Outcomes with General Anesthesia Compared to Conscious Sedation for Endovascular Treatment of Medium Vessel Occlusions: Results of an International Multicentric Study

BACKGROUND

Optimal anesthetic strategy for the endovascular treatment of stroke is still under debate. Despite scarce data concerning anesthetic management for medium and distal vessel occlusions (MeVOs) some centers empirically support a general anesthesia (GA) strategy in these patients.

METHODS

We conducted an international retrospective study of MeVO cases. A propensity score matching algorithm was used to mitigate potential differences across patients undergoing GA and conscious sedation (CS). Comparisons in clinical and safety outcomes were performed between the two study groups GA and CS. The favourable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes were 90-days mortality and symptomatic intracranial hemorrhage (sICH). Predictors of a favourable outcome and sICH were evaluated with backward logistic regression.

RESULTS

After propensity score matching 668 patients were included in the CS and 264 patients in the GA group. In the matched cohort, either strategy CS or GA resulted in similar rates of good functional outcomes (50.1% vs. 48.4%), and successful recanalization (89.4% vs. 90.2%). The GA group had higher rates of 90-day mortality (22.6% vs. 16.5%, p < 0.041) and sICH (4.2% vs. 0.9%, p = 0.001) compared to the CS group. Backward logistic regression did not identify GA vs CS as a predictor of good functional outcome (OR for GA vs CS = 0.95 (0.67-1.35)), but GA remained a significant predictor of sICH (OR = 5.32, 95% CI 1.92-14.72).

CONCLUSION

Anaesthetic strategy in MeVOs does not influence favorable outcomes or final successful recanalization rates, however, GA may be associated with an increased risk of sICH and mortality.

Use of the pRESET LITE thrombectomy device in combined approach for medium vessel occlusions: A multicenter evaluation

PURPOSE

Our purpose was to assess the efficacy and safety of the pRESET LITE stent retriever (Phenox, Bochum, Germany), designed for medium vessel occlusion (MeVO) in acute ischemic stroke (AIS) patients with a primary MeVO.

METHODS

We performed a retrospective analysis of the MAD MT Consortium, an integration of prospectively maintained databases at 37 academic institutions in Europe, North America, and Asia, of AIS patients who underwent mechanical thrombectomy with the pRESET LITE stent retriever for a primary MeVO. We subcategorized occlusions into proximal MeVOs (segments A1, M2, and P1) vs. distal MeVOs/DMVO (segments A2, M3-M4, and P2). We reviewed patient and procedural characteristics, as well as angiographic and clinical outcomes.

RESULTS

Between September 2016 and December 2021, 227 patients were included (50% female, median age 78 [65-84] years), of whom 161 (71%) suffered proximal MeVO and 66 (29%) distal MeVO. Using a combined approach in 96% of cases, successful reperfusion of the target vessel (mTICI 2b/2c/3) was attained in 85% of proximal MeVO and 97% of DMVO, with a median of 2 passes (IQR: 1-3) overall. Periprocedural complications rate was 7%. Control CT at day 1 post-MT revealed a hemorrhagic transformation in 63 (39%) patients with proximal MeVO and 24 (36%) patients with DMVO, with ECASS-PH type hemorrhagic transformations occurring in 3 (1%) patients. After 3 months, 58% of all MeVO and 63% of DMVO patients demonstrated a favorable outcome (mRS 0-2).

CONCLUSION

Mechanical thrombectomy using the pRESET LITE in a combined approach with an aspiration catheter appears effective for primary medium vessel occlusions across several centers and physicians.

First pass effect as an independent predictor of functional outcomes in medium vessel occlusions: An analysis of an international multicenter study

INTRODUCTION

First pass effect (FPE), achievement of complete recanalization (mTICI 2c/3) with a single pass, is a significant predictor of favorable outcomes for endovascular treatment (EVT) in large vessel occlusion stroke (LVO). However, data concerning the impact on functional outcomes and predictors of FPE in medium vessel occlusions (MeVO) are scarce.

PATIENTS AND METHODS

We conducted an international retrospective study on MeVO cases. Multivariable logistic modeling was used to establish independent predictors of FPE. Clinical and safety outcomes were compared between the two study groups (FPE vs non-FPE) using logistic regression models. Good outcome was defined as modified Rankin Scale 0-2 at 3 months.

RESULTS

Eight hundred thirty-six patients with a final mTICI ⩾ 2b were included in this analysis. FPE was observed in 302 patients (36.1%). In multivariable analysis, hypertension (aOR 1.55, 95% CI 1.10-2.20) and lower baseline NIHSS score (aOR 0.95, 95% CI 0.93-0.97) were independently associated with an FPE. Good outcomes were more common in the FPE versus non-FPE group (72.8% vs 52.8%), and FPE was independently associated with favorable outcome (aOR 2.20, 95% CI 1.59-3.05). 90-day mortality and intracranial hemorrhage (ICH) were significantly lower in the FPE group, 0.43 (95% CI, 0.25-0.72) and 0.55 (95% CI, 0.39-0.77), respectively.

CONCLUSION

Over 2/3 of patients with MeVOs and FPE in our cohort had a favorable outcome at 90 days. FPE is independently associated with favorable outcomes, it may reduce the risk of any intracranial hemorrhage, and 3-month mortality.

Incidence and clinical outcomes of perforations during mechanical thrombectomy for medium vessel occlusion in acute ischemic stroke: A retrospective, multicenter, and multinational study

BACKGROUND

Mechanical thrombectomy (MT) has revolutionized the treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO), but its efficacy and safety in medium vessel occlusion (MeVO) remain less explored. This multicenter, retrospective study aims to investigate the incidence and clinical outcomes of vessel perforations (confirmed by extravasation during an angiographic series) during MT for AIS caused by MeVO.

METHODS

Data were collected from 37 academic centers across North America, Asia, and Europe between September 2017 and July 2021. A total of 1373 AIS patients with MeVO underwent MT. Baseline characteristics, procedural details, and clinical outcomes were analyzed.

RESULTS

The incidence of vessel perforation was 4.8% (66/1373). Notably, our analysis indicates variations in perforation rates across different arterial segments: 8.9% in M3 segments, 4.3% in M2 segments, and 8.3% in A2 segments (p = 0.612). Patients with perforation had significantly worse outcomes, with lower rates of favorable angiographic outcomes (TICI 2c-3: 23% vs 58.9%, p < 0.001; TICI 2b-3: 56.5% vs 88.3%, p < 0.001). Functional outcomes were also worse in the perforation group (mRS 0-1 at 3 months: 22.7% vs 36.6%, p = 0.031; mRS 0-2 at 3 months: 28.8% vs 53.9%, p < 0.001). Mortality was higher in the perforation group (30.3% vs 16.8%, p = 0.008).

