Cervical cancer screening cotesting with cytology and MRNA HPV E6/E7 yields high rates of CIN2+ lesions in young women

BACKGROUND

European guidelines recommend primary HPV testing for cervical cancer screening. However, the starting age remains to be defined, with an undecided window between 30 and 35 years. This pilot study compares the effectiveness of primary HPV testing to that of cytology for the detection of high-grade (CIN2+) lesions stratified by age.

METHODS

Cotesting with LBC cytology and APTIMA^® HPV (AHPV) was performed in 5053 women aged 25-65 in an opportunistic screening program in Madrid. AHPV-positive cases were referred to colposcopy and genotyped for HPV16 and 18/45 (AHPV-GT). Results were analyzed stratified in four age groups.

RESULTS

454 cases (9.0%) were AHPV-positive. Women under 35 had a 30.2% CIN2+ rate, compared to 21.9% and 20.4% for women aged 35-44 or 45-54. There was a significant increase (P < .05) in the rate of CIN2+ in AHPV-GT-positive women when compared to that for other HPV types (AHPV-other), being 43.3% versus 15.7%. AHPV-GT-positive women under 35 had significantly higher rates of CIN2+ lesions than any other age-group. The sensitivity of cytology for cervical CIN2+ in APHV-positive women was 60.6%. All 4 carcinomas, including one AHPV-negative endometrial adenocarcinoma, had abnormal cytology. All cervical CIN2+ lesions biopsied were AHPV-positive.

CONCLUSIONS

Aptima HPV shows a significantly higher sensitivity for cervical CIN2+ lesions than cytology alone. Unexpectedly, AHPV-positive women under 35 had the highest incidence of CIN2+ lesions, particularly when they are HPV16/18/45-positive. Reconsidering HPV primary screening before the recommended age of 35 is warranted.

Combined administration of synthetic RNA and a conventional vaccine improves immune responses and protection against foot-and-mouth disease virus in swine

Foot-and-mouth disease virus (FMDV) is the causative agent of a highly contagious disease and a major concern in animal health worldwide. We have previously reported the use of RNA transcripts mimicking structural domains in the non-coding regions of the FMDV RNA as potent type-I interferon (IFN) inducers showing antiviral effect in vivo, as well as their immunomodulatory properties in combination with an FMD vaccine in mice. Here, we describe the enhancing effect of RNA delivery on the immunogenicity and protection induced by a suboptimal dose of a conventional FMD vaccine in pigs. Animals receiving the RNA developed earlier and higher levels of neutralizing antibodies against homologous and heterologous isolates, compared to those immunized with the vaccine alone, and had higher anti-FMDV titers at late times post-vaccination. RNA delivery also induced higher specific T-cell response and protection levels against FMDV challenge. Peripheral blood mononuclear cells from pigs inoculated with RNA and the vaccine had a higher IFN-γ specific response than those from pigs receiving the vaccine alone. When challenged with FMDV, all three animals immunized with the conventional vaccine developed antibodies to the non-structural viral proteins 3ABC and two of them developed severe signs of disease. In the group receiving the vaccine together with the RNA, two pigs were fully protected while one showed delayed and mild signs of disease. Our results support the immunomodulatory effect of these RNA molecules in natural hosts and suggest their potential use for improvement of FMD vaccines strategies.

Anatomical and morphological study of the subcoracoacromial canal

INTRODUCTION

Many clinical anatomy studies have looked into how variations in the acromion, coracoacromial ligament (CAL) and subacromial space are associated with rotator cuff injuries. However, no study up to now had defined anatomically the fibro-osseous canal that confines the supraspinatus muscle in the subcoracoacromial space. Through an anatomical study of the scapula, we defined the bone-related parameters of this canal and its anatomical variations.

MATERIALS AND METHODS

This study on dry bones involved 71 scapulas. With standardised photographs in two orthogonal views (superior and lateral), the surface area of the subcoracoacromial canal and the anatomical parameters making up this canal were defined and measured using image analysis software. The primary analysis evaluated the anatomical parameters of the canal as a function of three canal surface area groups; the secondary analysis looked into how variations in the canal surface area were related to the type of acromion according to the Bigliani classification.

RESULTS

Relative to glenoid width, the group with a large canal surface area (L) had significantly less lateral overhang of the acromion than the group with a small canal surface area (S), with ratios of 0.41±0.23 and 0.58±0.3, respectively (P=0.04). The mean length of the CAL was 46±8mm in the L group and 39±9mm in the S group (P=0.003). The coracoacromial arch angle was 38°±11° in the L group and 34°±9° in the S group; the canal surface area was smaller in specimens with a smaller coracoacromial arch angle (P=0.20).

CONCLUSION

Apart from acromial morphology, there could be innate anatomical features of the scapula that predispose people to extrinsic lesions to the supraspinatus tendon (lateral overhang, coracoacromial arch angle) by reducing the subcoracoacromial canal's surface area.

LEVEL OF EVIDENCE

Anatomical descriptive study.

Bone mass and vitamin D levels in women with a diagnosis of fibromyalgia

No differences in either bone mineral density or serum 25OHD levels have been found between 205 women with fibromyalgia (both pre- and postmenopausal) and their controls. However, a lack of the expected 25OHD summer rise was observed in patients.

