Escherichia coli O80 hybrid pathotype strains producing Shiga toxin and ESBL: molecular characterization and potential therapeutic options

OBJECTIVES

Enterohaemorrhagic Escherichia coli (EHEC) infections may be complicated by haemolytic uraemic syndrome (HUS). The emerging worldwide EHEC serogroup O80 has acquired a mosaic plasmid combining extraintestinal virulence and antibiotic resistance. This hybrid pathotype is associated with invasive infections that require antibiotic therapy, classically not recommended in EHEC infections, increasing the risk of HUS. We characterized two ESBL-producing O80 EHEC strains, which is an unusual resistance mechanism among EHECs, and determined the safest therapy to be used for invasive infections.

METHODS

WGS of two strains isolated from the stools of an asymptomatic carrier and a patient with HUS was performed using Illumina and Nanopore technologies. Generated reads were combined to assemble genomes. We determined the safest therapy by comparing Shiga toxin (Stx) production by the two strains in the presence of several antibiotics.

RESULTS

The strains were genetically close to the O80 EHEC clone, belonging to ST301 and harbouring stx2d, eae-ξ, ehxA and genes characteristic of the extraintestinal virulence plasmid pS88. Long-read sequencing identified the acquisition of an additional plasmid harbouring CTX-M-type genes (blaCTX-M-14 and blaCTX-M-1). Azithromycin decreased Stx production at subinhibitory concentrations, ciprofloxacin increased it and imipenem had no major effect. The combination of azithromycin and imipenem overall reduced Stx production.

CONCLUSIONS

Acquisition of an additional plasmid harbouring ESBL genes is a step towards increasing the risk of O80 EHEC dissemination and represents a serious public health concern. The combination of azithromycin and imipenem reduced Stx production and suggests that this combination could be tested in clinical trials.

Combination therapy with ciprofloxacin and third-generation cephalosporin versus third-generation cephalosporin monotherapy in Escherichia coli meningitis in infants: a multicentre propensity score-matched observational study

OBJECTIVES

Escherichiacoli is the second cause of bacterial meningitis in neonates. Despite the use for 35 years of third-generation cephalosporins (3GCs), high morbidity and mortality rates with E. coli meningitis continue to occur. Because ciprofloxacin has good microbiologic activity against E. coli and good penetration in cerebrospinal fluid and brain, some authors have suggested adding ciprofloxacin to a 3GC regimen. The objective of this study was to assess combining 3GCs with ciprofloxacin versus 3GCs alone in a cohort of infants with E. coli meningitis.

METHODS

We included all cases of E. coli meningitis diagnosed in infants <12 months of age that were prospectively collected through the French paediatric meningitis surveillance network between 2001 and 2016. The main outcome was the proportion of short-term neurologic complications with versus without ciprofloxacin. The analysis was conducted retrospectively by multivariable regression and propensity score (PS) analysis.

RESULTS

Among the 367 infants enrolled, 201 (54.8%) of 367 had ciprofloxacin and 3GC cotreatment and 166 (45.2%) of 367 only a 3GC. Median age and weight were 15 days (range, 1-318 days) and 3.42 kg (range, 0.66-9.4 kg). A total of 86 (23.4%) of 367 infants presented neurologic complications (seizures, strokes, empyema, abscesses, hydrocephalus, arachnoiditis); 57 received ciprofloxacin cotreatment. Complications were associated with ciprofloxacin cotreatment on multivariable analysis (odds ratio (OR) = 1.9; 95% confidence interval (CI), 1.1-3.4) and PS analysis (OR = 1.9; 95% CI, 1.1-3.3). Mortality rate did not differ with and without ciprofloxacin: 22 (10.9%) of 201 versus 16 (9.6%) of 166 deaths (OR = 0.7; 95% CI, 0.3-1.6; PS analysis).

CONCLUSIONS

Ciprofloxacin added to 3GCs at least offers no advantage for neurologic outcome and mortality in infants with E. coli meningitis.

Evaluation at 3 years of concurrent bevacizumab and radiotherapy for breast cancer: Results of a prospective study

PURPOSE

To determine the 3 years late toxicity among patients with non-metastatic breast cancer who received concurrent bevacizumab and locoregional radiotherapy.

MATERIAL AND METHODS

This is a single-arm, multicentre, prospective study, of the toxicity of adjuvant concomitant association of bevacizumab and radiotherapy in patients with breast cancer. Toxicity was assessed by the Common Terminology Criteria for Adverse Events version 3.0 during the radiotherapy and follow-up clinics at 12 and 36 months after its completion. The study was designed to evaluate the toxicity at one year, 3 years and 5 years.

