Imaging of acute and chronic thromboembolic disease: state of the art

Acute pulmonary embolism (PE) is a life-threatening condition that requires prompt diagnosis and treatment. Recent advances in imaging allow acute and rapid recognition even by the non-specialist radiologist. Most acute emboli resolve on anticoagulation without sequelae; however, some emboli fail to fully resolve becoming endothelialised with the development of chronic thromboembolic disease (CTED). Increased pulmonary vascular resistance arising from CTED may lead to chronic thromboembolic pulmonary hypertension (CTEPH) a debilitating disease affecting up to 5% of survivors of acute PE. Diagnostic evaluation is more complex in CTEPH/CTED than acute PE with subtle imaging features often being overlooked or misinterpreted. Differentiation of acute from chronic PE and from other forms of pulmonary hypertension has profound therapeutic implications. Diverse imaging techniques are available to diagnose and monitor PEs both in the acute and chronic setting. Broadly they include techniques that provide data on lung parenchymal perfusion (ventilation-perfusion [VQ] scintigraphy), angiographic techniques (computed tomography [CT], magnetic resonance imaging [MRI], and invasive angiography) or a combination of both (MR angiography and time-resolved angiography or dual-energy CT angiography). This review aims to describe state of the art imaging highlighting the strength and weaknesses of individual techniques in the diagnosis of acute and chronic PE.

Treatment of Inflammatory Acne with a Combination Therapy with Lymecycline and Adapalene Followed by Maintenance Treatment with Adapalene

Oral antibiotics, especially tetracyclines, are commonly used to treat moderate to moderately severe acne vulgaris. There are hints suggesting that a combination treatment with oral tetracyclines and topical retinoids can cause a greater and prompter improvement of acne than monotherapy with tetracyclines. We evaluated the clinical activity of a 12-week combined therapy with oral lymecycline (300mg/day for 2 weeks and then 150mg/day) and topical adapalene (gel or cream) in 419 patients with inflammatory acne. A significant reduction in the number of acne lesions was noted at 4 and 12 weeks (P<0.0001). Thereafter, 400 patients underwent a maintenance treatment with adapalene alone for 12 weeks. At week 24 a relevant improvement of acne lesions still persisted (P<0.0001) in most patients. Only 16 patients relapsed and required additional use of oral lymecycline which proved again successful. No substantial differences were noted in the magnitude of clinical response between patients treated with adapalene gel and those treated with cream formulation. Treatment was well tolerated. Local adverse reactions occurred in 11.7 % of patients and resulted in premature discontinuation of treatment in 1.4 %. Systemic (gastrointestinal) untoward effects developed in 1.2 % of patients and caused treatment interruption in 0.7 % of cases. No serious adverse events occurred.

Comparison of Two Different Dosing Regimens with Lymecycline, in Association with Adapalene, in Inflammatory Acne

Combined treatment with oral lymecycline and topical adapalene has been shown to induce greater and faster improvement of acne than monotherapy with lymecycline. We wanted to evaluate the effects of combined therapy with topical adapalene (cream or gel) plus oral lymecycline used at different dosages (group A: 300mg/day for 2 weeks and then 150mg/day for 14 weeks; group B: 300mg/day for 16 weeks) in 242 patients with inflammatory acne. Both dosage regimens were well tolerated in the majority of patients and significantly improved both the acne lesion count and seborrhoea. There was a trend towards a greater reduction of seborrhoea and nodules in patients of group B. After the initial 16-week phase, patients entered an 8-week follow-up phase, consisting of the use of adapalene monotherapy. The results obtained after this phase confirm the therapeutic value and the favourable tolerability of adapalene as maintenance treatment after successful treatment of inflammatory acne. At the same time, a significantly reduced count of comedones was observed in patients of group B as compared with group A, suggesting that prolonged use of high-dose lymecycline may have a more pronounced influence on comedogenesis.

