['Cases against KiSS': a diagnostic algorithm for children with torticollis]

In 1991, Biedermann coined the term "kinetic imbalance due to suboccipital strain" ("KiSS-syndrome"). He assumed a functional abnormality of the suboccipital-high cervical spine, resulting in positional preference of the infant;s head. A broad spectrum of symptoms and complaints have been attributed to "KiSS-Syndrome". Patients are advised to undergo manual therapy, with pressure applied locally in order to readjust the cervical spine. Life threatening side-effects have been published repeatedly. We present two infants with brain tumours who developed torticollis and further neurological findings such as ataxia and reflex differences. In both cases, symptoms caused by the tumour were interpreted as "KiSS-syndrome", and appropriate diagnostics and therapy were delayed for months. There is no scientific evidence for the actual existence of "KiSS-syndrome" as a clinical entity or for the positive effects of manual therapy. Approximately 12% of all infants <12 months show a positional preference of the head, about 8% present with body asymmetry. Whereas most cases are benign, there is a long list of serious differential diagnoses for torticollis in infants. We give an updated review of the literature regarding "KiSS-Syndrome" and discuss the differential diagnostics in infants with torticollis.

Scheie syndrome: enzyme replacement therapy does not prevent progression of cervical myelopathy due to spinal cord compression

Hurler-Scheie syndrome is caused by alpha-l-iduronidase deficiency. Enzyme replacement therapy (ERT) can improve physical capacity and reduces organomegaly. However, the effect on bradytrophic connective tissue is limited. As intravenously administered enzyme cannot cross the blood-brain barrier, the therapy of choice for the more severe Hurler syndrome is haematopoietic stem cell transplantation (HCT). In the more attenuated Scheie syndrome, neurological impairment is less severe; therefore, ERT may be appropriate to treat these patients. Information on long-term outcome in Scheie patients undergoing ERT is scarce. We report a 38-year-old female Scheie patient who has been on ERT for 8 years. While non-neurological symptoms improved, she developed paresthesias in her hands and feet and progressive pain in her legs. Somatosensory evoked potentials were abnormal, suggesting dysfunction of the dorsal funiculus and lemniscus medialis. After 6 years of ERT, a spinal MRI showed dural thickening at the upper cervical spine. These soft-tissue deposits are presumably due to the accumulation of mucopolysaccharides. Intramedullary hyperintensities at the level of C1/2 revealed cervical myelopathy. An MRI before the start of ERT had shown milder spinal lesions. Cystic lesions in the white matter of the centrum semiovale due to dilated Virchow-Robin spaces were essentially unchanged compared with the MRI scan before ERT. Decompression of the spinal cord resulted in clinical improvement. In an adult patient with Scheie syndrome, ERT failed to prevent progression of cervical myelopathy. Clinical significance of cerebral changes is unclear. Whether early HCT or intrathecal ERT could have prevented these lesions remains speculative.

Phagocytosis and postphagocytic reaction of cord blood and adult blood monocyte after infection with green fluorescent protein-labeled Escherichia coli and group B Streptococci

BACKGROUND

Neonatal sepsis is characterized by an excessive inflammatory response induced by immune cells (monocytes). We investigated the initial stage of monocyte-pathogen interaction, i.e. bacterial ingestion and degradation at the single-cell level, by comparing a new flow cytometric procedure with culture methods. We also examined the hypothesis that, in terms of phagocytosis-induced cell death (PICD), phenotype, or cytokine production, cord blood monocytes (CBMO) differ from monocytes derived from adults (peripheral blood monocytes, PBMO).

METHODS

Phagocytosis and intracellular degradation were assessed by means of flow cytometry and bacterial cultures of green fluorescent protein-labeled group B Streptococci (GBS) and Escherichia coli. The production of reactive oxygen species (ROS) was measured through luminol-enhanced chemiluminescence. Apoptosis, phenotype, and cytokine production were assessed through flow cytometry.

RESULTS

Flow cytometry and bacterial cultures showed no difference between phagocytosis and degradation of GBS and E. coli by PBMO and CBMO. A high correlation between both methods was observed. No difference in ROS production was evident. In comparison with PBMO, CBMO apoptosis was lower after exposure to GBS and E. coli. Similarities were found between nonapoptotic monocytes and pro-inflammatory monocytes.