CONCLUSION

This study reveals that while the occurrence of vessel perforation in MT for AIS due to MeVO is relatively rare, it is associated with poor functional outcomes and higher mortality. The findings highlight the need for increased caution and specialized training in performing MT for MeVO. Further prospective research is required for risk mitigation strategies.

CTA and CTP for Detecting Distal Medium Vessel Occlusions: A Systematic Review and Meta-analysis

BACKGROUND

The optimal imaging method for detecting distal medium vessel occlusions (DMVOs) remains undefined.

PURPOSE

The objective of this study is to compare the diagnostic performance of CTA with CTP in detecting DMVOs.

DATA SOURCES

We searched PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials up to March 31, 2023 (PROSPERO: CRD42022344006).

STUDY SELECTION

A total of 12 studies reporting accuracy values of CTA and/or CTP were included, comprising 2607 patients with 479 cases (18.3%) of DMVOs.

DATA ANALYSIS

Pooled sensitivity and specificity of both imaging methods were compared using a random-effects model. Subgroup analyses were performed based on the technique used in CTA (multi or single-phase) and the subtype of DMVOs (M2-only vs. M2 and other DMVOs). We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria.

DATA SYNTHESIS

CTA demonstrated significantly lower sensitivity compared to CTP in detecting DMVOs [0.74, 95%CI (0.63-0.82) vs. 0.89, 95% CI (0.82-0.93), P < 0.01]. When subgrouped into single-phase and multi-phase CTA, multi-phase CTA exhibited higher sensitivity for DMVO detection than single-phase CTA [0.91, 95%CI (0.85-0.94) vs. 0.64, 95%CI (0.56-0.71), P < .01], while reaching similar levels to CTP. The sensitivity of single-phase CTA substantially decreased when extending from M2 to other non-M2 DMVOs [0.74, 95%CI (0.63-0.83) vs. 0.61, 0.95%CI (0.53-0.68), P = .02].

LIMITATIONS

We identified an overall high risk of bias and low quality of evidence, attributable to the design and reference standards of most studies.

CONCLUSIONS

Our findings highlight a significantly lower sensitivity of single-phase CTA compared to multi-phase CTA and CTP in diagnosing DMVOs.

Augenblickdiagnose in neurology: Revisiting 'diagnosis in the blink of an eye'

BACKGROUND AND PURPOSE

The art of diagnosis in clinical neurology requires attentive listening and careful observation. In certain situations, a fragment of the history or a physical sign may be so distinctive that it allows clinicians to evoke a specific diagnosis. This quick mental process was previously referred to as 'Augenblickdiagnose' ('diagnosis in the blink of an eye') in a seminal paper by Dr. William Campbell in 1998. We aimed to revisit this concept by providing additional clinical vignettes.

METHODS

The authors wrote clinical vignettes using examples from their own clinical practice and performed a non-systematic review of influential neurology textbooks using the words 'pathognomonic' and 'highly suggestive'.

RESULTS

Twenty examples from various fields of neurology are presented in a table, stratified by major fields of neurology. A short educational reflection is provided for each diagnosis considered.

CONCLUSION

'Augenblickdiagnose' is an engaging teaching resource that also contributes to 'neurophilia', that is, a fascination for neurology, perhaps increasingly in today's modern neurology practice. However, multiple cognitive biases underlying mental shortcuts may lead to an incorrect diagnosis. It is important to stress that good clinical practice in neurology requires taking a thorough history and performing a careful neurological examination.

Aspiration Versus Stent‐Retriever as First‐Line Endovascular Therapy Technique for Primary Medium and Distal Intracranial Occlusions: A Propensity‐Score Matched Multicenter Analysis

BACKGROUND

For acute proximal intracranial artery occlusions, contact aspiration may be more effective than stent‐retriever for first‐line reperfusion therapy. Due to the lack of data regarding medium vessel occlusion thrombectomy, we evaluated outcomes according to first‐line technique in a large, multicenter registry.

METHODS

Imaging, procedural, and clinical outcomes of patients with acute proximal medium vessel occlusions (M2, A1, or P1) or distal medium vessel occlusions (M3, A2, P2, or further) treated at 37 sites in 10 countries were analyzed according to first‐line endovascular technique (stent‐retriever versus aspiration). Multivariable logistic regression and propensity‐score matching were used to estimate the odds of the primary outcome, expanded Thrombolysis in Cerebral Infarction score of 2b–3 (“successful recanalization”), as well as secondary outcomes (first‐pass effect, expanded Thrombolysis in Cerebral Infarction 2c‐3, intracerebral hemorrhage, and 90‐day modified Rankin scale, 90‐day mortality) between treatment groups.

RESULTS

Of the 440 included patients (44.5% stent‐retriever versus 55.5% aspiration), those treated with stent‐retriever had lower baseline Alberta Stroke Program Early Computed Tomography Scale scores (median 8 versus 9; P <0.01), higher National Institutes of Health Stroke Scale scores (median 13 versus 11; P =0.02), and nonsignificantly fewer medium‐distal occlusions (M3, A2, P2, or other: 17.4% versus 23.8%; P =0.10). Use of a stent‐retriever was associated with 15% lower odds of successful recanalization (odds ratio [OR], 0.85; [95% CI 0.74–0.98]; P =0.02), but this was not significant after multivariable adjustment in the total cohort (adjusted OR, 0.88; [95% CI 0.72–1.09]; P =0.24), or in the propensity‐score matched cohort (n=105 in each group) (adjusted OR, 0.94; [95% CI 0.75–1.18]; P =0.60). There was no significant association between technique and secondary outcomes in the propensity‐score matched adjusted models.

CONCLUSION

In this large, diverse, multinational medium vessel occlusion cohort, we found no significant difference in imaging or clinical outcomes with aspiration versus stent‐retriever thrombectomy.