RESULTS

Sixty-four patients were included from October 2007 to August 2010. All of them received concurrent adjuvant radiotherapy and bevacizumab (in 24 cases after primary systemic treatment). All patients received non-fractionated radiotherapy to breast or chest wall with or without irradiation of regional lymph nodes. Early toxicity has been previously reported. Median follow-up was 46.4 months (range: 18-77 months). Median age was 53 years old (range: 23-68 years). The 3-years overall survival was 93% (range: 87-100%). Evaluation of the toxicity at 3 years was available for 67% of the patients. There was a low rate of toxicity: 14% grade 1 pain, 9% grade 1 fibrosis, 2% grade 1 telangiectasia, 2% grade 1 paresis, 7% grade 1 lymphedema and 2% grade 3 lymphedema. No grade 4 toxicity was observed. No patient had a left ventricular ejection fraction below 50% at 3 years.

CONCLUSIONS

Concurrent bevacizumab with locoregional radiotherapy is associated with acceptable 3-years toxicity in patients with breast cancer.

Final results of the TANIA randomised phase III trial of bevacizumab after progression on first-line bevacizumab therapy for HER2-negative locally recurrent/metastatic breast cancer

BACKGROUND

The randomised phase III TANIA trial demonstrated that continuing bevacizumab with second-line chemotherapy for locally recurrent/metastatic breast cancer (LR/mBC) after progression on first-line bevacizumab-containing therapy significantly improved progression-free survival (PFS) compared with chemotherapy alone [hazard ratio (HR) = 0.75, 95% confidence interval (CI) 0.61-0.93]. We report final results from the TANIA trial, including overall survival (OS) and health-related quality of life (HRQoL).

PATIENTS AND METHODS

Patients with HER2-negative LR/mBC that had progressed on or after first-line bevacizumab plus chemotherapy were randomised to receive standard second-line chemotherapy either alone or with bevacizumab. At second progression, patients initially randomised to bevacizumab continued bevacizumab with their third-line chemotherapy, but those randomised to chemotherapy alone were not allowed to cross over to receive third-line bevacizumab. The primary end point was second-line PFS; secondary end points included third-line PFS, combined second- and third-line PFS, OS, HRQoL and safety.

RESULTS

Of the 494 patients randomised, 483 received second-line therapy; 234 patients (47% of the randomised population) continued to third-line study treatment. The median duration of follow-up at the final analysis was 32.1 months in the chemotherapy-alone arm and 30.9 months in the bevacizumab plus chemotherapy arm. There was no statistically significant difference between treatment arms in third-line PFS (HR = 0.79, 95% CI 0.59-1.06), combined second- and third-line PFS (HR = 0.85, 95% CI 0.68-1.05) or OS (HR = 0.96, 95% CI 0.76-1.21). Third-line safety results showed increased incidences of proteinuria and hypertension with bevacizumab, consistent with safety results for the second-line treatment phase. No differences in HRQoL were detected.

CONCLUSIONS

In this trial, continuing bevacizumab beyond first and second progression of LR/mBC improved second-line PFS, but no improvement in longer term efficacy was observed. The second-line PFS benefit appears to be achieved without detrimentally affecting quality of life.

CLINICALTRIALSGOV

NCT01250379.

When should clinicians suspect group A streptococcus empyema in children? A multicentre case-control study in French tertiary care centres

BACKGROUND

The incidence of invasive group A streptococcus (GAS) infections is increasing worldwide, whereas there has been a dramatic decrease in pneumococcal invasive diseases. Few data describing GAS pleural empyema in children are available.

OBJECTIVE

To describe the clinical and microbiological features, management and outcome of GAS pleural empyema in children and compare them with those of pneumococcal empyema.

DESIGN, SETTING AND PATIENTS

Fifty children admitted for GAS pleural empyema between January 2006 and May 2013 to 8 hospitals participating in a national pneumonia survey were included in a descriptive study and matched by age and centre with 50 children with pneumococcal empyema.

RESULTS

The median age of the children with GAS pleural empyema was 2 (range 0.1-7.6) years. Eighteen children (36%) had at least one risk factor for invasive GAS infection (corticosteroid use and/or current varicella). On admission, 37 patients (74%) had signs of circulatory failure, and 31 (62%) had a rash. GAS was isolated from 49/50 pleural fluid samples and from one blood culture. The commonest GAS genotype was emm1 (n=17/22). Two children died (4%). Children with GAS empyema presented more frequently with a rash (p<0.01), signs of circulatory failure (p=0.01) and respiratory disorders (p=0.02) and with low leucocyte levels (p=0.04) than children with pneumococcal empyema. Intensive care unit admissions (p<0.01), drainage procedures (p=0.04) and short-term complications (p=0.01) were also more frequent in patients with GAS empyema.

CONCLUSIONS

Pleural empyema following varicella or presenting with rash, signs of circulatory failure and leucopenia may be due to GAS. These features should prompt the addition to treatment of an antitoxin drug, such as clindamycin.