Audiological Monitoring in Children Treated with Platinum Chemotherapy

Platinum compounds constitute the standard treatment for solid tumors in pediatric oncology. The purpose of this study is to assess the impact of platinum compounds in the development of ototoxicity in children following chemotherapy. This study included 160 patients treated with cisplatin and carboplatin for malignant solid diseases from 2007 to 2014. Their audiograms were classified according to the Boston SIOP ototoxicity scale. Twenty-five percent of the children treated with platinum compounds developed ototoxicity. The incidence of ototoxicity was correlated with the type of platinum derivative (i.e. cisplatin vs. carboplatin), coadministration of both drugs and concomitant cranial radiotherapy, but not with sex and age. Cumulative dose was correlated only with the cisplatin administration. Nine patients (8.6%) showed further progression of hearing impairment after the end of chemotherapy. The low rate of ototoxicity suggests the pivotal role of auditory monitoring in children treated with platinum compounds in order to be able to identify hearing loss at an early stage and to provide, jointly with pediatric oncologists, strategies to reduce further progression of cochlear toxicity.

In vivo MRI mapping of iron oxide-labeled stem cells transplanted in the heart

In various stem cell therapy approaches poor cell survival has been recognized as an important factor limiting therapeutic efficacy. Therefore noninvasive monitoring of cell fate is warranted for developing clinically effective stem cell therapy. In this study we investigated the use of voxel-based R₂ mapping as a tool to monitor the fate of iron oxide-labeled cells in the myocardium. Mesenchymal stem cells were transduced with the luciferase gene, labeled with ferumoxide particles and injected in the myocardium of healthy rats. Cell fate was monitored over a period of 8 weeks by bioluminescence and quantitative magnetic resonance imaging. Bioluminescence signal increased during the first week followed by a steep decrease to undetectable levels during the second week. MR imaging showed a sharp increase in R₂ values shortly after injection at the injection site, followed by a very gradual decrease of R₂ over a period of 8 weeks. No difference in the appearances on R₂-weighted images was observed between living and dead cells over the entire time period studied. No significant correlation between the bioluminescence optical data and R₂ values was observed and quantitative R₂ mapping appeared not suitable for the in vivo assessment of stem cell. These results do not follow previous in vitro reports where it was proposed that living cells may be distinguished from dead cells on the basis of the R₂ relaxivities (intracellular and extracellular iron oxides). Cell proliferation, cell migration, cell death, extracellular superparamagnetic iron oxide dispersion and aggregation exhibit different relaxivities. In vivo these processes happen simultaneously, making quantification very complex, if not impossible.

Overexpression of wild-type p53 overrides the mitogenic effect of ri-alpha subunit of protein-kinase-a in human breast cells

Protein kinase A type I (PKAI) and its regulatory subunit RI alpha are overexpressed in cancer cells and are induced by mitogenic hormones and growth factors in nontransformed cells. RI alpha/PKAI are directly involved in the G1>S transition and cell proliferation of non-transformed human breast MCF-10A cells. Retroviral vector-mediated overexpression of RI alpha in these cells (MCF-10A RI alpha) confers the ability to grow in serum-free medium. p53 controls a G1 check point before transition to the S phase, playing a key role in the regulation of cell proliferation and in the preservation of DNA integrity. In this study we evaluated the interaction of p53 and RI alpha on cell cycle progression and cell proliferation of MCF-10A cells. Retroviral vector-mediated overexpression of wild-type p53 in the MCF-10A neo and MCF-10A RI alpha cells determined a marked inhibition of RI alpha protein expression in MCF-10A-p53 cells and induced G0/G1 accumulation, cell gowth arrest and changes in cell morphology not due to apoptosis in both MCF-10A-p53 and MCF-10A RI alpha-p53 cells. On the other hand, in the MCF-10A RI alpha cells we observed an increased expression of the endogenous p53, although these cells were still able to proliferate. These results suggest that overexpression of wildtype p53 acts in a dominant fashion to abrogate the RI alpha induction of G1>S transition and cell proliferation. Moreover, overexpression of RI alpha leads to increased synthesis of endogenous p53 which, however, is unable to interfere with the RI alpha-dependent mitogenic signalling.

Human parvovirus B 19 and Epstein-Barr virus co-infection in a child with hereditary spherocytosis

BACKGROUND

In patients with chronic congenital haemolytic disorders, human Parvovirus B19 (HPV B19) is frequently involved in pure red-cell aplastic crises. Furthermore, it may inhibit three-lineage haematopoiesis in the bone marrow, causing severe pancytopenia. In such patients, Epstein Barr virus (EBV) infection also seems to share the same mechanism as HPV B19 in inducing bone marrow aplasia, but at present the clinical effect of an infection sustained by both viruses is unknown.

CLINICAL REPORT

We present a 7-year-old boy affected by hereditary spherocytosis (HS) who suffered from transient aplastic crisis, in whom laboratory findings revealed a double HPV B19 and EBV infection.

