FRI0551 PERFORMANCE OF THE 2019 AMERICAN COLLEGE OF RHEUMATOLOGY/EUROPEAN LEAGUE AGAINST RHEUMATISM SYSTEMIC LUPUS ERYTHEMATOSUS CLASSIFICATION CRITERIA

Background:

Systemic lupus erythematosus (SLE) is a heterogenous autoimmune disease, with increased morbidity and mortality, often diagnosed in advanced stages. The recently published 2019 American College Of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for SLE are weighted, hierarchically clustered criteria developed to increase reliability and the identification of early SLE.

Objectives:

To compare the sensitivity and specificity of the 2019 ACR/EULAR criteria with the 2012 SLICC criteria in a large single-centre cohort of patients with SLE, diagnosed according to expert oppinion.

Methods:

Data of SLE patients evaluated in our centre between 1996-2019 have been retrospectively analyzed. The control cohort included patients with positive antinuclear antibodies of other ethiology than SLE, evaluated between 2001-2019. The sensitivity and specificity of the 2019 ACR/EULAR and 2012 SLICC criteria were tested using the McNemar test for correlated proportions.

Results:

Four hundred and forty-six patients with SLE (413 women, mean±SD age 40.5±12.7 years, disease duration 10.1±9.2 years) and 67 controls (63 women, mean±SD age 50.4±12.6 years, disease duration 7.6±6.9 years; 29 systemic sclerosis (SSc), 18 mixed connective tissue dissease (MCTD), 15 undifferentiated CTD, 2 rheumatoid arthritis (RA), 2 SSc – RA overlaps and 1 dermatomyositis) were included. The sensitivity of the 2019 ACR/EULAR and 2012 SLICC criteria were similar 85.4% and 83.6 %, respectively (p=0.3). The specificity of the 2019 ACR/EULAR and 2012 SLICC criteria were 70.2 % and 86.6%, respectively (p=0.007). In the SLE group, patients missclassified according to the new 2019 ACR/EULAR criteria were 65, whereas according to the 2012 SLICC criteria were 73; of them, 44 patients did not fulfill any criteria. In the control group, patients misclassified had mainly MCTD (13/20 patients according to the new 2019 ACR/EULAR, and 8/9 according to the 2012 SLICC criteria).

Conclusion:

In this real-life cohort, the 2019 ACR/EULAR criteria have a similar sensitivity and lower specificity than the 2012 SLICC criteria, misclassifying especially MCTD patients. These results might be due to the long disease duration in our cohort.

References:

[1] Aringer M, Costenbader K, Daikh D, et al. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol. 2019;71(9):1400–1412. doi:10.1002/art.40930

Disclosure of Interests:

None declared

[Correlation of genetic and cytogenetic alterations in pathological aggressiveness urothelial carcinoma of the bladder: Performance of BCA-1, a mini-array comparative genomic hybridisation-based test]

INTRODUCTION

Urothelial carcinomas are the fourth leading cause of cancer in humans. Their incidence is increasing by more than 50% in 25 years. The superficial forms (70% cases) require a close active surveillance to identify frequent recurrences and progression to invasive stage. Our main goal was to identify prognostic molecular markers for bladder cancer that could be used alone or in combination in routine clinical practice. In this aim, we evaluated the capability of the BCA-oligo test based on a CGH array to correctly classify tumoral grade/stage.

METHOD

Urinary DNA was extracted from 81 patients with superficial bladder cancer and has been hybridized on the BCA-oligo array. The results from the molecular analysis were correlated with the tumoral grade and stage.

RESULTS

Several chromosomal alterations were significantly more frequent in tumors of higher grade and more advanced stage. A significant association was observed between a high grade and the presence of one of these alterations: loss on 6p, gain on 8q or 13q, loss or gain on 9q or 11q, with an odds ratio of 6.91 (95% CI=2.20-21.64; P=0.0009). Moreover, a significant association was found between a more advanced stage (pT1) and the presence of one of these alterations: loss on 6p, gain on 8q, loss or gain on 5p, with an odds ratio of 15.2 (95% CI=3.71-62.58; P=0.0002).

