The uncalibrated prothrombinase-induced clotting time test

The activated partial thromboplastin time test (aPTT) represents one of the most commonly used diagnostic tools in order to monitor patients undergoing heparin therapy. Expression of aPTT coagulation time in seconds represents common practice in order to evaluate the integrity of the coagulation cascade. The prolongation of the aPTT thus can indicate whether or not the heparin level is likely to be within therapeutic range. Unfortunately aPTT results are highly variable depending on patient properties, manufacturer, different reagents and instruments among others but most importantly aPTT’s dose response curve to heparin often lacks linearity. Furthermore, aPTT assays are insensitive to drugs such as, for example, low molecular weight heparin (LMWH) and direct factor Xa (FXa) inhibitors among others. On the other hand, the protrombinase-induced clotting time assay (PiCT®) has been show to be a reliable functional assay sensitive to all heparinoids as well as direct thrombin inhibitors (DTIs). So far, the commercially available PiCT assay (Pefakit®-PiCT®, DSM Nutritional Products Ltd. Branch Pentapharm, Basel, Switzerland) is designed to express results in terms of units with the help of specific calibrators, while aPTT results are most commonly expressed as coagulation time in seconds. In this report, we describe the results of a pilot study indicating that the Pefakit PiCT UC assay is superior to the aPTT for the efficient monitoring of patients undergoing UFH therapy; it is also suitable to determine and quantitate the effect of LMWH therapy. This indicates a distinct benefit when using this new approach over the use of aPPT for heparin monitoring.

Procedures and recommended times in the care process of the patient with pancreatic cancer: PAN-TIME consensus between scientific societies

PURPOSE

Pancreatic cancer (PC) is a disease with bad prognosis. It is usually diagnosed at advanced stages and its treatment is complex. The aim of this consensus document was to provide recommendations by experts that would ameliorate PC diagnosis, reduce the time to treatment, and optimize PC management by interdisciplinary teams.

METHODS

As a consensus method, we followed the modified Delphi methodology. A scientific committee of experts provided 40 statements that were submitted in two rounds to a panel of 87 specialists of 12 scientific societies.

RESULTS

Agreement was reached for 39 of the 40 proposed statements (97.5%).

CONCLUSIONS

Although a screening of the asymptomatic population is not a feasible option, special attention to potential symptoms during primary care could ameliorate early diagnostic. It is especially important to decrease the period until diagnostic tests are performed. This consensus could improve survival in PC patients by decreasing the time to diagnose and time to treatment and by the implementation of multidisciplinary teams.

The PiCT® test is a reliable alternative to the activated partial thromboplastin time in unfractionated heparin therapy management: results from a multicenter study

Essentials Activated partial thromboplastin time (APTT) or anti-Xa tests are used to monitor heparin. Prothrombinase-induced Clotting Time (PiCT) was compared to APTT in a clinical study. PiCT shows higher correlation to anti-Xa than APTT does and is more comparable between centers. PiCT demonstrates significantly higher accuracy and reliability than APTT in heparin monitoring.

SUMMARY

Background Unfractionated heparin (UFH) is still a commonly used anticoagulant for prevention and treatment of thromboembolism in a variety of situations. Increasingly, chromogenic anti-Xa assays are used for UFH monitoring given the high variability of the activated partial thromboplastin time (APTT) in this setting. On the other hand, and despite the known variability, the APTT test remains the most frequently used monitoring tool in UFH therapy because of its broad availability, lower costs and wide acceptance. Various guidelines continue to recommend the use of the APTT as an anti-Xa surrogate, but this approach remains controversial. Objective To assess the prothrombinase-induced clotting time (PiCT® ) test, reported in seconds, as an alternative to the APTT in the management of UFH-mediated anticoagulation. Methods Plasma samples from patients receiving UFH were obtained in three different centers in the USA and Europe. Samples were analyzed for PiCT, APTT and anti-Xa activities with conditions set to allow comparability. Target-ranges in seconds for PiCT and APTT were established for a UFH concentration of 0.3-0.7 IU mL-1 , derived from anti-Xa results as suggested by the ACCP guidelines. Results PiCT demonstrated better correlation with anti-Xa IU mL-1 than APTT, higher ability to identify samples within target range and, importantly, comparable target-ranges between different centers. Conclusion Accuracy and reliability of PiCT are significantly better than those of APTT in monitoring UFH for anticoagulant therapy.

Risk factors for advanced lesions undetected at prior colonoscopy: not always poor preparation

BACKGROUND AND STUDY AIM

Colonoscopy is regarded as the gold standard for diagnosis of colonic lesions. However, adenoma miss rates in tandem colonoscopy studies vary from 2 % to 26 %. We aimed to investigate the rates of advanced neoplasia in patients with a prior normal colonoscopy in an outpatient endoscopy unit.

METHODS

Review of reports for colonoscopies performed in our Endoscopy Unit from 2000 to 2005. Undetected lesions were defined as advanced adenoma or colorectal cancer (CRC) not reported in a colonoscopy performed in the previous 2 or 3 years, respectively. Patients with hereditary nonpolyposis CRC (HNPCC) and familial adenomatous polyposis (FAP) were excluded.