Coastal warming under climate change: Global, faster and heterogeneous

The assessment of expected changes in coastal sea surface temperature (SST) on a global scale is becoming increasingly important due to the growing pressure on coastal ecosystems caused by climate change. To achieve this objective, 17 Global Climate Models from CMIP6 were used, with data from historical and hist-1950 experiments spanning 1982-2050. This analysis highlights significant warming of coastal areas worldwide, with higher and more variable rates of warming than observed in previous decades. All basins are projected to experience an increase in coastal SST near 1 °C by mid-century, with some regions exhibiting nearshore SST anomalies exceeding 2 °C for the period 2031-2050 relative to 1995-2014. Regarding the Eastern Upwelling Boundary Systems, only the Canary upwelling system and the southern part of the Humboldt upwelling system manage to show lower-than-average SST warming rates, maintaining, to a certain extent, their ability to buffer global warming.

Safety and Outcome of Revascularization Treatment in Patients With Acute Ischemic Stroke and COVID-19: The Global COVID-19 Stroke Registry

BACKGROUND AND OBJECTIVES

COVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.

METHODS

This was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).

RESULTS

Of a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).

DISCUSSION

Patients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.

TRIAL REGISTRATION INFORMATION

The study was registered under ClinicalTrials.gov identifier NCT04895462.

Predictors of cognitive dysfunction one-year post COVID-19

OBJECTIVES

(a) To characterize the frequency of objective cognitive deficits and self-perceived cognitive difficulties and (b) to explore demographic and clinical predictors of cognitive dysfunction and cognitive complaints.

METHOD

One hundred and ten adults diagnosed with COVID-19 between March and November 2020, aged ≤ 74 years underwent a brief neuropsychological evaluation 12 months after infection, which included: Brief Visuospatial Memory Test-Revised, California Verbal Learning Test, and Symbol Digit Modalities Test. T scores < 38 were considered abnormal performance; cognitive dysfunction was defined as ≥ 2 abnormal tests. Participants also completed Broadbent's Cognitive Failure Questionnaires (CFQ), Hospital Anxiety and Depression Scale, Modified Fatigue Impact Scale, and Short-Form Health Survey. CFQ ≥ 43 was considered indicative of cognitive complaints.

RESULTS

Twenty participants (18.2%) had cognitive dysfunction and 36 (33.3%) had cognitive complaints. Cognitive dysfunction was related to lower education, preinfection history of headache/migraine, and acute COVID-19 symptoms of headache and sleep disturbance. Cognitive complaints were more likely to occur in women, those with fewer years of education, and acute COVID-19 symptoms of headache and sleep disturbance. Cognitive complaints were also significantly related to symptoms of anxiety, depression, and fatigue. Sex and psychopathology were not significant predictors of cognitive dysfunction. Modest associations were found between CFQ total score and cognitive test performance.

DISCUSSION

A subset of individuals develops cognitive difficulties in the context of post-COVID syndrome. Results may support the protective effect of education, a known proxy of cognitive reserve. COVID-19 infection symptoms of headache and sleep disturbance appear to be risk factors for long-term cognitive difficulties. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Diagnostic accuracy of CT angiography and CT perfusion imaging for detecting distal medium vessel occlusions: Protocol for a systematic review and meta-analysis

BACKGROUND

Distal medium vessel occlusions (DMVOs) represent 25-40% of all acute ischemic strokes (AIS). DMVO clinical syndromes are heterogenous, but as eloquent brain regions are frequently involved, they are often disabling. Since current intravenous fibrinolytic therapies may fail to recanalize up to two-thirds of DMVOs, endovascular treatment is progressively being considered in this setting. Nevertheless, the optimal imaging method for diagnosis remains to be defined. Stroke centers that use computed tomography as a routine stroke imaging approach rely on either isolated computed tomography angiography (CTA) or combined perfusion (CTP) studies. Despite a simplified non-CTP-dependent approach seeming reasonable for large vessel occlusion AIS diagnosis, CTP may still hold advantages for DMVOs workup. Therefore, this systematic review aims to compare the diagnostic performance of CTA and CTP in detecting DMVOs.

METHODS

We will perform a systematic search in PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials. In addition, grey literature and ClinicalTrials.gov will be scanned. We will include any type of study that presents data on the diagnostic accuracy of CTA and/or CTP for detecting DMVOs. Two authors will independently review retrieved studies, and any discrepancies will be resolved by consensus or with a third reviewer. Reviewers will extract the data and assess the risk of bias in the selected studies. Data will be combined in a quantitative meta-analysis following the guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. We will assess cumulative evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

DISCUSSION

This will be the first systematic review and meta-analysis that compares two different imaging approaches for detecting DMVOs. This study may help to define optimal acute ischemic stroke imaging work-up.

TRIAL REGISTRATION

PROSPERO registration: CRD42022344006.

Neuro-COVID frequency and short-term outcome in the Northern Portuguese population

Background and purpose

COVID‐19‐related acute neurological phenotypes are being increasingly recognised, with neurological complications reported in more than 30% of hospitalised patients. However, multicentric studies providing a population‐based perspective are lacking.

Methods

We conducted a retrospective multicentric study at five hospitals in Northern Portugal, representing 45.1% of all hospitalised patients in this region, between 1 March and 30 June 2020.

Results

Among 1261 hospitalised COVID‐19 patients, 457 (36.2%) presented neurological manifestations, corresponding to a rate of 357 per 1000 in the North Region. Patients with neurologic manifestations were younger (68.0 vs. 71.2 years, p = 0.002), and the most frequent neurological symptoms were headache (13.4%), delirium (10.1%), and impairment of consciousness (9.7%). Acute well‐defined central nervous system (CNS) involvement was found in 19.1% of patients, corresponding to a rate of 217 per 1000 hospitalised patients in the whole region. Assuming that all patients with severe neurological events were hospitalised, we extrapolated our results to all COVID‐19 patients in the region, estimating that 116 will have a severe neurological event, corresponding to a rate of nine per 1000 (95% CI = 7–11). Overall case fatality in patients presenting neurological manifestations was 19.8%, increasing to 32.6% among those with acute well‐defined CNS involvement.

Conclusions

We characterised the population of hospitalised COVID‐19 patients in Northern Portugal and found that neurological symptoms are common and associated with a high degree of disability at discharge. CNS involvement with criteria for in‐hospital admission was observed in a significant proportion of patients. This knowledge provides the tools for adequate health planning and for improving COVID‐19 multidisciplinary patient care.

Psychiatric manifestations of autoimmune encephalitis

Introduction

Autoimmune encephalitis (AE) refers to a newly described, heterogeneous group of rare diseases characterized by brain inflammation and circulating autoantibodies. Various AE have been described and each of them is linked to the presence of specific autoantibodies directed against synaptic and neuronal cell surface antigens. The clinical picture includes a wide array of neuropsychiatric symptoms and is correlated with the associated antibody subtype. Since pronounced psychiatric symptoms are relatively common at the onset, patients can be misdiagnosed and initially driven to psychiatric institutions, thus delaying the adequate diagnosis and management of AE.

