Epilepsy with faint capillary malformation or reticulated telangiectasia associated with mosaic AKT3 pathogenic variants

Capillary malformations (CMs) are the most common type of vascular anomalies, affecting around 0.3% of newborns. They are usually caused by somatic pathogenic variants in GNAQ or GNA11. PIK3CA and PIK3R1, part of the phosphoinositide 3-kinase-protein kinase B-mammalian target of rapamycin pathway, are mutated in fainter CMs such as diffuse CM with overgrowth and megalencephaly CM. In this study, we present two young patients with a CM-like phenotype associated with cerebral anomalies and severe epilepsy. Pathogenic variants in PIK3CA and PIK3R1, as well as GNAQ and GNA11, were absent in affected cutaneous tissue biopsies. Instead, we identified two somatic pathogenic variants in the AKT3 gene. Subsequent analysis of the DNA obtained from surgically resected brain tissue of one of the two patients confirmed the presence of the AKT3 variant. Focal cortical dysplasia was also detected in this patient. Genetic analysis thus facilitated workup to reach a precise diagnosis for these patients, associating the vascular anomaly with the neurological symptoms. This study underscores the importance of searching for additional signs and symptoms to guide the diagnostic workup, especially in cases with atypical vascular malformations. In addition, it strongly emphasizes the significance of genotype-phenotype correlation studies in guiding clinicians' informed decision-making regarding patient care.

Preliminary results of the European multicentric phase III trial regarding sirolimus in slow-flow vascular malformations

BACKGROUNDSlow-flow vascular malformations frequently harbor activating mutations in the PI3K/AKT/mTOR cascade. Phase II trials pinpointed sirolimus effectiveness as a drug therapy. Efficacy and safety of sirolimus thus need to be evaluated in large prospective phase III trials.METHODSThe Vascular Anomaly-Sirolimus-Europe (VASE) trial, initiated in 2016, is a large multicentric prospective phase III trial (EudraCT 2015-001703-32), which evaluates efficacy and safety of sirolimus for 2 years in pediatric and adult patients with symptomatic slow-flow vascular malformations. In this interim analysis, we studied all patients enrolled up to October 2021 who received sirolimus for 12 or more months or who prematurely stopped the treatment.RESULTSThirty-one pediatric and 101 adult patients were included in this analysis; 107 completed 12 or more months of sirolimus, including 61 who were treated for the whole 2-year period. Sirolimus resulted in a clinical improvement in 85% of patients. The efficacy appeared within the first month for the majority of them. Grade 3-4 adverse events were observed in 24 (18%) patients; all resolved after treatment interruption/arrest. Sirolimus increased feasibility of surgery or sclerotherapy in 20 (15%) patients initially deemed unsuitable for intervention. Among the 61 patients who completed the 2-year treatment, 33 (54%) reported a recurrence of symptoms after a median follow-up of 13 months after sirolimus arrest. While there was no difference in efficacy, clinical improvement was faster but subsided more rapidly in PIK3CA-mutated (n = 24) compared with TIE2-mutated (n = 19) patients.CONCLUSIONSirolimus has a high efficacy and good tolerance in treatment of slow-flow vascular malformations in children and adults.TRIAL REGISTRATIONClinicalTrials.gov NCT02638389 and EudraCT 2015-001703-32.FUNDINGThe Fonds de la Recherche Scientifique (FNRS grants T.0247.19, P.C005.22, T.0146.16, and P.C013.20), the Fund Generet managed by the King Baudouin Foundation (grant 2018-J1810250-211305), the Walloon Region through the FRFS-WELBIO strategic research programme (WELBIO-CR-2019C-06), the MSCA-ITN network V.A. Cure no. 814316, the Leducq Foundation Networks of Excellence Program grant "ReVAMP" (LFCR grant 21CVD03), the European Union's Horizon 2020 research and innovation programme under grant agreement no. 874708 (Theralymph), the Swiss National Science Foundation under the Sinergia project no. CRSII5_193694, and a Pierre M. fellowship.

Phenotypic spectrum of patients with Poretti-Boltshauser syndrome: Patient report of antenatal ventriculomegaly and esophageal atresia

Poretti-Boltshauser syndrome (PTBHS) is an autosomal recessive disorder characterized by cerebellar dysplasia with cysts and an abnormal shape of the fourth ventricle on neuroimaging, due to pathogenic variants in the LAMA1 gene. The clinical spectrum mainly consists of neurological and ophthalmological manifestations, including non-progressive cerebellar ataxia, oculomotor apraxia, language impairment, intellectual disability, high myopia, abnormal eye movements and retinal dystrophy. We report a patient presenting with ventriculomegaly on antenatal neuroimaging and a neonatal diagnosis of Type III esophageal atresia. She subsequently developed severe myopia and strabismus with retinal dystrophy, mild developmental delay, and cerebellar dysplasia. Genetic investigations confirmed PTBHS. This report confirms previous reports of antenatal ventriculomegaly in PTBHS patients and documents a so far unreported occurrence of esophageal atresia in PTBHS. We additionally gathered phenotype and genotype descriptions of published cases in an effort to better define the spectrum of PTBHS.