Abstract P6-14-01: Final results of the TANIA randomized phase III trial of bevacizumab (BEV) after progression on 1st-line BEV therapy for HER2-negative locally recurrent/metastatic breast cancer (LR/mBC)

BACKGROUND: The open-label randomized phase III TANIA trial (NCT01250379) evaluated 2nd-line BEV-containing therapy in BEV-pretreated LR/mBC. The primary objective was met: 2nd-line PFS was statistically significantly improved in patients (pts) receiving further BEV (hazard ratio [HR] 0.75, 95% CI 0.61–0.93; p=0.0068) [von Minckwitz, Lancet Oncol 2014]. We report final efficacy, safety, and health-related quality of life (HRQoL) results.

METHODS: Eligible pts had HER2-negative LR/mBC that had progressed on/after 1st-line BEV plus chemotherapy (CT). Pts were randomized to receive 2nd-line CT (investigator's choice) either alone or combined with BEV (15 mg/kg q3w or 10 mg/kg q2w) until disease progression (PD), unacceptable toxicity, or consent withdrawal. At 2nd PD, pts in the CT arm received 3rd-line CT without BEV (no crossover); pts initially randomized to BEV–CT received 3rd-line BEV–CT. Secondary endpoints included 3rd-line PFS, 2nd- and 3rd-line PFS (from randomization to 3rd PD/death), overall survival (OS), HRQoL, and safety. HRQoL was assessed using FACT-B at baseline, every 8/9 weeks (depending on treatment schedule) during 2nd-line therapy, and at the time of 2nd PD. Prespecified HRQoL analyses included differences between treatment arms in mean change from baseline for each FACT-B subscale.

RESULTS: At the time of data cut-off for the prespecified final analysis (April 30, 2015, 24 months after the last pt was randomized), median follow-up was 32.1 vs 30.9 months in the CT vs BEV–CT arms, respectively. All pts had stopped study treatment. Of the 494 pts randomized to 2nd-line therapy, 234 began 3rd-line therapy (105 initially randomized to CT; 129 from the BEV–CT arm, of whom 17 received CT without BEV). The most commonly selected 3rd-line CT was vinorelbine (33% of CT pts vs 31% of BEV–CT pts).

EndpointNo. of events/pts (%)Median, months (95% CI)Stratified HR (95% CI)p-value CTBEV–CTCTBEV–CT  3rd-line PFS99/105 (94)124/129 (96)2.9 (2.2-3.9)3.8 (2.4-5.1)0.79 (0.59-1.06)0.10802nd- and 3rd-line PFS177/247 (72)206/247 (83)10.7 (9.2-12.5)12.8 (10.7-14.5)0.85 (0.68-1.05)0.1349OS156/247 (63)163/247 (66)18.7 (15.4-21.2)19.7 (17.6-21.0)0.96 (0.76-1.21)0.7253

Subgroup analyses of 3rd-line PFS and OS according to stratification factors were consistent with the overall ITT result. Before study closure, 68% and 61% of pts in the 3rd-line ITT population CT and BEV–CT arms, respectively, received further CT. 3rd-line safety results showed no new safety signals. At week 8/9, mean change from baseline for all FACT-B subscales was &lt;1.5 points in either direction in both treatment arms, representing no significant difference. Similarly, exploratory HRQoL analyses of the physical and functional wellbeing subscales using mixed-model repeated measures and responder analyses revealed no meaningful significant differences between treatment arms.

CONCLUSIONS: Although BEV given after PD on 1st-line BEV-containing therapy showed improvement in 2nd-line PFS, no OS benefit was demonstrated. No new safety signals were observed. There were no differences in HRQoL between treatment arms, suggesting that the PFS benefit with BEV is achieved with maintained HRQoL.

Citation Format: Vrdoljak E, Marschner N, Zielinski C, Gligorov J, Cortes J, Puglisi F, Aapro M, Fallowfield L, Fontana A, Inbar M, Kahan Z, Welt A, Lévy C, Brain E, Pivot X, Putzu C, Gonzalez-Martin A, Ebel K, Easton V, von Minckwitz G. Final results of the TANIA randomized phase III trial of bevacizumab (BEV) after progression on 1st-line BEV therapy for HER2-negative locally recurrent/metastatic breast cancer (LR/mBC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-14-01.

REBECA: a phase I study of bevacizumab and whole-brain radiation therapy for the treatment of brain metastasis from solid tumours

BACKGROUND

Brain metastases (BMs) are associated with a poor prognosis. Standard treatment comprises whole-brain radiation therapy (WBRT). As neo-angiogenesis is crucial in BM growth, combining angiogenesis inhibitors such as bevacizumab with radiotherapy is of interest. We aimed to identify the optimal regimen of bevacizumab combined with WBRT for BM for phase II evaluation and provide preliminary efficacy data.

PATIENTS AND METHODS

In this multicentre single-arm phase I study with a 3 + 3 dose-escalation design, patients with unresectable BM from solid tumours received three cycles of bevacizumab at escalating doses [5, 10 and 15 mg/kg every 2 weeks at dose levels (DL) 0, 1 and 2, respectively] and WBRT (30 Gy/15 fractions/3 weeks) administered from day 15. DL3 consisted of bevacizumab 15 mg/kg with WBRT from day 15 in 30 Gy/10 fractions/2 weeks. Safety was evaluated using NCI-CTCAE version 3. BM response (RECIST 1.1) was assessed by magnetic resonance imaging at 6 weeks and 3 months after WBRT.