Objectives

We aim to review and summarize the psychiatric manifestations of AE that might dominate the clinical picture. We also aim to describe the clinical signs that should alert the psychiatrist to the possibility of these diagnoses.

Methods

We performed an updated review in the PubMed database using the terms “autoimmune”, “encephalitis” and “psychiatric manifestations”. The included articles were selected by title and abstract. We also consulted a reference textbook.

Results

We summarize the reported psychiatric manifestations of AE and also include two situations that can be helpful in AE diagnosis in the psychiatric setting: symptoms that should alert the physician for the possibility of AE and symptoms that should prompt an antibody detection test.

Conclusions

AE are rare diseases that present very frequently with psychiatric symptoms as the first manifestation. Psychiatrists need to be aware of the most common psychiatric manifestations of AE since the early recognition and treatment of AE is fundamental for a good outcome.

Persistent heat waves projected for Middle East and North Africa by the end of the 21st century

The duration and intensity of future heat waves are analyzed for 53 cities in the Middle East and the North Africa (MENA) region for the 21st century under two different scenarios (RCP4.5 and RCP8.5). A consistent approach is carried out using data from 13 Regional models within the framework of the Coordinated Regional Climate Downscaling Experiment (CORDEX). By the end of the century, 80% of the most populated MENA cities are expected to be at least 50% of the days under heat wave conditions during the warm season. In addition, the mean and maximum intensity of the heat waves will also increase. Changes in the duration and intensity of heat waves have shown to be negatively correlated. Therefore, the vulnerability of the MENA cities to future heat waves was determined using a cumulative index (CI) that takes into account both duration and intensity. This CI indicates that Middle East and the eastern part of Africa will suffer the most unfavorable temperature conditions in the future. Assuming no intervention trough adaptation/mitigation strategies, these results, together with the particular properties of the MENA region, such as aridity or lack of precipitation, make it likely that the area will be affected by disease or famine.

Headache intensity is associated with increased white matter lesion burden in CADASIL patients

OBJECTIVES

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common hereditary cause of vascular dementia in adults. Migraine is a major symptom of the disease. We aimed to identify clinical and demographical features of the headache associated with increased cerebral lesion burden in a cohort of CADASIL patients.

METHODS

Thirty-two patients with CADASIL were enrolled in this cross-sectional study. Demographics data, vascular risk factors and headache characteristics were collected through a structured questionnaire. MRI (3-T) was used to determine white matter hyperintensities burden evaluated by its volume (WMH-V).

RESULTS

Regression analysis showed that age (β = 1.266, 95%CI = [0.805, 1.726], p < 0.001), headache intensity (β = 5.143, 95%CI = [2.362, 7.924], p = 0.001) and female sex (β = 19.727, 95%CI = [8.750, 30.075], p = 0.001) were the main predictors of WMH-V.

DISCUSSION

Age, female sex and headache intensity are associated with increased white matter lesion volume in CADASIL.

Blood Pressure Variability in Acute Ischemic Stroke: The Role of Early Recanalization

We performed a retrospective study with the aim of investigating the association between blood pressure (BP) variability in the first 24 h after ischemic stroke and functional outcome, regarding arterial recanalization status. A total of 674 patients diagnosed with acute stroke and treated with revascularization therapies were enrolled. Systolic and diastolic BP values of the first 24 h after stroke were collected and their variation quantified through standard deviation. Recanalization state was evaluated at 6 h and clinical outcome at 3 months was assessed by modified Rankin Scale. In multivariate analyses systolic BP variability in the first 24 h post-stroke showed an association with 3 months clinical outcome in the whole population and non-recanalyzed patients. In recanalyzed patients, BP variability did not show a significant association with functional outcome.

Metástasis inusuales en carcinoma de células renales

Introducción y Objetivos El carcinoma renal de células claras (CCR), es la neoplasia renal más frecuente. Hasta el 30% de los casos presentan enfermedad sistémica, siendo las más usuales: pulmón, ganglios, hígado y cerebro. El objetivo de este trabajo es informar casos poco frecuentes de metástasis por CCR y establecer posibles factores relacionados con las metástasis.

Métodos y Materiales revisión retrospectiva de historias clínicas en el instituto nacional de cancerología de los pacientes con carcinoma de células renales metastásico entre los años 2013 a 2017. Se identificaron 6 casos con sitios de metástasis inusuales en pacientes del servicio de urología oncológica del instituto nacional de cancerología, destacando histopatología e inmunohistoquímica de los especímenes quirúrgicos tanto del primario como de la metástasis, reportando marcadores específicos y clasificaciones según corresponda.

Resultados Caso 1 Metástasis a duodeno, Caso 2 metástasis a ovario, caso 3 metástasis a testículo, caso 4 metástasis a piel, caso 5 metástasis a glándula tiroides, caso 6 metástasis a mama y piel. Se evaluaron diferentes variables y se analizaron con base en la literatura.

Conclusiones Consideramos que la edad, el tabaquismo, el grado histológico, la invasión de la vena renal, el tamaño tumoral y el estadio pueden ser factores predisponentes para ese comportamiento.

Influence of Coastal Upwelling on SST Trends along the South Coast of Java

The south coast of Java has warmed at a much lower rate than adjacent ocean locations over the last three decades (1982-2015). This behavior can be observed during the upwelling season (July-October) and it is especially patent in August and September when upwelling attains the highest values. Although different warming rates (ocean-coast) had been previously observed in other areas around the world, this behavior was always linked to situations where upwelling increased or remained unchanged. South Java warming is observed at ocean locations and cooling near shore but under a scenario of decreasing upwelling (~30% in some cases). The origin of coastal cooling is due to changes in the vertical structure of the water column. A vein of subsurface water, which has cooled at a rate higher than 0.3°C per decade, is observed to enter from the northwestern part of the study area following the South Java Current. This water only manifests at surface near coast, where it is pumped up by coastal upwelling.

[Vertebral hydatidosis: case report]

Hydatidosis caused by echinococcus granulosus may affect any organ in the body, with the lungs and the liver as the most commonly affected organs. Vertebral compromise resulting from echinococcus granulosus has a low prevalence and accounts for less than 1% of bone compromise. We report the case of a 50 year-old female who presented at the Trauma Service with progressive low back pain with 5 months of duration that irradiated to the right lower limb, and led to neurologic compromise of the limb. Imaging studies showed spondylodiscitis at T12-L1, confirmed by a biopsy. Treatment of this condition is both orthopedic and surgical. The recurrence rate is high, between 30 and 40%. The objective of describing this case is to propose the differential diagnosis of a vertebral mass of unknown origin and provide details as to how to manage this condition.