RESULTS

Between 2002 and 2005, 795 patients were diagnosed with at least one advanced adenoma and 386 with CRC. Among these, 107/795 patients (13.5 %) had advanced adenoma that had been undetected in a previous colonoscopy (39 % [53/135 lesions] in the right colon); 92/107 (86 %) had an undetected advanced adenoma ≥ 10 mm. Previously undetected CRCs were found in 27/386 patients (6.7 %), located in the left colon in 21/27 (78 %); in 7 the area had not been reached in the previous colonoscopy. Risk factors for undetected advanced adenoma were advanced age, male gender, the presence of another advanced adenoma at first colonoscopy, and history of advanced neoplasia.

CONCLUSIONS

Failure to detect advanced neoplasia is common in a community-based endoscopy facility. Previously undetected advanced lesions are more frequently found in the left colon and rectum. Risk factors for non-detection of advanced adenoma are similar to those for advanced neoplasia recurrence. Lowering non-detection rates is crucial for correct follow-up recommendations. Patients should be aware of rates of detection of advanced neoplasia after previous normal colonoscopic findings.

The uncalibrated prothrombinase-induced clotting time test. Equally convenient but more precise than the aPTT for monitoring of unfractionated heparin

The activated partial thromboplastin time test (aPTT) represents one of the most commonly used diagnostic tools in order to monitor patients undergoing heparin therapy. Expression of aPTT coagulation time in seconds represents common practice in order to evaluate the integrity of the coagulation cascade. The prolongation of the aPTT thus can indicate whether or not the heparin level is likely to be within therapeutic range. Unfortunately aPTT results are highly variable depending on patient properties, manufacturer, different reagents and instruments among others but most importantly aPTT's dose response curve to heparin often lacks linearity. Furthermore, aPTT assays are insensitive to drugs such as, for example, low molecular weight heparin (LMWH) and direct factor Xa (FXa) inhibitors among others. On the other hand, the protrombinase-induced clotting time assay (PiCT®) has been show to be a reliable functional assay sensitive to all heparinoids as well as direct thrombin inhibitors (DTIs). So far, the commercially available PiCT assay (Pefakit®PiCT®, DSM Nutritional Products Ltd. Branch Pentapharm, Basel, Switzerland) is designed to express results in terms of units with the help of specific calibrators, while aPTT results are most commonly expressed as coagulation time in seconds. In this report, we describe the results of a pilot study indicating that the Pefakit PiCT UC assay is superior to the aPTT for the efficient monitoring of patients undergoing UFH therapy; it is also suitable to determine and quantitate the effect of LMWH therapy. This indicates a distinct benefit when using this new approach over the use of aPPT for heparin monitoring.

Spanish growth studies 2008. New anthropometric standards

Cross-sectional and longitudinal growth studies have recently been conducted in Spain. These studies have allowed neonatal anthropometry in premature and term neonates and postnatal growth in children and adolescents to be evaluated. Moreover, a longitudinal study that allows pubertal growth to be evaluated for distinct groups according to maturation has also been published. Between 1999 and 2002, birth weight and vertex-heel length were evaluated in 9,362 newborns (4,884 boys and 4,478 girls), with a gestational age of 26-42 weeks. An increase in these values compared with previous Spanish studies (1987-1992) and sexual dimorphism were observed. Between 2000 and 2004, height, weight and body mass index (BMI) were evaluated in 32,064 individuals (16,607 males, 15,457 females) aged 0-24 years. An increasing secular trend was observed compared with data obtained 20 years previously. Increases in BMI exceeded those in height for BMI values above the 50th percentile. A longitudinal growth study of 458 healthy individuals (223 boys, 235 girls) born between 1978 and 1982 yielded pubertal growth and maturity standards for each of the five pubertal maturity groups. In addition, data on skinfolds, bone mass and intellectual development from birth to adulthood were also provided. Adult height in both studies was similar to that reported by European and American studies, but was lower than that reported for German, Swedish and Dutch populations. In males, BMI was higher than in other European populations and was close to that of the US population. In females, BMI was similar to that in European populations and was lower than that in the US population.

COX-2 and colorectal cancer

Metabolites of arachidonic acid participate in normal growth responses and in aberrant cellular growth and proliferation, including carcinogenesis. The key step in the conversion of free arachidonic acid to prostaglandins is catalyzed by the cyclooxygenase enzyme (COX). There are two COX enzymes, COX-1 and COX-2. COX-1 is expressed constitutively and is part of normal cell metabolic functions. COX-2, on the other hand, is induced and expressed in neoplastic growths. The connection between COX expression and carcinogenesis was first implicated in studies that demonstrated the efficacy of aspirin and non-steroidal anti-inflammatory drugs to reduce the relative risk of colon cancer and also promote tumor regression in both humans and animal models of colon cancer. Investigation of the molecular basis of these observations showed that high levels of COX-2 protein were present in both human and animal colorectal tumors. A variety of evidence gathered from epidemiological, whole animal, and cellular studies indicate that unregulated COX-2 expression is a rate-limiting step in tumorigenesis and also that the loss of regulation occurs early in carcinogenesis. The interest in the COX-2 enzyme is that specific inhibition of COX-2 could theoretically avoid the gastrointestinal and other complications observed with the use of nonspecific COX inhibitors (most NSAIDs) or COX-1 inhibitors. The mechanisms by which COX-2 inhibitors lead to decreased colon carcinogenesis are not fully understood but they involve an increase not only in COX-2 dependent but also in COX-2 independent mechanisms.