RESULTS

Nineteen patients were treated, of whom 13 had breast cancer. There were no DLTs. Grade 1-2 in-field and out-field toxicities occurred for five and nine patients across all DLs, respectively, including three and six patients (including one patient with both, so eight patients overall) of nine patients in DL3. One patient experienced BM progression during treatment (DL0). At the 3-month post-treatment assessment, 10 patients showed a BM response: one of three treated at DL0, one of three at DL1, two of three at DL2 and six of seven at DL3, including one complete response. BM progression occurred in five patients, resulting in two deaths. The remaining patient died from extracranial disease progression.

CONCLUSION

Bevacizumab combined with WBRT appears to be a tolerable treatment of BM. DL3 warrants further efficacy evaluation based on the favourable safety/efficacy balance. ClinicalTrials.gov Identifier: NCT01332929.

Influence of Proteins on the Perception of Flavored Stirred Yogurts

Among yogurt dairy components, protein type is known to modify the texture of the products and the volatility of odorous volatile organic compounds. The aim of this study was to investigate the impact of 3 protein ratios (caseinate to total protein) on the sensory properties of 4% fat, strawberry-flavored stirred yogurts. A sensory methodology study was therefore investigated to choose the most efficient method in terms of sensitivity, quantification, and ease with which the panel could distinguish slight differences in olfactory property between the yogurts. Three kinds of product presentation procedures were compared: a monadic presentation, a comparative presentation, and a comparative presentation with a reference. The results showed that the 3 presentation methods emphasized some important texture differences between the yogurts in the same way. However, the comparative procedure with a reference was the only one to reveal clear olfactory property differences between the yogurts. The main effect of protein ratio variation in yogurt concerned the texture properties, which greatly differed between the 3 yogurts and was confirmed by complex viscosity measurements. Olfactory differences between the yogurts were more subtle. Overall, the flavor intensity and the fruity notes were less intense in the yogurts with the high caseinate ratio than in those with the low ratio. This result was in agreement with the physicochemical measurements, which showed a higher retention of a large majority of aroma compounds of the strawberry flavor in the yogurts with a high caseinate ratio.

Méningites à pneumocoque de l'enfant en France : âge de survenue et facteurs de risques médicaux

Streptococcus pneumoniae (Sp) is an important cause of morbidity and mortality among paediatric infectious diseases. The aim of this study is to analyse specific data on Sp meningitis out of the Bacterial Meningitis (BM) French Surveillance Network about mean age of BM cases and clinical features. Overall 367 Sp BM were reported between January 2001 to January 2004 (sex ratio M/F: 1.3), 69.7% were < 2 years old, median age 0.8 year (minmax 0-16.8 years). Before two years old children, 94.1% had no medical risk factor and no underlying conditions: on the other hand, after two years old, these factors were reported in 27% cases (P < 0.001). Mortality rate was 10.9%. On account of a Sp BM's pic at five months, data of the BM French Surveillance Network confirm the necessity of an early vaccination. The vaccine administration at two, three, four months with a booster during the second year, recommended in the vaccinal french calendar, seems particularly adapted to the Sp BM in France.

[Severe thyroid ophthalmopathy related to interferon alpha therapy]

The authors report a case of a 49-year-old patient presenting with dysthyroid ophthalmopathy, who was treated with interferon alpha for chronic hepatitis C. Proptosis appeared 3 months after treatment onset and many complications occurred over more than 1 year. The extreme severity seen in this case is infrequent. After a summary of other ocular damage linked to interferon, the authors suggest that every interferon treatment include a check-up before beginning therapy and regular biological and ophthalmological monitoring.

Appearance of new lesions in two nonfamilial cerebral cavernoma patients

Cavernomas are vascular malformations mostly observed in the central nervous system. They occur in sporadic and familial forms. Familial forms are characterized by the presence of multiple lesions, an autosomal dominant pattern of inheritance and possible de novo lesions. We report two sporadic cases whose follow-up showed the appearance of new lesions.

Low cerebral blood flow velocity and risk of white matter hyperintensities

Cerebral blood flow velocity (CBF-V) measured by transcranial doppler was assessed in 628 elderly individuals who had cerebral magnetic resonance imaging performed as part of a population-based study on vascular aging. Cerebral white matter hyperintensities (WMHs) were associated with low CBF-V, such as the adjusted odds ratios of severe WMHs from highest (referent) to lowest quartile of mean CBF-V were 1.0, 1.7, 3.7, and 4.3 (p = 0.001). Further, CBF-V was found to be a stronger risk factor for WMHs than high blood pressure. These findings suggest that the assessment of CBF-V might be a powerful tool in future studies on WMHs.