Conservative management of congenital hepatic hemangioma complicated by ascites

Involution of a rapidly involuting congenital hemangioma is an unknown cause of neonatal ascites. As involution phase is completed by 14 months after birth, conservative management with diuretics and drainage is possible and may avoid surgical resection.

Osteofibrous dysplasia-like adamantinoma of isolated fibula in a child mimicking chronic osteomyelitis with pathological fracture

The occurrence of a pathological fracture in children requires a rigorous diagnostic approach in order to establish the etiology and to develop a precise therapeutic strategy. Several causes are associated with these fractures, the most frequent being benign tumors in children in developed countries and chronic osteomyelitis in developing countries. More rarely, malignant tumors must however always be considered. The differential diagnosis on imaging may be difficult to establish between bone tumors and chronic infection. Surgical biopsy is therefore often performed to establish the precise origin of the fracture. We report the case of an adamantinoma (osteofibrous dysplasia-like) of the fibula in a 7-year-old child, discovered during the management of a pathologic fracture. The presumed diagnosis before biopsy was chronic osteomyelitis. A 14-cm-resection of the affected fibula was performed with good functional result. Differential diagnosis between adamantinoma, osteofibrous dysplasia and osteofibrous dysplasia-like adamantinoma remains very challenging.

Transient synovitis of the hip : is systematic radiological screening necessary for the detection of Perthes disease?

Current imaging guidelines in Belgium advise a systematic X-ray screening of the hips after an episode of transient synovitis of the hip, in order to detect Perthes disease. The aim of this study was to analyze whether systematic radiological screening is necessary for all children or whether the X-ray indication could be guided by clinical symptoms. A retrospective single center study including all children with the diagnosis of transient synovitis of the hip between 2013 and 2018 was performed. 242 patients with the diagnosis of one or more transient synovitis episodes were included, 102 of whom underwent a follow up X-ray. Persistence or recurrence of symptoms were recorded for all patients, as well as the results of follow-up hip X-rays. 12 children did not remain symptom-free after the episode of transient synovitis. Of these patients 10 had a normal follow-up X-ray and 3 were diagnosed with Perthes disease. 1 patient of those 3 had a normal X-ray but was diagnosed with Perthes disease on MRI. Of the children which remained symptom-free after the episode of transient synovitis, none were diagnosed with Perthes disease afterwards. A follow-up X-ray to exclude Perthes disease after a diagnosis of transient hip synovitis appears to be necessary only in patients with persistent or recurrent symptomatology.

Transient synovitis of the hip : is systematic radiological screening necessary for the detection of Perthes disease?

Current imaging guidelines in Belgium advise a systematic X-ray screening of the hips after an episode of transient synovitis of the hip, in order to detect Perthes disease. The aim of this study was to analyze whether systematic radiological screening is necessary for all children or whether the X-ray indication could be guided by clinical symptoms. A retrospective single center study including all children with the diagnosis of transient synovitis of the hip between 2013 and 2018 was performed. 242 patients with the diagnosis of one or more transient synovitis episodes were included, 102 of whom underwent a follow up X-ray. Persistence or recurrence of symptoms were recorded for all patients, as well as the results of follow-up hip X-rays. 12 children did not remain symptom-free after the episode of transient synovitis. Of these patients 10 had a normal follow-up X-ray and 3 were diagnosed with Perthes disease. 1 patient of those 3 had a normal X-ray but was diagnosed with Perthes disease on MRI. Of the children which remained symptom-free after the episode of transient synovitis, none were diagnosed with Perthes disease afterwards. A follow-up X-ray to exclude Perthes disease after a diagnosis of transient hip synovitis appears to be necessary only in patients with persistent or recurrent symptomatology.

Chudley-McCullough Syndrome: A Recognizable Clinical Entity Characterized by Deafness and Typical Brain Malformations

Chudley-McCullough syndrome, a rare autosomal recessive disorder due to pathogenic variants in the GPSM2 (G-protein signaling modulator 2) gene, is characterized by early-onset sensorineural deafness and a typical combination of brain malformations, including ventriculomegaly, (partial) agenesis of the corpus callosum, cerebellar dysplasia, arachnoid cysts, frontal subcortical heterotopia, and midline polymicrogyria. When hearing loss is managed early, most patients have minor or no impairment of motor and cognitive development, despite the presence of brain malformations. We report 2 cases of Chudley-McCullough syndrome, one presenting with congenital deafness and normal development except for speech delay and one presenting prenatally with ventriculomegaly and an atypical postnatal course characterized by epileptic spasms, deafness, and moderate intellectual disability. These highlight the challenges faced by clinicians when predicting prognosis based on pre- or postnatal imaging of brain malformations. We have also reviewed the phenotype and genotype of previous published cases to better understand Chudley-McCullough syndrome.

