Cytotoxic innate intraepithelial lymphocytes control early stages of Cryptosporidium infection

Background

Intraepithelial lymphocytes (IELs) are the first immune cells to contact and fight intestinal pathogens such as Cryptosporidium, a widespread parasite which infects the gut epithelium. IFN-γ producing CD4+ T IELs provide an efficient and a long-term protection against cryptosporidiosis while intraepithelial type 1 innate lymphoid cells limits pathogen spreading during early stages of infection in immunodeficient individuals. Yet, the role of T-cell like innate IELs, the most frequent subset of innate lymphocytes in the gut, remains unknown.

Methods

To better define functions of innate IELs in cryptosporidiosis, we developed a co-culture model with innate IELs isolated from Rag2-/- mice and 3D intestinal organoids infected with C. parvum using microinjection.

Results

Thanks to this original model, we demonstrated that innate IELs control parasite proliferation. We further showed that although innate IELs secrete IFN-γ in response to C. parvum, the cytokine was not sufficient to inhibit parasite proliferation at early stages of the infection. The rapid protective effect of innate IELs was in fact mediated by a cytotoxic, granzyme-dependent mechanism. Moreover, transcriptomic analysis of the Cryptosporidium-infected organoids revealed that epithelial cells down regulated Serpinb9b, a granzyme inhibitor, which may increase their sensitivity to cytolytic attack by innate IELs.

Conclusion

Based on these data we conclude that innate IELs, most likely T-cell-like innate IELs, provide a rapid protection against C. parvum infection through a perforin/granzymes-dependent mechanism. C. parvum infection. The infection may also increase the sensitivity of intestinal epithelial cells to the innate IEL-mediated cytotoxic attack by decreasing the expression of Serpin genes.

Polyarthrite rhumatoïde et Covid-19

Introduction

Les rhumatismes inflammatoires chroniques et notamment la polyarthrite rhumatoïde (PR), nécessitent une attention particulière au cours de la pandémie COVID-19 (CV-19). L’objectif de notre étude était de détecter une infection CV-19 chez des patientes suivies pour PR, d’évaluer l’impact de cette infection sur leur maladie et leur volonté de se faire vacciner.

Patients et méthodes

Il s’agit d’une étude transversale incluant 51 patientes atteintes de PR au sein d’un service de Rhumatologie sur une période de 2 mois (juillet et août 2021). À travers un questionnaire-patient, nous avons cherché à évaluer l’impact de la pandémie sur les patientes présentant une PR, notamment concernant l’activité de la maladie, le maintien du suivi médical et du traitement, l’application des mesures de prévention et la vaccination.

Résultats

L’âge moyen était de 54,2 ± 10,4 ans. La durée moyenne d’évolution de la maladie était 10,2 ± 6,9 ans. Quarante patientes avaient une PR séropositive. Toutes les patientes étaient sous traitement de fond parmi lesquelles 33 % étaient sous biothérapie.

Onze patientes avaient attrapé l’infection à CV-19 dont une est décédée. Quatre-vingt-deux % avaient une forme légère, 9 % une forme modérée et 9 % une forme grave. Vingt-deux patientes avaient au moins un sujet atteint par le CV-19 dans la famille. Un test PCR était le moyen de confirmation pour 7 patientes.

Les signes cliniques présentés par ces patientes étaient : fièvre, céphalées, vertiges, asthénie, toux, anosmie, agueusie, diarrhées, épigastralgies, douleur thoracique et dyspnée. Soixante-trois % d’entre eux gardant des séquelles type d’arthralgies, radiculalgies, orteil Covid, hypoacousie, hyposmie, toux, asthénie.

Concernant l’activité de leur PR au cours de l’infection, 36 % avaient une aggravation ;18 % présentaient une poussée et 27 % gardaient un état stationnaire.

Au cours de la période pandémique, 12 patientes ont arrêté leur traitement de fond ;12 patientes ont raté leur rendez-vous de consultation et 9 patientes ont déclaré la survenue de poussées plus fréquentes.

