HMGB-1 and TGFβ-1 highlight immuno-inflammatory and fibrotic processes before proteinuria onset in pediatric patients with Alport syndrome

INTRODUCTION

Alport syndrome (ALP) is a rare genetic condition characterized by progressive involvement of the basal membranes and renal dysfunction. The purpose of the study was to evaluate urinary (u) and serum (s) levels of tumor growth factor (TGF)-beta(β) and high mobility group box (HMGB)-1 in ALP patients with normal renal function, albuminuria and proteinuria.

METHODS

A prospective, single-center study was performed with a follow-up period of 12 months, enrolling 11 pediatric ALP patients and 10 healthy subjects (HS). Normal values of serum creatinine, albuminuria and proteinuria, as well as unaltered estimated glomerular filtration rate (eGFR) were required at enrollment.

RESULTS

ALP patients had significantly higher levels of serum and urinary HMGB1 compared to HS. The same trend was observed for TGF-β1, with higher values in ALP patients than in HS. HMGB1 and TGF-β1 correlated with each other and with markers of renal function and damage. Urinary biomarkers did not correlate with eGFR, whereas sHMGB1 and sTGF-β1 were negatively related to filtration rate (r: - 0.66; p = 0.02, r: - 0.96; p < 0.0001, respectively). Using proteinuria as a dependent variable in a multiple regression model, only the association with sTGF-β1 (β = 0.91, p < 0.0001) remained significant.

CONCLUSIONS

High levels of HMGB1 and TGF-β1 characterized ALP patients with normal renal function, highlighting the subclinical pro-fibrotic and inflammatory mechanisms triggered before the onset of proteinuria. Further studies are needed to evaluate the role of HMGB1 and TGFβ-1 in ALP patients.

Metacognition amidst narratives of self and illness in schizophrenia: associations with neurocognition, symptoms, insight and quality of life

OBJECTIVE

Impairments in laboratory tasks of metacognition appear to be associated with symptoms, functioning, and neurocognition in schizophrenia. We sought to replicate these results in a study of metacognition within personal narratives of self and illness.

METHOD

Narratives of 61 men with schizophrenia were rated using the Metacognition Assessment Scale and correlated with concurrent assessment of symptoms, quality of life, neurocognition and insight.

RESULTS

Controlling for age and education, understanding of one's own mind was linked with better neurocognition across multiple domains, and lesser emotional withdrawal. Greater understanding of other's mind was linked with better verbal memory and less emotional withdrawal. Greater metacognition in the context of purposeful problem solving was associated with better verbal memory, insight and social function, and less emotional withdrawal and paranoia.

CONCLUSION

Deficits in metacognition within the narratives of persons with schizophrenia are linked with symptoms, quality of life, neurocognition and poorer awareness of illness.

Pigmented villonodular synovitis of the foot: MR findings

PURPOSE

To evaluate the MRI findings in the various forms of pigmented villonodular synovitis (PVNS) of the foot.

MATERIALS AND METHODS

Seven hundred and fifty-three MR studies of the foot performed at our institute between June 1994 and April 2000 were retrospectively reviewed for the presence of PVNS. Spin echo (SE) T1W, Gradient echo (GE) T2*W, and fat suppression (Short Time Inversion Recovery: STIR) images were acquired with a 0.5 T superconductive unit (Vectra, GE Medical System, Milwaukee, WI, USA) provided with a dedicated transmitter/receiver coil. The site and type of lesions, the signal intensity patterns, and the presence of associated changes were evaluated.

RESULTS

On the basis of the MR images and the above parameters, six patients (3 men, 3 women, age range: 35-48 years) with PVNS were selected. Three out of six PVNS were nodular, whereas the remaining three were diffuse. Of the three nodular forms, one was found in the sub-talar joint and the remaining two antero-medially to the talus. Instead, all of the diffuse lesions were located on the metatarsus. Perilesional oedema was seen in all cases, although more obvious in the nodular forms, whereas bone involvement (osteochondral erosion) was observed only in the diffuse metatarsal PVNS. Intra-articular bloody effusion was never observed. The MRI findings were confirmed by surgery in all cases.