Value of magnetic resonance imaging for the diagnosis and follow-up of haemophilic arthropathy

An orthopaedic assessment of the joint status of seven severe haemophiliacs (mean age 12.5 y - range 8.9-15.5) on prophylactic treatment (PT) by magnetic resonance imaging (MRI) and physical examination was carried out. Median duration of PT of these patients was 84 months (range 32-107). A locally designed MRI joint score considering seven parameters (1 - joint effusion, 2 - synovial membrane thickening, 3 - haemosiderin deposits, 4 - joint cartilage injury, 5 - subchondral bone erosion, 6 - subchondral bone cysts, 7 - osteonecrosis) was used (maximum score = 13 points). MRI scans were performed in 17 joints (nine ankles, seven knees and one elbow): mean MRI scores for the affected joints was 5.1. A poor consistency between physical examination and MRI findings or the real extent of joint damage was found (Cohen kappa index 0.320). MRI is a precise non-invasive tool for the assessment of early joint cartilage and synovium pathological changes still undetectable by physical examination or conventional X-rays in the haemophilic setting.

Biodegradation of aromatic compounds by Escherichia coli

Although Escherichia coli has long been recognized as the best-understood living organism, little was known about its abilities to use aromatic compounds as sole carbon and energy sources. This review gives an extensive overview of the current knowledge of the catabolism of aromatic compounds by E. coli. After giving a general overview of the aromatic compounds that E. coli strains encounter and mineralize in the different habitats that they colonize, we provide an up-to-date status report on the genes and proteins involved in the catabolism of such compounds, namely, several aromatic acids (phenylacetic acid, 3- and 4-hydroxyphenylacetic acid, phenylpropionic acid, 3-hydroxyphenylpropionic acid, and 3-hydroxycinnamic acid) and amines (phenylethylamine, tyramine, and dopamine). Other enzymatic activities acting on aromatic compounds in E. coli are also reviewed and evaluated. The review also reflects the present impact of genomic research and how the analysis of the whole E. coli genome reveals novel aromatic catabolic functions. Moreover, evolutionary considerations derived from sequence comparisons between the aromatic catabolic clusters of E. coli and homologous clusters from an increasing number of bacteria are also discussed. The recent progress in the understanding of the fundamentals that govern the degradation of aromatic compounds in E. coli makes this bacterium a very useful model system to decipher biochemical, genetic, evolutionary, and ecological aspects of the catabolism of such compounds. In the last part of the review, we discuss strategies and concepts to metabolically engineer E. coli to suit specific needs for biodegradation and biotransformation of aromatics and we provide several examples based on selected studies. Finally, conclusions derived from this review may serve as a lead for future research and applications.

Psammomatous malignant melanoma arising in an intradermal naevus

AIMS

A wide variety of differentiation patterns may be found in malignant melanoma. Schwannian features are unusual, and mostly present in the desmoplastic variant. We report the first description of psammoma bodies in malignant melanoma.

METHODS AND RESULTS

A malignant melanoma arose in an intradermal naevus of the scalp in a 51-year-old woman, displaying focal neural-like features in the form of rosette-like pseudo-meissnerian alveolar nests, as well as numerous psammoma bodies grouped in a few areas. Tumour cell immunostaining for S100, HMB45, NKI-C3, and vimentin was detected. In addition, both malignant and benign melanocytic cells showed widespread MART-1 immunoreactivity. Differential diagnosis with psammomatous melanotic schwannoma, a feature of Carney's complex, is particularly emphasized, since dermal variants of this nerve sheath neoplasm have been described. In addition, its potential relationship with cutaneous malignant melanotic neurocristic tumour is discussed.

CONCLUSIONS

This is, to our knowledge, the first reported case of cutaneous malignant melanoma with psammoma bodies.

Computational models of blood flow in the circle of Willis

A two-dimensional, steady state model of the circle of Willis has been developed. To simulate the peripheral resistance of the cerebrovascular tree, blocks of porous media were used. Their effective resistance was kept constant, disregarding the effects of arterial auto-regulation. The model was then used to simulate different common abnormalities of the circle of Willis while a range of varying boundary conditions was imposed to the right internal carotid artery (ICA). The total flux was tabulated and compared favourably with both clinical measurements and other models of the circle of Willis. Relevant fluid dynamics effects were also observed and analysed. The present model demonstrates that the use of CFD can produce physiological results if the appropriate boundary conditions are used. We can provide clinicians with a priority list of the severity of the flux reduction for the considered abnormalities for different degrees of stenosis of the right ICA. From this study it is apparent that the redistribution of blood via the circle of Willis is mainly driven by changes in the vascular resistance of the brain rather than in the local arterial geometry. The use of valid peripheral resistances allows for a more realistic model of the circle of Willis but also highlights the need for more accurate means to estimate the vascular resistance of a patient.

Clinical, physical, sperm and hormonal data in 251 adults operated on for cryptorchidism in childhood

OBJECTIVE

To determine the clinical, physical, sperm and hormonal status during adulthood in cryptorchid patients operated on during childhood, and to assess these variables according to the age at surgery and preoperative testicular position.