[Optic neuropathy after proton-beam therapy for malignant choroidal melanoma]

Proton-beam irradiation is a conservative therapy commonly used for the treatment of uveal malignant melanomas. Some adverse effects such as optic neuropathy can compromise the visual outcome. We were interested in determining the risk factors for radiation papillopathy. Since there is currently no effective therapy, this is an interesting way to improve prevention of optic neuropathy. Six hundred sixty-two eyes had more than 24 month follow-up after proton-beam irradiation for uveal melanoma. In five hundred twenty-two cases, the clinical examination of the optic nerve head by ophthalmoscopy was possible. One-hundred eleven optic discs were pathologic, whereas 411 remained disease-free. Retrospective study of these two groups allowed to quantify the risk factors for optic neuropathy. The irradiation of more than 2mm of optic nerve at 30 Grays-equivalents appeared to be the major risk factor for optic neuropathy. For a given irradiation dose, the observed pattern of clinical responses was heterogeneous. These results are discussed and compared to the previous published reports. Visual results and life prognosis are also discussed, considering the optic nerve head status. Proton-beam therapy can preserve the optic nerve when the tumor location allows to keep it away from the irradiation-field. Patients must be informed about the risk of optic neuropathy after proton-beam irradiation.

The natural history of familial cerebral cavernomas: a retrospective MRI study of 40 patients

Our objective was to determine the natural history and prognostic factors of familial forms of cerebral cavernous malformations (CCM). Cavernomas are one of the most common central nervous system vascular malformations. Familial CCM is increasingly diagnosed, but little is known about its natural history. In a national survey, we analysed clinical and MRI features of 173 patients from 57 unrelated French families. Of these 40 had undergone at least two clinical and MRI examinations. Occurrence of haemorrhage, new lesions, change in signal intensity and size of lesions have been studied by comparison between first and last MRI studies. The CCM were classified according to Zabramski et al. Mean follow-up was 3.2 years (range 0.5-6.5 years). We followed 232 cavernomas (mean 5.9 per patient, range 1-17). Serial MRI demonstrated changes in 28 patients (70%). Bleeding occurred in 21 lesions (9.1%) in 14 patients (35%). The haemorrhagic risk was 2.5% per lesion-year, higher in type I and brain-stem CCM. We saw 23 new lesions appear in 11 patients (27.5%), with an incidence of 0.2 lesions per patient year. Signal change was observed in 11 patients (27.5%), in 14 lesions (6%), while 9 lesions (3.9%) in 9 patients (22.5%) changed significantly in size.

MR angiography for the long-term follow-up of dissecting aneurysms of the extracranial internal carotid artery

OBJECTIVE

We used MR angiography to examine and follow up the changes of dissecting aneurysms of the extracranial internal carotid artery (ICA).

MATERIALS AND METHODS

We retrospectively reviewed the records of 101 consecutive patients with dissecting aneurysms of the extracranial ICA. Twenty patients with 26 spontaneous dissecting aneurysms were followed up with MR angiography every 1-2 years (men, 16; women, four; age range, 28-67 years; mean age, 51 years).

RESULTS

The mean duration of follow-up was 41 months (range, 10-93 months). At MR angiography follow-up, 20 aneurysms did not change, four decreased from their original size by 33-53% (mean, 43%), and two resolved. One patient had an asymptomatic recurrent dissecting aneurysm of the extracranial ICA. Clinically, no patient had a thromboembolic stroke or transient ischemic attack during the follow-up period.

CONCLUSION

MR angiography revealed that dissecting aneurysms of the extracranial ICA remain stable, decrease in size, or resolve--but they do not increase in size.

Individuals with presumably hereditary uveal melanoma do not harbour germline mutations in the coding regions of either the P16INK4A, P14ARF or cdk4 genes

In familial cutaneous malignant melanoma (CMM), disruption of the retinoblastoma (pRB) pathway frequently occurs through inactivating mutations in the p16 (p16INK4A/CDKN2A/MTS1) gene or activating mutations in the G1-specific cyclin dependent kinase 4 gene (CDK4). Uveal malignant melanoma (UMM) also occurs in a familial setting, or sometimes in association with familial or sporadic CMM. Molecular studies of sporadic UMM have revealed somatic deletions covering the INK4A-ARF locus (encoding P16INK4A and P14ARF) in a large proportion of tumours. We hypothesized that germline mutations in the p16INK4A, p14ARF or CDK4 genes might contribute to some cases of familial UMM, or to some cases of UMM associated with another melanoma. Out of 155 patients treated at the Institut Curie for UMM between 1994 and 1997, and interviewed about their personal and familial history of melanoma, we identified seven patients with a relative affected with UMM (n = 6) or CMM (n = 1), and two patients who have had, in addition to UMM, a personal history of second melanoma, UMM (n = 1), or CMM (n = 1). We screened by polymerase chain reaction single-strand conformation polymorphism the entire coding sequence of the INK4A-ARF locus (exon 1alpha from p16INK4A, exon 1beta from p14ARF, and exons 2 and 3, common to both genes), as well as the exons 2, 5 and 8 of the CDK4 gene, coding for the functional domains involved in p16 and/or cyclin D1 binding. A previously reported polymorphism in exon 3 of the INK4A-ARF locus was found in one patient affected with bilateral UMM, but no germline mutations were detected, either in the p16INK4A, p14ARF or CDK4 genes. Our data support the involvement of other genes in predisposition to uveal melanoma.