Concernant la vaccination, 14 patientes ne voulaient pas faire le vaccin pour plusieurs raisons : peur d’effets indésirables dans 50 % des cas, peur d’aggravation de la PR (50 %), inefficacité du vaccin (28 %), peur d’interaction avec leur traitement (28 %), peur des vaccins en général (28 %), non recommandé par un médecin (14 %), manque de confiance envers les labos pharmaceutiques (14 %), croyances religieuses (7 %).

Parmi les sujets vaccinés, 21 patientes ont déjà reçu une dose complète. Seize % des patientes ont présenté une poussée après le vaccin et 53 % des patientes ont déclarées la survenue d’effets indésirables type : douleur au niveau du site d’injection, asthénie, fièvre, céphalées, vertiges, arthralgies.

Pour les mesures de prévention, 88 % portaient leur masque dans les lieux publics, 92 % lavaient leurs mains régulièrement, 90 % gardaient une distance de sécurité et 74 % évitaient les espaces encombrés.

Conclusion

Les sujets atteints de PR ne sont pas épargnés de l’infection COVID-19. Cette pandémie a influencé la qualité de leur prise en charge. Un certain nombre de patients ne sont pas encore convaincu par la vaccination et ne prennent pas les mesures de précaution nécessaires. C’est pourquoi, il faut les sensibiliser.

Multispacer sequence typing of Coxiella burnetii from milk and hard tick samples from ruminant farms in Lebanon

his study was carried out to detect and characterize Coxiella burnetii in ruminant milk samples and in different tick species from seropositive farms in four Lebanese regions. Milk and tick samples were screened for C. burnetii presence by quantitative real-time PCR (qPCR) targeting IS1111 region followed by multispacer sequence typing (MST). The overall positive percentages of 9.6% (27/282) and 95.45% (84/88) for C. burnetii were recorded in ruminant milk and tick samples, respectively. In detail, the C. burnetii DNA was recorded in 52/54 (96.3%) of Rhipicephalus annulatus, 20/21 (95.24%) of Rhipicephalus turanicus, 6/6 (100%) of Hyalomma anatolicum, 5/6 (83.3%) of Rhipicephalus sanguineus and 1/1 of Rhipicephalus bursa. After genotyping of some IS1111-positive samples (17/111), different MST genotypes were identified. Out of 15 positive ticks, 10 were infected with MST2 genotype, 4 were infected with MST7 genotype and 1 was infected with MST57. Moreover, genotypes MST20 and MST58 were found in one cow and one goat milk samples, respectively. The present study confirmed the high genetic diversity of C. burnetii in Lebanon.

Occurrence and risk factors of Coxiella burnetii in domestic ruminants in Lebanon

Coxiella burnetii causes diseases in humans (Q fever) and animals, domestic ruminants playing a major role in the epidemiology of the infection. Information on C. burnetii infection in Lebanon is scanty. In order to assess the prevalence of C. burnetii infection in ruminants, a cross-sectional study was undertaken in 2014. A total of 1633 sera from ruminants (865 cattle, 384 sheep and 384 goats) from 429 farms (173 cattle, 128 sheep and 128 goats), in seven provinces of Lebanon were randomly selected and assayed for the presence of antibodies. 39.86% of farms (95% CI: 35.23-44.56) resulted positive. The seroprevalence was 30.63% in Cattle-farms, 46.88% in sheep-farms and 45.31% in goat-farms. Milk samples collected from 282 seropositive animals (86 cows, 93 sheep and 103 goats) from 171 positive farms were tested by a high sensitive Real-Time PCR targeted to the IS1111 transposon of C. burnetii. The overall prevalence in farms was estimated to be 14.04%. Cattle-, sheep- and goat farm prevalence rates were 15.09%, 10% and 17.24%, respectively. The findings of the study show that C. burnetii prevalence in Lebanese domestic ruminants is related to animal species and farming practices. Indeed, the mixed herds with sheep (p < 0.01), the presence of common lambing/kidding areas (p < 0.001) in farms where the use of disinfectants was not a routine practice (p < 0.05) were identified as important risk factors. The results of the study provide baseline information for setting up herd management and public health measures for the prevention and control of Q fever in Lebanon.