INTRODUCTION

Contradictory data have been published regarding a possible association between fibromyalgia and osteoporosis or hypovitaminosis D. Most studies, however, have been performed in small size samples and have excluded postmenopausal women. We decided to study this association in a larger sample of fibromyalgia patients including both pre- and postmenopausal women.

METHODS

Two hundred five patients were recruited from a clinic specializing in fibromyalgia and 205 healthy controls were enrolled from the census of a Primary Care Center. Controls were matched with patients by age and the time of the year they were included in the study. Bone mineral density (BMD) was measured by DXA. Serum 25OHD, iPTH, P1NP, and CTX were also determined.

RESULTS

BMD was similar in both groups (lumbar spine, 0.971 ± 0.146 g/cm(2) in patients and 0.970 ± 0.132 g/cm(2) in controls; femoral neck, 0.780 ± 0.122 g/cm(2) and 0.785 ± 0.117 g/cm(2), respectively). 25OHD levels were also similar: 23.0 ± 9.5 ng/ml and 24.1 ± 9.6 ng/ml. However, while controls showed the usual summer rise in 25OHD, fibromyalgia patients did not. PTH did not show seasonal changes, but on average was higher in patients (51 pg/ml vs. 48 pg/ml; p = 0.034). P1NP or CTX were similar in both groups.

CONCLUSIONS

No differences in BMD were found between patients and controls. As for 25OHD, a lack of its expected summer rise was observed. It is doubtful whether this has any homeostatic consequence. We consider that the association reported in other studies is merely circumstantial, and not due to the intrinsic characteristics of these disorders.

Delivery of synthetic RNA can enhance the immunogenicity of vaccines against foot-and-mouth disease virus (FMDV) in mice

We have recently described the antiviral effect in mice of in vitro-transcribed RNAs mimicking structural domains in the non-coding regions of the foot-and-mouth disease virus (FMDV) genome RNA. These small, synthetic and non-infectious RNA molecules (ncRNAs) are potent type-I interferon (IFN) inducers in vivo. In this work, the immunomodulatory effect of the ncRNA corresponding to the internal ribosome entry site (IRES) on immunization with two different FMD vaccine formulations, both based on inactivated virus, including or not a commercial adjuvant, was analyzed in the mice model. The effect of the time interval between RNA inoculation and immunization was also studied. RNA delivery consistently increased the titers of specific anti-FMDV antibodies, including neutralizing antibodies, elicited after vaccination. Moreover, at day 2 after immunization, significant differences in mean antibody titers could be detected between the groups of mice receiving either vaccine co-administered with the RNA and the control group, unlike those immunized with the vaccine alone. When vaccinated mice were challenged with FMDV, the mean values of viral load were lower in the groups receiving the RNA together with the vaccine. Our results show the enhancing effect of the IRES RNA on the immune response elicited after vaccination and suggest the potential of this molecule as an adjuvant for new FMD vaccine design.

Protection of IFNAR (-/-) mice against bluetongue virus serotype 8, by heterologous (DNA/rMVA) and homologous (rMVA/rMVA) vaccination, expressing outer-capsid protein VP2

The protective efficacy of recombinant vaccines expressing serotype 8 bluetongue virus (BTV-8) capsid proteins was tested in a mouse model. The recombinant vaccines comprised plasmid DNA or Modified Vaccinia Ankara viruses encoding BTV VP2, VP5 or VP7 proteins. These constructs were administered alone or in combination using either a homologous prime boost vaccination regime (rMVA/rMVA) or a heterologous vaccination regime (DNA/rMVA). The DNA/rMVA or rMVA/rMVA prime-boost were administered at a three week interval and all of the animals that received VP2 generated neutralising antibodies. The vaccinated and non-vaccinated-control mice were subsequently challenged with a lethal dose of BTV-8. Mice vaccinated with VP7 alone were not protected. However, mice vaccinated with DNA/rMVA or rMVA/rMVA expressing VP2, VP5 and VP7 or VP2 alone were all protected.

Development and characterization of monoclonal antibodies against Rift Valley fever virus nucleocapsid protein generated by DNA immunization

This paper describes the generation of monoclonal antibodies directed to immunogenic nucleoprotein N epitopes of Rift Valley fever virus (RVFV), and their application in diagnostics, both for antibody detection in competitive ELISA and for antigen capture in a sandwich ELISA. Monoclonal antibodies (mAbs) were generated after DNA immunization of Balb/c mice and characterized by western blot, ELISA and cell immunostaining assays. At least three different immunorelevant epitopes were defined by mAb competition assays. Interestingly, two of the mAbs generated were able to distinguish between RVFV strains from Egyptian or South African lineages. These monoclonal antibodies constitute useful tools for diagnosis, especially for the detection of serum anti-RVFV antibodies from a broad range of species by means of competitive ELISA.

Acalculous cholecystitis in a patient with Plasmodium falciparum infection after a trip to the Dominican Republic

Acalculous cholecystitis has been associated with several infectious agents, but its relation with Plasmodium falciparum infection has not been clearly defined. This is the first case of acalculous cholecystitis produced by Plasmodium falciparum infection that is directly documented and should be included among the differential diagnoses of acalculous cholecystitis.

[Antiparasitic drugs. Review of the useful drugs in the treatment of classic and emergent parasitic diseases]

INTRODUCTION

In the 10 last years, the increase of international travels and immigration from low income countries to Spain was related with an increased of prevalence of parasitic diseases.