CONCLUSIONS

To our knowledge, this is the first report of a case of HPV B19 and EBV co-infection diagnosis in a paediatric patient. Despite underlying HS, no signs of haemolytic anaemia were detected, but the infection only produced transient pancytopenia. Nevertheless, the reason why there was no additive effect of the two viruses on the aplastic crisis is still unclear.

A quick, least-invasive, inexpensive and reliable method for sampling Gadus morhua postlarvae for genetic analysis

The present study describes the successful design and testing of a quick, least-invasive, reliable and inexpensive sampling procedure for Atlantic cod Gadus morhua. This protocol can be easily applied to postlarval fish following a simple three-step procedure, without availing of commercial DNA extraction kits, while ensuring survival of sampled individuals.

Pretreatment neuropsychological deficits in children with brain tumors

Treatment of childhood brain cancer has been associated with long-term cognitive morbidity in children. In the present study, the cognitive status of children with brain tumors was examined prior to any treatment to single out the role of tumor and tumor-related factors in cognitive deficits. Eighty-three children with newly diagnosed brain tumors (mean age, 8.6 years; range, 7 months to 16.6 years; median, 9.4 years) completed an extensive battery of age-related tests to assess cognitive function before any therapeutic intervention. Magnetic resonance imaging (MRI) was used to determine tumor site and volume and tumor-related factors. Performance under test was compared with symptom duration, neurological status, epilepsy, and MRI. Cognitive difficulties are detected at diagnosis in as many as 50% of patients for some cognitive domains; 6% of patients present with true-diagnosed mental retardation. The location of the tumor is the principal determinant of cognitive deficits, with major impairment in children with cortical tumors. Symptom duration and the presence of epilepsy are significantly associated with neuropsychological disabilities, while neuroradiological tumor-related variables do not correlate clearly with neurocognitive performance. The knowledge of the pre-existing cognitive deficits is critical to evaluate the results of treatment, providing a baseline for assessing the true impact of therapy in determining cognitive decline. In addition, the study suggests that some clinical variables require careful monitoring, because they could be specifically implicated in the neuropsychological outcome; the efforts to reduce the impact of these factors could ameliorate long-term prognosis.

Errors involving patients receiving intrathecal chemotherapy

Errors involving patients receiving intrathecal chemotherapy are a significant problem in oncology. Despite the improvement in the management of antineoplastic agents, unintentional intrathecal administration of chemotherapic drugs that are indicated only for systemic administration or intrathecal overdose of drugs regularly used for intrathecal chemotherapy, continue to occur. These events can result in severe neurotoxicity, usually fatal in outcome. We review reported cases of medication errors in intrathecal administration of chemotherapy described in the literature. Diverse rescue therapies have been proposed but the most effective means of managing these errors remains prevention.

Treatment of childhood sarcoma with irinotecan: bilirubin level as a predictor of gastrointestinal toxicity

Irinotecan is a promising anticancer agent for the treatment of childhood cancer unresponsive to conventional chemotherapy. Its active metabolite, 7-ethyl-10 hydroxycamptothecin (SN-38) is glucuronidated by a uridine-diphosphoglucuronosyltransferase (UGT1A1) to form an inactive metabolite. It was supposed that patients with the UGT1A1*28 polymorphism would have a greater prevalence of elevated pretreatment serum bilirubin levels and higher toxicity. The aim of our study was to investigate the predictive value of pre-treatment bilirubin levels in the development of severe diarrhea in solid tumor patients treated with irinotecan. The survey included 14 pediatric patients with refractory sarcomas treated with irinotecan (CPT-11). Patients were grouped based on the development of mild (G0-2) or severe (G3) gastrointestinal toxicity. The simple linear regression model and the non-parametric paired wilcoxon test were adopted for the analysis. p <0.05 was judged to indicate a significant difference. The results showed a significant increase in severity of diarrhea with increasing total pre-treatment bilirubin. therefore, we propose that pre-treatment bilirubin levels can predict gastrointestinal toxicity in pediatric cancer.

Pharmacological management of chemotherapy-induced nausea and vomiting in children with cancer

Nausea and vomiting are respectively the first and third most relevant chemotherapy-associated side effects in pediatric oncology, despite the introduction of new antiemetic agents. Symptoms change according to the antineoplastic agents used, and are influenced by age since emotional and psychological aspects play an important role. Studies conducted on new antiemetic therapies usually focus on adult populations affected by tumors, whereas there are very few series including pediatric patients, who are even more severely affected by this specific side effect.

