Hearing impairment in congenital diaphragmatic hernia: the inaudible and noiseless foot of time

AIM OF THE STUDY

Infants with congenital diaphragmatic hernia (CDH) are at high risk of sensorineural hearing loss (SNHL). Extracorporeal membrane oxygenation is known to increase this risk, but little is known about other potential causes. We evaluated the impact of several risk factors on SNHL development in CDH survivors not treated with extracorporeal membrane oxygenation.

METHODS

All high-risk CDH survivors consecutively treated between 1999 and 2005 were included. SNHL was diagnosed based on formal assessment with standard audiologic tests. Patients with and without SNHL were compared for patient-related and treatment-related risk factors. Subsequently, a logistic regression analysis was performed to identify independent risk factors associated with SNHL development.

MAIN RESULTS

Out of 87 CDH survivors, 82 had a formal audiologic evaluation and 40 (49%) had SNHL. Patients with SNHL had significantly lower gestational age (P = .045); higher prevalence of sepsis (P < .001); older age at audiologic examination (P < .001); more episodes of hypocapnia (P = .045); higher prevalence of inhaled nitric oxide use (P = .005); longer mechanical ventilation (P = .009); and longer aminoglycosides (P = .006), furosemide (P = .004), and pancuronium bromide (P = .001) treatments. On logistic regression analysis, the only variable independently associated with the development of SNHL was patient's age at audiologic follow-up (P = .012).

CONCLUSIONS

Several risk factors were associated with SNHL development at univariate analysis. After logistic regression, only age at evaluation remained independently associated with SNHL. Routine audiologic follow-up is advocated in all CDH patients. Further studies are needed to define if other (genetic) factors may be involved in the pathogenesis of SNHL in patients with CDH.

Musculoskeletal tumours: preliminary experience with perfusion MRI

PURPOSE

Our study aimed to assess the role of magnetic resonance imaging (MRI) in the characterisation of musculoskeletal tumours and to identify specific perfusion patterns for the different tumours.

MATERIALS AND METHODS

Between January 2003 and September 2005, we evaluated the conventional and perfusion MRIs of 39 patients with musculoskeletal tumours. Dynamic MRI was performed with a 1.5-T and 1.0-T MRI unit before and after the intravenous administration of contrast material, using dedicated phased-array coils appropriate for the region to be studied and fast and ultrafast consecutive sequences. Postprocessing was done on an independent workstation (Advantage Windows, GE Medical System), with Functool (GE) software, which allowed a quantitative evaluation of enhancement as a function of time. The results were compared with the histopathological diagnoses obtained by biopsy or surgery.

RESULTS

The lesions identified in the 39 patients included 23 soft tissue tumours (12 benign, 11 malignant) and 16 bone tumours (ten benign, six malignant). Comparing the time-intensity diagrams of lesions of the same histological type, we found typical enhancement patterns for some bone tumours only, especially for bone, cartilaginous, fibrohistiocytic and pseudoinflammatory lesions. No typical enhancement pattern could be detected for any of the histological types of soft tissue tumour. Analysis of the slope of the time-intensity curves has a sensitivity and specificity of 64%-58% for soft tissue tumours and 86%-67% for bone tumours in determining the biological aggressiveness of the lesions.

CONCLUSIONS

Perfusion MRI had moderate sensitivity and specificity in the differential diagnosis between lesions with high or low biological activity. Only in a few cases was it possible to find some correlation between perfusion patterns and lesion histology. The slope values should therefore be used in combination with conventional spin-echo images and other imaging and clinical data in order to narrow the field of the possible differential diagnoses and reliably predict the nature of the lesion.

Lipoid proteinosis: case report and review of the literature

Lipoid proteinosis is a rare autosomal recessive disorder, characterized histologically by infiltration of periodic acid Schiff-positive hyaline material into the skin, upper aerodigestive tract, and internal organs. Classical clinical features include skin scarring, beaded eyelid papules, and laryngeal infiltration leading to hoarseness. Moreover, the infiltrates in the tongue and its frenulum limit lingual movements and cause speech difficulties. Usually, the hoarse voice is present at birth or in early infancy, as the first manifestation. In more severe cases, diffuse infiltration of the pharynx and larynx might cause respiratory distress, at times requiring tracheostomy. The disorder has recently been shown to result from loss-of-function mutations in the extracellular matrix protein 1 gene on chromosome 1q21. The function of the protein extracellular matrix protein 1 gene is still unclear, although an important role in skin physiology and homeostasis has been hypothesized. In this report, the case is described of a 6-year-old girl with lipoid proteinosis. Histopathological examination of a laryngeal biopsy specimen showed massive deposits of eosinophilic, periodic acid Schiff-positive, and diastase resistant material in the lamina propria corroborating the clinical diagnosis of lipoid proteinosis. Molecular analyses in this patient also confirmed the clinical diagnosis. The proposita was a compound heterozygote for a new small rearrangement (543de1TG/ins15) in exon 6, and a nonsense mutation (Arg243Stop) in exon 7. Together with previously documented mutations in the extracellular matrix protein 1 gene, this study supports the hypothesis that exons 6 and 7 are the most common sites for extracellular matrix protein 1 gene mutations in lipoid proteinosis.