SOURCE

Critical review of the literature.

STRUCTURE

Firstly, several general considerations were made on the antiparasitic drugs revised in this paper. Chemical structures and mechanisms of action of the main drugs with antiparasitic effect were considered in the second part of the review. Further, antiparasitic spectrum of selected drugs, main pharmacokinetical characteristics, usual posology, possible side effects and contraindications were detailed. Finally, some practical aspects, such as interactions and the methods for practical obtention of these drugs are indicated. This information is relevant because in Spain many anti-parasitic drugs may be obtained using non conventional methods.

CONCLUSION

In Spain, the increase of parasitic diseases necessitates an update on antiparasitics drugs for their treatment.

Time-to-positivity in patients with Escherichia coli bacteraemia

The time from the start of incubation to a positive reading of blood cultures (time-to-positivity; TTP) is related to the concentration of bacteria in blood. Information concerning the correlation of TTP with clinical parameters, and its usefulness as a prognostic factor in patients with Escherichia coli bacteraemia, is limited. To investigate the relationship of TTP to clinical parameters, 459 cases of monomicrobial E. coli bloodstream infections from a single institution between 1997 and 2005 were reviewed. All cases involved patients who were not undergoing antibiotic treatment at the time of blood sampling. The in-hospital mortality rate was 6.3%. Median TTP was significantly shorter for patients who died than for those who survived (9.7 h, inter-quartile range 7.85-11.05 h vs. 11.2 h, inter-quartile range 10.1-11.4 h; p <0.001). Patients with TTP in the lowest quartile were more likely to be female, to have a non-urinary tract or an unknown origin of bacteraemia, to have severe sepsis or shock, and to subsequently die. In a multivariable Cox regression model, the hazard ratio for death from any cause for patients with a short TTP was 3.13 (95% CI 1.28-7.64; p 0.01). TTP in patients with E. coli bacteraemia provides prognostic information beyond that provided by the presence of haematological illness, a Charlson score > or =3, a non-urinary tract origin of bacteraemia, and the presence of severe sepsis or shock.

Corynebacterium striatum first reported case of prosthetic valve endocarditis

We describe the case of a prosthetic valve endocarditis in a 72-year-old woman. Corynebacterium striatum was isolated in the blood samples. This organism has been described in a few cases of native valve endocarditis, but this is the first case reported of prosthetic valve endocarditis.

Spontaneous carotid and vertebral artery dissection in children

Carotid and vertebral artery dissection is a rarely reported cause of stroke in childhood and adolescence, especially if there is not a direct trauma to the neck. Four patients, under 15 years of age, presented with an internal carotid artery dissection, and one patient presented with a vertebral artery dissection. They were all making a physical effort when the event occurred. The five patients had ischemic symptoms, and in two the events were preceded by transient ischemic attacks. Headache was associated in four patients. The diagnosis was made by magnetic resonance imaging and angiography, which included transfemoral angiography in two patients. All improved before leaving the hospital, and four patients did not suffer recurrent episodes. The diagnostic accuracy of artery dissection has improved because of noninvasive neuroimaging testing, but it should still be suspected in any pediatric ischemic stroke, especially if there is headache or cervical pain associated.

[Evaluation of 2 tuberculosis chemoprophylaxis regimens in patients infected with human immunodeficiency virus. The GECMEI Group]

OBJECTIVE

To assess the compliance, tolerance and efficacy of a short chemoprophylaxis regimen (IR) for tuberculosis using isoniazid (INH) plus rifampin (RIF) during 3 months versus a standard regimen (I) of isoniazid during 12 months in HIV positive patients.

MATERIAL AND METHODS

Prospective, comparative, randomized and open clinical trial in four general hospitals and one prison hospital of Castilla-La Mancha. Prophylaxis was administered to PPD-positive patients and to anergic patients according to the CDC recommendations (1991). Patients were randomized in two treatment groups: regimen IR, isoniazid 300 mg daily and rifampin 600 mg daily; regimen I, isoniazid 300 mg during 12 months.

RESULTS

133 patients were included, 64 to regimen I and 69 to regimen IR. Regimen IR had a better tolerance with a 28% of adverse effects versus 55% in regimen I. Hepatotoxicity was more frequent in regimen I with a RR = 2.2 (CI 95% 1.23-4.01). Severe hepatotoxicity leading to treatment withdrawal was related to drug administration time and was more frequent in the 12 months regimen group. Short regimen showed a better compliance, without significant differences. Tuberculosis incidence rate was a 4.23 cases/100 persons--year for regimen I and 2.08 in regimen IR, with a relative risk for developing tuberculosis with regimen IR group of 0.51 (CI 95% 0.09-2.8) versus regimen I group, without statistical significance. Prison stay was associated to a significant risk for tuberculosis, regardless of both regimens (RR = 9.2 CI 95%, 1.06-80.2).

CONCLUSIONS

In HIV-infected patients with PPD(+) or anergic, regimen with IR is at least as effective as regimen I for preventing the development of tuberculous disease, and has less adverse effects.

[Acute cerebrovascular accident associated with drepanocytosis complicated by pneumococcal meningitis in two children]

INTRODUCTION

Between 6% and 17% of the patients with drepanocytosis will have an acute cerebrovascular accident (ACVA). Precipitating factors have been described including bacterial meningitis, upper respiratory tract obstruction, dehydration, intense exercise, postoperatively, and hypoxia due to altitude.