Ultrasound in pediatric orbital cellulitis

Orbital cellulitis is an infrequent but serious complication of sinus infections in children, as was the case of a 7-year-old who presented to the emergency room with ultrasound signs of preseptal cellulitis. Despite a well conducted antibiotic treatment a control ultrasound demonstrated associated signs of retro-septal extension. This case brings to light the essential role of ultrasound in suspected cellulitis, as a mean to differentiate between preseptal cellulitis and retroseptal (orbital) cellulitis. In the paediatric population ultrasound should be the first intention exam to diagnose the extension of the illness, and help guide the management and follow-up of the patients.

Novel insights into the assessment of risk of upper gastrointestinal bleeding in decompensated cirrhotic children

OBJECTIVES

Cirrhotic children wait-listed for liver transplant are prone to bleeding from gastrointestinal varices. Grade 2-3 esophageal varices, red signs, and gastric varices are well-known risk factors. However, the involvement of hemostatic factors remains controversial because of the rebalanced state of coagulation during cirrhosis.

METHODS

Children suffering from decompensated cirrhosis were prospectively included while being on waitlist. Portal hypertension was assessed by ultrasound and endoscopy. Coagulopathy was evaluated through conventional tests, thromboelastometry, and platelet function testing. The included children were followed up until liver transplantation, and all bleeding episodes were recorded. Children with or without bleeding were compared according to clinical, radiological, endoscopic, and biological parameters. In addition, validation of a predictive model for risk of variceal bleeding comprising of grade 2-3 esophageal varices, red spots, and fibrinogen level <150 mg/dL was applied on this cohort.

RESULTS

Of 20 enrolled children, 6 had upper gastrointestinal bleeding. Significant differences were observed in fibrinogen level, adenosine diphosphate, and thrombin-dependent platelet aggregation. The model used to compute the upper gastrointestinal bleeding risk had an estimated predictive performance of 81.0%. Platelet aggregation analysis addition improved the estimated predictive performance up to 89.0%.

CONCLUSIONS

We demonstrated an association between hemostatic factors and the upper gastrointestinal bleeding risk. A low fibrinogen level and platelet aggregation dysfunction may predict the risk of bleeding in children with decompensated cirrhosis. A predictive model is available to assess the upper gastrointestinal bleeding risk but needs further investigations. Clinicaltrials.gov number: NCT03244332.

First Measurement of a Long-Lived π^{+}π^{-} Atom Lifetime

The adapted DIRAC experiment at the CERN PS accelerator observed for the first time long-lived hydrogenlike π^{+}π^{-} atoms, produced by protons hitting a beryllium target. A part of these atoms crossed the gap of 96 mm between the target and a 2.1  μm thick platinum foil, in which most of them dissociated. Analyzing the observed number of atomic pairs, n_{A}^{L}=436_{-61}^{+157}|_{tot}, the lifetime of the 2p state is found to be τ_{2p}=(0.45_{-0.30}^{+1.08}|_{tot})×10^{-11}  s, not contradicting the corresponding QED 2p state lifetime τ_{2p}^{QED}=1.17×10^{-11}  s. This lifetime value is three orders of magnitude larger than our previously measured value of the π^{+}π^{-} atom ground state lifetime τ=(3.15_{-0.26}^{+0.28}|_{tot})×10^{-15}  s. Further studies of long-lived π^{+}π^{-} atoms will allow us to measure energy differences between p and s atomic states and so to discriminate between the isoscalar and isotensor ππ scattering lengths with the aim to check QCD predictions.

SLC13A3 variants cause acute reversible leukoencephalopathy and α-ketoglutarate accumulation

OBJECTIVE

SLC13A3 encodes the plasma membrane Na⁺ /dicarboxylate cotransporter 3, which imports inside the cell 4 to 6 carbon dicarboxylates as well as N-acetylaspartate (NAA). SLC13A3 is mainly expressed in kidney, in astrocytes, and in the choroid plexus. We describe two unrelated patients presenting with acute, reversible (and recurrent in one) neurological deterioration during a febrile illness. Both patients exhibited a reversible leukoencephalopathy and a urinary excretion of α-ketoglutarate (αKG) that was markedly increased and persisted over time. In one patient, increased concentrations of cerebrospinal fluid NAA and dicarboxylates (including αKG) were observed. Extensive workup was unsuccessful, and a genetic cause was suspected.

METHODS

Whole exome sequencing (WES) was performed. Our teams were connected through GeneMatcher.