Diversity and distribution of ticks from domestic ruminants in Lebanon

Ticks (Acari: Ixodidae) are ectoparasites infesting livestock in every geographic area in the world and they are vectors of several viral, bacterial, and protozoan pathogens to animals and humans worldwide. A deep knowledge of the geographical distribution of these arthropods would have a key role in the control of tick-borne diseases. Few data are available about tick presence in domestic ruminants in Lebanon. The study aimed at providing an analysis of tick presence and distribution in Lebanon. Ticks were collected from cattle, sheep, and goats farms distributed in 6 Lebanese provinces between June and September 2014. A total of 272 adult hard ticks were randomly collected from domestic ruminants (cattle, sheep, and goats) located at 37 Lebanese farms, distributed among 30 villages. Ticks belonged to 4 Ixodidae genera: Rhipicephalus (72.4%), Haemaphysalis (11.4%), Dermacentor (8.1%), and Hyalomma (8.1%). They included the following species: Rhipicephalus annulatus (50.7%), Rhipicephalus turanicus (18.8%), Hyalomma anatolicum (8.1%), Haemaphylasis punctata (11.4%), Dermacentor marginatus (8.1%), Rhipicephalus sanguineus (2.5%), and Rhipicephalus bursa (0.4%). Rhipicephalus turanicus and H. anatolicum were found on cattle, sheep, and goats, R. annulatus on cattle and sheep, R. sanguineus, D. marginatus and Hea. punctata on sheep and goats, while R. bursa was collected only on sheep. Tick species involved in pathogen transmission were found and some of the identi ed species were recorded in Lebanon for the rst time.

The First Serological Study of Q Fever in Humans in Lebanon

OBJECTIVE

The aim of this study was to estimate, for the first time, the human seroprevalence of Q fever in Lebanon, by assessing the presence of antibodies against the causative agent, Coxiella burnetii. A total number of 421 serum samples (226 females and 196 males) were collected in February 2015 from hospitals and laboratories dispersed in five Lebanese provinces: Akkar, Bekaa, Mount Lebanon, Nabatieh, and South Lebanon.

METHODS

Serial testing approach was used. Samples were first screened for IgG phase II antibodies against C. burnetii by Enzyme Linked Immunosorbent Assay (ELISA) Kit. Then, both positive and inconclusive sera were reexamined by immunofluorescence assay (IFA) test with the aims to confirm and specify the infection status (past or probably acute infection) by detecting IgG (I/II) and IgM (I/II) in human sera.

RESULTS

Screening of 421 samples was estimated to be 38.70% (95% CI 34-43.3) positive samples, 5.90% (95% CI 3.7-8.2) suspect samples (as doubtful results), and 55.40% (95% CI 50.7-60.1) negative samples. Furthermore, all positive and suspect samples by ELISA test were retested by immunofluorescence assay test (IFAT), and the prevalence of positive sample was 37% and the infection case was recorded: 23.75% (95% CI 19.7-27.8) samples resulted from past infection, 1.9% (95% CI 0.6-3.2) probably acute infection characterized by several dominance clinical symptoms as: fever, cough, headache, difficulty breathing, and atypical pneumonia, and 0.23% (95% CI 0-0.7) inconclusive sample accompanied by different symptoms as bone metastasis and lung cancer.

CONCLUSION

The study records the exposition of 37% of 421 patients to C. burnetii distributed in five Lebanese provinces with the highest seroprevalence in Bekaa and Akkar provinces and the lowest reported in Mount Lebanon. This difference may be due to the presence of high density of livestock production and of major agricultural areas in these two provinces.