DISCUSSION

The high contrast resolution and multiplanar capabilities of MRI allow the complete evaluation of the structures of the foot affected by PVNS, and of the extent of soft tissue (bursae, synovial or nervous structures), bone and articular involvement. Although not specific, the presence of haemosiderin results in characteristic MR findings, due to the shortening of both T1 and T2 relaxation times. GET2* images are particularly well suited to this

PURPOSE

Furthermore, in our experience, FIR images added better depiction of associated swelling.

CONCLUSIONS

According to our results, MRI is now the most reliable technique for identifying and classifying PVNS, and allows correct treatment planning and effective monitoring.

[Sportsman hindfoot pain: role of magnetic resonance imaging]

PURPOSE

To assess the outcome of Magnetic Resonance Imaging (MRI) in the diagnosis of sportsman hindfoot pain.

MATERIALS AND METHODS

Fortythree professional athletes (31 men, 12 women, age range: 17-37 years) affected by hindfoot pain underwent MRI. Spin echo (SE) T1W, Gradient echo (GE) T2*W, and fat suppression (Short Time Inversion Recovery: STIR) images were acquired with a 0.5 T superconductive unit (Vectra, GE Medical System, Milwaukee, WI, USA). A dedicated extremities transmitter/receiver coil was used. The lesion site, the presence of anatomic variants (os trigonum, Haglund's deformity), and signal intensity changes were evaluated.

RESULTS

In all cases MRI allowed the identification of the cause of the hindfoot pain, in relation to soft tissue (bursae, synovial or nervous structures), bone and articular diseases. Particularly, as regards soft tissue diseases, tendinous abnormalities and inflammatory bursal involvement were frequently found (77% of cases). Bone diseases (22% of cases with posterior talalgia alone), mostly involved the heel (60%), whereas cartilagineous diseases were present in 9% of cases. In 60% of cases an intra-articular osseous or cartilagineous displaced fragment coexisted, determinating joint locking during foot flexo-extension movements. In 38% of cases contemporary involvement of different articular structures was observed.

DISCUSSION

Both MRI high contrast resolution and multiplanar capabilities allow the complete evaluation of hindfoot region. In our experience sagittal and axial planes were particularly well suited for the diagnosis and the assessment of disease extension. Furthermore, T2W (GET2*) and fat suppression (STIR) images allow high sensitivity even in early disease detection, when hyperemia or fluid collection occur.

CONCLUSIONS

According to our results, it seems possible to state that nowadays MRI is the most reliable technique for identifying the causes of hindfoot pain, in order to provide a correct and effective pre-therapeutic planning.

[Usefulness of CT colonography in the preoperative evaluation of patients with distal occlusive colorectal carcinoma]

PURPOSE

To evaluate the role of preoperative virtual colonoscopy to study the proximal colon in patients with distal occlusive carcinomas, diagnosed by conventional colonoscopy.

MATERIAL AND METHODS

We examined 19 patients aged 46 to 83 years (13 men and 6 women) with distal occlusive colorectal carcinomas diagnosed by conventional colonoscopy, who were preoperatively studied with virtual colonoscopy. Patients with acute bowel obstruction were excluded. Results were compared with the findings of preoperative conventional colonoscopy and barium enema examination, intraoperative colon palpation, histopathologic outcome, postoperative conventional colonoscopy and barium enema examination.

RESULTS

Virtual colonoscopy identified all 19 distal occlusive colon carcinomas and 22 synchronous lesions, 2 cancers (prevalence 10,6%) and 20 polyps (prevalence 68,4%). Both synchronous cancers were confirmed intraoperatively by direct palpation. Postoperative conventional colonoscopy, which was performed in 18 patients, confirmed the presence of 15 polyps in 12 patients. Three subcentimeter polyps were removed during conventional colonoscopy and were missed at virtual colonoscopy. Two polyps shown by virtual colonoscopy were not found at conventional colonoscopy. Postoperative barium enema was performed in three patients and confirmed three polyps identified at virtual colonoscopy. Preoperative barium enema was performed in five patients and failed to adequately demonstrate the proximal colon. Virtual colonoscopy showed a sensitivity of 87% and a specificity of 75%.

