis (DVT) were examined with clinical follow-up and impedance plethysmography to evaluate the rate of contrast media complications. Seventy-nine patients had immediate and mild side effects, and one had moderate side effects (bronchospasm); no patient suffered from severe life-threatening conditions. There was only one case of DVT which occurred after an initially negative phlebography. In a subgroup of 40 patients, who underwent iodine-125-fibrinogen scanning after phlebography, the study was positive in 9 cases. None of them presented with any evidence of DVT at follow-up phlebography. Contrast phlebography with iohexol is a safe and comfortable procedure. Low-osmolality nonionic contrast media are well tolerated by the patient.

Detection of deep-vein thrombosis by real-time B-mode ultrasonography

In 220 consecutive outpatients with clinically suspected deep-vein thrombosis of the leg, we compared contrast venography with real-time B-mode ultrasonography, using the single criterion of vein compressibility with the ultrasound transducer probe. The common femoral and popliteal veins were evaluated for full compressibility (no thrombosis) and noncompressibility (thrombosis). Both veins were fully compressible in 142 of the 143 patients with normal venograms (specificity, 99 percent; 95 percent confidence interval, 97 to 100). All 66 patients with proximal-vein thrombosis had noncompressible femoral veins, popliteal veins, or both (sensitivity, 100 percent; 95 percent confidence interval, 95 to 100). For all patients (including 11 with calf-vein thrombi), sensitivity and specificity were 91 (95 percent confidence interval, 82 to 96) and 99 percent, respectively. The sensitivity for isolated calf-vein thrombosis was only 36 percent. The compression ultrasound test was repeated in a subset of 45 consecutive patients by a second examiner, unaware of the results of the first test, whose results agreed in all patients with those of the first examiner (kappa = 1). We conclude that ultrasonography with the single criterion of vein compressibility is a highly accurate, simple, objective, and reproducible noninvasive method for detecting proximal-vein thrombosis in outpatients with clinically suspected deep-venous thrombosis.

[High-resolution echography of the neck. Preoperative evaluation of lymph node metastases in patients with thyroid carcinoma]

Twenty-six patients with papillary and 4 with medullary thyroid carcinoma were examined by HRUS before surgery in order to evaluate its accuracy in detecting lymph node metastasis (N) of the neck from thyroid carcinoma. All patients underwent total thyroidectomy and nodal dissection. HRUS was accurate in 73% of cases in N staging, while clinical staging was accurate in 60% of cases only. In 50% of patients HRUS provided with interesting additional information, such as disclosing lymphadenopathy in 8 patients with no clinical evidence, proving nodal involvement in 5 cases, and showing extranodal extension in 5 cases. HRUS allowed the observation of anechoic necrotic areas and microcalcified nodes. On the other hand, according to our results, HRUS cannot either discriminate metastatic from benign nodal involvement, or identify mediastinal adenopathy. False negatives are possible due to micrometastatic areas in normal size nodes. Nevertheless, HRUS proved to be a valuable aid to complete clinical examination of the neck, and a good guide for the surgeon during nodal neck dissection.

[Staging of prostatic carcinoma. Accuracy of magnetic resonance]

Twenty-nine prostatic cancer patients were evaluated for staging purpose by Magnetic Resonance (MR). MR findings were correlated with the pathologic examination in 18/29 patients who underwent radical prostatectomy. Four MR staging parameters were evaluated individually: periprostatic fat; periprostatic venous plexus; seminal vesicles and pelvic adenopathy. MR correctly staged 16/18 patients, with one case of overstaging and one case of understaging. The diagnostic accuracy of MR in differentiating intracapsular stage B from extracapsular stage C was 87%, with a sensitivity of 90% and a specificity of 87%. MR and CT results agreed in 4 of the 7 operated patients who were examined with both techniques; in 3 cases there was disagreement, and MR was correct.