Prevalence of interstitial lung involvement in patients with connective tissue diseases assessed with high‐resolution computed tomography

OBJECTIVES

To assess the prevalence of interstitial lung disease (ILD) in patients with different forms of connective tissue disease (CTD) using non-invasive procedures including high-resolution computed tomography (HRCT) and to evaluate the relationship between the imaging and functional status of the patients.

METHODS

Eighty-one subjects with CTD (47 inpatients and 34 outpatients) were evaluated with pulmonary function tests (PFT) and radiological investigations. The extent and severity of lung disease was quantified with an HRCT scoring system previously used in patients with systemic sclerosis (SSc). Interstitial lung involvement was defined as predominantly fibrotic or inflammatory based on HRCT abnormalities.

RESULTS

HRCT abnormalities suggestive of ILD were observed in 69 patients (85.1%), whereas PFT and plain radiograph alterations occurred less frequently (40.7%). The most frequent HRCT abnormalities were septal/subpleural lines and ground-glass appearance whereas lesions consistent with advanced fibrosis were observed in a minority of patients. The HRCT score was higher in patients with abnormal PFT (p<0.001). Thirty-five patients had predominant fibrosis and 34 patients predominantly inflammatory abnormalities. A score of 10 points represented the best compromise between sensitivity and specificity in predicting functional impairment.

CONCLUSIONS

A high prevalence of ILD was found based on HRCT abnormalities. However, HRCT scans characterized by minor abnormalities have poor specificity for clinically significant disease and functional findings should also be considered. The large number of patients with predominantly inflammatory HRCT abnormalities suggests that many cases of ILD may be diagnosed in a relatively early stage of the disease.

[Use of bulking agents in urinary incontinece]

Urinary incontinence consist in voluntary urine leakage. Female affected in the world are about 200 thousand. Urinary incontinence affect severely women quality of life. There are different kinds of urinary incontinence that can be treated in different ways. We can use pelvic floor rehabilitation, drug therapy, invasive and non-invasive surgical treatment. Different treatments are used for different incontinence types. Periurethral injection is the most common procedure between non-invasive surgery. The most recent bulking agents occasionally determine severe adverse reaction or complication. Frequently we can have just pain during injection and a temporary urine retention. During the latest years we used a lot of bulking agents: bovine collagen, autologous fat, carbon particles, macroplastique, calcium hydroxylapatite, ethylene vinyl alcohol copolymer, dextranomer. Urethral injection have success in 40-90%. We can assert that macroplastique is the most efficacy and safe on the basis of literature data and of our experience data. This surgical procedure, in fact, has good percentage of success in accurately selected patients. In our experience Macroplastique can also be used in oncological patients, in elderly women, in patients with important comorbidity and with high surgical risk with good objective and subjective results.

Anthracycline cardiotoxicity in childhood

Over the last 40 years, a significant advance has been made in the treatment of childhood and adult cancers. However, the increase of the survival rate points out medium- and long-term adverse effects that constitute a serious limitation for the quality of life in adults survived from a childhood cancer. Cardiovascular disease is an important cause of morbidity and mortality in adults treated with chemo- and radiotherapy for childhood cancers. Although some antitumor treatments are potentially cardiotoxic, anthracycline therapy and radiotherapy are mostly responsible for long-term cardiac damage. Anthracycline toxicity is generally limited to the myocardium, while radiation can cause injury to all components of the heart. The purpose of this review is to discuss the mechanisms of action of anthracyclines, their cardiotoxicity, the feasibility of screening, and the prevention of cardiac damage after treatment in childhood.

The prognostic role of Ki-67 in childhood low-grade glioma

Gliomas currently represent a group of uncommon diseases originating from glial elements. According to their biologic features they can be distinguished in low-grade gliomas--not very aggressive and with a poor tendency to progression--and high-grade gliomas--with a greater proliferative drive and aggressiveness. Such definitions outline two distinct disease types, which profoundly differ as for epidemiological, clinical, diagnostic and molecular features. The introduction of biomolecular techniques has provided a deeper knowledge of low-grade gliomas: the use of new molecular markers, such as Ki-67, makes it possible to study peculiar features of the neoplasm, with strong prognostic implications. Nonetheless, in the literature there is still no agreement on their role, nor on their prognostic validity in pediatric age, also because the criteria that are currently used for adult patients haven't still been codified for pediatric age.