PATIENTS AND METHODS

A letter was sent to all 890 patients > 18 years old who underwent surgery for cryptorchidism during childhood; 274 responded and were assessed using a sexual history, physical examination, pituitary axis study and sperm analysis. Data were complete for 251 patients (mean age 21 years, range 18-30); 196 had unilateral (25 anorchic) and 55 had bilateral cryptorchidism. Clinical, surgical and anatomopathological records at surgery during childhood were also reviewed.

RESULTS

The mean (SD) age at orchidopexy was 6.4 (3.3) years and the mean age at assessment 21.1 (2.7) years. Semen samples generally showed abnormalities; 10 patients (4%) with bilateral and 57 (23%) with unilateral cryptorchidism had semen values within the normal range. There was no correlation between the sperm count and age at surgery for unilateral or bilateral cases (Spearman test). There was a significant correlation (r = - 0.41) between the sperm count and level of follicle-stimulating hormone (FSH). There were no significant differences in the sperm count for patients with different testicular locations (ANOVA) or in those treated or untreated with human chorionic gonadotrophin (Student's t-test). The only significant relationship (P < 0.001) was between the sperm count and unilateral or bilateral cryptorchidism.

CONCLUSIONS

The sperm quality of adults operated on for cryptorchidism during childhood is independent of the age at surgery or testicular location, but is influenced by whether the cryptorchidism was unilateral or bilateral. FSH levels were negatively correlated with sperm density.

Transcriptional regulation of the divergent paa catabolic operons for phenylacetic acid degradation in Escherichia coli

The expression of the divergently transcribed paaZ and paaABCDEFGHIJK catabolic operons, which are responsible for phenylacetic acid (PA) degradation in Escherichia coli, is driven by the Pz and Pa promoters, respectively. To study the transcriptional regulation of the inducible paa catabolic genes, genetic and biochemical approaches were used. Gel retardation assays showing that the PaaX regulator binds specifically to the Pa and Pz promoters were complemented with in vivo experiments that indicated a PaaX-mediated repression effect on the expression of Pa-lacZ and Pz-lacZ reporter fusions. The region within the Pa and Pz promoters that is protected by the PaaX repressor in DNase I footprinting assays contains a conserved 15-base pair imperfect palindromic sequence motif that was shown, through mutational analysis, to be indispensable for PaaX binding and repression. PA-coenzyme A (PA-CoA), but not PA, specifically inhibited binding of PaaX to the target sequences, thus confirming the first intermediate of the pathway as the true inducer and PaaX as the only bacterial regulatory protein described so far that responds to an aryl-CoA compound. Superimposed in the specific PaaX-mediated regulation is transcriptional activation by the cAMP receptor protein and the integration host factor protein. These global regulators may adjust the transcriptional output from Pa and Pz promoters to the overall growth status of the cell.

Catabolism of phenylacetic acid in Escherichia coli. Characterization of a new aerobic hybrid pathway

The paa cluster of Escherichia coli W involved in the aerobic catabolism of phenylacetic acid (PA) has been cloned and sequenced. It was shown to map at min 31.0 of the chromosome at the right end of the mao region responsible for the transformation of 2-phenylethylamine into PA. The 14 paa genes are organized in three transcription units: paaZ and paaABCDEFGHIJK, encoding catabolic genes; and paaXY, containing the paaX regulatory gene. The paaK gene codes for a phenylacetyl-CoA ligase that catalyzes the activation of PA to phenylacetyl-CoA (PA-CoA). The paaABCDE gene products, which may constitute a multicomponent oxygenase, are involved in PA-CoA hydroxylation. The PaaZ protein appears to catalyze the third enzymatic step, with the paaFGHIJ gene products, which show significant similarity to fatty acid beta-oxidation enzymes, likely involved in further mineralization to Krebs cycle intermediates. Three promoters, Pz, Pa, and Px, driven the expression of genes paaZ, paaABCDEFGHIJK, and paaX, respectively, have been identified. The Pa promoter is negatively controlled by the paaX gene product. As PA-CoA is the true inducer, PaaX becomes the first regulator of an aromatic catabolic pathway that responds to a CoA derivative. The aerobic catabolism of PA in E. coli represents a novel hybrid pathway that could be a widespread way of PA catabolism in bacteria.

Influence of pretreatment lesions on histologic response to interferon therapy in chronic hepatitis C

We have assessed the predictive value of the grade of pretreatment liver lesions on histologic response to interferon therapy in patients with chronic hepatitis C. In 93 patients with chronic hepatitis C virus (HCV) infection who showed an initial response to interferon therapy, HCV RNA load and serum aminotransferase levels together with grade of liver histologic lesions were assessed at baseline and 6 months after treatment cessation. Regression of portal and periportal necroinflammation was observed only in sustained responders (normalization of aminotransferase levels and HCV RNA clearance). Neither short-term response nor the absence of virus was associated with significant histologic changes in the liver biopsies. Logistic regression analysis showed that pretreatment histologic lesion was an independent predictive factor of biologic response in the histologic regression of lesions 6 months after cessation of interferon treatment. In conclusion, a dense inflammatory necrotic activity is a positive predictor of histologic response in interferon-treated patients with HCV.