CONCLUSIONS

Virtual CT colonoscopy can be considered an important diagnostic technique to evaluate preoperatively the proximal colon in patients with distal occlusive carcinomas,as it gives better results than barium enema or conventional colonoscopy, as well as being well tolerated and less invasive.

[Normal anatomy and pathological conditions of subscapular muscle: US findings compared with surgery]

PURPOSE

To compare US results with those of surgery in the assessment of the subscapularis tendon.

MATERIAL AND METHODS

From January 1995 to December 1998 1500 patients underwent US of the shoulder. 12 of these patients had an injured subscapularis tendon. US results of these patients were evaluated retrospectively and compared with those of surgery. US examinations of the subscapularis tendon were performed with two US units (AU4 Idea and HDI 3000), using linear arrays 10-13 MHz transducers. The following features of the tendon were evaluated: morphology, thickness and echotexture.

RESULTS

A) US findings. US showed: - chronic degenerative tendon changes with diffusely inhomogeneous echotexture (5 cases); - focal tears with small hypoechoic ill-defined areas or gross hypo-anechoic areas involving the full thickness of the tendon (4 cases); - complete tendon tear with disappearance on US of the subscapularis tendon or with severe thickening of the tendon (2 cases); - in 1 case of recent anterior dislocation of the shoulder a bulky hematoma was seen with coexisting thickening and subtotal tear of the tendon. B) Surgical findings. US findings were confirmerd at surgery in 10 of the 12 patients. In the patient with anterior dislocation of shoulder the diagnosis hematoma was confirmed, but the subscapularis tendon was undamaged. Moreover, in 1 out of the 5 patients with US diagnosis of chronic degenerative tendon changes, a small focal tear of the tendon was found at surgery.

CONCLUSION

US is a first level investigation which is able to demonstrate early changes of the subscapularis tendon and nearby structures. Awareness of pitfalls might decrease the use of second level investigations such as CT arthrography and MR imaging, which on the other hand allow a better definition and assessment of the extent of the injury.

[Benign hepatic tumors: MRI features before and after administration of superparamagnetic contrast media]

PURPOSE

To assess the yield of superparamagnetic iron oxide (SPIO)-enhanced MR images in the detection and characterization of benign hepatic tumors and to evaluate the potential role and safety of SPIO administration in the diagnosis of these tumors.

MATERIAL AND METHODS

Eighteen patients underwent MRI before and after administration of SPIO particles. Spin echo (SE) T1, DP, T2 and Gradient echo (GE) T2* images were acquired with a.5 T superconductive unit. MR diagnosis was bioptically proved in 12 patients. In the remaining six patients, who had hemangiomas only, diagnosis was confirmed by at least two imaging techniques-such as MR, CT, ultrasonography, radio-labeled red cells scintigraphy-and by both clinical and imaging follow-up.

RESULTS

Thirthy-four tumors were detected on the MR images: 29/34 (85,3%) before and 33/34 (97%) after SPIO administration - 6 focal nodular hyperplasias (FNH), 6 adenomas and 22 hemangiomas. One small tumor (adenoma) was detected on the unenhanced MR images only, while 4 lesions (3 adenomas, 1 FNH) were detected after SPIO administration only.

DISCUSSION

SPIO-enhanced MRI increased the detection rate of benign hepatic tumors compared to non-enhanced MRI. Iron oxide was also useful in the characterization of such lesions as it was able to demonstrate any heterogeneity resulting from the presence of central scars or septa. Nevertheless, in our experience it was useful to compare baseline with SPIO-enhanced MRI, even if time consuming. Indeed the uptake of iron oxide particles by well-differentiated lesions and normal hepatic parenchyma, is comparable, so that well-differentiated lesions appear isointense and therefore undetectable.