Measurement Reliability of the Remaining Dentin Thickness below Deep Carious Lesions in Primary Molars

Aim

This study was carried out to assess the reliability of measurements of the remaining dentin thickness under deep carious lesions as estimated from digital radiographs. The goal is to allow clinicians to correlate the radiographic measurement to the exact value of the remaining dentin thickness. The results obtained will be tested further in a study that will evaluate the histopathologic pulpal state according to the caries’ lesion depth.

Materials and methods

The study was conducted in the Pediatric Dentistry Department at the Lebanese University, in collaboration with the research platform of the same university. Fifty deciduous molars with deep caries on proximal surfaces liable to extraction were collected. Before extraction, a digital in vivo periapical radiograph was taken, followed by manual excavation of the caries. After excavation, another radiograph was taken before the tooth was sectioned through the deepest site of the lesion. Another radiograph was then obtained for each tooth fragment. To evaluate the exact thickness of the remaining dentin, each fragment was measured on a histologic macropho-tograph. The measurements were then compared statistically using a paired-samples t-test, and a correlation was sought.

Results

No significant difference was observed in the radiographs between the measurement of the remaining dentin thickness before and after the excavation of caries. In contrast, the radiographic measurements of remaining dentin thickness were underestimated by an average of 20% compared with those made with macrophotographs.

Limitations

Interpretation of radiographs varies from one practitioner to another and is a function of the operator’s visual acuity.

Conclusion

Measuring the residual dentin thickness on a radiograph underestimates the actual thickness by about 20%. Further studies are needed to confirm these results.

Clinical significance

Our results indicate that remaining dentin thickness is greater in reality than is shown on a radiograph. This information can help clinicians to refine their diagnoses and treatment plans.

How to cite this article: Berbari R, Khairallah A, Kazan HF, Ezzedine M, Bandon D, Sfeir E. Measurement Reliability of the Remaining Dentin Thickness below Deep Carious Lesions in Primary Molars. Int J Clin Pediatr Dent 2018;11(1):23-28.

Relationship Between the Remaining Dentin Thickness and Coronal Pulp Status of Decayed Primary Molars

AIMS AND OBJECTIVES

The aim of this study was to assess the correlation between the remaining dentin thickness (RDT) in deep decayed primary molars and the inflammatory status and bacterial composition of the corresponding coronal pulp. We hypothesized that RDT could be used as a reference for clinicians in assigning the indication for pulpotomy.

MATERIALS AND METHODS

Pulpotomies were conducted on the cameral pulp of 48 primary molars. Microorganisms, such as Lactobacillus sp., Streptococcus sp., and Prevotella sp., were identified and quantified and levels of tumor necrosis factor-alpha (TNF-α) and interlukin-6 (IL-6) were assessed. The correlation between the pre-operative RDT based on radiographic images and inflammatory-microbial profiles in vitro was evaluated using Spearman's rho correlation coefficient. All data analysis was performed using a statistical software program (SPSS 20.0, SPSS Inc., Chicago, IL, USA).

RESULTS

Immunological and microbiological studies revealed elevated levels of TNF-α and IL-6 cytokines, and Lactobacillus sp., Streptococcus sp. and Prevotella sp. in the cameral pulp with an RDT measuring up to 1.1 mm. No significant relationship could be established between RDT, inflammatory status and microbial content of the pulps.

CONCLUSION

The RDT remains a key clinical factor that needs to be assessed when establishing the indication for pulpotomy. Additional parameters that can improve this therapy should be investigated in the future.

Determination of inner implant's volumes: a pilot study for microleakage quantification by stereomicroscopy and spectrophotometry

AIM

Microleakage quantification of fluids and microorganisms through the connections of different implant parts seems to be sparse. Moreover, no data exist regarding the determination of the volumes of inner parts of dental implant systems. This study aims to determine the volumes of inner parts of three dental implant systems with the same interface and to evaluate the microleakage phenomenon.