CONCLUSION

Our results showed that molecular analyses of superficial bladder cancers based on urinary DNA and the BCA-oligo test could be used as prognostic factor for the tumor evolution, allowing then a more adapted clinical management.

Biomarkers in Rheumatoid Arthritis, what is new?

Rheumatoid arthritis (RA) is a chronic inflammatory disease with autoimmune pathogenesis. It affects mainly small joints (of the hands and feet) and has many systemic manifestations. Studying biomarkers in rheumatology intensely appeared from the need to understand the mechanisms underlying some rheumatic diseases. Discovering new biomarkers with key roles in various stages of evolution, remains a subject of interest for RA. Currently, according to the EULAR 2010 criteria, the rheumatoid factor (RF) and the anti-cyclic citrullinated peptide (anti-CCP) are used for RA diagnosis. Since 2010, new biomarkers were discovered and proved useful in identifying RA in early stages. For a more rigorous management of these cases, one of the key steps in the evolution of patients with RA is to recognize and distinguish the more aggressive forms of the disease through prognostic biomarkers. "Treat to target" recommends the use of 3 composite scores to monitor the evolution of the disease: disease activity score (DAS 28), simple disease activity index (SDAI) and clinical disease activity index (CDAI), but, a new test was developed which better monitors the disease activity. The introduction of biological therapies has revolutionized the treatment of RA. Despite these advances, 20-40% of the patients are declared nonresponders to at least one of the therapies. The patient exposure to the potential side effects and high costs requires the discovery of a biomarker that could identify those who can benefit from the pretreatment of a certain therapy.

ABBREVIATIONS

RA = rheumatoid arthritis, RF = rheumatoid factor, DAS 28 = disease activity score, SDAI = simple disease activity index, CDAI = clinical disease activity index, ACR = American College of Rheumatology, EULAR = European League against Rheumatism, anti-CCP = antibodies against cyclic citrullinated proteins, anti-MCV = mutated citrullinated vimentin antibodies, anti-CarP = antibodies against carbamylated proteins, MBDA = multi biomarker disease activity test, COMP = cartilage oligomeric matrix protein, ADAs = antidrug antibodies, CDA = clinical disease activity index, SDAI = simplified disease activity index, ESR = erythrocyte sedimentation rate, CRP = C reactive protein, SAA = serum amyloid A, VCAM-1 = vascular cell adhesion molecule-1, IL-6 = interleukin-6, TNF-R1 = tumor necrosis factor receptor 1, EGF = epidermal growth factor, VEGF-A = vascular endothelial growth factor A.

The efficiency of biologic therapy in a group of patients with rheumatoid arthritis

OBJECTIVES

The following study aims to evaluate the monotherapy with biologic agents: Infliximab (IFX), Etanercept (ETA), Adalimumab (ADA) and Rituximab (RTX) in patients diagnosed with rheumatoid arthritis (RA).

METHODS

To achieve these objectives, the database of "Dr. I. Cantacuzino" Clinical Hospital, Department of Internal Medicine and Rheumatology, was used. The study was retrospective and descriptive, covering 168 patients with RA, followed for 12 months, from January 2012 to January 2013. Admission criteria for the study were the following: patients diagnosed with RA according to ACR 1987/ EULAR 2010 criteria, disease activity score (DAS 28)> 5.1, positive inflammation tests, presence of RA refractory to classic remitting treatment administered at least 6 months prior to the initiation of biological therapy, on patients treated with RTX. They were considered non-responders after 6 months of treatment with anti tumor necrosis factor alpha (anti-TNF) and decided to switch agents with anti CD-20.

RESULTS

Comparing values between any two points in time (baseline - 6 months -12 months) for any type of therapy, there were significant decreases in the values of erythrocyte sedimentation rate (ESR), reactive C protein (CRP) and disease activity score (DAS 28). There were no significant differences between therapies regarding ESR at 6 months (p = 0.070, ANOVA) and 12 months (p = 0.375, Kruskal-Wallis), significant differences were regarding CRP at 6 and 12 months (p = 0.000, Kruskal-Wallis) and DAS 28 at 6 months (p = 0.000, Kruskal- Wallis) and 12 months (p = 0.018, Kruskal-Wallis).

CONCLUSION

All 4 therapies have proven efficient, prognostic markers decreasing gradually at 6 and 12 months.