RESULTS

WES analysis revealed variants in SLC13A3. A homozygous missense mutation (p.Ala254Asp) was found in the first patient. The second patient was heterozygous for another missense mutation (p.Gly548Ser) and an intronic mutation affecting splicing as demonstrated by reverse transcriptase polymerase chain reaction performed in muscle tissue (c.1016 + 3A > G). Mutations and segregation were confirmed by Sanger sequencing. Functional studies performed on HEK293T cells transiently transfected with wild-type and mutant SLC13A3 indicated that the missense mutations caused a marked reduction in the capacity to transport αKG, succinate, and NAA.

INTERPRETATION

SLC13A3 deficiency causes acute and reversible leukoencephalopathy with marked accumulation of αKG. Urine organic acids (especially αKG and NAA) and SLC13A3 mutations should be screened in patients presenting with unexplained reversible leukoencephalopathy, for which SLC13A3 deficiency is a novel differential diagnosis. ANN NEUROL 2019;85:385-395.

Liver and systemic hemodynamics in children with cirrhosis: Impact on the surgical management in pediatric living donor liver transplantation

Cirrhosis in adults is associated with modifications of systemic and liver hemodynamics, whereas little is known about the pediatric population. The aim of this work was to investigate whether alterations of hepatic and systemic hemodynamics were correlated with cirrhosis severity in children. The impact of hemodynamic findings on surgical management in pediatric living donor liver transplantation (LT) was evaluated. Liver and systemic hemodynamics were studied prospectively in 52 children (median age, 1 year; 33 with biliary atresia [BA]). The hemodynamics of native liver were studied preoperatively by Doppler ultrasound and intraoperatively using invasive flowmetry. Portosystemic gradient was invasively measured. Systemic hemodynamics were studied preoperatively by Doppler transthoracic echocardiography and intraoperatively by using transpulmonary thermodilution. Hemodynamic parameters were correlated with Pediatric End-Stage Liver Disease (PELD) score and the histological degree of fibrosis (collagen proportionate area [CPA]). Cirrhosis was associated with a 60% reduction of pretransplant total liver flow (n = 46; median, 36 mL/minute/100 g of liver) compared with noncirrhotic livers (n = 6; median, 86 mL/minute/100 g; P = 0.002). Total blood flow into the native liver was negatively correlated with PELD (P < 0.001) and liver CPA (P = 0.005). Median portosystemic gradient was 14.5 mm Hg in children with cirrhosis and positively correlated with PELD (P < 0.001). Portal vein (PV) hypoplasia was observed mainly in children with BA (P = 0.02). Systemic hemodynamics were not altered in our children with cirrhosis. Twenty-one children met the intraoperative criteria for PV reconstruction using a portoplasty technique during the LT procedure and had a smaller PV diameter at pretransplant Doppler ultrasound (median = 3.4 mm; P < 0.001). Cirrhosis in children appears also as a hemodynamic disease of the liver, correlated with cirrhosis severity. Surgical technique for PV reconstruction during LT was adapted accordingly. Liver Transplantation 23 1440-1450 2017 AASLD.

Performance of chest ultrasound in pediatric pneumonia

OBJECTIVE

The objective of this study was to evaluate the performance of ultrasound in detecting lung consolidation in children suspected of pneumonia, in comparison to the current gold standard, chest X-rays.

MATERIALS AND METHODS

From September 2013 to June 2014, a monocentric prospective study was performed on all children between 0 and 16 years-old, referred for chest X-ray for suspected pneumonia. Each child was examined by chest ultrasound by an examiner blinded to the chest X-ray. The presence or absence of areas of consolidation, their number and location were noted for each technique. The size of the consolidations identified only on ultrasound was compared with that of consolidations visible on both techniques.

RESULTS

143 children (mean age 3 years; limits between 8days and 14 years) were included. Ultrasound detected at least one area of consolidation in 44 out of 45 patients with positive X-rays. Of the 59 areas of consolidation on X-ray, ultrasound identified 54. In the 8 patients with negative X-ray, ultrasound revealed 17 areas of consolidation. The mean size of consolidations visible only on ultrasound was 9.4mm; for consolidations visible on both techniques the mean size was 26mm (p<0.0001). The sensitivity and specificity of ultrasound were calculated at 98% and 92%. PPV and NPV were 85% and 99%, respectively.

CONCLUSION

Chest ultrasound is a fast, non-ionizing and feasible technique. With its high negative predictive value, it can replace X-rays in order to exclude lung consolidation in children, thus reducing radiation exposure in this population.

Observation of π^{-}K^{+} and π^{+}K^{-} Atoms

The observation of hydrogenlike πK atoms, consisting of π^{-}K^{+} or π^{+}K^{-} mesons, is presented. The atoms are produced by 24  GeV/c protons from the CERN PS accelerator, interacting with platinum or nickel foil targets. The breakup (ionization) of πK atoms in the same targets yields characteristic πK pairs, called "atomic pairs," with small relative momenta Q in the pair center-of-mass system. The upgraded DIRAC experiment observed 349±62 such atomic πK pairs, corresponding to a signal of 5.6 standard deviations. This is the first statistically significant observation of the strange dimesonic πK atom.