MATERIALS AND METHODS

Three implant system sets (Euro-teknika(®), Astra Tech(®) and Implantium(®)) were used in this study. Implants were inoculated with safranin, brain heart infusion and distilled water. After inoculation and assembly of the different parts, different inner volumes (V1, V2, V3, V4, V5 and V6) were measured and, the surfaces of the micro gaps were observed through a stereomicroscope. Implants containing safranin were immersed in vials containing distilled water. Samples then were taken to determine optical density using a spectrophotometer.

RESULTS

Regardless the used substance, volumes of the 3-implant systems are different. Although volumes V1, V 2, V 3 and V5 appeared to be constant within the same system regardless the used substance, volumes V4 and V6 were not.

CONCLUSION

The determination of the volumes and the evaluation of leaked substance using stereomicroscopic and spectrophotometric methods showed the accuracy of these methods and the importance of their use in the study of microleakage.

CLINICAL SIGNIFICANCE

Leakage is an important factor for chronic inflammatory infiltration and marginal bone resorption. Studies have shown fluid and bacterial leakage into abutment- implant (A-I) assemblies of certain implants with 'closely locked' abutments and the creation of a constant bacterial reservoir in the empty space found between the implant and the abutment.

The combination of arsenic, interferon-alpha, and zidovudine restores an "immunocompetent-like" cytokine expression profile in patients with adult T-cell leukemia lymphoma

Background

HTLV-I associated adult T-cell leukemia/lymphoma (ATL) carries a dismal prognosis due to chemo-resistance and immuno-compromised micro-environment. The combination of zidovudine and interferon-alpha (IFN) significantly improved survival in ATL. Promising results were reported by adding arsenic trioxide to zidovudine and IFN.

Results

Here we assessed Th1/Th2/T_reg cytokine gene expression profiles in 16 ATL patients before and 30 days after treatment with arsenic/IFN/zidovudine, in comparison with HTLV-I healthy carriers and sero-negative blood donors. ATL patients at diagnosis displayed a T_reg/Th2 cytokine profile with significantly elevated transcript levels of Foxp3, interleukin-10 (IL-10), and IL-4 and had a reduced Th1 profile evidenced by decreased transcript levels of interferon-γ (IFN-γ) and IL-2. Most patients (15/16) responded, with CD4⁺CD25⁺ cells significantly decreasing after therapy, paralleled by decreases in Foxp3 transcript. Importantly, arsenic/IFN/zidovudine therapy sharply diminished IL-10 transcript and serum levels concomittant with decrease in IL-4 and increases in IFN-γ and IL-2 mRNA, whether or not values were adjusted to the percentage of CD4⁺CD25⁺ cells. Finally, IL-10 transcript level negatively correlated with clinical response at Day 30.

Conclusions

The observed shift from a T_reg/Th2 phenotype before treatment toward a Th1 phenotype after treatment with arsenic/IFN/zidovudine may play an important role in restoring an immuno-competent micro-environment, which enhances the eradication of ATL cells and the prevention of opportunistic infections.

Algodystrophie des membres inférieurs au cours de la grossesse

Algodystrophy (AD) of the lower limbs during pregnancy is rare and probably underdiagnosed. The physiopathologic mechanisms remain under discussion and seem multiple and complex. This report describes a retrospective survey of 6 patients seen between 1993 and 2004 who had algodystrophy of the lower limbs during pregnancy. Comparing the clinical, radiological and evolutionary results to the literature allows for identifying the main features of AD during pregnancy: disease progression during the second or third trimester, preferential localization of the left hip associated or not with other lower limb joint involvement and decalcification as seen on radiography. Magnetic resonance imaging (MRI), which is accurate, specific and non-invasive, is currently the exam of choice in early and differential diagnosis. The evolution is favourable in a few months, with general recovery without disability.