CONCLUSIONS

In our experience, although numerically limited, SPIO-enhanced MRI was clinically safe and more effective than non-enhanced MRI in both the detection and characterization of benign hepatic tumors, providing useful clues for diagnosis.

[Os trigonum tarsi syndrome. Role of magnetic resonance]

INTRODUCTION

The os trigonum tarsi is an accessory bone of the foot localized posterolateral to the lateral tubercle of talus. It is usually an asymptomatic condition. However, particular activities such as ballet, soccer, or football may cause repeated stress and chronic microtraumas to the hindfoot, resulting in the os trigonum syndrome. Pain is typically localized anterior to the Achilles tendon; nevertheless, diagnosis may be very difficult because other conditions may show the same symptoms. Radiography can only demonstrate the os trigonum and its morphostructural changes, while MR imaging can also depict associated soft tissue damage. We report on 9 cases of os trigonum tarsi syndrome studied with MR imaging.

MATERIAL AND METHODS

Nine patients with the os trigonum tarsi syndrome were submitted to MRI. All the examinations were performed with the patients in supine recumbency with the injured foot in neutral position and then in forced plantar flexion. Axial and sagittal T1 SE, T2* GE and FIR images were acquired. We evaluated os trigonum location and shape, signal intensity of bone, cartilages and adjacent soft tissues, and possible associated tendon injuries.

RESULTS

No changes were found in the os trigonum location and shape. Signal intensity changes were seen in 2/9 cases. Particularly, a small area of very high signal intensity, due to necrosis, was depicted on the talar aspect in 1 case; a subchondral spot of slightly increased signal intensity, with a low-signal outline, was seen on the calcanear aspect in another case. Disruption of the cartilaginous synchondrosis between the accessory navicular bone and the posterior tibial aspect was observed in 7/9 patients. Tenosynovitis of the flexor hallucis longus was associated in 6/9 patients. Pseudoarthrosis with irregular bone margins and high-signal spots within the cartilage was found in 3 cases. Finally, fluid effusion surrounding the os trigonum and adjacent soft tissues was always detected.

DISCUSSION AND CONCLUSIONS

The os trigonum syndrome may result from chronic microtraumas. Indeed, forced plantar flexion may cause os trigonum compression between the posterior aspect of the tibial malleolus and the calcaneus, with disruption of the synchondrosis with the lateral tubercle of talus. Joint inflammation may be associated with possible development of pseudoarthrosis. Other possible complications are related to vascular changes which may lead to bone necrosis. Furthermore, the particular anatomical site of the os trigonum may sometimes cause compression to the flexor hallucis longus tendon, resulting in severe tenosynovitis. MR imaging allows complete morphostructural assessment because it depicts the margins and the signal intensity of bone and ligaments on the 3 spatial planes. Particularly, sagittal T2 images best demonstrate the cartilage changes indicating synchondrosis disruption. This condition may cause abnormal mobility of the accessory bone with possible impingement with the posterior aspect of the tibia, or hypomobility due to pseudoarthrosis. Forced plantar flexion acquisitions are particularly useful in this condition because they can demonstrate the mechanism of injury.

[The heart of the patient with beta thalassemia major. Study with magnetic resonance]

PURPOSE

The main cause of death in beta-thalassemia major patients is congestive heart failure which is traditionally referred to myocardial iron overload. Recently, some investigators have found that cardiac failure is not caused by the iron overload. In their opinion, left-sided heart failure develops years after the onset of acute myocarditis and might be related to a late autoimmune process. Right-sided heart failure is related to the combination of left ventricular diastolic restriction and pulmonary hypertension. The aim of this work is to study myocardial iron overload by MRI and to correlate the signal intensity changes of the myocardium with cardiac function.

MATERIAL AND METHODS

Sixteen patients with beta-thalassemia major were examined with a .5 super-conducting unit. SE and cine-GE sequences were used in the 4 chamber and 2 chamber views. Left ventirclar ejection fraction (EF) was calculated by using the biplane area-length method. Right ventricular size was assessed by measuring the end-diastolic anteroposterior diameter (APD). Myocardial signal intensity was evaluated qualitatively and quantitatively (myocardium/subcutaneous fat) in all the beta-thalassemia patients and in 10 normal volunteers.