Unusual association between lysinuric protein intolerance and moyamoya vasculopathy

INTRODUCTION

Lysinuric protein intolerance (LPI) is a form of inherited aminoaciduria caused by a deficiency in the cationic amino acid transport process on the basolateral membrane of enterocytes and renal tubular cells. Clinical signs include gastrointestinal symptoms, failure to thrive, hepatosplenomegaly, osteoporosis, episodes of coma, intellectual deficiency, lung and renal involvement, bone marrow abnormalities, as well as altered immune response. Moyamoya disease is a cerebrovascular disorder predisposing sufferers to stroke through progressive stenosis of the intracranial internal carotid arteries and their proximal branches. Patients with characteristic moyamoya vasculopathy who also exhibit well-recognized associated conditions, such as Down syndrome or sickle-cell disease, are diagnosed with moyamoya syndrome, whereas those with no known associated risk factors are said to suffer from moyamoya disease.

CASE STUDY

A 5-year-old girl exhibiting aversion to protein-rich food and splenomegaly presented with a history of recurrent ischemic strokes. Cerebral angiography confirmed moyamoya vasculopathy. Metabolic investigation revealed abnormalities characteristic of LPI. This diagnosis was confirmed by the detection of a mutation within the SLC7A7 gene upon molecular investigation.

CONCLUSION

To the best of our knowledge, this is the first reported case of an association between moyamoya vasculopathy and LPI. While the question of association or coincidence cannot yet be answered, several pathophysiological consequences of LPI can be defined as separate, such as links between the impact of low arginine levels on the function of vascular endothelium and brain nitric oxide metabolism, as well as hemophagocytic syndrome associated with the risk of vasculitis, thus accounting for the development of moyamoya vasculopathy.

Postendoscopic duodenal hematoma in children: ultrasound diagnosis and follow-up

Intramural duodenal hematomas have most frequently been reported in children in a traumatic setting. We present two cases of duodenal hematoma that occurred after upper gastrointestinal tract endoscopy with biopsy in children without significant prior medical history. The diagnosis was made by ultrasound, in correlation with the clinical presentation. Because the patients were hemodynamically stable, they were treated conservatively and the regression of the hematoma was followed up with ultrasound until its complete resolution. These cases demonstrate the risks of endoscopy, which are not to be neglected even in children without impaired coagulation, and the manner in which ultrasound can provide the correct diagnosis and follow-up.

Differential effects of aging on dendritic spines in visual cortex and prefrontal cortex of the rhesus monkey

Aging decreases the density of spines and the proportion of thin spines in the non-human primate (NHP) dorsolateral prefrontal cortex (dlPFC). In this study, we used confocal imaging of dye-loaded neurons to expand upon previous results regarding the effects of aging on spine density and morphology in the NHP dlPFC and compared these results to the effects of aging on pyramidal neurons in the primary visual cortex (V1). We confirmed that spine density, and particularly the density of thin spines, decreased with age in the dlPFC of rhesus monkeys. Furthermore, the average head diameter of non-stubby spines in the dlPFC was a better predictor than chronological age of the number of trials required to reach criterion on both the delayed response test of visuospatial working memory and the delayed nonmatching-to-sample test of recognition memory. By contrast, total spine density was lower on neurons in V1 than in dlPFC, and neither total spine density, thin spine density, nor spine size in V1 was affected by aging. Our results highlight the importance and selective vulnerability of dlPFC thin spines for optimal prefrontal-mediated cognitive function. Understanding the nature of the selective vulnerability of dlPFC thin spines as compared to the resilience of thin spines in V1 may be a promising area of research in the quest to prevent or ameliorate age-related cognitive decline.

Differentiating benign from malignant superficial lymph nodes with sonoelastography

The aim of the paper is to provide a comprehensive overview on the applications of real time sonoelastography (SE) in the diagnosis of superficial lymphadenopathy. Some technical aspects of performing SE are presented as a preamble. The typical appearance of benign and malignant nodes is illustrated. The paper discusses and depicts the various elastographic scores in use. It also provides a critical appraisal of the relative strain ratio (SR) or stiffness index. Shear wave elastography, as a novel technique, is mentioned. In conclusion, hardness on more than 50% of the node surface or SR > 1.5 is fair to good indicators of malignancy. Work is still needed both to fully understand the various appearance of disease and to standardize the application.

Typical and unusual sonoelastographic patterns of breast cystic lesions: impact on BI-RADS classification

PURPOSE

To describe the sonoelastographic appearance of breast cysts (simple, complicated-cysts with sedimentation and complex-cysts with internal solid parts). To assess the influence of sonoelastography on the BI-RADS classification of complicated cysts.