[Congenital lobar emphysema: report of 38 cases]

We present our experience of 38 patients suffering from congenital lobar emphysema (CLE) treated in the Department of Pediatric Surgery in our hospital between 1966-1991. 22 of these patients had to undergo surgical correction due to the severity of their respiratory symptoms. The other 16 presented mild respiratory symptoms: 8 of them received conservative treatment and the remainin 8 had to be operated on due to broncial compression caused by the vascular malformation. In most cases the main symptoms were dyspnea and cyanosis, which indicate the severity of the process. 20 cases presented during the patient's first month of life, 10 within the first 6 months and the remaining 8 between the first 6 months and 5 years. The different aetiologics forms in our study are analysed and compared with those described in the literature. The main diagnostic tested and revied, specially radiology tested led to a correct differential diagnosis and subsequently to an adequate therapeutic treatment. It is possible to carry out other tests since they do not actually help diagnosis, we have considered them unnecessary. All the surgical operations used are analysed as well as the complications observed. The clinical course of the patients has proved to be particularly good, since there was no mortality and the morbility rate was low.

[Adenomatous cystic pulmonary malformations: presentation of 26 cases]

We present our experience of 26 cases of cystic adenomatoid malformations of the lung (CAM), treated in the Department of Pediatric Surgery in our hospital between 1967-1991. There were two clinical pictures: one neonatal severe respiratory distress and successive repeated pulmonary infection appearing after the patient's first year of life and requiring both urgent diagnosis and treatment. Embryological development determines the pathologic classification of this entity in 3 types. Basic examinations by image are analyzed, bearing in mind their diagnostic value and the patterns they show. After analysing all the conditioning factors, no explanation has been found to the different course that this affectation (< 1 month and > 1 year of age respectively). Normally, neonatal mortality is closely related to other malformations, particularly to cardiovascular ones. Differential diagnosis is very important in the neonatal period, especially with regard to diaphragmatic hernia, lobar emphysema and pulmonary cysts. All these cases have been verified and classified by means of a pathologic study, which has shown the need for surgical operation. In the follow up of the patients no alteration has been noticed in the pulmonary function.

[Bronchiectasis in early childhood. Its surgical treatment]

We discuss the measures used, including physical examination, radiology, scintigraphy, T.A.C. and bronchography, to diagnoses 34 patients with bronchiectasis. In addition, the treatment used up until the time where the decision to perform surgery is also presented. Ten patients were submitted to surgical intervention and their operations, as well as the effected lobes, are described. The guidelines for surgical preparation, surgical difficulties encountered, postoperative care and the results of the surgeries are all discussed. Due to the age of some of these patients, obvious difficulties prevented functional testing. In those patients in whom it was possible, no loss in respiratory capacity has been observed.

[Surgical technique in reduced hepatic transplantation in children]

The lack of availability of pediatric donors for liver transplant has resulted in a high mortality rate among children awaiting transplantation, especially in patients weighing less than 10 kg. Knowledge of techniques of liver reduction allows liver transplantation in low-weight children with an adult liver graft, although with increased risk. The authors studied 70 pediatric liver transplants, 14.3% of whom received a reduced-size organ. Maximal difference between donor and recipient weight was 7.7. Segments II, III and IV (right hepatectomy) were transplanted in eight cases while segments II and III were transplanted in two cases. Transfusional requirements during the 48 hour postoperative period were not significantly different between patients with reduced-size liver and patients who received the full-size organ. There was not morbi-mortality secondary to surgical technique in reduced liver transplant group of patients.

[Complications of the use of implantable reservoirs of central venous access++ in pediatrics: causes and treatment]

The use of a totally implantable reservoir venous system (RIAV) in children improved the quality of life of a large group of patients undergoing long-term drug therapy. We have routinely used RIAV in the last four years with specific therapeutic indications. One hundred and seven Low Profile model Port-a-Cath (PAC) and two PAS-Port were followed in 104 patients, for a total of 43.000 days, i.e. 395 days per system. Complications which arose in our series were classified as severe (requiring system withdrawal) and slight (resolved medically). There were 17 severe complications: 9 obstructions, 5 infections, 2 skin necrosis and 1 catheter roture, and 5 slight complications including 2 obstructions, 2 system infections and 1 haematoma. Analysis of complications provided the experience necessary to establish a protocol, in order to reduce the number of catheter withdrawals to a minimum.