The development and validation of a questionnaire to measure the clinical learning environment for undergraduate dental students (DECLEI)

AIM

The aim of this study was to develop and validate according to psychometric standards a self-administered instrument to measure the students' self-perceptions of the undergraduate clinical dental environment (DECLEI).

MATERIALS AND METHODS

The initial questionnaire was developed using feedback from dental students, experts' opinion and an extensive literature review. Critical incident technique (CIT) analysis was used to generate items and identify domains. Thirty clinical dental students participated in a pilot validation that generated a 67-item questionnaire. To develop a shorter and more practical version of the instrument, DECLEI-67 was distributed to 153 clinical students at the University of Athens and its English version to 51 students from various dental schools, attending the 2012 European Dental Students Association meeting. This final procedure aimed to select items, identify subscales and measure internal consistency and discriminant validity.

RESULTS

A total of 202 students returned the questionnaires (response rate 99%). The final instrument included 24 items divided into three subscales: (i) organisation and learning opportunities, (ii) professionalism and communication and (iii) satisfaction and commitment to the dental studies. Cronbach's α for the total questionnaire was 0.89. The interscale correlations ranged from 0.39 to 0.48. The instrument identified differences related to school of origin, age and duration of clinical experience. An interpretation of the scores (range 0–100) has been proposed.

CONCLUSIONS

The 24-item DECLEI seemed to be a practical and valid instrument to measure a dental school's undergraduate clinical learning environment.

Students' perceptions of the educational environment in a Greek Dental School, as measured by DREEM

AIM

The aim of this study was to estimate the dental students' perceptions of their educational environment and to identify any differences related both to their gender and semester of studies.

MATERIALS AND METHODS

The translated and validated in Greek Dundee Ready Education Environment Measure (DREEM) questionnaire was distributed to all 2nd- to 5th-year students of the Athens Dental School. The questionnaire consisted of 50 statements organised in five subscales (perceptions of learning, teachers, atmosphere, academic self-perceptions and social self-perceptions). Internal validity was checked with Cronbach alpha. Confirmatory factor analysis (CFA) was performed under the same conditions as the original inventory. Mean statement, subscale and overall scores were calculated and given as percentages.

RESULTS

The response rate was 64%. Overall Cronbach alpha was 0.93 (excellent). CFA produced five meaningful subscales, not matching the original ones. The overall DREEM mean score was 56%. Gender did not influence the findings. The students' perceptions of the educational environment with the exception of the academic self-perceptions were more positive in the pre-clinical years. Statistically significant differences were revealed only for the 'learning' subscale between the 3rd- and the 4th-year students. Seventy-eight percent of the statements were in the positive side. The lowest scores were related to students' stress, tiredness and lack of appropriate feedback from the teachers, and the highest were related to accommodation, school friends and perceptions that they feel socially comfortable in class.

CONCLUSIONS

Students' perceptions of the educational environment were reasonably positive, with no gender difference. However, some weaknesses were identified, particularly in the clinical years. Further research is needed to clarify appropriate interventions.

Effect of addition of rituximab to salvage chemotherapy on outcome of patients with diffuse large B-cell lymphoma relapsing after an autologous stem-cell transplantation

BACKGROUND

We have investigated if rituximab-based salvage regimens improve response rates and survival of patients with diffuse large B-cell lymphoma (DLBCL) relapsing after an autologous stem-cell transplantation (ASCT).

PATIENTS AND METHODS

We have retrospectively analyzed 82 patients with DLBCL who received salvage therapy for relapse or progression after ASCT. Patients were divided into two groups, according to whether rituximab-based salvage regimens were given (n = 42, 'R-' group) or not (n = 40, 'R+' group) after ASCT.

RESULTS

Patients in the R+ group had better complete remission (CR) (55% versus 21.4%, P = 0.006) and overall response (OR) (75% versus 40.4%, P = 0.001) rates, and better 3-year event-free survival (EFS) (37% versus 9%, P = 0.002) and overall survival (OS) (50% versus 20%, P = 0.005) than patients in the R- group. Patients retreated with rituximab had better CR (42.9% versus 21.4%, P = 0.032) and OR (66.7% versus 40.4%, P = 0.019) rates, and better OS (36.2% versus 20% at 3 years, P = 0.05) and EFS (36.2% versus 9% at 3 years, P = 0.05) than patients who received chemotherapy alone at relapse after ASCT.

CONCLUSIONS

The addition of rituximab to salvage chemotherapy improves response rates and EFS in patients with relapsed DLBCL after ASCT. These patients may benefit from rituximab retreatment, although larger prospective studies are needed to confirm these results.

Gn-RH antagonist possible response, after Gn-RH agonist failure in a man with metastatic prostate cancer

Gn-RH agonists or surgical castration are considered standard treatment for patients affected by metastatic prostate cancer. Despite greater cost, chemical castration is often considered the treatment of choice as it is psychologically better tolerated. We report our experience of one patient undergoing treatment with Gn-RH agonist who developed an early resistance to the administered drug, with serum testosterone levels within the range of normality.

Autologous stem-cell transplantation in diffuse large B-cell non-Hodgkin's lymphoma not achieving complete response after induction chemotherapy: the GEL/TAMO experience

BACKGROUND

Here we evaluate the results of high-dose chemotherapy and autologous stem-cell transplantation (HDC/ASCT) in 114 patients included in the GEL/TAMO registry between January 1990 and December 1999 with diffuse large B-cell lymphoma who failed to achieve complete remission (CR) with front-line conventional chemotherapy.

PATIENTS AND METHODS

Sixty-eight per cent had a partial response (PR) and 32% failed to respond to front-line therapy. At transplant, 35% were chemoresistant and 29% had two to three adjusted International Prognostic Index (a-IPI) risk factors.

RESULTS

After HDC/ASCT, 57 (54%) of 105 patients evaluable for response achieved a CR, 16 (15%) a PR and 32 (30%) failed. Nine patients were not assessed for response because of early death due to toxicity. With a median follow-up of 29 months for alive patients, the survival at 5 years is 43%, with a disease-free survival for complete responders of 63%. The lethal toxicity was 8%. Multivariate analysis revealed a-IPI and chemoresistance to be predicting factors.