CONCLUSIONS

PICD is lower in CBMO during the early stages of monocyte-pathogen interaction. Our results emphasize that monocyte apoptosis has a potential role in tailoring the immune response in neonatal sepsis.

Glucose metabolism and liver cirrhosis

Chronic liver disease is characterized by numerous metabolic alterations, predominantly catabolic, resulting in the clinical picture of malnutrition and even cachexia in some patients. The following review focuses on disturbances of glucose metabolism and of hormonal interactions that could contribute to the clinical picture of malnutrition seen in chronic liver disease. Body composition is altered in a characteristic manner with an increase in fat mass and a significant loss of muscle tissue. Furthermore, defective glucose storage due to reduced insulin sensitivity predominantly of muscle tissue has been observed. The pathogenesis of insulin resistance leading to an impaired glucose tolerance or a manifest diabetes mellitus is as yet unknown. A receptor/postreceptor dysfunction probably exists in chronic liver disease that might be explained by the following factors: 1. Altered membrane lipid composition and increased levels of free fatty acids; 2. long-lasting hyperinsulinemia; 3. increased plasma levels of insulin counteracting hormones such as growth hormone, glucagon, catecholamines and possibly cytokines; 4. a lack of liver-derived humoral factors with insulin-like activity, i.e. insulin-like growth factors I and II.

Prenatal benzoate treatment in urea cycle defects

OBJECTIVE

In patients with severe urea cycle defects (UCD) metabolic decompensation with hyperammonaemia typically occurs during the first days of life resulting in severe neurological damage or death. Benzoate can eliminate nitrogen independent of the urea cycle. Usually, benzoate is started soon after birth, but prenatal administration might improve metabolic stability.

DESIGN

Two fetuses with a prenatal diagnosis of UCD (female: citrullinaemia; male: ornithine transcarbamylase deficiency) were loaded with benzoate prenatally via the placenta by infusing their mothers with benzoate. Benzoate concentrations were measured in umbilical cord blood and the blood of the mothers and their newborns.

RESULTS

Therapeutic concentrations of benzoate were found in umbilical cord blood and in the children's blood. Thus, benzoate transfer across the placenta was demonstrated. Plasma ammonia and glutamine levels in the postnatal period were within the normal range.

CONCLUSIONS

Benzoate infusion of the mother shortly before birth is safe and results in therapeutic levels of benzoate in umbilical cord blood.

Influence of different oral rehydration solutions on abomasal conditions and the acid-base status of suckling calves

The aim of the study was to investigate the influence of oral rehydration solutions (ORS) on milk clotting, abomasal pH, electrolyte concentrations, and osmolality, as well as on the acid-base status in blood of suckling calves, as treatment with ORS is the most common therapy of diarrhea in calves to correct dehydration and metabolic acidosis. Oral rehydration solutions are suspected to inhibit abomasal clotting of milk; however, it is recommended to continue feeding cow's milk or milk replacer (MR) to diarrheic calves to prevent body weight losses. Three calves with abomasal cannulas were fed MR, MR-ORS mixtures, or water-ORS mixtures, respectively. Samples of abomasal fluid were taken before and after feeding at various time points, and pH, electrolyte concentrations, and osmolality were measured. The interference of ORS with milk clotting was examined in vivo and in vitro. To evaluate the effects of ORS on systemic acid-base status, the Stewart variables strong ion difference ([SID]), acid total ([A(tot)]), and partial pressure of CO2 (pCO2) were quantified in venous blood samples drawn before and after feeding. Calves reached higher abomasal pH values when fed with MR-ORS mixtures than when fed MR. Preprandial pH values were re-established after 4 to 6 h. Oral rehydration solutions prepared in water increased the abomasal fluid pH only for 1 to 2 h. Oral rehydration solutions with high [SID(3)] ([Na(+)] + [K(+)] - [Cl(-)]) values produced significantly higher abomasal pH values and area under the curve data of the pH time course. Caseinomacropeptide, an indicator of successful enzymatic milk clotting, could be identified in every sample of abomasal fluid after feeding MR-ORS mixtures. The MR-ORS mixtures with [SID(3)] values > or =92 mmol/L increased serum [SID(3)] but did not change venous blood pH. Oral rehydration solutions do not interfere with milk clotting in the abomasum and can, therefore, be administered with milk. In this study, MR-ORS mixtures with high [SID(3)] values caused an increase of serum [SID(3)] in healthy suckling calves and may be an effective treatment for metabolic acidosis in calves suffering from diarrhea.