RESULTS

Left ventricular function was decreased (EF < 55%) in 2/16 patients. The right ventricle was dilated in 5/16 patients (APD > 42 mm). The myocardium had a lower signal intensity than that of normal volunteers in 15/16 patients. No statistical correlation was found between myocardial signal intensity and serum ferritine levels or cardiac function.

CONCLUSIONS

The small number of patients in our series does not allow any definitive statements. However, our results show that cardiac function is not influenced by myocardial iron overload.

Lymphoproliferative disorders in Sotos syndrome: observation of two cases

Sotos syndrome is included among the overgrowth disorders, most of which have an increased risk of neoplasms. Sotos syndrome does not appear to be related to a specific tumor type, but rather to the development of solid tumors of ectodermal or mesodermal origin in general. We report on two Sotos syndrome patients who developed a non-Hodgkin lymphoma and an acute lymphoblastic leukaemia, respectively. Our experience suggests that there may exist a high frequency of lymphoproliferative disorders in Sotos syndrome, and points out the importance of a long-term follow-up of Sotos syndrome patients, to detect a possible neoplastic evolution.

[Obstructive emphysema of infant during pulmonary tuberculosis]

A rare complication of pulmonary tuberculosis of infant is the obstructive emphysema following to the compression by enlarged lymphadenopathy. The authors report a case of obstructive emphysema observed in a 12 month old infant affected by pulmonary tuberculosis, and debate its more important pathogenethic, clinical and differential diagnosis aspects. At last they comment upon favourable clinical course observed as results of an exclusive medical treatment (antitubercular antibiotic therapy shortly combined with moderate corticotherapy) without making use of surgical, but aggressive, treatment.

[Role of diagnostic imaging in Rubinstein-Taybi syndrome. Personal experience with 8 cases]

Both etiology and pathogenesis of Rubinstein-Taybi syndrome (RTS) are still questionable, even though a genetic factor seems to be certain. A typical face, psychomotor delay, and thumb and halluces abnormalities (big, prevalently short, and often "spoon-like" toes) are the main characteristic patterns of RTS. Eight subjects (4 male and 3 female children aged 26 days-7 years, and a 31-year-old woman, mother of 1 of the affected children) with different signs of RTS were studied over the last 3 years. The results are here reported, with a special emphasis on malformations detected with conventional radiography (Rx), Computerized Tomography (CT), and ultrasound (US). Evaluated parameters were thumbs and halluces (Rx), bone age and skeleton (Rx), cranium (Rx) and encephalon (US, CT), cryptorchidism (US, CT), and urological (Rx, US) and cardiovascular (US) systems. A typical face and psychomotor delay were found in all cases, while thumb and halluces abnormalities were observed only in 6 cases. Among several clinical signs of RTS, we found: severe (less than 3rd centile) bone maturation delay in 4 cases; skull volume reduction (less than 50th centile) in 3 subjects and microcrania in 4; skeletal abnormalities in 7 cases (5 of them positive for bilateral coxofemoral abnormalities); urinary tract (4 cases) and cardiovascular (3 cases) malformations; and cryptorchidism in 3 of 4 males. A case was diagnosed during neonatal period (within the first month of life); it was a rare case associated with a variant form of Dandy-Walker anomaly; semiologic similarities were observed between mother and daughter patients. X-rays, US and CT rarely play an important role in the diagnosis of RTS, considering the several clinical signs, mainly the face, affecting the patients. However, diagnostic imaging techniques help diagnose hidden malformations and confirm and integrate clinical signs.