CLINICAL CASES

We report two Negro children with drepanocytosis who, at the ages of 8 and 20 months, had pneumococcal meningitis complicated by an ACVA. The 20 month old boy had been previously diagnosed as having drepanocytosis; the 8 month old girl was diagnosed when she was admitted to hospital with meningitis. In both cases the clinical features of the ACVA were focal epileptic seizures followed by hemiplegia. On cranial CT and MR regions of focal ischaemia of the hemisphere were observed. The boy of 20 months made an excellent recovery with no long term sequelae. The 8 month old girl had severe permanent sequelae: hemiparesia, blindness, mental deficiency and epileptic encephalopathy.

CONCLUSIONS

We present two Negro children with drepanocytosis who had ischemic ACVAs, a common complication of the disease, during the course of pneumococcal meningitis but with very different clinical courses. Recent increases in immigration will mean that previously rare illnesses will be more commonly seen in our environment, and should be considered in the differential diagnosis.

Mitochondrial diseases in children: neuroradiological and clinical features in 17 patients

Mitochondrial diseases result from structural, biochemical or genetic defects of mitochondria, which contain the respiratory chain. They usually affect children and young adults. We report the CT and MRI findings in 17 patients under 14 years of age, the youngest reported to date, with various mitochondrial diseases. Although imaging studies may be normal negative in the early stages, follow-up usually shows many abnormalities, which depend on clinical status and the disease. We have recognised a spectrum of findings that can be divided into four patterns: nonspecific myelin lesions (8/17); grey-matter nuclei involvement (6/17); a leukodystrophic pattern; and calcification of the brain (1/17), although mixed forms, particularly myelin and grey-matter lesions are frequent.

[Spinal cord infarction/ischemia]

INTRODUCTION

Vascular pathology is considered to be uncommon, with a much lower incidence than cerebral vascular pathology.

PATIENTS AND METHODS

We reviewed the clinical histories of patients with a clinical diagnosis of spinal cord infarction-ischemia attended by the Neurology Department and the Neuropaediatric section at our centre between 1990 and 1997. We analyzed the clinical and investigational findings and compared them with those in the literature.

RESULTS

We studied the cases of 12 patients (nine adults and three children). There was only one case in which no etiological factor of any type was found to justify the spinal vascular condition. All the children had had surgery to repair coarctation of the aorta. The most frequent clinical presentation was of paraparesis-paraplegia with signs of involvement of the anterior spinal artery. MR was done in all cases, except in that of an adult who was diagnosed on arteriography. The adults were studied by means of MR during the first 24-48 hours after onset of the condition. In five cases this was normal. In two of the latter cases, MR was repeated and alterations were seen in one whilst the other was not satisfactory. In the other three cases MR was not repeated since in two there was clinical improvement and in the other excessive technical problems. On discharge the children had not improved at all although the six adults improved completely or almost completely.

CONCLUSIONS

In general, our findings are comparable to those in the literature. We consider that the diagnosis is basically clinical and differential diagnosis should be made with other spinal disorders. MR is helpful, although early use does not show changes which help in diagnosis.

[Estimation of the neurologic demand in a health care area of Madrid, Spain (area 11, University Hospital, 12 of October)]

OBJECTIVES

To analyse the demand for neurologic care and the neurological resources in a health district.

PATIENTS AND METHODS

Demographic, medical care aspects, neurologic care demands and neurological resources of the health district 11 of Madrid (University Hospital "12 de Octubre"), referred to 1996, were reviewed.

RESULTS

The rate of aging (17%) and the consulting rates in the National Health System (86%) versus private care were high in this health district. The neurologic care demands were 17.5-18.1 and 36 consultations respectively per 1,000 inhabitants/year. There were 2 patient-care neurologists and 3.7 neurologic beds per 100,000 inhabitants.

CONCLUSIONS

The neurologic care was considered high and with a tendency to increase. The available neurological resources were judged to be insufficient.

[Gamma-sarcoglycanopathy:two new cases in a gypsy family family in Spain]

INTRODUCTION

Included under the heading of limb girdle muscular dystrophy is a heterogeneous group of myopathies which share the same phenotype characteristics. The illness is of early onset, progressive and basically involves muscles of the shoulder and pelvic girdles. Recent identification of muscle proteins and the genes which codify them has led to new classification of these conditions according to their genetic characteristics. It is currently accepted that there are two major groups: the dominant and recessive forms. The latter includes type 2C limb girdle muscular dystrophy associated with chromosome 13, where the gene for gamma-sarcoglycan is found. This protein belongs to the glycoprotein complex associated with dystrophin. Recently a new mutation has been identified, the C283Y, exclusive to the Gypsy race, which affects this gene and therefore the alterations in gamma-sarcoglycan produced by it.

CLINICAL CASE

We describe two patients, Gypsy brothers, who complained of myopathy, which they had had for some years, compatible with this condition and in whom the C283Y mutation had recently been detected.

CONCLUSIONS

We describe another Spanish Gypsy family, all members of which have the characteristic mutation. We emphasize the importance of genetic studies in all cases of myopathy which have not been fully diagnosed.