Characterization of the hca cluster encoding the dioxygenolytic pathway for initial catabolism of 3-phenylpropionic acid in Escherichia coli K-12

We have identified, cloned, and sequenced the hca cluster encoding the dioxygenolytic pathway for initial catabolism of 3-phenylpropionic acid (PP) in Escherichia coli K-12. This cluster maps at min 57.5 of the chromosome and is composed of five catabolic genes arranged as a putative operon (hcaA1A2CBD) and two additional genes transcribed in the opposite direction that encode a potential permease (hcaT) and a regulator (hcaR). Sequence comparisons revealed that while hcaA1A2CD genes encode the four subunits of the 3-phenylpropionate dioxygenase, the hcaB gene codes for the corresponding cis-dihydrodiol dehydrogenase. This type of catabolic module is homologous to those encoding class IIB dioxygenases and becomes the first example of such a catabolic cluster in E. coli. The inducible expression of the hca genes requires the presence of the hcaR gene product, which acts as a transcriptional activator and shows significant sequence similarity to members of the LysR family of regulators. Interestingly, the HcaA1A2CD and HcaB enzymes are able to oxidize not only PP to 3-(2,3-dihydroxyphenyl)propionate (DHPP) but also cinnamic acid (CI) to its corresponding 2, 3-dihydroxy derivative. Further catabolism of DHPP requires the mhp-encoded meta fission pathway for the mineralization of 3-hydroxyphenylpropionate (3HPP) (A. Ferrández, J. L. García, and E. Díaz, J. Bacteriol. 179:2573-2581, 1997). Expression in Salmonella typhimurium of the mhp genes alone or in combination with the hca cluster allowed the growth of the recombinant bacteria in 3-hydroxycinnamic acid (3HCI) and CI, respectively. Thus, the convergent mhp- and hca-encoded pathways are also functional in S. typhimurium, and they are responsible for the catabolism of different phenylpropanoid compounds (3HPP, 3HCI, PP, and CI) widely available in nature.

Molecular characterization of the phenylacetic acid catabolic pathway in Pseudomonas putida U: the phenylacetyl-CoA catabolon

Fourteen different genes included in a DNA fragment of 18 kb are involved in the aerobic degradation of phenylacetic acid by Pseudomonas putida U. This catabolic pathway appears to be organized in three contiguous operons that contain the following functional units: (i) a transport system, (ii) a phenylacetic acid activating enzyme, (iii) a ring-hydroxylation complex, (iv) a ring-opening protein, (v) a beta-oxidation-like system, and (vi) two regulatory genes. This pathway constitutes the common part (core) of a complex functional unit (catabolon) integrated by several routes that catalyze the transformation of structurally related molecules into a common intermediate (phenylacetyl-CoA).

What is the relationship between spermatozoa per milliliter at adulthood and the tubular fertility index at surgical age for patients with cryptorchidism?

PURPOSE

The aim of this study was to find out the relationship in the patient with cryptorchidism between the number of spermatogonia at surgical age and spermiogram data at adulthood.

METHODS

Between 1971 and 1996 the authors surgically treated 1,550 children for 2,249 undescended testis. In 21 unilateral and 41 bilateral cryptorchidism patients, both testis were biopsied at surgical procedure during childhood. We currently have spermiogram data for a patient at adulthood.

RESULTS

By using the best Tubular Fertility Index (TFI) figures of both testis, the Sperman correlation index between the two parameters is r = 0.22, statistically nonsignificant. The TFI test sensitivity is 0.68 and the specificity is 0.60. The likehood ratio for a positive test result is 0.84 and the likehood ratio for a negative test result is 0.37.

CONCLUSION

Although the authors have only one spermiogram, and there are few cases, they suspect the TFI is not a good index to predict the potential fertility in cryptorchidism patients.

Designing recombinant Pseudomonas strains to enhance biodesulfurization

The dsz biodesulfurization cluster from Rhodococcus erythropolis IGTS8 has been engineered under the control of heterologous broad-host-range regulatory signals to alleviate the mechanism of sulfur repression, and it was stably inserted into the chromosomes of different Pseudomonas strains. The recombinant bacteria were able to desulfurize dibenzothiophene more efficiently than the native host. Furthermore, these new biocatalysts combine relevant industrial and environmental traits, such as production of biosurfactants, with the enhanced biodesulfurization phenotype.

Genetic characterization and expression in heterologous hosts of the 3-(3-hydroxyphenyl)propionate catabolic pathway of Escherichia coli K-12