Longitudinal assessment of childhood optic gliomas: Relationship between brain imaging and optic pathway function

2087

Background: To evaluate longitudinally the relationship between brain imaging and functional findings in childhood optic gliomas (OG) by comparing over time magnetic resonance imaging (MRI) with flicker visual evoked potential (FVEP) changes. Methods: Fourteen children (median age 3 yrs, range: 2–7) suffering from OGs involving chiasm and retro-chiasmatic visual pathways underwent serial MRI and FVEP examinations over a median follow-up time of 38 months (range 12–76). FVEPs were monocularly recorded in response to 8 Hz sine-wave flicker stimuli presented in a mini-Ganzfeld according to a published technique (Trisciuzzi et al., Clin. Neurophysiol., 2004). MRI examinations were performed according to standard procedures. Longitudinal results of both tests were examined in a blind fashion by independent evaluators. FVEPs were judged to be improved, stable or worsened if changes in the amplitude and/or phase of the fundamental response component exceeded the limits of test-retest variability (±90th percentile) established in the same patients. MRI results were judged to show regression, stabilization or progression of OG based on its changes in size (±20%) or extension. Two to seven pairs (< one month apart) of FVEP/MRI examinations per patient (median: 4, range 2–7) were collected. Agreement between test changes over time were evaluated by K-statistics. Results: Based on a total of 38 pairs of longitudinal FVEP/MRI examinations, both tests agreeed in showing worsening (progression), stabilization and improvement (regression) in 5, 10 and 15 cases, respectively. In 3 cases, FVEPs showed a worsening and MRI a stabilization, while in 5 cases FVEPs showed an improvement and MRI a stabilization. Agreement between FVEP and MRI changes was 78.9% (95% CI: ± 37%, K = 0.67, p < 0.001). Conclusions: The results indicate that changes over time in FVEPs, an objective and non-invasive test of visual function, can accurately predict associated changes in OG size and extension as assessed by MRI, and suggest that the latter changes may have a significant impact on visual function during developmental age.

No significant financial relationships to disclose.

Safety and efficacy of fentanyl administered by patient controlled analgesia in children with cancer pain

BACKGROUND

Pain is the most common discomfort experienced by children with cancer and occurs in almost 89% of patients in an advanced stage of the disease. It is most often not adequately treated because of inexperience and unfounded fears of analgesic treatment. In adults, patient controlled analgesia (PCA) is widely administered, while in children with moderate to severe cancer pain its use is still under evaluation for safety and efficacy.

GOALS OF WORK

To evaluate the efficacy and safety of fentanyl administered by PCA in children with cancer pain.

MATERIALS AND METHODS

Eighteen children (range 6 to 15 years) with moderate to severe pain were enrolled and treated with fentanyl by PCA plus background infusion (BI) (BI of 1 microg/kg/h with booster doses of 1 microg/kg by intravenous route). To evaluate efficacy and safety of the analgesic treatment, different subjective and objective parameters were monitored at 4-h intervals. In addition, patients' satisfaction was assessed by a questionnaire at the end of the treatment.

MAIN RESULTS

All children experienced a good degree of analgesia and did not require any other analgesic drug during the treatment. Both subjective and objective parameters improved after starting pain-relieving treatment and no major side effects occurred. The questionnaire administered to the children showed a high grade of satisfaction.

CONCLUSIONS

PCA plus BI with fentanyl administered by intravenous route is a safe and efficacious method for analgesia in children with moderate to severe cancer pain. Our policy of fentanyl-treatment did not show any major side effects.

A newborn with multiple fractures as first presentation of infantile myofibromatosis

Pathological fractures occur in infancy from a variety of causes, but are a rare condition during neonatal period. We describe the case of a male newborn with a metaphyseal fracture of femur and multiple lytic lesions, diagnosed as infantile myofibromatosis.

Phase II trial of temozolomide in children with recurrent high-grade glioma

PURPOSE

The objective of the study was to evaluate the efficacy and toxicity of Temozolomide (TMZ) administered for 5 consecutive days in three daily dosing in children with recurrent or refractory high-grade glioma.