Diagnostische Bewertung der Stewart-Variablen des Säuren-Basen-Status bei klinisch gesunden und erkrankten Pferden mit Infusionstherapie

Gegenstand und Ziel: Vergleichende Beurteilung des Säuren-Basen-Status (SBS) mit dem Henderson- Hasselbalch-(HH-)-Modell und der Stewart-Variablen PCO2, [strong ion difference = SID] und [Acid total = Atot]. Material und Methoden: Im arteriellen und venösen Blut wurden von 38 klinisch gesunden Pferden Referenzwerte der Stewart-Variablen ermittelt. Ferner wurden bei zwei erkrankten Tieren in den vor, während und nach Infusionstherapie entnommenen Blutproben die SBS-Parameter bestimmt. Im venösen Blutserum erfolgte die Analyse der Elektrolyte und des Gesamtproteins inklusive seiner Fraktionen. Ergebnisse: Referenzbereiche (̄ ± 1,96⋅s) für die Stewart-Variablen von den klinisch gesunden Pferden: PvCO2 = 5,0–7,3 kPa, Serum-[SID3] = 38,5–45,1 mmol/l bzw. -[SID4] = 37,7–44,2 mmol/l, Serum-[Atot1] = 11,7–17,3 mmol/l bzw. -[Atot2] = 11,5–15,4 mmol/l. Der aus den Stewart-Variablen kalkulierte pH war 0,06 Einheiten alkalischer als der gemessene Blut-pH. Patient 1 (chronische respiratorische Erkrankung) wies vor Infusion keinen veränderten SBS auf. Während und nach Hyperinfusion von 30 l isotoner NaCl-Lösung binnen 3 h kam es im venösen Blut zu folgenden Reaktionen: ↓pH, ↓[HCO3 –], ↓[BE] (= HH-Parameter); ↓[SID3, 4] und ↓[Atot1, 2] (= Stewart-Parameter). Die post infusionem (p. i.) transiente milde Azidose des Pferdes erklärt sich aus den unphysiologisch niedrigen Stewart-Variablen der 0,9%igen NaCl-Lösung mit [SID3, 4] = 0 mmol/l und [Atot1, 2] = 0 mmol/l. Das kolikkranke Pferd (Fall 2) zeigte vor Infusionsbeginn im Blut →pH, ↓[HCO3 –], ↓[BE], ↓PCO2 und ↓[SID4], was eine metabolische Azidose mit respiratorischer Kompensation signalisiert. Die Infusion von 12 l Ringerlösung ([SID3, 4] = –4,5 mmol/l, [Atot1, 2] = 0 mmol/l) bewirkte 1 h p. i. den ↓[SID3, 4] (= azidotische Reaktion) und den ↓[Atot1, 2] (= basische Reaktion). Klinische Relevanz: Anhand der HH-Parameter lassen sich SBS-Störungen hinsichtlich Azidämie oder Alkalämie sowie respiratorisch verursachter Imbalancen eindeutig diagnostizieren. Für die bei Tieren häufigeren nichtrespiratorischen (= metabolischen) Azidosen bzw. Alkalosen leisten die Stewart-Variablen ([SID], [Atot]) wertvolle Hilfe bezüglich Ursachenaufklärung, wie Imbalancen der Elektrolyte oder Proteine, und ermöglichen so eine gezielte Auswahl von geeigneten Korrekturlösungen bei der Flüssigkeitstherapie.

Inclusive K(S);(0)K(S);(0) resonance production in ep collisions at HERA

Inclusive K_{S};{0}K_{S};{0} production in ep collisions at the DESY ep collider HERA was studied with the ZEUS detector using an integrated luminosity of 0.5 fb;{-1}. Enhancements in the mass spectrum were observed and are attributed to the production of f_{2}(1270)/a_{2};{0}(1320), f_{2};{'}(1525) and f_{0}(1710). Masses and widths were obtained using a fit which takes into account theoretical predictions based on SU(3) symmetry arguments, and are consistent with the Particle Data Group values. The f_{0}(1710) state, which has a mass consistent with a glueball candidate, was observed with a statistical significance of 5 standard deviations. However, if this state is the same as that seen in gammagamma-->K_{S};{0}K_{S};{0}, it is unlikely to be a pure glueball state.