Flow cytometry immunophenotyping and polymerase chain reaction-site-specific primers genotyping for HPA-1 alloantigens in an Italian blood donor population

BACKGROUND AND OBJECTIVES

There is increasing interest in the development of rapid and reliable techniques for human platelet alloantigen (HPA) typing. This study investigates the reliability of flow cytometry for large-scale immunophenotyping of platelet alloantigens.

MATERIALS AND METHODS

We used flow cytometry and polymerase chain reaction-site-specific primer (PCR-SSP) for the characterization of the human platelet antigen 1 (HPA-1) mosaic in blood donors.

RESULTS

By using specific alloantisera and immunofluorescence labelling 9 (2.6%) out of 351 samples were HPA-1a-negative. To confirm this antigenic phenotype, all of the latter samples were submitted to PCR-SSP analysis, showing an HPA1-b/b genomic pattern. In HPA-1a-positive donors, flow cytometry was unable to distinguish HPA-1a/b heterozygous from HPA-1a/a homozygous subjects who were clearly identified by genotyping.

CONCLUSIONS

Flow cytometry is a valuable tool for large-scale screening to identify HPA-1a-negative persons, whereas genotyping is the assay of choice for zygosity testing, antenatal diagnosis, and for thrombocytopenic alloimmunized patients.

Results and potential of somatostatin receptor imaging in gastroenteropancreatic tract tumours

BACKGROUND

Somatostatin receptor imaging with 111In-pentetreotide is widely accepted as an essential step in the management of patients affected by neuroendocrine tumours of the gastro-entero-pancreatic tract. Many data are already available on the high sensitivity of this technique.

METHODS

We present a review of the published data together with the results of a study involving 253 patients submitted to somatostatin receptor imaging in three Italian hospitals. The patients were divided into two groups treated with different acquisition and processing protocols.

RESULTS

The overall sensitivity was as high as (169/176) 96% in both groups, while the specificity was higher in the group in which semi-quantitative evaluation of somatostatin receptor density was performed: (23/26) 88% vs (39/51) 76%. The use of this method is recommended to increase the specificity of 111In-pentetreotide imaging.

CONCLUSIONS

Our results with somatostatin receptor imaging in neuroendocrine tumours of the gastro-entero-pancreatic tract demonstrate that all figures of merit are excellent when imaging is accurately performed and analysed by experienced operators.

Characterizing an ectopic secreting carcinoid with indium-111-DTPA-D-Phe-pentetreotide

This report describes a technique that increases the specificity of 111In-pentetreotide as evaluated in a patient with ectopic Cushing syndrome.

METHODS

Two separate SPECT studies were performed with different pharmacologic protocols, both including treatment with cold octreotide. The imaging protocol provides acquisitions at 4 and 24 hr after injection. The quantitative approach was based on the ROI activity (manually designed) of an area of pathological lung uptake (ROI-T) versus background (ROI-NT). Histological, histochemical and specific mRNA measurements confirmed the presence of an SSR2 receptor carcinoid in the lung.

RESULTS

The time course of ROI-T/ROI-NT is a linear increase between 4 and 24 hr. Washout with cold octreotide diminished the ROI-T activity content and the saturation protocol increased ROI-T/ROI-NT, confirming the specific nature of the uptake.

CONCLUSION

Displacement and saturation protocols in 111In-pentetreotide imaging demonstrated the specificity of tumor binding.

Application of a surface matching image registration technique to the correlation of cardiac studies in positron emission tomography (PET) by transmission images

The aim of this work is to assess the accuracy of a surface matching registration (SMR) technique for the correlation of cardiac studies in positron emission tomography (PET). Registration parameters were estimated by matching corresponding body surfaces, extracted from transmission studies, aligned to the PET emission images to be correlated. The accuracy of the SMR technique in this specific application was assessed by computer simulations, phantom experiments and on clinical PET data. Registration accuracy was evaluated in relation to the body surfaces (external, internal and the combination of the two) used by the SMR method. Better results were found when matching shaped and irregular surfaces such as internal lung contours. The robustness of the method was verified for different counting statistics recorded in transmission images. A clinical validation of the SMR method was performed on fluorine-18-deoxyglucose PET cardiac studies.