CONCLUSIONS

Our results show that one-third of patients who do not obtain a CR to front-line chemotherapy may be cured of their disease with HDC/ASCT. However, most chemoresistant patients pretransplant failed this therapy. For this population, as well as for those who presented with adverse factors of the a-IPI, pretransplant novel therapeutic modalities need to be tested.

Magnetic resonance imaging combined with artificial erection for local staging of penile cancer

OBJECTIVES

To assess magnetic resonance imaging (MRI) combined with artificial erection for local staging of penile cancer.

METHODS

We compared local clinical, MRI plus artificial erection, and pathologic staging in 9 cases of penile cancer. Erection was obtained by injecting 10 microg prostaglandin E1 into the corpora cavernosa. T1-weighted and T2-weighted MRI with and without contrast was obtained using a phased array coil. Local treatment was based on tumor location and extent, as defined by the clinical and MRI findings.

RESULTS

The histologic diagnosis was squamous cell carcinoma in 8 patients and sarcoma in 1. The MRI and pathologic staging coincided in 8 of 9 patients. MRI, clinical, and pathologic staging coincided in 5 patients: 4 had Stage T2 and 1 had Stage T1 disease. In 2 patients, the MRI and pathologic stage was T2, but the clinical stage differed. Another patient had Stage T2 clinically but T3 by MRI and pathologic staging. In the last patient, none of the stages coincided (clinical Stage T1, MRI Stage T0, and pathologic Stage Tis). The only complication during the procedure was that 1 patient developed priapism after prostaglandin injection, which was relieved by evacuation of the corpora cavernosa.

CONCLUSIONS

To our knowledge, this is the first study to use artificial erection with MRI to stage local penile cancer. The method appears promising for local staging of penile cancer, but additional studies are necessary to confirm its utility.

Mycobacterial Infection: A Difficult and Late Diagnosis in Stem Cell Transplant Recipients

The Infectious Diseases Working Party of the European Blood and Marrow Transplant Group conducted a survey to obtain information about the frequency, presentation, and treatment of mycobacterial infection (MBI) in stem cell transplant (SCT) recipients. Among 29 centers, MBI was diagnosed in 0.79% of 1513 allogeneic and 0.23% of 3012 autologous SCT recipients during 1994-1998 a median of 160 days after transplantation. The mean interval between first symptoms and diagnosis was 29 days and was still longer for patients with atypical MBI or recipients of corticosteroid therapy. The prevalence of MBI was highest among those who received matched unrelated or mismatched STCs from related donors. Of 31 patients, 20 had tuberculosis, 8 had atypical MBI, and 3 had diagnoses based on histological findings only. Five patients (16%) died, all of whom had received an allogeneic SCT. Because of the increased numbers of unmatched donors and transplantation programs in countries with a high prevalence of tuberculosis, constant vigilance is required to early detect MBI in SCT recipients.

High-dose chemotherapy and autologous stem cell transplantation in peripheral T-cell lymphoma: the GEL-TAMO experience

BACKGROUND

T-cell immunophenotype constitutes an unfavorable prognostic factor in aggressive non-Hodgkin's lymphomas. High-dose chemotherapy with autologous stem-cell rescue (HDC/ASCT) is the best salvage therapy for patients with aggressive B-cell lymphomas. However, results with this therapy in peripheral T-cell lymphoma (PTCL) are not well defined.

PATIENTS AND METHODS

From January 1990 to December 1999, 115 patients with PTCL underwent HDC/ASCT inside the Grupo Español de Linfomas/Trasplante Autólogo de Médula Osea (GEL-TAMO) registry. At diagnosis the median age was 41 years and 60% of patients presented with two or three risk factors from the adjusted International Prognostic Index (a-IPI). Thirty-two per cent of patients were transplanted in first complete response (CR), 62% in chemosensitive disease and 5% in refractory disease.

RESULTS

Eighty-six per cent of the patients attained a CR and 5% a partial response (PR). With a median follow-up of 37 months (range 1-133), overall survival (OS), time-to-treatment failure (TTF) and disease-free survival (DFS) at 5 years was 56%, 51% and 60%, respectively; for the 37 patients transplanted in first CR, OS and DFS at 5 years were 80% and 79%, respectively. Lactase dehydrogenase (LDH), a-IPI and disease status pre-transplant were associated with outcome.

CONCLUSIONS

More than half of patients with chemosensitive disease who were transplanted are expected to be alive at 5 years. We confirm the utility of the pre-transplant IPI system in predicting outcome. Salvage treatment results with HDC/ASCT in PTCL are similar to those found in corresponding aggressive B-cell lymphomas.

High-dose therapy in diffuse large cell lymphoma: results and prognostic factors in 452 patients from the GEL-TAMO Spanish Cooperative Group

BACKGROUND

The purpose of this study was to analyse the results and prognostic factors influencing overall survival (OS) and disease-free survival (DFS) in 452 patients diagnosed with diffuse large cell lymphomas (DLCL) treated with high-dose therapy (HDT) included in the Grupo Español de Linfomas/Trasplante Autólogo de Médula Osea (GEL-TAMO) Spanish registry.

PATIENTS AND METHODS

At transplantation, median age was 42 years (range 15-73), 146 patients (32%) were transplanted in first complete remission (1st CR), 19% in second CR (2nd CR) and 47% had active disease: sensitive disease in 157 (35%) patients [95 were in first partial remission (1st PR) and 62 in second PR (2nd PR)] and refractory disease in 55 (12%) patients. Age-adjusted International Prognostic Index (IPI) was 2 or 3 in 51 patients (12%). Conditioning regimen consisted of BEAM (carmustine, etoposide, cytarabine and melphalan) in 39% of patients, BEAC (carmustine, etoposide, cytarabine and cyclophosphamide) in 33%, CBV (carmustine, etoposide and cyclophosphamide) in 10% and cyclophosphamide plus total body irradiation (TBI) in 12%.

RESULTS

Estimated overall survival (OS) and disease-free survival (DFS) at 5 years were 53% and 43%, respectively. The transplant-related mortality was 11% (53 cases). By multivariate analysis three variables significantly influenced OS and DFS: number of protocols to reach 1st CR, disease status at transplant and TBI in the conditioning regimen. Age-adjusted IPI at transplantation also influenced OS.