PATIENTS AND METHODS

Twenty-four patients with a median age of 10.5 years were enrolled onto this open-label, multicenter, phase II study. The patients were previously treated with surgical resection (17 of 24), radiotherapy (19 of 24) and chemotherapy (18 of 24). Therapy was administered orally three times a day for 5 consecutive days at the dose of 200 mg/m(2)/dx5 for chemotherapy naive patients. In patients heavily pretreated with chemotherapy the starting dose was of 150 mg/m(2)/dx5.

RESULTS

A total of 95 cycles were administered. The median progression free-survival (PFS) was 3 months for the entire group while disease stabilization was obtained in 7 patients (29.1%), all with supratentorial tumors. No CR or PR was observed. TMZ treatment showed a limited toxicity. Thrombocytopenia was the most common hematological adverse effect. Our data suggest a marginal activity of TMZ in children with recurrent high-grade glioma.

Chronic idiopathic thrombocytopenic purpura in children: case reports of spontaneous recovery without splenectomy

Children with chronic idiopathic thrombocytopenic purpura generally show a favorable outcome with a high spontaneous recovery rate even many years after the initial diagnosis. In this retrospective study, 5 out of 12 children with chronic ITP achieved a spontaneous recovery. A careful follow-up appears to be adequate for most of the patients, reserving splenectomy to the rare severely affected patients.

The lumbar puncture in pediatric oncology

In pediatric oncology, LPs are frequently performed for diagnostic and therapeutic purposes. A LP procedure may be helpful in diagnosing many diseases and disorders. In addition, a LP may be performed therapeutically, to inject medications directly into the spinal canal. Intrathecal administration of antineoplastic drugs allows to bypass the selective filter of BBB and to achieve significant concentrations of the antineoplastic agents in CSF reducing the likelihood of systemic toxicity. Lumbar puncture is generally well tolerated but might be characterized by several disadvantages and risks.

Second case of hepatoblastoma in a young patient with Simpson-Golabi-Behmel syndrome

Simpson-Golabi-Behmel syndrome (SGBS) is an X-linked overgrowth syndrome associated with multiple congenital anomalies caused by a mutant X-linked recessive trait. The authors report on a 14-month-old male patient affected by hepatoblastoma. As far as is known, this is the second patient reported with SGBS and hepatoblastoma. The observations emphasize that an increased risk of neoplasia in SGBS must be kept in mind, especially in young patients.

A 35 kDa NAD(P)H oxidase previously isolated from the archaeon Sulfolobus solfataricus is instead a thioredoxin reductase

A thioredoxin reductase (TrxR) has been identified in the hyperthermophilic archaeon Sulfolobus solfataricus (Ss). This enzyme is a homodimeric flavoprotein that was previously identified as NADH oxidase in the same micro-organism ('Biotechnol. Appl. Biochem. 23 (1996) 47'). The primary structure of SsTrxR is made of 323 amino acid residues and contains two putative betaalphabeta regions for the binding of FAD, and a NADP(H) binding consensus sequence in the proximity of a CXXC motif. These findings indicate that SsTrxR is structurally related to the class II of the pyridine nucleotide-disulphide oxidoreductases family. Moreover, the enzyme exhibits a NADP(H) dependent thioredoxin reductase activity requiring the presence of FAD. Surprisingly, the reductase activity of SsTrxR is reduced in the presence of a specific inhibitor of mammalian TrxR. This finding demonstrates that the archaeal enzyme, although structurally related to eubacterial TrxR, is functionally closer to eukaryal enzymes. Experimental evidences indicate that a disulphide bridge is required for the reductase but also for the NADH oxidase activity of the enzyme. These results are further supported by the significantly reduced activities exerted by the C147A mutant. The integrity of the CXXC motif is also involved in the stability of the enzyme.

Critical presentation of pleuropulmonary blastoma

We report two cases of critical presentation of a quite rare lung neoplasm of childhood. Presentation findings were at the extremes of the clinical pattern of this polymorphous neoplasm, ranging from an enormous solid mass causing airway compression and dislocation to an apparently benign cystic lesion discovered because of a tension pneumothorax. Both children were discharged from the pediatric intensive care unit and underwent appropriate surgical removal and oncological management. Congenital lung cysts, even asymptomatic, should not be underestimated and need elective surgical excision and histologic examination.