Effect of eprosartan and losartan on uric acid metabolism in patients with essential hypertension

OBJECTIVE

The influence of angiotensin II AT-1 receptor antagonists on uric acid metabolism, and the potential differences among them with regard to this effect, remains to be precisely established. This study was designed to compare the effects of losartan and eprosartan on uric acid metabolism in patients with mild to moderate essential hypertension.

DESIGN

Randomized, double-blind, parallel-group study in hypertensive patients.

SETTING

Outpatient clinic.

PATIENTS

Following a 2- to 3-week single-blind placebo run-in period, 60 patients with sitting diastolic blood pressure > or = 95 and < or = 114 mmHg were randomized. Fifty-eight patients completed the study.

INTERVENTIONS

Patients were randomized to receive losartan 50 mg or eprosartan 600 mg once daily for 4 weeks.

MAIN OUTCOME MEASURES

The primary endpoint was the change in the ratio of urinary uric acid/creatinine in the period 0-4 h of a 24 h urine collection after 4 weeks of treatment. Secondary endpoints included 24 h urinary uric acid excretion, as well as serum urate and anti-hypertensive efficacy.

RESULTS

Mean urinary uric acid/creatinine changes from baseline were 0.14 (day 1) and 0.11 (week 4) for losartan and -0.04 for eprosartan (at both day 1 and week 4; P < 0.01 between groups at both time-points). The mean increase in 24 h urinary uric acid excretion with losartan was 0.7 mmol/24 h (25% increase from baseline) at both day 1 and week 4. No significant difference was observed in the change of serum urate levels versus baseline between both treatment groups after 4 weeks (- 23.4 and - 19.5 micromol/l for losartan and eprosartan, respectively). Patients with hyperuricaemia in both treatment groups showed similar modifications of uric acid metabolism compared with non-hyperuricaemic subjects. Blood pressure control (sitting diastolic blood pressure < 90 mmHg or < 100 mmHg with a decrease of at least 10 mmHg from baseline) was achieved in 22 patients (73%) with eprosartan and in 16 (53%) with losartan.

CONCLUSIONS

Losartan increased uric acid excretion in hypertensive patients, whilst eprosartan did not Neither AT-1 receptor antagonist substantially modified serum urate concentrations.

[Spinal tumors in infancy. A report of 48 cases]

INTRODUCTION

Spinal tumours in infancy are an infrequent oncological disorder. The clinical features, usually of insidious onset, are alterations in gait and a painful spine.

OBJECTIVE

To analyze the different histological types of spinal tumours seen in infancy and their form of presentation in our series.

PATIENTS AND METHODS

We reviewed the clinical histories of 48 patients with intraspinal tumours, aged under 15 years, whose reports of histological diagnosis had been sent to our centre.

RESULTS

Of the patients studied, 17 were girls (35.4%) and 31 boys (64.6%) with an average age of 7.7 years. The histological diagnoses made most frequently were astrocytomas (22.9%) and lipomas (18.8%) followed by metastases (12.5%), ependymomas (8.3%) and Edwing's sarcoma (8.3%). The clinical features were present prior to diagnosis for between 1 and 6 months in 13 patients, and for less than one month in 9 patients. The presenting symptoms were alterations in gait and back pain in most patients. Exploratory tests were related to the involvement of long vias and second motor-neurone lesions. The main topographical findings were: in the axial plane the lesions were extradural (23 patients) and in the sagittal plane there was dorsal involvement (34 patients).

CONCLUSIONS

Insidious, progressive alterations in gait together with continuous, nocturnal back pain are valuable data when a serious spinal disorder is to be suspected. Early diagnosis should be based on neuroimaging tests, essentially MR, in the patients in whom spinal cord involvement is considered.

[Vascular malformations of the central nervous system in children]

OBJECTIVE

To present the experience of vascular malformations (VM) of the central nervous system (CNS) in children obtained in our centre. Since these lesions do not often present clinically in childhood, there are few series described in the literature.

PATIENTS AND METHODS

We made a retrospective review of the clinical histories of patients with VM of the CNS shown on MR, angiography and/or morbid anatomy, who were aged 15 years or under. Patients with Sturge-Weber or Von Hippel-Lindau syndromes were excluded.

RESULTS

We describe 32 patients with VM of the CNS. Twenty four had arteriovenous malformations (AVM), 5 had cavernous malformations (CM), 2 had malformations of Galeno's vein (MGV) and one patient had a congenital fusiform arterial aneurysm. Twenty two children (68%) presented clinically with hemorrhages. This was the form of presentation in 20 patients with AVM. In 4 of the 5 patients with CM the first sign was epileptic crisis. The two patients with MGV presented with macrocephaly, in one neonate it was associated with heart failure and in on older baby with hydrocephaly. The patient with a congenital arterial aneurysm presented with paroxystic episodes of facial pain.

CONCLUSIONS

The AVM are the VM which most frequently cause symptoms in childhood.

[Polymyositis in childhood]

INTRODUCTION AND OBJECTIVE

Idiopathic inflammatory myopathies are very rare in infancy. We present five cases of polymyositis in children in which the clinical variability and difficulty in diagnosis that occurs with this disorder are clearly seen, and analyze their response to steroid treatment.