CONCLUSIONS

Prolonged OS and DFS can be achieved in patients with DLCL after HDT and our results suggest that the best line of chemotherapy should be used up-front in patients considered as candidates for HDT in order to obtain an early CR. Resistant patients are not good candidates for HDT and they should be offered newer strategies. Finally, polichemotherapy conditioning regimens offer better results compared with TBI.

[Intestinal parasite infections and schistosomiasis in a poor urban area, in townships of the sugar cane belt and in villages of the semi-arid area of North-East Brazil]

We determined the prevalence of intestinal parasite infections between 1993 and 1998 in the populations of a poor quarter of Recife (Pernambuco), in two townships in the sugar cane belt and in three villages of the semi-arid area far from the coast. Intestinal schistosomiasis was present in the sugar-growing area but was not observed in the populations inland that use dams to provide irrigation and fishing. Ascaris was very common in the city and the sugar cane belt and large numbers of hookworms were observed, especially in the sugar-growing area. These nematodes were very rare in the semi-arid area. This distribution probably results from both climatic conditions and human behavior. The high frequency of Amoeba cysts demonstrates that the peasants, farmers and fisherman living in these areas have poor hygiene practices. There are probably many, complex relationships between education, income, lifestyle and intestinal parasite infections.

Protein architecture of avian reovirus S1133 and identification of the cell attachment protein

There are a number of discrepancies in the literature regarding the protein composition of the avian reoviruses. The present study demonstrates that avian reovirus S1133 contains at least 10 proteins (lambdaA, lambdaB, lambdaC, muA, muB, muBC, muBN, sigmaA, sigmaB, and sigmaC). Polypeptides muB, muBC, muBN, sigmaB, and sigmaC are components of the outer capsid layer of the virus, while lambdaA, lambdaB, muA, and sigmaA are core polypeptides. Protein lambdaC is a component of both layers, extending from the inner core to the outer capsid. The minor outer-capsid polypeptide sigmaC is shown to be the cell attachment protein, since it is the only viral polypeptide present in extracts of S1133-infected cells that binds specifically to chicken embryo fibroblasts; furthermore, its binding to avian cells was competitively inhibited by S1133 reovirions but not by mammalian reovirions. Our results also show that sigmaC is an oligomeric protein both in the virion and free in the cytoplasm, and preliminary results suggest that the multimer is made up of three monomeric units.

Motor function of the esophagus after caustic burn

During the subacute and chronic phases of esophagitis due to ingestion of a caustic substance, the patient commonly displays stricture, esophageal rigidity and dysphagia. We used esophageal manometry, radiology, pH monitoring and 99mTc scintigraphy to investigate esophageal motor function in 25 children (mean age 24 +/- 7 months) with chronic esophagitis after second- and/or third-degree caustic burns. The results were compared with those for a control group of 12 children (mean age 32 +/- 19 months) under surveillance for suspected gastroesophageal reflux (GER) but for whom this pathology was later ruled out. Seventeen (68%) of the lesioned-group children showed esophageal dysfunction as revealed by monitoring of pH over a 24-hour period. Over this period, the mean percentage of time with pH below 4 was 19 +/- 10%, the mean number of reflux episodes was 48 +/- 52, the mean number of reflux episodes lasting longer than 5 min was 10 +/- 5, and the mean duration of the longest reflux episode was 51 +/- 21 min. Manometry indicated that, in the lesioned group, an average of 77 +/- 18% of peristaltic waves were nonpropulsive, while the mean Esophageal Work Index (number of propulsive waves per hour x mean maximum pressure developed during propulsive waves) was 227 +/- 192 units. All of the above means were significantly different (p < 0.01) from the corresponding control-group means. Esophageal strictures were observed in 60% (15) of the children. In 2 cases it was minimal, 2 cases moderate and 11 cases had severe strictures. 99mTc scintigraphy indicated that esophageal transit was slightly delayed in four, moderately delayed in five and severely delayed in 16 of the lesioned-group subjects. There was close correspondence between the results of manometry and scintigraphy as regards severity of esophageal dysfunction. These results indicate that motility disturbances and GER are very frequent sequelae of caustic burns of the esophagus, and should be taken into account when evaluating symptoms and deciding on the therapeutic strategy (including diet) to be followed.

Effects of prednisolone and dexamethasone in children with alkali burns of the oesophagus

We compared the efficacies of prednisolone and dexamethasone for treatment of children with oesophageal burns due to ingestion of caustic substances. The criteria of efficacy used were a) stricture severity by 3 weeks post-ingestion, b) reduction in burn severity by 3 weeks post-ingestion and c) number of dilatations required over the first year post-ingestion. Thirty-six children (24 boys and 12 girls; mean age 23.6 +/- 7.4 months) were selected from a total of 63 patients admitted over a ten-year period to the General Hospital of Galicia with second- or third-degree oesophageal burns due to accidental ingestion of liquid alkali preparations. The patients were divided into two groups of 18, one group for treatment with prednisolone (2 mg/kg/day) and the other for treatment with dexamethasone (1 mg/kg/day). Strictures developed in 12 (66.7%) of the children in the prednisolone-treated group and only 7 (38.9%) of the children in the dexamethasone-treated group. Severe strictures developed in 10 (55.6%) of the children in the prednisolone-treated group and only 5 (27.8%) of the children in the dexamethasone treated group. However, there was no significant difference between the groups in the posttreatment distribution of stricture-severity ratings. Burn healing was significantly better in the dexamethasone-treated group. Similarly, the number of dilatations necessary during the first year of treatment was significantly lower in the dexamethasone-treated group. Our results thus indicate that, by comparison with prednisolone, dexamethasone leads to improved burn healing and reduced need for dialatations during the first year post-injury.

Intracellular posttranslational modifications of S1133 avian reovirus proteins

Avian reovirus S1133 specifies at least 10 primary translation products, eight of which are present in the viral particle and two of which are nonstructural proteins. In the work presented here, we studied the covalent modifications undergone by these translation products in the infected cell. The structural polypeptide mu2 was shown to be intracellularly modified by both myristoylation and proteolysis. The site-specific cleavage of mu2 yielded a large carboxy-terminal fragment and a myristoylated approximately 5,500-Mr peptide corresponding to the amino terminus. Both mu2 and its cleavage products were found to be structural components of the reovirion. Most avian reovirus proteins were found to be glycosylated and to have a blocking group at the amino terminus. In contrast to the mammalian reovirus system, none of the avian reovirus polypeptides was found to incorporate phosphorus during infection. Our results add to current understanding of the similarities and differences between avian and mammalian reoviruses.