[Predictive value of the penile cuff-test for the assessment of bladder outlet obstruction in men]

PURPOSE

To assess the diagnostic performances and the acceptability of the penile cuff test (PCT) which is a non invasive method for the evaluation of bladder outlet obstruction (BOO), in comparison with the pressure flow study (PFS), the actual gold-standard.

MATERIAL

Monocentric prospective study comparing the following subsets: "obstructed", "not obstructed" or "equivocal", deduced from PFS vs PCT, in 30 consecutive patients presenting with lower urinary tract symptoms. For the PCT, a cuff placed around the penis inflated automatically during the micturition, until flow rate interruption. The interruption cuff pressure revealed the isovolumetric bladder pressure (Pcuff-int). The data collected - Pcuff-int and maximum flow rate - were automatically reported on ICS modified nomogram.

RESULTS

With the PFS, 11 patients (39%) were classified "obstructed", six patients (22%) "non-obstructed" and 11 patients (39%) "equivocal". In 61% cases, the patient was classified in the same category by both techniques. The "obstructed positive predictive value" of the PCT was 82% and the "non-obstructed-equivocal negative predictive value" was 88%. The median acceptability visual analogic scale score was 1/10 (0-3) for the PCT whereas it was 5/10 (2-10) for the PFS. This difference was statistically significant (p=0.004).

CONCLUSION

The PCT was a reliable non-invasive tool for the diagnosis of BOO in male, in comparison with PFS. The predictive values of the PCT were relevant and its tolerance was better than PFS.

[Salvage therapy with artificial urinary sphincter after Advance™ male sling failure for post-prostatectomy incontinence: a first clinical experience]

OBJECTIVES

To assess the clinical outcome following artificial urinary sphincter (AUS) implantation after failure of Advance™ sub-urethral male sling for post-prostatectomy incontinence (PPI).

METHODS

A prospective evaluation was conducted about consecutive patients who received an AUS after failure of Advance™ therapy in one tertiary reference center. Evaluation included medical history, pad use and operative data (duration, cuff size, technical difficulties). Follow-up was scheduled at 1, 6, 12 months and yearly thereafter. Clinical outcome was evaluated by pad use, patient global impression of improvement (PGI-I) scale and assessment of side effects. Cure was defined as no pad usage.

RESULTS

Twelve patients were included in this evaluation. Median follow-up was 20 months (12-43). No patient was lost to follow-up. Four patients had a history of radiation therapy and all patients had mild or moderate PPI with previous failed Advance™ surgery. Median (range) operative time was 47 minutes (40-60). No technical problem occurred during AUS implantation. Hospital stay duration and catheterization duration were respectively 2 days and 24 hours in all but one case. At last follow-up, 10/12 patients (83%) were cured and fully satisfied. Two were improved, wearing only one pad per day. Postoperative complications were noted in two cases (17%) (one case of cutaneous erosion and one case of superficial iliac wound infection).

CONCLUSIONS

AUS implantation is feasible in patients who have undergone Advance™ male sling implantation. Mid-term results of this procedure are comparable to those obtained after first line AUS implantation.

Trends of rheumatoid arthritis monitorization in Romania

BACKGROUND

rheumatoid arthritis (RA) is associated with the loss of overall functionality, which leads to substantial economic losses. Second line agents used in RA treatment require careful monitorization in terms of efficiency and tolerability.

OBJECTIVE

trends, predictive factors and characteristics of clinical, biological and radiological RA monitorization in a cross sectional observational cohort study, conducted on over 206 patients in Romania, with a 12 months follow up (December 2007 - December 2008).

METHOD

Cases were recruited from the south-west region of the country, covering a geographical area of 23 counties. Patients were invited to complete three sets of interviews (collected by post) in a consent letter, containing self reported questionnaires, at 6 months intervals: an original questionnaire (which included quantitative self reported of pain, disease activity and fatigue on visual analogue scale-VAS), Health Assessment Questionnaire-HAQ-Disability and Discomfort Scales and EUROQOL EQ-5D, validated in Romanian (obtaining a user agreement by authors of the original version).