Long-term follow-up of aneurysms developed during extracranial internal carotid artery dissection

OBJECTIVE

To evaluate the clinical course of aneurysms developed during extracranial internal carotid artery (ICA) dissection.

BACKGROUND

Aneurysms developed during extracranial ICA dissection are detected angiographically in 5 to 40% of cervical artery dissections. The clinical and radiologic course of these aneurysms is not known, and it is not known how they should be treated.

METHODS

Fifty-eight consecutive patients with extracranial ICA dissection were reviewed, and those with radiographically detectable dissecting aneurysm at the acute stage or during early follow-up were included in this study. All patients had regular clinical and MR angiography examinations. Sixteen patients (27.5%) with a total of 20 ICA dissecting aneurysms were followed for a mean period of 36.9+/-21 months (range, 10 to 93 months).

RESULTS

No clinical symptoms suggestive of aneurysmal rupture or embolization from the aneurysm were identified. Extracranial ICA aneurysms remained unchanged in 65% of patients, were resolved in 5% of patients, and decreased in size in 30% of patients.

CONCLUSIONS

The clinical course of dissecting aneurysms was benign, although spontaneous radiologic resolution occurred rarely. Medical management with antiplatelet therapy alone (after early anticoagulation) is generally sufficient, and surgical management was seldom required.

[Brain imaging in AIDS]

Encephalic diseases remain an important problem in AIDS patients despite improvement in the rate of disease spread. We provide data on the current situation and describe the clinical, pathological and imaging features commonly observed in encephalic diseases in AIDS patients.

Ophthalmologic manifestations of internal carotid artery dissection

PURPOSE

To report the ophthalmologic symptoms and signs associated with extracranial internal carotid artery dissection.

METHODS

One hundred forty-six consecutive patients with extracranial internal carotid artery dissection were evaluted; 29 were studied retrospectively from 1972 to 1984 and 117 prospectively from 1985 to 1997.

RESULTS

Sixty-two percent of patients (91/146) with extracranial internal carotid artery dissection had ophthalmologic symptoms or signs that were the presenting symptoms or signs of dissection in 52% (76/146). Forty-four percent (65/146) had painful Horner syndrome, which remained isolated in half the cases (32/65). Twenty-eight percent (41/146) had transient monocular visual loss, which was painful in 31 cases, associated with Horner syndrome in 13 cases, and described as "scintillations" or "flashing lights"-often related to postural changes or exposure to bright lights-suggesting acute choroidal hypoperfusion in 23 cases. Four patients had ischemic optic neuropathy; one had diplopia. Among the 76 patients with ophthalmologic symptoms or signs as the presenting features of carotid dissection, a nonreversible ocular or hemispheric stroke later occurred in 27, within a mean of 6.2 days (range, 1 hour to 31 days). Eighteen patients had a stroke within the first week after the onset of neuro-ophthalmic symptoms and signs, and 24 had a stroke within the first 2 weeks.

CONCLUSION

Ophthalmologic symptoms or signs are frequently associated with and are often the presenting features in internal carotid artery dissection. Painful Horner syndrome or transient monocular visual loss should prompt investigations to diagnose carotid artery dissection and begin early treatment to prevent a devastating ocular or hemispheric stroke.

[Artifacts in magnetic resonance angiography]

Magnetic resonance angiography (MRA) has become a major tool in the management of vascular diseases. However, many artifacts that may lead to misinterpretations are encountered with this imaging modality. The purpose of this paper was to enumerate, explain and illustrate each kind of artifact encountered with "time of flight" or "phase contrast" imaging methods. For each artifact, we tried to provide one or several techniques to minimize its consequences.

[Utilization of rapid diagnostic tests for group A streptococcus and and bacteriologic and clinical correlations with acute angina in general medicine]

OBJECTIVES

A prospective study was conducted between November 1995 and May 1996 by 130 general practitioners in France to assess feasibility of a rapid routine diagnostic test for group A streptococcus infection in a general medicine setting and to search for bacteriological and clinical correlations.

METHODS

A routine diagnostic test was performed in all patients presenting acute pharyngitis and cultures were ordered in case of positive tests. Among the 2,800 patients included, there were 563 children under 14 years and 2,226 adults. The routine diagnostic test was positive in 393 cases (14%). A culture was obtained in 375 case and isolated group A streptococcus in 324 (11.5% of the total population). The positive predictive value of the routine diagnostic test was 86.4% in this general medicine setting.