Health care and seniors. Ethnic, racial, and cultural dimensions

The profiles of Canadian seniors are changing. Racial, cultural, and social context is becoming increasingly important in the health care of seniors. This article discusses the interactions between physicians and seniors affected by ethnocultural variables and suggests a framework for cross-cultural care.

Communication: Cross-cultural applications of the physician's art

Cross-cultural care should not be viewed as a problem to be dealt with within a physician's practice. Rather it must be seen as providing a solution to health care within the context of global demographic changes. It is clear that in Canada, as elsewhere, family physicians need to develop a better understanding of the cross-cultural process in order to be able to provide appropriate care for patients who are from culturally diverse backgrounds.

Systemic absorption of 3H-fenticonazole after vaginal administration of 1 gram in patients

Fourteen women, five with normal cervicovaginal mucosa (Group 1), five with cervical carcinoma (Group 2) and four with relapsing vulvovaginal candidiasis (Group 3) were enrolled and completed this open clinical trial. Each subject received a single dose of 1.82 +/- 0.3 g on average of vaginal paste (for ovules) containing about 1000 mg of 3H-fenticonazole nitrate (266 microCi). Twelve hours after vaginal administration, the paste was removed by vaginal washing. Blood, urine and stool samples were collected at specified time intervals for five days. Plasma, urine, stools and all used material in contact with the paste were assayed for radioactivity. No measurable levels of radioactivity were detected in plasma of subjects of Groups 1 and 3 while in 4 of the 5 subjects with cervical carcinoma (Group 2) fenticonazole was detected during the 24 h after administration with a peak level at about 8 hours. For a period of 5 days, 0.4-1.5% of the dose on average was recovered from urine, and 0.18-0.32% from feces. Based on the excretion data, the extent of vaginal absorption of fenticonazole nitrate in women with vulvovaginal candidiasis was 1.81 +/- 0.57% of the dose, while in women with normal cervicovaginal mucosa it accounted for 0.58 +/- 0.28% of the administered dose. In patients with cervical carcinoma, absorption was 1.12 +/- 0.53%. The maximum amount absorbed corresponds to an exposure of about 0.4 mg/kg of fenticonazole nitrate (for a subject weighing 50 kg). Consequently, the vaginal administration of one ovule containing 1000 mg of fenticonazole nitrate seems to be devoid of risk for patients.

Cervical chordoma in childhood: clinical statistical contribution

Parapharyngeal neoplasias are rarely noticed in childhood, since they have their peak incidence between the 2nd and 4th decade of life. The authors report a case of a 4-year-old patient presenting with a retrostyloid mass, accompanied by nasal obstruction and some difficulty in swallowing at 12 months of age. CT scanning well ascertained the delimitation of the tumor, but it was of no help in the differential diagnosis. In fact, after surgical excision, the histological examination of the specimen revealed a chordoma. This result was unexpected because of the region concerned and the lack of a CT demonstration of the cervical boney involvement. A cervical vertebral localization of a chordoma is rare in all age groups and it is of particular clinical and statistical interest in infancy.

Immunoscintigraphy of adenocarcinomas by means of radiolabeled F(ab')2 fragments of an anti-carcinoembryonic antigen monoclonal antibody: a multicenter study

F(ab')2 fragments of anti-carcinoembryonic antigen (CEA) monoclonal antibody F023C5, determined to be more suitable than intact IgG and Fab fragments for immunoscintigraphy, were labeled with 131I or conjugated to DTPA for instant 111In-labeling, and administered i.v. (2-3 mCi/0.5 mg) to 509 patients in 11 nuclear medicine departments: 284 patients had gastrointestinal adenocarcinomas, 204 had nongastrointestinal adenocarcinomas and 21 were control; serum CEA was elevated in 169 patients, normal in 115, and not determined in 225. The following results were obtained: (a) no adverse reactions; (b) tumor imaging in 324 patients (in particular, in 81.5% CEA-seropositive and in 69.0% CEA-seronegative patients); (c) no significant difference in sensitivity among the results of the 11 departments; (d) no significant difference in overall sensitivity between 131I-and 111In-labeled immunoradiopharmaceuticals; (e) the fraction of documented lesions imaged was 73.3% in CEA-seropositive and 53.7% in CEA-seronegative patients; (f) the detection of liver metastases was hampered, particularly when using the 111In-labeled reagent, by nonspecific radioactivity uptake; (g) the major cause of negative immunoscintigraphy results was a lack of CEA in tumor lesions, as documented by immunohistochemistry; (h) lesion size is also important since the sensitivity was 64% for lesions up to 2 cm in diameter and 84% for larger lesions; (i) many "unexpected" radiolocalizations were recorded. Most were identified as occult tumor lesions. In 35 patients, this finding contributed to the early detection of tumor recurrences.