We report the complete nucleotide sequence of the gene cluster encoding the 3-(3-hydroxyphenyl)propionate (3-HPP) catabolic pathway of Escherichia coli K-12. Sequence analysis revealed the existence of eight genes that map at min 8 of the chromosome, between the lac and hemB regions. Six enzyme-encoding genes account for a flavin-type monooxygenase (mhpA), the extradiol dioxygenase (mhpB), and the meta-cleavage pathway (mhpCDFE). The order of these catabolic genes, with the sole exception of mhpF, parallels that of the enzymatic steps of the pathway. The mhpF gene may encode the terminal acetaldehyde dehydrogenase (acylating) not reported previously in the proposed pathway. Enzymes that catalyze the early reactions of the pathway, MhpA and MhpB, showed the lowest level of sequence similarity to analogous enzymes of other aromatic catabolic pathways. However, the genes mhpCDFE present the same organization and appear to be homologous to the Pseudomonas xyl, dmp, and nah meta-pathway genes, supporting the hypothesis of the modular evolution of catabolic pathways and becoming the first example of this type of catabolic module outside the genus Pseudomonas. Two bacterial interspersed mosaic elements were found downstream of the mhpABCDFE locus and flank a gene, orfT, which encodes a protein related to the superfamily of transmembrane facilitators that might be associated with transport. All of the genes of the 3-HPP cluster are transcribed in the same direction, with the sole exception of mhpR. Inducible expression of the mhp catabolic genes depends upon the presence, in the cis or trans position, of a functional mhpR gene, which suggests that the mhpR gene product is the activator of the 3-HPP biodegradative pathway. The primary structure of MhpR revealed significant similarities to that of members of the IclR subfamily of transcriptional regulators. A 3-HPP catabolic DNA cassette was engineered and shown to be functional not only in enteric bacteria (E. coli and Salmonella typhimurium) but also in Pseudomonas putida and Rhizobium meliloti, thus facilitating its potential application to improve the catabolic abilities of bacterial strains for degradation of aromatic compounds.

Spontaneous ascent of the testis

OBJECTIVE

To report confirmed cases of spontaneous testicular ascent in patients with a cryptorchid testis which had been previously placed in the scrotum.

PATIENTS AND METHODS

Between 1972 and 1992, 46 cryptorchid testes (36 patients), which were previously verified to be in the scrotum by staff paediatricians or paediatric surgeons, were treated surgically. The clinical, surgical and anatomicopathological records were reviewed to determine testicular position and associated conditions, and biopsies were taken from 35 testes.

RESULTS

The mean time between the last "normal' exploration until the testes ascended was 4.5 years. Before ascent, the testes were confirmed to be in the scrotum by up to seven separate recorded examinations. During surgical treatment, an open processus vaginalis was found in 18 testes. The mean (SD) tubular fertility index was 40 (37)%.

CONCLUSIONS

This study confirms that a previously descended testis can ascend spontaneously. The clinical and anatomicopathological characteristics of these testes were similar to those of the cryptorchid testis.

Chronic hepatitis and cirrhosis: evaluation by means of MR imaging with histologic correlation

To characterize the relationship between findings on magnetic resonance (MR) images and histologic changes in chronic liver disease, a prospective study was performed in 100 patients with chronic hepatitis and cirrhosis and 28 healthy subjects. Biopsy specimens, obtained in all patients before MR imaging, were evaluated with the histologic activity (HA) index; MR images were obtained with short inversion time inversion-recovery (STIR) and spin-echo sequences. On STIR images, normal livers were iso-intense to fat. Significant differences (P < .001) existed between signal intensity of normal livers and that of diseased livers, which were brighter than normal livers on STIR images. The ratio of signal intensity of liver to that of fat on STIR images was associated with an HA index grouped by severity (P < .05): Patients with higher HA scores had a brighter liver. Signal intensity ratios on MR images were statistically significantly associated with periportal and lobular necrosis and portal inflammation. The signal intensity of liver on STIR images is associated with the degree of histologic severity in patients with chronic liver disease.

[Phage count in the waters of the Canal Imperial de Aragón and the Ebro River in Saragossa]

Saragossa city supply channel and the river Ebro (up and downstream urban sewage) were studied for the presence of coliphages and B. fragilis phages and their relationship with the bacterian faecal indicators. In the supply channel the coliphages geometric mean was of 130 ufp/100 ml, and showed no correlation with faecal and total coliforms, but it showed indirect correlation with ambient temperature. In the river Ebro the coliphages geometric mean ranged from 290 to 8,000 ufp/100 ml; the relationship with total and faecal coliforms and faecal streptococci was high, but they were temperature independent. With the methodology utilized B. fragilis phages only were recovered in samples with faecal coliforms levels > 1 x 10(4) ufc/100 ml.

Multicenter clinical trial to evaluate the therapeutic use of recombinant growth hormone from mammalian cells in the treatment of growth hormone neurosecretory dysfunction

The efficacy and safety of a 12-month treatment with recombinant human growth hormone from mammalian cells (r-hGH, Saizen) in growth hormone neurosecretory dysfunction (GHND) are evaluated in this study. r-hGH was administered subcutaneously, at a dosage of 0.5 IU/kg/week divided into 6 equal daily doses. A total of 16 (12 M and 4 F) poorly growing patients, height -2.3 SD or more below the mean for chronological age and sex, were included in the study. r-hGH therapy significantly increased the growth velocity; from 3.57 +/- 0.85 cm/year, before therapy, to 7.09 +/- 2.29 cm/year after 12 months (p less than 0.001). Patients' height SD score rose from -3.40 +/- 0.84 SDS to -2.98 +/- 0.69 SDS (p less than 0.01). Somatomedin C increased significantly from a baseline value of 0.59 +/- 0.32 U/ml to 1.26 +/- 0.66 U/ml after therapy (p less than 0.01). Finally, r-hGH therapy improved the pretreatment adult height prediction; from an initial prognosis of -2.66 +/- 0.79 SDS to -2.17 +/- 0.81 SDS after treatment (p less than 0.01). No side effects or adverse reactions were observed during treatment. Anti-r-hGH antibody formation was not found in any of the patients included in the study.