[Biliary complications in hepatic transplantation in children]

Biliary reconstruction continuous to be a source of severe complications in paediatric liver transplantation (PLT). Five (7%) biliary complications in 70 PLT in patients aged from 8 months to 13 years with a body weight of 4-37 Kg. were studied. End-to-end common duct anastomosis (group I) with Kehr drainage was performed in 18 cases. End-to-side common duct jejunostomy (group II) was performed in the remaining 52 cases. In this group, two patients were found to have stenosis and biliary stones or sludge respectively and one obstruction with sludge without evident stenosis. All cases required surgery and there was no mortality. Transparietohepatic cholangiography has provided early diagnosis of these complications and has proved to be a reliable method of choice. The use of inert biological material in Kher tubes and steroids slow down the organization of a fistulous tract, thereby causing the complications which arose in group I.

[Abdominal trauma at a third-level pediatric hospital: study of 150 patients]

All paediatric patients with abdominal trauma admitted in our hospital from 1975 to 1989 were retrospectively studied. We present 150 children with ages ranging from 1 to 14 years, mean age 6 +/- 2.6 years. Sixty-five percent of them were male. Trauma was classified as severe (37%) and mild (63%) and relationated with associated extra-abdominal injuries. The 42% of patients could be attended in other less specialized centres. Since 1982, severe abdominal trauma patient with parenchymal lesions of liver, kidney and spleen were treated according to a non-surgical protocol without secondary complications.

[Primary bladder diverticula. Study of 47 cases]

We report on 47 patients, surveyed and treated by us, diagnosed of primary vesical diverticula, having thus excluded all those secondary to lower obstructive anomalies, such as urethral valves and neurogenic bladder. Only seven out of the 47 patients were females: two of them had a iatrogenic cause and the remainder were of small size and associated with vesicoureteral reflux. All the cases have been documented by means of an intravenous pyelography (IVP), an excretory cystogram and a voiding cystourethrogram (VCUG). Many diverticula may go unnoticed when screened by IVP, whereas the cystogram and preferentially the VCUG are a 100 for 100 diagnostic. A 45 for 100 of these children (22 cases) had an attendant reflux and 23 for 100 (11 cases) had some other concomitant renal disease. Three further cases were iatrogenic, as a result of the methods employed for antireflux ureteral reimplantation. A 77 for 100 of the patients had urinary tract infection demonstrated by a urinary sediment and a positive culture. Surgery was performed on 34 patients, the indication being made on the basis of the big size of the diverticulum, its clinical repercussion, or because of its association with vesicoureteral reflux or any other kidney malformation. We employ an intravesical approach for the small diverticula with attendant reflux, but for resection of the sizeable ones, irrespective of the existence of reflux, we prefer the combined extra and intravesical approach, which allows a most accurate extravesical dissection, as well as the recognition and control of the ureter and the deferes duct, structures both that are usually anatomically distorted.

[Bolande's tumor: significance of its early diagnosis and treatment]

Four patients diagnosed of having a tumor of Bolande and treated at our institution in the past ten years are presented. In two of them, early diagnosis was aided by prenatal echographic techniques; the other two diagnoses were suspected ar three and ten days of age because of an abdominal mass. The four of them underwent a complete study which included: a plain abdominal film, an ultrasound scan and an intravenous urogram; the last three patients were also surveyed by a CT scan of the abdomen. Surgery was undertaken early on all the patients, the time of operation being in every instance within the first month of life. A laparotomy was performed and, once the contralateral kidney had been carefully examined, a nephroureterectomy was implemented, having been able to preserve in all the cases the suprarenal gland in view of the benign nature of the tumor. A histologic study confirmed the diagnosis and revealed the complete delimitation of the tumor by the renal capsule. The authors underscore the importance of this tumor's suspicion in the face of any solid renal mass detected by prenatal echography or in the neonatal period, since early diagnosis and treatment are imperative in order to prevent the ensuing complications in the rare and unfortunate cases that show a malignant tumoral trend.