RESULTS

analysis was carried out in SPSS 10. The cohort enrolled 206 patients, with the average age of 54.90 +/- 12.67 years, 66% urban, 86.4% women, 29.1% professionally active, 48.5% graduates of primary education. The average disease duration after diagnosis of RA was of 9.40 +/- 8.87 years. The duration of the treatment reported at baseline was of 2.70 +/- 2.64 years. Most patients followed a program of monthly monitoring at a general practitioner (GP) (41.7% at baseline and 37.1% to 12 months). Visits to the rheumatologist followed a monthly regimen (32.3% at baseline and 31.7% to 12 months) or a 2 months interval (19.4% at baseline and 29.6% to 12 months, p = 0.000). Biological monitoring was quarterly (39.6% and 53.2% at 12 months; p = 0.000) or at 2 months interval (26.2% at baseline and 16.7% to 12 months, p = 0.000). X-ray monitoring lacked in over half the cases in a year of disease progression (63.3% at 6 months and 62.2% at 12 months), although it sums between 1 and 3 radiographs to one third of the cases (36.8%),

CONCLUSION

generally, in our country, there is a lack of aggregation in the dispensarization algorithm of patients with RA; consequently, the decision is awarded to the human factor. Under these circumstances, some patients are over evaluated. Promoting a dispensarization guide for RA patients could induce benefits both clinically and economically. Therefore, we submit a proposal of recommendations as a guideline for clinical, biological and radiological monitoring, according to the phase and stage of RA.

[Management of premature ejaculation in adults]

Premature ejaculation is a very frequent form of sexual dysfunction characterized by loss of control of ejaculation, inducing performance anxiety and, consequently, impaired quality of life of patients and their partners. The pathophysiology of this symptom is often both psychogenic and organic. The various organic causes must be systematically investigated. Several drug treatments are used with varying degrees of efficacy and their adverse effects must be taken into account when choosing a molecule. Psychological management is an essential complement to drug treatment.

Apport du VLPP dans l’examen urodynamique

The Valsalva leak point pressure (VLPP) is fully part of urologic assessment. Several factors can influence it: the patient's position, the bladder volume, the presence or absence of the urethral catheter, and the way of observing the leakage (direct visualisation or video-urodynamics). Sometimes VLPP is not feasible because patients cannot push strong enough. Nevertheless, a standardisation of the methodology has been suggested by the Société internationale francaphone d'urodynamique (SIFUD). Values below 60 cmH2O should be considered suggestive for sphincter insufficiency. Conversely, the diagnosis of urethral sphincter insufficiency should rely on the tripod: clinical examination (low urethral mobility), low closure pressure and low VLPP.

Atteinte vésicale dans la sclérodermie : à propos de 3 cas

Lower urinary tract involvement is the common manifestation of systemic sclerosis. It may represent a troublesome disturbance affecting the quality of life in systemic sclerosis patients. We report three patients with progressive systemic sclerosis who manifested pathologic abnormalities in the urinary bladder. The first patient manifested a recurrent macroscopic hematuria requiring transfusions. Both other patients developed functional and urodynamic abnormalities. With a review of the literature on this involvement of the bladder in systemic sclerosis we try to more understand urinary symptoms and urodynamics features of vesical involvement in systemic sclerosis patients.

Tension-free vaginal tape: why an unusual concept is so successful

The surgical treatment of female stress urinary incontinence has been dramatically changed during the last 5 years, after Ulmsten introduced the tension-free vaginal tape procedure. This technique is based on a series of experimental investigations of the urethral closure mechanisms in women. The procedure is easy to learn, could be performed on an outpatient basis, and is recognized as a minimally invasive surgery. Despite these arguments, the most probable reason for its present success is the reproducibility of the results in the various published series. The success rate is estimated at between 85 and 95% for correction of genuine stress urinary incontinence. However, longer follow-up will be necessary to confirm these preliminary results, and probably to determine what are the most valuable prognostic factors.

Results of the tension-free vaginal tape procedure for the treatment of type II stress urinary incontinence at a minimum followup of 1 year

PURPOSE

We evaluated the safety and efficacy of the tension-free vaginal tape procedure for treating type II stress urinary incontinence in females.