CLINICAL CASES

We can distinguish two groups of patients: the first is formed of the case of a two and a half month old baby with generalized hypotonia; and the second includes the other four cases, children of between 2 and 8 years old with weakness, which was mainly proximal. One of the second group later developed juvenile chronic arthritis. In all cases there was a raised CPK and a myopathic EMG, with or without spontaneous muscle activity. Muscle biopsy showed inflammatory myopathy. The first group corresponds to so-called infantile polymyositis which is characterized by generalized hypotonia. The second group includes older children in whom the clinical features of the disorder are similar to those in adults. The association of other autoimmune diseases with infantile polymyositis is exceptional. All cases show more or less improvement with corticosteroids.

CONCLUSIONS

The polymyositis are extremely rare before puberty and have a broad clinical spectrum. Congenital cases have been described in infants and in older children. The biopsy results are usually unexpected. Treatment with corticosteroids leads to clinical improvement which may be only partial and is less favorable than in the dermatomyositis.

Contribution of transvaginal sonography to the evaluation of benign cervical conditions

PURPOSE

We evaluated the role of transvaginal sonography in imaging the normal cervix and its benign changes.

METHODS

This prospective study included 512 postmenopausal women who underwent transvaginal sonography before hysterectomy and within 15 days of a colposcopy examination that showed no malignant findings. The sonographic findings were compared to the pathology report.

RESULTS

Naboth's cysts were the most common sonographic finding (102 cases), followed by cervicitis (43 cases). In 26 cases, endocervical polyps were found sonographically, and in 20 cases myomas were found. In 321 cases, the cervix showed no sonographic abnormality. Pathologic studies showed 104 Naboth's cysts, 25 cases of nonspecific cervicitis, 26 endocervical polyps, 21 myomas, and 336 normal cervices.

CONCLUSIONS

The sensitivity and specificity of transvaginal sonography in diagnosing normal cervices and benign changes of the cervix are high. Transvaginal sonography provides easily obtainable, reliable information about the cervix.

Elevated non-transferrin bound iron in the lungs of patients with Pneumocystis carinii pneumonia

OBJECTIVE

The aim of the present work was to determine the concentrations of iron and iron-binding proteins in the lungs of patients suffering from Pneumocystis carinii (PCP), which is crucial for justifying the treatment with iron-chelating agents in this disease.

PATIENTS AND METHODS

Bronchoalveolar lavage was performed in 10 HIV patients with PCP and five healthy controls. Total iron and iron-binding proteins (transferrin, ferritin and lactoferrin) were measured in acellular bronchoalveolar lavage fluid (BALF) in both groups. Iron was determined by atomic absorption spectrometry; transferrin and lactoferrin were measured using specific enzyme-linked immunosorbent assays (ELISA); and ferritin concentration was quantified by automated immunonephelometry.

RESULTS

Our findings in patients with PCP demonstrated a six- to seven-fold increase of total iron levels and an eight-fold increase of ferritin in bronchoalveolar lavage fluid when compared with controls. No significant differences were found in transferrin or lactoferrin levels. Moreover, our results suggest that this iron is non-transferrin bound.

CONCLUSION

Non-transferrin bound iron is increased in the lower respiratory tracts of PCP patients. This finding would lend experiment support to the use of iron-chelating agents in this disease.

[Ischemic stroke in children]

OBJECTIVE

Ischemic stroke in children and infants is a rare condition. We present a series of 23 pediatric patients of ischemic stroke.

PATIENTS AND METHODS

A retrospective series of 23 patients, aged between 1 month and 13 years, diagnosed by anamnesis, clinical examination and neuroimaging. The clinical picture, neuroimaging findings, etiology, evolution and sequelae are evaluated.

RESULTS

Eighteen of the patients had an ischemic stroke in the carotid territory (78.3%) and 5 in the vertebro-basilar (21.7%). Idiopathic (30.4%), cardiopathy (21.7%) and migraine (17.4%) were the most frequent etiologies. The recovery was complete in 9 patients (39.1%). There was a death as a result of systemic complications caused by dehydration (4.3%), and 13 patients (56.6%) were disabled: 6 with hemiparesis of diverse grades, 5 with epilepsy and hemiparesis, one with epilepsy, and one with mental retardation.

CONCLUSIONS

Ischemic stroke in children and infants is an unusual entity. The causes are multiple, although there is an elevated percentage of idiopathic cases. In our series, we highlight the significative percentage of vertebro-basilar strokes and the finding of three unusual etiologies in ischemic stroke in childhood, such as migraine, Mycoplasma pneumoniae infection and smallpox.

Assessment with transvaginal ultrasonography of endometrial thickness in women with postmenopausal bleeding

OBJECTIVE

The aim of this study was to assess the use of transvaginal ultrasonography in measuring endometrial thickness in postmenopausal women with bleeding, thus to determine the least invasive treatment.

STUDY DESIGN

We evaluated 168 women with postmenopausal bleeding by transvaginal ultrasonography and histological study of the endometrium.

RESULTS

No cancerous or precancerous lesions were found when endometrial thickness was under 10 mm. The mean endometrial thickness in women with cancerous and precancerous lesions was 10.75 +/- 1.63 mm, while in non-pathological lesions it was 1.36 +/- 1.18 mm.

CONCLUSIONS

To diagnose endometrial pathology, an endometrial thickness over 6 mm yields a sensitivity of 88.6%, a specificity of 90.6%, a positive predictive value of 92%, with 4.6% of false-positives and 4.6% of false-negatives (six small polyps and one irregular maturation). Although we are waiting for other prospective and multicentric studies, our present experience leads us to believe that Dilatation and Curettage (D&C) can be avoided in postmenopausal bleeding with endometrial thickness under or equal to 6 mm.