Malignant retroperitoneal paraganglioma: case report and review of the literature

Paraganglioma is a rare neuroendocrine neoplasm observed in patients of all ages but it has not been characterized in children. The authors describe a retroperitoneal paraganglioma diagnosed by chance in an 11-year-old boy. Many aspects of retroperitoneal paraganglioma are still under investigation. The treatment of choice is radical resection. Surgery may be possible following chemotherapeutic debulking with cyclophosphamide, vincristine, and dacarbazine. 131I-MIBG radiotherapy has proved increasingly useful in reducing the pain associated with disseminated disease and also in facilitating surgical resection in cases that appear inoperable. Conventional radiotherapy is purely palliative and used to reduce the pain of bone metastases.

Pulmonary Hemorrhage Complicating a Typical Hemolytic-Uremic Syndrome

We describe a case of pulmonary bleeding and subsequent acute respiratory distress syndrome (ARDS) in a 20-month-old female suffering from a typical postdiarrheal hemolytic-uremic syndrome (HUS). Acute renal failure was treated early by peritoneal dialysis. It is of interest to underline that thrombocytopenia or any coagulative impairment was absent when this complication occurred, and spontaneous diuresis recovery was ongoing. All examinations failed to identify a unique site of bleeding in the main stem bronchi or trachea. Complete renal and clinical recovery was obtained in spite of this very uncommon complication. Intensivists should be aware of this rare and potentially fatal complication of typical (D+)HUS.

Microangiopathic hemolytic anemia complicating a postneonatal pertussis pneumonia

The authors describe a 2-month-old female with microangiopathic hemolytic anemia complicating a pertussis pneumonia. The baby was admitted to the Pediatric Intensive Care Unit for monitoring and treatment. Remission occurred without sequelae, but multiple hemotransfusions were needed in the acute phase. This represents the first reported case of such a complication in childhood.

Cellular and molecular aspects of drugs of the future: oxaliplatin

Oxaliplatin (Eloxatine) is a third-generation platinum compound which has shown a wide antitumour effect both in vitro and in vivo, a better safety profile than cisplatin and a lack of cross-resistance with cisplatin and carboplatin. In this scenario, oxaliplatin may represent an innovative and challenging drug extending the antitumour activity in diseases such as gastrointestinal cancer that are not usually sensitive to these coordination complexes. Oxaliplatin has a non-hydrolysable diaminocyclohexane (DACH) carrier ligand which is maintained in the final cytotoxic metabolites of the drug. Like cisplatin, oxaliplatin targets DNA producing mainly 1,2-GG intrastrand cross-links. The cellular and molecular aspects of the mechanism of action of oxaliplatin have not yet been fully elucidated. However, the intrinsic chemical and steric characteristics of the DACH-platinum adducts appear to contribute to the lack of cross-resistance with cisplatin. To date, mismatch repair and replicative bypass appear to be the processes most likely involved in differentiating the molecular responses to these agents.

Management of idiopathic thrombocytopenic purpura in children: a single institution experience

Idiopathic thrombocytopenic purpura (ITP) is a relatively common hematologic disease in childhood. ITP is often self-limiting and is characterized by a good clinical outcome. About 10-20% of cases can have a chronic course. In our retrospective analysis we have evaluated 45 patients affected by ITP from January '92 to December '97. Thirty-seven patients (82%) met the criteria of acute ITP and 8 (18%) had chronic ITP. Patients were stratified into 3 categories based up on the type of treatment received: no treatment, steroids, steroids and IVIG. In our series children treated with oral prednisone showed a slightly faster recovery in the first days from treatment. We suggest the use of steroids in children with low platelet count and signs and symptoms of bleeding.

Intrathecal chemotherapy with antineoplastic agents in children

Intrathecal chemotherapy with antineoplastic agents is mainly utilised in children with leukaemia and lymphoma, and in selected brain tumours. In these diseases, intrathecal use is restricted to methotrexate (MTX), cytosine arabinoside (Ara-C) and corticosteroids. A number of other agents are, at the present time, under evaluation. Intrathecal MTX administered sequentially with systemic high dose MTX infusion prolongs therapeutic cerebral spinal fluid (CSF) levels of the drug. Prolonged therapeutic CSF levels can also be achieved by giving repeated small intrathecal doses of MTX over an extended period in selected patients, with an implanted Ommaya reservoir. In the CSF, the metabolic inactivation of Ara-C is significantly lower than in plasma with a CSF clearance similar to the rate of CSF bulk flow. A slow-release formulation of Ara-C may be given intrathecally, resulting in a prolonged cytotoxic concentration in the CSF. CNS relapse and neurotoxicity in patients with acute lymphoblastic leukaemia, especially younger children, may be reduced by using age-related dosing of intrathecal MTX and Ara-C. Hydrocortisone is used in combination with MTX and Ara-C for so-called 'triple intrathecal chemotherapy' in the treatment of meningeal leukaemia. Intrathecal thiotepa does not appear to be advantageous over systemic administration in patients with brain and meningeal leukaemia. Monoclonal antibodies, reactive with tumour-associated antigens, can be used as delivery systems for chemotherapeutic agents and radionuclides. However, the development of this new approach is currently under evaluation in larger clinical studies. Neurological adverse effects may be expected with intrathecal chemotherapy and are increased by high dose systemic therapy, concomitant cranial radiotherapy or meningeal infiltration by neoplastic cells. Inadvertant intrathecal administration of antineoplastic agents that are indicated for systemic administration only, is dangerous and may result in a fatal outcome.