[Hyperplasia of the pancreatic islets or nesidioblastosis in adults? Apropos 2 cases]

Nesidioblastosis is an anatomopathological situation defined as the transformation or the exocrine ductal epithelium into endocrine tissue which can be hormonally active or inactive. In this study we present two cases which to our knowledge fulfil criteria for nesidioblastosis. Both patients were male (73 and 45 years, respectively) who were admitted to our department because they presented hypoglycemia. Blood examination revealed the existence of an hyperinsulinism although axial computerized tomography, pancreatic echocardiography and selective angiography of the celiac arterial trunk failed to demonstrate the presence of the tumor in either of the two cases. Due to the persistence of the clinical picture in the first case and to the intolerance to the diazoxide in the second patient, a subtotal pancreatectomy was performed in both cases. The surgical procedure involved removal of the 80% and 75% of the head and body respectively. Both patients are presently free of symptoms although the first patient in under diazoxide therapy due to persistent hypoglycemia (more spaced crisis).

[Mucocele: a retrospective study and presentation of our experience]

Ten cases of the paranasal sinuses mucoceles are reported. We analyse their incidence, localization, presentation symptoms and signs, treatment, operative and pathological findings.

[Type I pseudohypoparathyroidism. Study and prolonged follow-up of a case]

The prolonged evolution of a case of pseudohypoparathyroidism with hereditary osteodystrophy (AHO) and osteitis fibrosa is presented. The diagnosis was confirmed by the existence of a peculiar phenotype, hypocalcaemia, hyperphosphatemia, increased PTH values, and a lack of tubular response after PTH and radiological signs of hyperparathyroidism. The clinical and biochemical evolution, under 1.25 (OH)2D3 therapy with special emphasis on the growth and development were shown. The bibliography was also reviewed.

Effect of recombinant human growth hormone therapy on bone and clinical parameters in girls with Turner's syndrome. The Spanish Collaborative Group

Forty-eight girls with Turner's syndrome were assigned to one of three treatments; recombinant human growth hormone (rhGH) alone, rhGH plus oxandrolone, and rhGH plus ethinyloestradiol. Treatment with rhGH alone or in combination with oxandrolone induced catch-up growth. Older girls treated with rhGH plus ethinyloestradiol showed less marked improvement. The gain in height was associated with a gain in bone diameter and cortical thickness (reflecting increased bone mass). There was a rapid loss of subcutaneous fat. These effects of growth hormone are similar to those observed in patients with growth hormone deficiency.

[Developmental quotient/intelligence quotient (DQ/IQ) in children with congenital hypothyroidism]

The aim of neonatal thyroid screening is prevention of mental retardation by early diagnosis and early institution of thyroid replacement therapy. With relatively simple and inexpensive means it should be possible to shift the distribution curve of developmental and intelligence quotients as it was found in hypothyroid patients before the screening towards that one of healthy children. The results of our collaborative study show that we are approaching this aim. However, this study also demonstrates, that risk factors and associated findings may have a considerable influence on mental development and therefore should not be neglected in such an investigation. In response to our inquiry of 1985 we received detailed data on mental outcome of nearly 1,000 individual patients with CH representing not less than 14% of all children with CH detected in Europe since the introduction of neonatal thyroid screening. This shows that in many screening centers, a large number of children have not only been diagnosed and treated, but also followed carefully with respect to their development.

[Diagnostic use of the GRF test in the study of GH secretion]

A good response after an intravenous bolus of GRF-1-29 NH2 in patients with hypopituitary dwarfism localities the site of the GH-deficiency in the hypothalamus (GRF deficiency). These patients could be treated with GH and GRF. Never the less some patients with hypothalamic responses after TRH don't respond after GRF. Probably these non responders need GRF in pulsatile or prolonged administration and T4 substitution before and during the test if TSH is also deficient. At least some cases without GRF response can be accepted as pure pituitary only GH would be effective.

[Tests for studying the secretion of growth hormone. Update]

Some tests to study the growth hormone secretion have been analysed. According to our own experience and to the present criteria the physiologic tests seem to be more suitable than the pharmacologic ones. In case of discordant results, those obtained in physiologic tests completed with the clinical data and if necessary with biologic probes are conclusive. The availability of GRF will allow the treatment of some cases of dwarfism of hypothalamic origin, that in our opinion are more frequent than those of pituitary origin. Otherwise the gene studies will contribute to the understanding of some cases of genetic dwarfism and make possible an appropriate genetic counseling.

Some comparative aspects of a longitudinal growth study in normal Spanish children and other longitudinal studies

The differences existing among some european longitudinal growth studies make it necessary to be cautious in the use of standards constructed on different populations. The improvement of the environmental conditions during the last 20 years is probably the most important cause of the "catch-up" phenomenon of the spanish stature. It is probable that racial characteristics also play a role, even in the same country as can be appreciated on comparing two spanish longitudinal studies based on children originally from different regions. All of which indicates the need to use own standards in those countries which, like ours, have lived through a period of intense changes. Even exploratory studies of regional differences in the same country seem necessary.