Accuracy of Topcon CM-1000 Videokeratoscope on Spherical Test Surfaces

BACKGROUND

Many videokeratoscopes use mathematical formulas to calculate corneal radii; calculations depend on slope, curvature, coordinate position, or focal properties of the surface. Accuracy of each type of videokeratoscope must be evaluated. A controversy exists about whether axial or tangential methods best provide a precise description of corneal shape; therefore results with the Topcon CM-1000 using both methods were evaluated.

METHODS

Measurements were done on black polymethylmethacrylate (PMMA) spherical calibrated surfaces. Lenses were first aligned and measured and then misaligned in different directions and measured. Results for each position were compared with the zero or alignment position.

RESULTS

Accuracy of the CM-1000 was high even under extreme misalignment conditions. Tolerance to misalignment was high (about 300 mm). Misalignment-induced variations in the output results were small (usually less than 0.05 mm). However, important variations (more than 1.00 diopter [D]) were found for the lowest measured radius (6 mm). In some cases, small differences between axial and tangential radii for the same point could be found.

CONCLUSION

With the exception of extremely low radii of curvature, the CM-1000 was accurate for measuring spherical surfaces. Further investigation remains to be done on aspheric surfaces and in clinical practice.

[Spontaneous intracranial hemorrhages in childhood]

INTRODUCTION

Spontaneous or non-traumatic intracranial haemorrhages seen in children of under 15 years old are most frequently due to cerebral vascular malformations, followed at a considerable distance by blood disorders, vasculopathies, tumours and the complications of radio-therapy.

OBJECTIVE

To present the cases of spontaneous and non-traumatic cerebral haemorrhage seen at our hospital.

MATERIAL AND METHODS

We reviewed all the paediatric cases of spontaneous cerebral haemorrhage diagnosed in our hospital over the previous sixteen years, excluding bleeding in the neonatal period. Computerized tomography was done in all cases, study of the cerebrospinal fluid, angiography and/or magnetic resonance in some cases.

RESULTS

We selected 44 patients, of who the aetiology could be determined in 30. Of these, 20 cases were due to vascular malformations, 7 were associated with haematological disorders, 2 with cerebral tumours and one case with meningococcal sepsis. The commonest form of presentation was that of an acute intracranial hypertension syndrome, also showing focal deficits, partial crises and meningism.

CONCLUSIONS

The commonest cause of spontaneous intracranial haemorrhage in children is due to rupture of a vascular malformation, namely an arterio-venous malformation. Angiography and/or magnetic resonance are the techniques of choice for diagnosis. The various causes of disorders of haemostasia also are important in giving rise to intracranial bleeding.

[Treatment of refractory infantile epilepsy with vigabatrin in a series of 55 patients]

We present the results of treatment with vigabatrin in the polytherapy of resistant infantile epilepsy. A retrospective review of 55 children with resistant epilepsy aged between 2 months and 15 years was carried out between January 1992 and January 1995. Semiologically, the crises treated were simple partial crises (CPS), complex partial crises (CPC), West's syndrome, the Lennox-Gastaut syndrome and polymorphic crises. The efficacy of the drug (defined as a 50% or more reduction in crises), secondary effects and the reduction in the number of drugs necessary were evaluated. 60% of the children studied improved. 20% became completely free of crises. 34% remained unchanged and 3% became worse. In West's syndrome 100% responded satisfactorily, as did 80% of the cases of partial crises, but only 40% of those with Lennox's syndrome responded. Generalized tonic-clonic crises did not respond, and myoclonic crises became worse. Aetiologically, there was greater improvement in the symptomic cases than in the essential cases, the improvement being 70% while 5 patients with tuberose sclerosis responded particularly well. Medication was stopped in one case because of side-effects, due to a psychiatric disturbance, and in another case vigabatrin caused transitory side-effects. In 10% of the subjects the initial efficacy wore off around 6 months later. We have shown the usefulness of vigabatrin in the polytherapy of infantile epilepsy, which is resistant to conventional epileptic drugs, mainly in simple and complex partial crises and in West's syndrome. Its minimal side-effects and the favourable response in over 50% of cases make it an extremely useful drug.

Miller Fisher syndrome in infancy

Miller Fisher syndrome (MFS) is characterized by the triad of ataxia, areflexia and ophthalmoplegia. It is exceptional for infants to be involved. Two infants, aged 11 and 16 months, developed acute-onset MFS. Both patients had prodromal upper respiratory tract infection. Pupillary responses to light, strength and sensation modalities were preserved. One patient was lethargic for a day; the electroencephalogram disclosed slightly slow background activity that later became normal. The other received high-dose intravenous immunoglobulins for 5 consecutive days starting at once on admission; within the next 7 days he became asymptomatic. Increased cerebrospinal fluid protein content and delayed nerve conduction studies with prolonged distal latencies were encountered in both patients.

[Neuroimaging techniques in the Gilles de la Tourette syndrome]

Tourette's syndrome (GdT) is a chronic neuropsychiatric disorder of unclear etiology characterized clinically by the presence of motor and phonic tics as well as a variety of behavioral and cognitive abnormalities such as Obsessive-Compulsive Disorder (TOC) and Attention Deficit Hyperactivity Disorder (ADHD). Dopaminergic pathway and movement control related structures may have some implications for pathogenesis. Neuroimaging techniques may yield relevant data for a better understanding of the symptoms and physiopathology of this disease. Among them, functional isotopic techniques such as PET and SPECT and other like quantitative EEG are the most remarkable. In this article we intend to perform a thorough review of the most recent literature, contributing with our own experience and discuss the pathogenesis of GdT.