MATERIALS AND METHODS

Between April 1998 and April 1999, 62 women 28 to 86 years old (mean age 62.8) were treated consecutively for stress urinary incontinence with the tension-free vaginal tape procedure. Preoperative evaluation included history, physical examination and multichannel video urodynamics. All patients had type II stress urinary incontinence, none had preoperative detrusor instability or significant pelvic prolapse and in 16 previous surgery for stress incontinence had failed.

RESULTS

All patients were followed at least 12 months after the procedure (median 16.2). A total of 42 and 20 women received spinal and local anesthesia, respectively. We noted 6 bladder perforations, including 5 in patients with a history of surgery for stress urinary incontinence. Blood loss was less than 200 cc in all cases. We observed no prolonged postoperative pain, infection or sling rejection. Post-void residual urine was less than 100 cc the day after surgery in 59 cases. Only 3 patients self-catheterized a maximum of 4 days. At followup 54 women (87.1%) were cured of stress urinary incontinence, 6 were improved (9.6%) and 2 had failure (3. 3%), while 4 (6.4%) had new onset detrusor instability without evidence of bladder outlet obstruction.

CONCLUSIONS

The tension-free vaginal tape procedure appears to be a minimally invasive, safe and effective treatment for type II stress urinary incontinence. A history of surgery for stress incontinence seems to be a risk factor for bladder perforation.

[Prospective, multicentric, open, and controlled evaluation of the effectiveness of prostatron 2.5 in the treatment of prostatic benign hypertrophy: 1-year results]

OBJECTIVE

Evaluation of the efficacy at 1 year of the Prostatron 2.5 in the treatment of BPH weighing more than 40 grams.

MATERIAL AND METHODS

46 patients over the age of 50 years presenting with BPH > 40 grams responsible for a maximum flow rate (MFR) < 9 ml/s and a mean IPSS score of 18 were prospectively included without randomization, by 5 French Urological Centres. These patients were reviewed at 3, 6 and 12 months. Primary endpoint: MFR; secondary endpoints: Madsen score and IPSS.

RESULTS

No major complications were observed. The mean postoperative catheterization time was 10 days, causing discomfort with a mean score of 5 on a visual analogue scale from 0 to 10.. Maximum flow rate waas 13.4 ML/s at 3 months, 13.4 ml/s at 6 months and 14.7 ml/s at 12 months. The IPSS was improved by 75%.

CONCLUSION

Treatment by Prostatron 2.5 improves the MFR and the patient's quality of life, which is maintained for at least 1 year after treatment.

[Surgical treatment of stress urinary incontinence in women]

INDICATION FOR SURGERY: Exercise-induced urinary incontinence is responsible for more than 75% of all cases of urinary incontinence in women. Surgery can provide excellent cure if the initial indication is established properly.

SURGICAL PROCEDURES

The aim is to correct the mechanical alterations leading to urine leakage: sphincter anomalies and cervico-urethral hypermobility. Colpo-suspension using the indirect Burch procedure and the direct Goebell-Stoeckel procedure are indicated for physically active patients. For sphincter failure, an artificial sphincter with a fixed bladder neck is indicated. Simplified transvaginal colpo-suspension is indicated for elderly women. TENSION FREE VAGINAL TAPE: The recently developed, this new technique appears extremely promising for the treatment of urethral hypermobility.

[Physiopathology and evaluation of urinary incontinence in non-institutionalized aged patients]

The prevalence of urinary incontinence increases with age, with a predominance of incontinence due to detrusor instability. The development of incontinence in an elderly person can be explained pathophysiologically by the development of age-related histological and functional alterations of the bladder, by increased nocturnal diuresis at the expense of diurnal diuresis and finally, in women, by a reduction of urethral pressure. The initial assessment is essentially clinical and must comprise evaluation of concomitant diseases and drugs likely to favour the development of incontinence, a voiding diary and assessment of the post-voiding residual volume. Only a test for urinary tract infection by dipsticks or urine culture constitutes an essential first-line complementary investigation, as urodynamic studies can be reserved for more complex situations.

[Feasibility of "Valsalva Leak Point Pressure". Prospective study]

OBJECTIVE

To prospectively evaluate the feasibility of determination of the Valsalva Leak Point Pressure (VLPP).