RESULTS

Comparing clinical signs with the results of the routine diagnostic test showed that an erythematous pultaceous aspect of the pharynx, severe dysphagia and the presence of enlarged nodes were more frequent in patients with streptococcal pharyngitis. The association of these 3 clinical signs with fever > 38 degrees C was also more frequent in patients with a positive routine diagnostic test (OR = 3.3; 95% CI = 2.5-4.4). The triad hoarseness + cough + rhinorrhea was more frequent in subjects with a positive routine diagnostic test (22.7% versus 9%; OR = 2.6; 95% CI = 2.1-4.3).

CONCLUSION

The general practitioners who participated in this study found the routine diagnostic test for group A streptococcal pharyngitis was easy to use and compatible with everyday practice. This diagnostic tool was seen as a progress in the management of acute pharyngitis, but only 53.7% of the practitioners were willing to use antibiotics only for cases where a highly specific routine diagnostic test performed during the consultation identifies group A streptococcus. Lack of reimbursement by the national health assurance however makes it impossible to use this test routinely in the general medicine setting.

Internal carotid artery dissection: an update

Carotid artery dissection is a major cause of cerebral infarction in the young. The extracranial portion of the internal carotid artery is much more frequently involved than the intracranial portion. In up to 20% of cases it is bilateral or associated with vertebral artery dissection. It is mainly characterised by local signs such as headache or facial pain, Horner's syndrome, lower cranial nerve palsies and pulsatile tinnitus, followed a few hours or days later by signs of cerebral or retinal ischemia. Ultrasound investigations show signs of distal stenosis or occlusion, highly suggestive of dissection, but the best diagnostic tool is presently the association of magnetic resonance imaging (MRI) and MR angiography which tend to replace intra-arterial angiography. The prognosis is highly variable: excellent in cases limited to local signs, but very poor leading to death or major sequelae in about 15% of cases. Various treatments have been suggested but no controlled trial has ever been performed in this condition. Heparin in the acute stage followed by warfarin or aspirin for 3 to 6 months is most commonly used.

[Cerebral arteritis in AIDS. Demonstration with MRA in 2 patients]

Two cases of cerebral arteritis related to varicella-zoster virus in seropositive patients are presented. Diagnosis of arteritis was made by conventional angiography. However, 3D Time of Flight MR Angiography demonstrated an excellent sensitivity in detection of cerebral arterial stenosis located at the skull base.

[Anatomy of the circle of Willis with 3D time of flight magnetic resonance angiography and analysis of partitions]

The purpose of this study was to analyse with 3D TOF MR angiography the anatomical variants of the circle of Willis (CW) in 109 consecutive patients. In all cases, the quality of exams was sufficient to analyse the anatomy of CW. Nevertheless, MRA over estimated hypoplastic segments because incomplete CW were more frequently demonstrated with MRA than in anatomic literature. This lack of MRA sensitivity was related to artifacts as MIP artifacts and blood flow artifacts. MRA sensitivity was improved by analysis of partitions with MIP reconstructions.

Carotid artery dissection with renal infarcts. Two cases

BACKGROUND

Clinical features of carotid artery dissection include ipsilateral local signs, contralateral ischemic stroke, or both. We observed two patients in whom these features were associated with renal infarcts.

CASE DESCRIPTIONS

A 57-year-old woman had painful Horner's syndrome caused by a right internal carotid artery dissection. On days 3 and 4 she had acute abdominal pain, first on the right side and later on the left. The computed tomographic (CT) scan showed a left renal infarct. No aortic dissection or cardiac source of embolism was found. Transesophageal echocardiography showed a mild dystrophy of the ascending aorta and of the mitral valve. Cerebral angiography showed irregularities of the V3 segment of the left vertebral artery compatible with fibromuscular dysplasia. Erythrocyte sedimentation rate was 100 mm/h, and she complained of intense fatigue. She fully recovered within 3 months. A 53-year-old man had sudden severe abdominal pain followed by headache and difficulty in swallowing. He had 9th, 10th, 11th, and 12th cranial nerve involvement on both sides due to bilateral internal carotid artery dissections and pseudoaneurysms. CT scan showed a left renal infarct. Angiography showed extensive signs of fibromuscular dysplasia involving carotid, vertebral, renal, iliac, and mesenteric arteries as well as a dissection of the left renal artery. Erythrocyte sedimentation rate was 65 mm/h, and he complained of severe fatigue. His neurological signs returned to normal in 6 months.

CONCLUSIONS

Renal infarct due to renal artery dissection may occur together with cerebral artery dissection. Acute abdominal pain, increased erythrocyte sedimentation rate, and intense fatigue are the warning symptoms.

Carotid and vertebral artery dissections: three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography

PURPOSE

To compare three-dimensional time-of-flight magnetic resonance (MR) angiography, MR imaging, and transfemoral four-vessel angiography in diagnosis and follow-up of cervical artery dissection.

MATERIALS AND METHODS

Eighteen patients with 19 extracranial internal carotid artery and five vertebral artery dissections were included in this prospective study. Blind interpretation of MR and angiographic images was made by two independent radiologists.