[Neurological impairment in children with HIV infection]

We retrospectively checked 53 paediatric patients suffering from infection with human immunodeficiency virus (HIV) registered in our Centre between the years 1987 and 1993, and evaluated the appearance of HIV encephalopathy. We noted important neurological signs in eleven patients (20.7%) ten of whom had HIV infection via vertical transmission and one as a result of contamination from haemoderivatives. In this review we give a detailed description of neurological signs, the moment of onset of these signs and their possible relationship with the state of the HIV infection. We also analyzed the resulting neuroradiological findings as well as any abnormalities in cerebrospinal fluid. Follow-up period ranged from one month to two and a half years from the moment of onset of the appearance of encephalopathy. Although most of our patients showed a clear improvement after oral or intravenous treatment with zidovudine, this improvement generally proved to be short-lived. The mortality rate in our HIV encephalopathy series was 81.8%, this figure being reached two and a half years after encephalopathy. The appearance of neurological signs in HIV patients therefore represents a very gloomy prognostic factor in the evolution of the disease.

[Nitric oxide in the lower respiratory tract]

The aim of this work is to review of the role of nitric oxide (NO) in the lower respiratory tract. This review mainly focuses on the generation of nitric oxide by alveolar macrophages. In the first part of the paper, we summarize the literature on nitric oxide synthesis by different cell types and the effects of this mediator on target cells. Methods for measuring nitric oxide are also analyzed. The core of the paper is a review of the role of nitric oxide in diffuse interstitial lung diseases (both human and experimental models). We include data about the concentration of this mediator in bronchoalveolar lavage fluid and then summarize the knowledge about the regulation of nitric oxide synthesis by animal or human alveolar macrophages. Finally, we review the biological effects of nitric oxide in the lower respiratory tract.

[Neuromuscular gait disorders in pediatric age]

Alterations in gait are a frequent cause of consultation in neuropaediatric units. They have several different causes. One subgroup of special interest concerns those which have their origin in a neuromuscular disease. We studied the experience of the Child Neurology Unit at the Hospital 12 October from 1980 to 1993.

MATERIAL AND METHODS

between 1980 and 1993 a total of 176 were studied because they showed alterations in their gait caused by a neuromuscular disease. Frequency and clinical features were analysed (sex, age at the beginning of the deterioration, duration of the latter etc.).

RESULTS AND CONCLUSIONS

the alterations in gait were separated into two groups: Group I: backward or non-acquired gait. Group II: deterioration in gait. IIa: temporary. IIb: definitive. The most frequent cause in Group I was spinal muscular atrophy and in Group II, muscular dystrophy linked to sex. To sum up, muscular diseases are far more important than the neuropathic ones, except for Group IIa where acute demyelinating motor polyneuritis was to be found at the top of the list of frequent occurrences.

Meningioangiomatosis: advanced imaging and pathological study of two cases

Meningioangiomatosis (MA) is a rare benign intracranial tumour of uncertain pathogenesis, with only 33 cases reported in the literature. Imaging features have been described in 21 cases, only 3 with contrast-enhanced MRI. We present two cases of MA with MRI and/or CT findings and gross, ultrastructural, and immunohistochemical characteristics. MRI is particularly helpful for establishing the origin of the lesion and its anatomical location, while CT shows calcification, if present. The pathological characteristics establish the diagnosis and underline the differences from other entities such as malignant meningioma, one of the most important differential diagnostic considerations.

[Axilla skin biopsy in the diagnosis of Lafora's disease]

Skin biopsy is the method of choice for the diagnosis of Lafora's disease. The presence of PAS (+) inclusions characteristic of Lafora's disease has been thought to be more evident in aprocrine glands of the axillary skin than in the duct cells of the eccrine glands. We describe 4 patients with Lafora's disease diagnosed by axilla skin biopsy, confirming the usefulness of this procedure.

Changes in acid-base balance and calcium metabolism after urinary diversion through ileal segments. II. Treatment with nicotinic acid

Investigations in animals have shown that nicotinic acid, an intestinal cyclic-AMP inhibitor, partially corrects the metabolic changes associated with urinary diversion through intestinal segments. Blood and serum chemistry were studied in patients before and 3 to 5 months after undergoing urinary diversion through ileal segments, both with and without nicotinic acid treatment. It was found that diverted patients had metabolic acidosis, an increased anion gap and increased levels of serum alkaline phosphatase; there were no significant changes in serum PTH and vitamin D levels, calcaemia and phosphoraemia. There was a tendency towards dehydration, hypernatraemia, hyperchloraemia and secondary hyperaldosteronism produced by ileal secretion of a hypotonic fluid. Nicotinic acid 3 g/day significantly reduced the chloraemia but did not correct the metabolic acidosis, although it reduced its severity, since blood pH decreased when treatment was suspended. Nicotinic acid cannot be recommended for routine use in the management of metabolic acidosis after urinary diversion, and patients with a marginal renal reserve should not be considered for trans-intestinal urinary diversion.