PATIENTS AND METHODS

From 1st January to 31st July 1996, 155 consecutive patients investigated for urinary incontinence with no pelvis static disorder performed Valsalva manoeuvres during cystomanometry in order to determine the VLPP. The examination was performed in the standing position at a filling volume of 200 cc with then without a vesical pressure transducer. The mean age of the patients was 54 +/- 16 years (range: 16-84 years).

RESULTS

The mean maximal intensity of abdominal straining pressure measured by the intravesical transducer was 72 +/- 28 cm of water. The VLPP could not be determined in 50.4% of cases, as the abdominal straining pressure during the Valsalva manoeuvre was less than 60 cm of water. No correlation was observed between abdominal straining pressure and patient age (r = 0.13; p > 0.1).

CONCLUSION

Leak Point Pressure cannot always be determined by the Valsalva method. Other techniques of progressive increase of intravesical pressure must be investigated.

In situ extracorporeal shock wave lithotripsy for acute renal colic due to obstructing ureteral stones

The purpose of the present study was to evaluate in situ extracorporeal shock wave lithotripsy (ESWL) for the treatment of obstructing ureteral stones causing acute renal colic. In situ ESWL with an EDAP LT-02 piezo-electric lithotriptor was used in a prospective study to treat 67 patients with obstructing ureteral stones causing acute renal colic. Patients were treated without anesthesia on an out-patient basis or during a one-day hospital stay. The overall one month stone-free rate was 94% (94% for proximal stones and 95% for distal stones). The overall success rate after a single ESWL session was 81%. Treatment was well tolerated in 90% (60/67) of patients. There was one case of non-obstructive pyelonephritis and one of ureteral edema. These rates compare well with published reports for delayed treatment in patients without renal colic. Immediate ESWL for cases of acute renal colic due to obstructing ureteral stones is an effective treatment strategy that warrants wider consideration.

[The value of PSA density for the diagnosis of prostatic cancer and for the indication of radical prostatectomy]

We evaluated the diagnostic and prognostic value of PSA density (PSAD) in a prospective study of 100 men consulting for various urinary tract disorders. PSAD was calculated by the ratio of serum PSA over the ultrasonographic volume of the prostate gland, and was expressed in ng/ml/ml. The mean PSAD of 31 patients with prostate cancer was significantly higher than that of the 69 patients without prostate cancer (p = 0.0003). The patients were classified into two groups according to the serum PSA value. Forty nine patients had a serum PSA < or = 10 ng/ml, 31 of whom had a PSAD < or = 0.15 ng/ml/ml and 29 of these 31 patients (94%) did not have prostate cancer; 18 patients had a PSAD > 0.15 ng/ml/ml and six of them (33%) had prostate cancer (p = 0.04). Fifty one patients had a serum PSA > 10 ng/ml and 23 of them (45%) has prostate cancer; 14 of these 51 patients had a PSAD < or = 0.30 ng/ml/ml and two of them (14% à had prostate cancer; 37 patients had a PSAD > 0.30 ng/ml/ml, 21 of whom (57%) had prostate cancer (p = 0.016). Twenty one of these 31 patients with prostate cancer were candidates for radical prostatectomy. Four patients were N+ and 17 underwent radical prostatectomy. Capsular invasion was significantly correlated with PSAD. None of the four patients with PSAD < or = 0.30 ng/ml/ml showed capsular invasion, while 11 of the 13 patients (85%) with PSAD > 0.30 ng/ml/ml had capsular invasion. In conclusion, in patients with PSA < or = 10 ng/ml, calculation of the PSAD avoids approximately two-thirds of prostatic biopsies, with a very low risk of missing a clinically significant cancer. On the other hand, PSAD is of more limited value in patients with PSA > 10 ng/ml. In cancers considered to be operable clinically, the cut-off value of 0.30 ng/ml/ml for PSAD is predictive of capsular or lymph node invasion with a diagnostic accuracy of 94%.