RESULTS

MR angiography was more accurate than MR imaging in diagnosis of carotid dissection, although the difference was not statistically significant. In carotid artery dissection, respective sensitivity and specificity were 95% and 99% for MR angiography and 84% and 99% for MR imaging and in vertebral artery dissection were 20% and 100% for MR angiography and 60% and 98% for MR imaging.

CONCLUSION

MR angiography is a reliable, noninvasive method for use in diagnosis and follow-up of extracranial internal carotid artery dissection. In vertebral artery dissection, however, conventional angiography remains useful.

Causes and mechanisms of territorial and nonterritorial cerebellar infarcts in 115 consecutive patients

BACKGROUND AND PURPOSE

Territorial cerebellar infarcts have mainly a thromboembolic mechanism. Cerebellar infarcts less than 2 cm in diameter have recently been reported as nonterritorial infarcts, but it is not clear whether they are low-flow or embolic infarcts. The aim of the present study was to compare the characteristics and causes of territorial and nonterritorial infarcts in a prospective series of 115 patients.

METHODS

We collected data from 115 consecutive patients with cerebellar infarcts (79 territorial and 36 nonterritorial [ie, less than 2 cm]), using magnetic resonance imaging (88 patients) and computed tomography.

RESULTS

Patients with territorial infarcts and those with nonterritorial infarcts had similar vascular risk factors and clinical presentations and an equal frequency of cardiac source of embolism (32% versus 42%; P = NS) and of large artery occlusive disease (23% versus 19%; P = NS). Occlusive lesions of large arteries at angiography occurred at the level of one cerebellar artery (5% versus 0%; P = NS) and proximal to the ostia of the cerebellar arteries (18% versus 19%; P = NS). Infarcts distal to occlusive lesions were subdivided into unilateral vertebral artery occlusive disease (presumed artery-to-artery embolic mechanism; 18% versus 5%; P = NS) and low-flow state distal to bilateral vertebral or basilar artery occlusion (presumed hemodynamic mechanism; 0% versus 14%; P = .004). Patients with nonterritorial infarcts had more frequent hypercoagulable state (17% versus 1.25%; odds ratio, 15.6 [95% confidence interval, 1.8 to 135]). For the remaining patients, the mechanism of the infarct was unknown (34% versus 22%; P = NS).

CONCLUSIONS

Cerebellar infarcts less than 2 cm in diameter (ie, nonterritorial) have the same high rate of embolic mechanism as territorial infarcts (47% versus 49%; P = NS), have more frequent hypercoagulable state, and sometimes have a hemodynamic mechanism.

[Secondary lung diseases in patients with nasotracheal intubation. Role of nosocomial sinusitis]

Nosocomial pneumonia is a frequent infectious complication in ICU patients. All the patients with prolonged nasotracheal intubation presenting with nosocomial pneumonia according to Salata's criteria were examined for sinusitis in the prospective study. Diagnosis was confirmed via CT-scan views and transnasal sinus puncture. In eleven nasally intubated patients, CT-scan views showed air fluid levels and multiple sinus involvement. Bacteriological studies isolated the same gram negative bacilli in both sinus and bronchial aspirates. In four cases, a polymicrobial sinusitis was found with a single organism predominant. This predominant germ was always found in bronchial aspirate. Recovery from pneumonia was obtained only after sinus drainage. Treatment included removing the nasal tubes, or performing tracheostomy and systemic antibiotics. One patient required surgical maxillary sinus drainage after failure of medical management. The occurrence of nosocomial pneumonia in nasotracheally intubated patients should lead physicians to explore the paranasal sinuses. Sinus CT-scan views should be routinely obtained in the assessment of pulmonary sepsis in patients with prolonged nasotracheal intubation. Persistent or ignored nosocomial sinusitis in such circumstances could be a major source of treatment failure.

Unoccupied nuclear oestradiol-receptor sites in normal human endometrium

The existence of unoccupied nuclear oestradiol-receptor sites in normal human endometrium was investigated. Nuclei were prepared from endometrial samples obtained by curettage and exposed to [3H]oestradiol, which became maximmaly bound at 0 degrees C within 1 h. This result contrasted with the binding kinetics of oestradiol--receptor complexes, since the exchange of hormone took at least 3 h at 30 degrees C and no displacement occurred at 0 degrees C. Before concluding that the nuclear sites were unoccupied, the presence of endogenous low-affinity ligands was excluded, because the association rate of oestradiol was unchanged after nuclei were stripped from their putative ligands, and the displacement of oestrone bound to nuclear receptor by oestradiol was very slow at 0 degrees C. The available sites had high affinity for oestradiol (KD 1.3 nM) and binding-specificity characteristics of oestradiol receptors. Similar results were observed with crude and purified nuclear preparations. It was concluded that a significant proportion of nuclear oestradiol receptors in normal human endometrium is unoccupied by endogenous hormones.