[Nanism with high values of GH and no generation of somatomedin after hGH (Laron's syndrome). Clinico-biochemical study of 8 cases]

Eight familial cases with Laron type dwarfism (LTD) are presented. An autosomic recessive transmission seems to be possible with clear predominance in females (6/2). This syndrome first described in Jewish people is probably frequent in our country, with clear historic Jewish antecedents in some of our cases. Some features like prenatal growth deficiency, disproportion between face and calvarium and high levels of inmunoreactive GH distinguish clearly LTD from isolated GH-deficiency. The incapability of hGH to increase low somatomedin activity confirms diagnosis. Moreover low or null nitrogen retention after hGH excludes an inactive GH as a cause of dwarfism.

Congenital adrenal hypoplasia in a male with gonadotropin deficiency

We report the case of a boy with adrenal insufficiency diagnosed at the age of 2.5 months. He required immediate therapy with corticosteroids. His two brothers and a cousin died in infancy with vomiting and dehydration. Aged 17.5 years (bone age 13 years), he showed no signs of puberty, a testicular volume of 2 ml, an infantile penis, and no axillary or pubic hair. There was no evidence of a pubertal growth spurt. The low plasma levels of cortisol, 17-OHP, delta-4-A, LH and FSH did not increase after stimulation with ACTH or LHRH respectively. Urinary testosterone levels before and after HCG were extremely low. These factors strongly suggest the diagnosis of a sex-linked type of adrenal insufficiency (cytomegalic form), associated with gonadotropin deficiency.

[Endocrine maturation]

The beginning of puberty is caused by a decrease in high gonadostate sensibility to prepubertal levels of sexual steroids. What produces this change and timing is still unknown. However, it seems that the adrenal (delta-4 Androstenedione) as well as the pineal may play an important role. When it comes to that point, the hypothalamic LH-RH provokes a strong LH, FSH secretion; this triggers the gonadal sex-steroids production, which induces in turn the appearance of the secondary sex characteristics. Two years after the so called "mid growth spurt" begins the pubertal growth acceleration which reaches its peak to 2, 4 yrs later. The pubertal development is regulated by genetic factors. Bone age should be referred as a much better indicator than the chronological age.

[Hypothyroidism acquired in childhood. Apropos of case]

Authors present a patient who, when three years old, was studied because of weight and psychic retardation. Physical data were as following: weight, 9.9 Kg (less than 93); height, 90 cm (P 10-25); head circumference, 43,5 cm (less than P3); bone age, 2 3/12 years, and the thyroid function, normal. I131 uptake, 43.5% after 24 h. TBI: T3 index, 1.07; T4, 7.7 gamma %. FT4 index, 7.2. Thyroid scan, normal. Diagnosis was: intrauterine dwarfism and iron-deficiency anemia. At 6 6/12 years old, he had measles and at this time his mother noted rapid weight gain, decrease in the grow rate, besides a coarse, cold skin and constipation, that did-not previously exist. Thyroid study showed typical primary hypothyroidism: I131 uptake, 14% after 24 h. TBI: T3 index, 1.2; T4, 1.2 micrograms/100. TSH in the test of TRH of 165 micro U/ml base and 245 maximum. Anti-thyroidal antibodies were negative. In view of the time coincidence, authors speculate that measles virus is perhaps the aetiologic agent of the hypothyroidism either directly or through an autoimmune reaction.

[Report of a patient with Lesch-Nyhan syndrome caused by total deficiency of HGPRT and with normal activity in female family members]

Authors present a 10 year old boy with Lesch-Nyhan syndrome with self-inflicted mutilations to the lips, tongue and interior cheek wall, partially avoided by tooth extraction. Hand lesions were prevented by arm restriction. Born with anoxia and in spite of seizures for several years and a marked muscle stiffness, he is relatively aware of his surroundings. HGPRT activity in blood and hair was nil, while the APRT activity was increased. The mother, a maternal aunt and grandmother are not carriers. Hyperuricemia measured several times and treated with allopurinol is kept between 3 and 4 mg/dl and lastly under 3 mg after increasing dosage. Some years ago, elimination of acid uric stones in urine was observed without hematuria. It seems that recently stone elimination produced pain difficult to evaluate in this patient.

The trichorhinophalangeal syndrome. Report of 4 familial cases belonging to 4 generations

Four familial cases of trichorhinophalangeal syndrome have been observed. These four and five other possible cases in the same family confirm the autosomal dominant inheritance and show a wide clinical expressivity. The radiological study of case 1 also confirms the existence of a characteristic generalized bone dysplasia. This syndrome bears in itself short stature of unknown etiology with normal growth hormone production. The skeletal deformities doe not affect the physical activity, and life span is not reduced.

Follow-up hormonal controls on a HGH secreting pituitary adenoma. Pre- and postoperative study

The case of a 12 2/12-year-old boy with an HGH secreting eosinophilic adenoma is presented. The histologic investigation included conventional and ultrastructural techniques. The pre- and postoperative (1, 7, 11, and 20 months) hormonal controls are analyzed, indicating the persistence of HGH anteropituitary activity, even though surgical sectioning of the pituitary stalk was performed and the activities of thyroid, corticoadrenal and gonadotropin functions decreased. It is suggested that the hypothalamo-pituitary relationship may be maintained by extraportal venous circulations.