Acute hemiplegia in one infant

A previously healthy 9-month-old girl, obese (12,500 gm) with sudden onset of hyperthermia (40 degrees C), generalized tonic-clonic seizures, followed by focal seizures, drowsiness, left facial nerve palsy, left lagophthalmos and mydriasis is presented. CT-scan and MRI suggested temporal-parietal infarction due to Sylvian artery occlusion in a 9-month-old infant with familial hypercholesterolemia (type 2 A dyslipidemia). The possibility of a cerebral abscess or herpetic encephalitis was considered. Negative clinic and serologic results excluded this diagnosis. The management of the symptomatology was made with parenteral antibiotics, anticonvulsive and antioedematous cerebral therapy. Favourable evolution with residual left hemiparesis after 30 days, when the child was discharged. CT-scan reevaluation (after 5 months of evolution) showed a hypodense temporal-parietal area abnormality due to a right ischemic infarction.

[Radical prostatectomy: comparison of the perineal and retropubic route (40 patients). Preliminary results]

Transperineal radical prostatectomy, described at the beginning of the century for the treatment of prostatic cancer, is currently being reappraised following the development of surgical techniques allowing the dissection of subvenous external iliac nodes via a limited incision. Twenty four patients (group 1) underwent transperineal prostatectomy and 16 (group 2) underwent retropubic prostatectomy. The choice of surgical approach was left to the operator. We retrospectively compared the two groups. All patients had histologically proven prostatic cancer, clinically confined to the prostate. The operating time, the development of complications. the preoperative-postoperative haemoglobin difference, the number of patients transfused and the number of units transfused, urinary continence at three months and the histological results were studied. Three patients operated via the perineal approach and one patient operated via the retropubic approach suffered an operative rectal injury. The number of transfused patients (12.5% in group 1 and 37.5% in group 2) and the preoperative-postoperative haemoglobin difference for non-transfused patients (mean of 2.9 g/100 ml in group 1 vs 4.6 g/100 ml in group 2) were significantly different. No significant difference was observed between the two groups in terms of invasion of the prostatic capsule or seminal vesicles. Overall, only 106 out of 40 patients had a truly intraprostatic tumour, corresponding to understaging of the cancer in 60% of cases. Although the number of patients with imperfect continence was higher in group 1, the difference observed was not significant. The transperineal approach allows prostatectomy to be performed under similar oncological conditions to those of retropubic prostatectomy, while decreasing the operative blood loss.(ABSTRACT TRUNCATED AT 250 WORDS)

Infantile spinal amylotrophy Werding-Hoffman disease and congenital contractures

The authors present a rare case of a male infant aged 5 1/2 months with muscular contractures, hypotonia and areflexia. Two male siblings died with the same clinical picture. The microscopic findings of several spinal cord specimens are typical for Werding-Hoffman amylotrophia spinalis. The microscopical aspects are suggestive for neurogenic atrophy of muscular fibres with interstitial myositic process. It is proposed to include the present case in X-linked form of infantile spinal muscular atrophy.

Kawasaki disease in an infant with cystic fibrosis

The authors report a case of a 3-month-old infant with a very rare association: cystic fibrosis and Kawasaki disease. The clinical picture is atypical but cardiovascular signs consist of cardiomegaly, sick sinus syndrome and Q waves in D II, D III and AVF. The diagnosis is confirmed by the pathological changes found at the postmortem examination. The patient is the first case of Kawasaki disease reported in Romania.

[Clinical and histopathologic polymorphism in cystic fibrosis]

After reviewing recent data concerning the pathologic physiology of cystic fibrosis the authors present an anatomoclinical study of 30 infants, of which 13 neonates, with a diagnosis of mucoviscidosiss, emphasizing the clinical and pathohistologic polymorphism of this affection, and, particularly involvement of the liver and intestines. Specific hepatic lesions were encountered in only 10% of the group studied (Bodian biliary cirrhosis and mucus stoppers in the bile ducts). Unspecific hepatic lesions were dominant, common with those of neonatal hepatitis, and hepatic steatosis. Stress is laid on the presence of atrophy of the villi in children with hepatic steatosis, proof of a lesional substrate of malabsorption in this disease. The authors note the early onset of hepatic lesions, the gravity of the cases with an early clinical expression and hepatic biopsy puncture as the only method revealing hepatic affection in cystic fibrosis. In the first semester of life there exists purely digestive forms, hepatic steatosis and oedematous dystrophy in infants at this age being highly suspect of the etiology.