MATERIALS AND METHODS

A prospective study was conducted and all cysts diagnosed by the same radiologist between May 2007 and July 2008 in our breast unit were included. Each lesion was assessed according to BI-RADS and the Tsukuba elasticity score using a Hitachi 8500 US device. Cytology or histopathology was obtained for complicated and complex cysts.

RESULTS

49 simple, 43 complicated and 14 complex cysts were detected. The elasticity patterns were divided into 4 categories: typical BGR (blue-green-red) pattern, appearance similar to that described for solid. lesions, variants of BGR, an inverse score of 3. The BGR pattern was predominant in breast cysts. Atypical elasticity patterns were mostly associated with complicated and complex cysts. BI-RADS classification of complicated cysts before and after elastography showed a statistically significant difference in terms of final category assessment (most of the complicated cysts were downgraded to BI-RADS 2 after elastography).

CONCLUSION

Being aware of the wide spectrum of elastographic patterns of breast cysts and considering elastography when assessing the BI-RADS category of complicated cysts may lead radiologists to better patient management.

Musculoskeletal sonoelastography. Pictorial essay

Ultrasonic elastography (real-time elastography, sonoelastography) is a new ultrasound technique being one of the imaging mainstream in the last few years being used for characterizing soft tissue lesions, like breast, thyroid, prostate and lymph nodes. Musculoskeletal pathology was one of the first applications of sonoelastography, but, nevertheless the method is not yet standardized. The purpose of this pictorial essay is to briefly describe the technique and to exemplify the aspects of a variety of musculoskeletal pathologies.

Sonographic assessment of the retroperitoneal position of the third portion of the duodenum: an indicator of normal intestinal rotation

BACKGROUND

The diagnosis of intestinal malrotation is based on an upper gastrointestinal contrast series (UGI), which is considered the imaging reference standard. It may however be challenging even for experienced paediatric radiologists.

OBJECTIVE

The purpose of this study was to demonstrate the agreement between UGI and US in assessing the position of the third portion of the duodenum (D3) and to show that a retroperitoneal duodenum indicates normal forgut rotation.

MATERIALS AND METHODS

In a prospective study, US assessment of the duodenum and the superior mesenteric vessels was performed in consecutive children who were referred for clinically indicated UGI at a single institution.

RESULTS

Eighty-five children, 5 months to 14 years old, were studied. In 82/85 (96%), both US and UGI suggested normal forgut rotation. In three children, US demonstrated a normal position of the D3 whereas UGI showed an abnormal position of the duodeno-jejunal junction.

CONCLUSION

US is a non-invasive, easily performed technique for excluding malrotation. UGI may be reserved for situations where US does not demonstrate a normal position of the D3.

X-ray fluorescence from the element with atomic number Z=120

An atomic clock based on x-ray fluorescence yields has been used to estimate the mean characteristic time for fusion followed by fission in reactions 238U + 64Ni at 6.6  MeV/A. Inner shell vacancies are created during the collisions in the electronic structure of the possibly formed Z=120 compound nuclei. The filling of these vacancies accompanied by a x-ray emission with energies characteristic of Z=120 can take place only if the atomic transitions occur before nuclear fission. Therefore, the x-ray yield characteristic of the united atom with 120 protons is strongly related to the fission time and to the vacancy lifetimes. K x rays from the element with Z=120 have been unambiguously identified from a coupled analysis of the involved nuclear reaction mechanisms and of the measured photon spectra. A minimum mean fission time τ(f)=2.5×10(-18)  s has been deduced for Z=120 from the measured x-ray multiplicity.

Interactive effects of age and estrogen on cortical neurons: implications for cognitive aging

In the past few decades it has become clear that estrogen signaling plays a much larger role in modulating the cognitive centers of the brain than previously thought possible. We have developed a nonhuman primate (NHP) model to investigate the relationships between estradiol (E) and cognitive aging. Our studies of cyclical E treatment in ovariectomized (OVX) young and aged rhesus monkeys have revealed compelling cognitive and synaptic effects of E in the context of aging. Delayed response (DR), a task that is particularly dependent on integrity of dorsolateral prefrontal cortex (dlPFC) area 46 revealed the following: (1) that young OVX rhesus monkeys perform equally well whether treated with E or vehicle (V), and (2) that aged OVX animals given E perform as well as young adults with or without E, whereas OVX V-treated aged animals display significant DR impairment. We have analyzed the structure of layer III pyramidal cells in area 46 in these same monkeys. We found both age and treatment effects on these neurons that are consistent with behavioral data. Briefly, reconstructions of pyramidal neurons in area 46 from these monkeys showed that cyclical E increased the density of small, thin spines in both young and aged monkeys. However, this effect of E was against a background of age-related loss of small, thin spines, leaving aged V-treated monkeys with a particularly low density of these highly plastic spines, and vulnerable to cognitive decline. Our current interpretation is that E not only plays a critically important role in maintaining spine number, but also enables synaptic plasticity through a cyclical increase in small highly plastic spines that may be stabilized in the context of learning. Interestingly, recent studies demonstrate that chronic E is less effective at inducing spinogenesis than cyclical E. We have begun to link certain molecular attributes of excitatory synapses in area 46 to E effects and cognitive performance in these monkeys. Given the importance of synaptic estrogen receptor α (ER-α) in rat hippocampus, we focused our initial studies on synaptic ER-α in area 46. Three key findings have emerged from these studies: (1) synaptic ER-α is present in axospinous synapses in area 46; (2) it is stable across treatment and age groups (which is not the case in rat hippocampus); and (3) the abundance and distribution of synaptic ER-α is a key correlate of individual variation in cognitive performance in certain age and treatment groups. These findings have important implications for the design of hormone treatment strategies for both surgically and naturally menopausal women. This article is part of a Special Issue entitled: Neuroactive Steroids: Focus on Human Brain.