Effects of prednisolone and dexamethasone on alkali burns of the esophagus in rabbit

Steroids have been widely used to prevent the severe secondary strictures that inevitably follow accidental ingestion of caustic substances by children, though with controversial results. To confirm the efficacy of large early doses of dexamethasone, we conducted an experimental study in rabbits. A cotton swab soaked in sodium hydroxide was placed on the esophageal mucosa of 30 rabbits. The rabbits were then treated with antibiotics and randomly allocated to one of three groups. One group received no steroids; the second group was treated with prednisolone; and the third was given dexamethasone. After 21 days, the rabbits were killed and the severity of the lesion was evaluated by radiological, anatomical, and histological examination. Rabbits with moderate or severe stricture, as defined on the basis of radiological examination, made up 80% of the control group, 70% of the prednisolone-treated group, and 40% of the dexamethasone-treated group. Rabbits with third-degree burns, with or without macroscopic ulcers, made up 60% of the control group, 40% of the prednisolone-treated group, and 30% of the dexamethasone-treated group. On histological examination, rabbits with third-degree lesions made up 70% of the control group, 40% of the prednisolone-treated group, and only 20% of the dexamethasone-treated group. Only the difference between the control and dexamethasone-treated group was statistically significant. Taken together, our results clearly indicate that, in rabbits, rapid postburn administration of dexamethasone leads to significant reductions in the frequency and severity of strictures and in the severity of burns.

[Tubo-ovarian abscess. An analysis of 20 cases]

The authors make a 3-year retrospective analysis of the tubo-ovarian abscess cases admitted to the Gynecology Ward of Dr Alfredo da Costa Maternity Hospital. In the period studied (1991 through 1993) there were 20 such cases. The incidence in nulliparous patients was 25%. A significant percentage (30%) of the patients had recently undergone uterine instrumentation. A prior history of pelvic inflammatory disease was obtained in only 15% of the cases. In the IUD users the incidence of unilateral and bilateral abscesses was identical. Most patients (85%) became apyretic within 48 hours of instituting intravenous antibiotics. In most cases (90%) the patients underwent surgical therapy. The mean time elapsed between instituting antibiotics and the surgical procedure was 3 days. There was one case of intra-abdominal rupture of the abscess. Intraoperatively, an appendiceal abscess was found in 3 (15%) patients. In 30% of the cases a total hysterectomy with unilateral or bilateral adnexectomy was performed. One of the 2 (10%) patients treated solely with medical therapy presented abscess recurrence one month after hospital discharge. Although the management of tubo-ovarian abscesses has become more conservative it still includes, in most cases, surgical drainage or extirpation after appropriate antibiotic therapy.

Endogenous enzymatic activities of the avian reovirus S1133: identification of the viral capping enzyme

Avian reovirus S1133 was shown to contain all the enzymatic activities required for the synthesis of mature viral transcripts, including a dsRNA-dependent RNA polymerase, a nucleoside triphosphate phosphohydrolase, an mRNA guanylyltransferase, and two mRNA methyltransferases. The virus used these enzymes both in vitro and in vivo to catalyze the synthesis of viral mRNAs containing a type-1 cap at their 5' ends. Incubation of reovirions with GTP led to the formation of an intermediate structure consisting of GMP bound to the viral core protein lambda 3 through a phosphoamide linkage. The reaction was specific for GTP and required the presence of both Mg2+ and inorganic pyrophosphatase. The GMP moiety can be transferred from the lambda 3-GMP complex to acceptors such as GDP and GTP, yielding GpppG and GppppG, respectively. Our results demonstrate that lambda 3 is the avian reovirus guanylyltransferase.

[Pregnancy in women with neural tube fusion defects. Report of 3 cases with different clinical course]

The advances in surgical technique for closure of myelomeningocele and its complications, mainly neurogenic bladder, have resulted not only in a increased lifespan and a better quality of life for these patients, but also a progressively higher number of women are reaching childbearing age and becoming pregnant. The reports of pregnancy in these women are still sporadic. In spite of that, obstetricians must be aware of this situation in order to manage it accordingly. In the course of these pregnancies major complications seldom occur. However there are problems (high-risk of neural tube defects in the offsprings, urinary tract complications, muscular-skeletal disorders and psychosociological problems) that should not be ignored and that may influence the prognosis of these pregnancies. The authors present three case reports with different outcomes.

Protein coding assignment of avian reovirus strain S1133

Avian reovirus S1133 encodes 10 primary translation products, 8 of which are structural components of the viral particle and 2 of which are nonstructural proteins. The identity of the gene that codes for each of these polypeptides was determined by in vitro translation of denatured individual genome segments.

Cytogenetic study in children chronically habituated to inhalation of volatile substances

Deliberate inhalation of volatile substances is a common and harmful phenomenon among young persons around the world. Clinical and cytogenetic studies were performed in 35 children (33 boys and 2 girls) chronically habituated to inhalation of volatile agents, with the aim to define whether this practice is associated with chromosome abnormalities and if so to what extent. A significant increase in the rate of chromosome abnormalities and in the frequency of sister chromatid exchanges (SCE) was found in sniffers over the values in controls (p less than 0.001). Clinical, socioeconomic, and cytogenetic findings are discussed.

Biochemical characterization of carcinogen-induced mammary hyperplastic aveolar nodule and tumor in the rat

Biochemical parameters characterizing growth, functional activity, and hormone dependence were compared in the normal mammary gland, the 7,12-dimethylbenz(a)anthracene-induced hyperplastic aveolar nodule (HAN), and the mammary tumor in the rat. The rate of DNA synthesis in HAN was significantly lower than the rates in either the normal mammary gland cells or the mammary tumor cells cultured in medium containing identical hormone supplement for the same duration of time. The rate of casein synthesis in the explants of pregnant rat mammary gland and HAN was greatly stimulated when cultured in medium containing insulin, cortisol, and prolactin. The mammary tumor, however, failed to produce an increase in casein synthesis under the same experimental conditions. The specific estradiol-binding proteins were either absent or present in very low concentrations in HAN. In contrast, mammary tumor cytosol contained high concentrations of specific estrogen-binding proteins. The normal mammary gland, in spite of its low cellularity, had twice as many estradiol-binding macromolecules as did HAN. Altogether, these results show that HAN cell populations differ from normal mammary gland and mammary tumor cells by their nonresponsiveness to hormonal stimulation for growth and by their lack of specific receptors for extradiol. They retain, however, the functional capacity to synthesize casein, a biochemical property that the mammary tumor does not posses.