Carcinoid tumors of the appendix in children: two case reports and review of the literature

Carcinoid is the most common tumor of the appendix. Reported incidence in pediatric population is 1 per 100,000 per annum. Clinical presentation like acute appendicitis is frequent, but carcinoid tumor can be an incidental finding during surgical procedures other than appendectomy. Size and depth of invasion are important prognostic criteria and tumors larger than 2 cm metastasize more frequently than smaller ones. Simple appendectomy is considered appropriate treatment, while right colectomy is indicated in tumor bigger than 2 cm. The authors report 2 cases of carcinoid tumors of the appendix in children, smaller than 2 cm treated with appendectomy alone, and disease free at follow-up.

Primary nocturnal enuresis and left-handedness

To date, no previous studies have described the association between primary nocturnal enuresis and left-handedness. In our series of enuretic patients, the prevalence of left-handedness was significantly higher than the control group. These data suggest a new correlation which needs further investigation.

[Neutropenia in childhood]

The discovery of a neutropenia is a common problem in pediatric population. Some children with neutropenia have an uncomplicated clinical course and require no treatment. However, some patients are more severely affected and present a management challenge for the pediatrician and for the hematologist. The clinical approach to these children is directed primarily to understand the etiology of neutropenia in order to define a correct therapeutic behaviour, such as glucocorticoids, intravenous immunoglobulins or, more recently, rhG-CSF. In our article we have reviewed the etiology, the clinical course and the therapeutic options of constitutional and acquired neutropenias.

Nuclear DNA content-derived parameters correlated with heterogeneous expression of p53 and bcl-2 proteins in clear cell renal carcinomas

BACKGROUND

p53 and bcl-2 are two key genes involved in cell cycle and cell death regulation. Altered expression or mutation of these genes has been found in human cancers and also has been identified in clear cell renal carcinoma (RCC). Their role in RCC progression, however, is still unclear. By contrast, the prognostic significance of ploidy and S-phase fraction (SPF) have been studied extensively in RCC. To better characterize the biologic role of p53 and bcl-2 oncoproteins in RCC, we offer a multisample correlative analysis of the expression of these two proteins with ploidy and SPF.

METHODS

Ploidy and SPF along with p53 and bcl-2 expression were analyzed in 296 specimens, selected by multiple sampling of 33 consecutive operable RCCs. The expression of p53 and bcl-2 proteins was studied by immunohistochemistry, and SPF and tumor ploidy were studied by flow cytometry.

RESULTS

In our study, 4 of 32 (12.5%) were found to be diploid, and 28 of 32 (87.5%) cases showed an abnormal DNA content. Among the aneuploid tumors, 14 of 28 (50%) were multiploid. Heterogeneous DNA content was detected in 21 of 32 (65.6%) tumors and was correlated with the more advanced Robson stage tumor (P = 0. 03). Intratumor heterogeneity also was detected for p53 and bcl-2 protein expression. Expression of p53 protein correlated with the lack of bcl-2 protein expression (P = 0.0032), aneuploidy (P < 0. 0001), and high SPF (P = 0.0006), whereas bcl-2 expression was associated with a normal DNA content (P < 0.0001) and low SPF (P = 0. 035).

CONCLUSIONS

Within each RCC, p53 and bcl-2 expression is markedly heterogeneous. Our results depicted a scenario in which bcl-2 protein, expressed by normal renal parenchyma, is still present in euploid cell clones of RCC but disappears during the progression of renal neoplasm toward a more aggressive phenotype characterized by overexpression of p53 protein, aneuploidy, and high SPF.