Kabuki make-up (Niikawa-Kuroki) syndrome: clinical and radiological observations in two Sicilian children

The Authors describe two patients aged 5 and 8, a female and a male, affected by a condition of polymalformations known as Kabuki make-up or Niikawa-Kuroki syndrome, having a neonatal incidence of 1:32,000 in Japan. There are two hypothesis about the apparent rarity of the syndrome in the rest of the world, including the Asian Continent: the first is that it exists, but is infrequently recognized outside Japan and the second is that it is really more frequent in those parts of the world, where ethnic exchanges are uncommon, as it happens in Japan.

[Ultrasonics in the diagnosis and monitoring of cryptorchism in children]

The diagnostic reliability of US was investigated in the study of cryptorchidism during a 9-month clinical and US trial performed on 52 children (mean age 4.3 years). Cryptorchidism was unilateral in 44 cases (24 on the left side and 20 on the right side), and bilateral in 8 cases. Of 60 cryptorchid testes, 53--belonging to 45 of 52 patients--were located in the inguinal region (18 along the canal, 20 at the external ring, and 15 at the internal one); the others 7--belonging to the remaining 7 subjects--were found in an extra-inguinal region (4 in paravesical location and 3 in the inferior abdomen). US confirmed 29 undescended testes with clinical evidence in the inguinal region and identified, in the same area, 24 other testes which had been missed at clinical examination. In addition, US provided useful information as to both structure and volumetry of the gonads. On the other hand, US failed to provide reliable diagnostic results in the rare cases of pelvic and abdominal cryptorchidism, where precise testes localization was achieved by CT. US is the diagnostic technique of choice in the study of cryptorchidism (after clinical examination): the method is non-invasive and simple, has low cost and its use is widespread; moreover, US does not administer ionizing radiations. According to our experience, US had 88.3% diagnostic sensitivity as for undescended testes (53 of 60), and 100% specificity. In addition, US monitoring allowed clinical efficacy of therapeutic trials to be verified in 25 patients (17 sensitive to therapy): 16 of them were treated with human Chorionic Gonadotropin (hCG) and 9 with Luteinizing Hormone-Releasing Hormone (LH-RH).

Cervico-oculo-acusticus (Wildervanck's) syndrome: a clinical variant of Klippel-Feil sequence?

A 7-year-old female child with phenotype of Cervico-Oculo-Acousticus (Wildervanck's) syndrome is presented. In addition to fusion of multiple cervical vertebrae with short neck, abducens nerve palsy and deafness, the child showed severe growth and bone delay, renal abnormalities and slight mental retardation. The presence of such malformations seems to suggest that Wildervanck's syndrome is a clinical variant of Klippel-Feil sequence. Both conditions usually have sporadic occurrence with female prevalence, more consistent for cervico-oculo-acousticus syndrome. The possibility of dominant inheritance has been postulated for both, autosomal for Klippel-Feil, autosomal or X-linked with lethality in hemizygous for Wildervank's one. An environmental etiology, due to a vascular disruption sequence during embryonic development, has been noted in Klippel-Feil, as in Moebius and Poland sequences. A combination of defects (Klippel-Feil and Moebius) could induce the more complex phenotype observed in Wildervanck's syndrome.

[Preparation of patients in diagnostic contrast radiography of the urinary and bile tracts and the large intestine]

A preparation schedule including, for clysterisation, a substance based on palmitate, stearate and oleate of sodium of vegetable origin has been experimented in 130 patients of both sexes (70 awaiting contrastography of the urinary and bile ways, and 60 double contrastography of the colon). Excellent results were obtained in urography and colangiocholecystography when the schedule was limited to just one clyster with double dose of Radioced carried out on the same morning as the investigation. For an examination like double contrast clyster, which is more demanding from the viewpoint of correct intestinal cleansing, the number of clysters has to be increased to four. Three, at appropriate intervals, are carried out on the day preceding examination, and the last no more than two hours prior to the clyster. In all four, a double dose of Radioced dissolved in warm water (two litres for each of the first three and a litre and a half for the fourth) is used. Still on double contrast clyster, the preparation schedule requires a three-day diet (the first two involving low-waste foods and the third a liquid diet only) plus 30 g of Epsom salts (and no less than a litre of water) the day before double contrastography.