Value of ultrasound elastography in the diagnosis and management of prostate carcinoma

The aim of the paper is to review and illustrate the role of sonoelastography in the diagnostic and therapeutic approach of prostate cancer. The examination technique and normal appearance are presented. The paper describes and illustrates the appearance of prostate cancer and suggested diagnostic scores. Artifacts, causes for false results and limitations are discussed and also illustrated. The diagnostic influence of intraprostatic tumor location, tumor volume and Gleason score are presented. The paper also reviews the statistical diagnostic value of the method, the relation to prostate biopsy and magnetic resonance assessment. In the end, potential uses and future developments of the method are mentioned.

Ultrasonographic and sonoelastographic features of pleomorphic adenomas of the salivary glands

AIMS

The typical ultrasound features of pleomorphic adenomas are considered to be the well-defined contour, the regular, sometimes lobulated shape, homogeneous structure and poor vascularization. The goal of our study was to verify the validity of these features and to identify a typical sonoelastographic pattern for pleomorphic adenomas.

PATIENTS AND METHODS

Between April 2007 and February 2010, 70 salivary gland masses were examined prospectively (58 in the parotid gland, 12 in the submandibular gland). The following features were targeted: size, limits, contour, structure, echogenicity, vascularization, elasticity/stiffness.

RESULTS

Of the 70 tumors, 32 (45.7%) were pleomorphic adenomas, 12 (17.1%) Warthin tumors, 9 (12.8%) other benign tumors, 13 (18.5%) primary malignant tumors, 3 metastases from carcinoma, and 1 non-Hodgkin lymphoma. Among pleomorphic adenomas, 15 (46.9%) were inhomogeneous, 7 (21.9%) contained necrotic areas and 14 (43.7%) were well-vascularized. The lobulated contour was identified in 14 pleomorphic adenomas (43.7%), no other benign tumor presented this type of contour, but it was identified in 2 malignant tumors (15.3%). On sonoelastography, most pleomorphic adenomas were heterogeneous. The elastic component represented more than 50% of the tumor tissue in 22 cases (68.7%). This aspect was also identified for 6 malignant tumors (46.1%).

CONCLUSIONS

Our results demonstrate that features such as heterogeneous structure, rich vascularization and intra-tumoral necrosis may be identified in a significant number of pleomorphic adenomas. The most specific element in our group was the presence of a lobulated contour, which was not seen in any other benign tumor, but may rarely appear in certain malignant tumors. The elastographic aspect was heterogeneous for most tumors, but the elastic composition identified in most pleomorphic adenomas was also present in a significant proportion of malignant tumors. Therefore, a typical sonoelastographic pattern for pleomorphic adenomas could not be identified.

Benign intraductal papillary-mucinous neoplasm of the pancreas associated with spontaneous pancreaticogastric and pancreaticoduodenal fistulas

Invasive intraductal papillary-mucinous neoplasms (IPMNs) of the pancreas may be associated with pancreaticogastric fistulas as shown by case reports. We report the case of a benign IPMN associated with pancreaticogastric and pancreaticoduodenal fistulas. A 70-year-old woman was admitted with intestinal obstruction. Computed tomography and MRI showed a large dilatation of the main pancreatic duct (>1 cm) with intraductal nodules, and pancreaticogastric and pancreaticoduodenal fistulas. Several features in imaging were present to support a malignant IPMN, so that the patient underwent a pancreaticoduodenectomy. The histopathological examination of the surgical specimen showed a benign IPMN. This case proves that a benign IPMN can cause pancreaticogastric and pancreaticoduodenal fistulas, probably resulting from mechanical factors.

Health food store recommendations for breast cancer patients

CONTEXT

Despite cancer patients' widespread and growing use of complementary and alternative medicine, minimal attention has been paid to the role of health food stores in the "supply side" of this phenomenon.

OBJECTIVE

To gain a better understanding of health food store personnel's recommendations for breast cancer patient care.

DESIGN

Researcher posing as the daughter of a breast cancer patient and surveying health food store personnel on their product recommendations for cancer care.

SETTING

Oahu, Hawaii, summer 1998.

PARTICIPANTS

All health food stores (N = 40) offering products for cancer patients.

MAIN OUTCOME MEASURES

Recommended products and services, proposed mechanism of action, and costs.

RESULTS

Store personnel readily provided information and product recommendations, with shark cartilage being the most frequent. Suggested mechanisms of action drew on traditional healing, scientific, and pseudoscientific rationales. Costs for recommended dosages varied multifold across stores and brands.

CONCLUSIONS

Retailers supplying supplements can play an important role in the network of "authorities" for patients with breast and other cancers, as they readily provide advice and recommend products. The reasons why patients seek health food store remedies are useful in developing approaches to patient education. Physicians and other providers are in a key position to assist cancer patients in making informed choices when considering health store products.

Mechanism of action of leukotriene D4 on guinea pig tracheal smooth muscle cells: roles of Ca++ influx and intracellular Ca++ release

The effects of leukotriene D4 (LTD4) on the concentration of intracellular cytosolic free calcium ([Ca++]i) and on phosphoinositide hydrolysis were studied in cultured guinea pig tracheal smooth muscle cells. In Fura-2-loaded cells, LTD4 (10(-9)-10(-6) M) induced concentration-dependent changes in [Ca++]i consisting of a slow, transient increase followed by a sustained phase. Preincubation of cells with LTD4 receptor antagonist MK-571 (10(-6) M) blocked the increase in [Ca++]i. Similarly, LTD4-induced inositol phosphate ([3H]InsP(s) synthesis was transient, concentration-dependent and inhibited by the LTD4 antagonist. In the absence of extracellular Ca++, LTD4 failed to induce [Ca++]i increases and [3H]InsP(s) formation. Accordingly, NiCl2 completely inhibited the LTD4-stimulated [3H]InsP(s) synthesis. Nifedipine (10(-5) M) had a slight inhibitory effect on [Ca++]i increase but significantly reduced (40-50%) the [3H]lnsP(s) accumulation. These findings indicate that LTD4-stimulated inositol phosphate synthesis and [Ca++]i increases in tracheal smooth muscle cells are receptor-mediated events and are dependent on the availability of extracellular Ca++. It is suggested that Ca++ influx plays a major role in the LTD4 signal transduction mechanism.

Bioactive polymers 68--controlled release of neomycin-furazolidone bicomponent system from xanthan hydrogel

The neomycin-furazolidone-xanthan complex has been synthesized. Neomycin is covalently linked to xanthan, while furazolidone is inserted in the hydrogel formed by the reaction between neomycin and xanthan. The content of neomycin and furazolidone depends on the drug rate in the reaction medium. Thus, a zero-order kinetics is obtained for the release of both neomycin and furazolidone in basic medium. The complex's antimicrobial activity is intensified.

Bioactive polymers. 70. The kinetics of controlled release of neomycin in an alkaline medium

Neomycin is coupled on xanthan--a polysaccharide of microbial biosynthesis produced by Xanthomona campestris--through ionic complexation. The kinetics of neomycin release, in vitro, at pH = 8.2 is studied. A release of neomycin, following a zero order kinetics, is observed, regardless of the eluent flow-rate. The neomycin-xanthan complex, protected by a cellulosic membrane, behaves like a monolithic-type device. Diffusion coefficients--increasing with increasing the eluent flow-rate--are also calculated.

Bioactive polymers: in vitro and in vivo study of controlled release neomycin

Neomycin is coupled on xanthan-a polysaccharide of microbial biosynthesis produced by Xanthomonas campestris-through ionic complexation. The kinetics of neomycin release, in vitro, at pH = 8.2 is studied. A controlled release of neomycin, following a zero order kinetics is observed, regardless of the eluent flow. Neomycin complexed on xanthan, administered in a unique daily dose to patients suffering from dysentery in the 100 cases taken in study, has shown a high clinical efficiency as compared with the treatments with ampicillin or furazolidone, administered for 5-10 days or longer.

Bioactive polymers 54. Pharmacological properties of modified neomycin

Modified neomycin prepared by the ionic coupling on xanthan with an activity of 380 UI/mg was characterized in regard to its in vitro and in vivo release rate and therapeutic action with artificial tear eluent. The dynamic system in vitro release showed that after 4 h, there appears a "zero-order" kinetic. Ophthalmic inserts were prepared from modified neomycin and they are used in treating bacterial conjunctivitis. Sterilization of the conjunctival sac is obtained 12 h after insert administration.

Bioactive polymers. LX. Kinetics of delayed release neomycin-xanthan complex

The kinetics of delayed release neomycin-xanthan complex, and its antimicrobial activity, were studied. Delayed release neomycin (53.13% free neomycin) had zero-order release kinetics, when artificial tear solution was used as eluent. Microbiological tests revealed an activity of 380 units/mg, 10% higher than neomycin in its free form.