Multiculturalism, Medicine and Health: Part VI

In this article, which concludes the series, the author presents an overview of the earlier parts, contending that physicians must be aware of, and respond to, cultural factors in our increasingly pluralistic society in order to provide optimum health care for a variety of patients.

Multiculturalism, medicine and health part v: community considerations

In this article the author examines multicultural health issues from a community perspective, dealing with relationships between cultural communities and health-care systems in terms of: hospitals and health-care institutions, family and social supports, social norms, and community-health programs.

Multiculturalism, Medicine, and Health Part IV: Individual Considerations

In this fourth article of his series, the author examines some specific ethnoculturally related factors in the context of the doctor-patient interaction. Physicians should be aware of these factors in order to provide appropriate and effective care to individuals of various cultural backgrounds.

Multiculturalism, Medicine, and Health Part III: Health Beliefs

Supernatural beliefs relate to a Power or powers considered beyond nature. Persons who wish to draw upon the power of supernatural forces often attempt to do so through prayers, ceremonies, or special acknowledgement. While some physicians feel uncomfortable at times with beliefs that differ from their own, the chaplaincy system, in place in most hospitals, is evidence that health-care systems can comfortably accommodate supernatural beliefs. We must make an effort to understand and accommodate supernatural beliefs other than the Judaeo-Christian tradition and to acknowledge their importance to other cultural groups. A more accepting approach will improve physician-patient relationships.

Multiculturalism, Medicine and Health Part II: Multicultural Health Care

In this second article of a series, the author develops the concept of health-related beliefs as belonging to one of three classifications: beliefs in "nature" or natural causation of health and illness; beliefs relating to the "self" as affecting health; and beliefs in the effects of supernatural forces on the health of individuals. He goes on to discuss beliefs in the first category and to show how physicians, by recognizing and respecting their patients' views on these matters, can improve the doctor-patient relationship and increase patient compliance.

Multiculturalism, medicine and health part I: multicultural health care

CULTURALLY SENSITIVE HEALTH CARE IS NOT A MATTER OF SIMPLE FORMULAS OR PRESCRIPTIONS THAT PROVIDE A SINGLE DEFINITIVE ANSWER: rather, it requires understanding of the principles on which health care is based and the manner in which culture may influence those principles. This series of six articles will examine influences that ethnic and cultural background may have on health and health care. Part I outlines the development, importance and relevance of multicultural health care. The author stresses the importance of understanding community needs, cultures and beliefs; the active interest and participation of the patient in his or her own health care; the importance of a good physician-patient relationship; and the benefit of an open-minded approach by physicians and other health-care workers to the delivery of health-care services.

Otologic impairments in achondroplasia: a nosologic assessment

The AA report a clinical and radiological study performed in 18 achondroplastic patients in order to achieve a nosological settlement of the otological impairments. They found two main otological syndromes; one, a congenital dysplasic syndrome, showing permanent conductive or sensory-neural hearing loss due to malformations of the middle ear or of the inner ear; the other, an inflammatory tubal tympanic syndrome with transient conductive hearing loss, which is relatively frequent in achondroplastic patients, but seems not related to the main disease.

Treatment of elevated intraocular pressure with concurrent levobunolol and pilocarpine

Between July 1983 and January 1986, 54 patients with open-angle glaucoma or ocular hypertension were treated for 3 months with 2% pilocarpine hydrochloride (given four times daily) and one of two beta-adrenoceptor blocking drugs, levobunolol hydrochloride (0.5% [17 patients] or 1% [19 patients]) or 0.5% timolol maleate (18 patients), given twice daily. Before entry into the study all patients had had stable intraocular pressure (IOP) with treatment with 0.5% timolol and 2% pilocarpine. Stable IOP was successfully maintained in up to 88% of the patients in the two levobunolol-pilocarpine groups and in 83% of those in the timolol-pilocarpine group. Two patients experienced adverse reactions: one, who received timolol and pilocarpine, suffered blepharoconjunctivitis, and the other, who received 1% levobunolol and pilocarpine, experienced bradycardia. The results indicate that the levobunolol-pilocarpine regimens were as safe and effective as the timolol-pilocarpine regimen in stabilizing IOP.

Multicenter study of immunoscintigraphy with radiolabeled monoclonal antibodies in patients with melanoma

A multicenter study was performed to analyze the efficacy of 99mTc- and 111In-labeled F(ab')2 fragments of monoclonal antibody (MoAb) 225.28S (reactive with a high molecular weight melanoma associated antigen) to radioimage malignant lesions in patients with melanoma. A total of 254 melanoma patients, carrying 412 documented melanoma lesions, were studied in 10 nuclear medicine departments. A total of 377 lesions were visualized in 206 patients; in particular (a) 250 of 412 known lesions were visualized in 159 of 191 patients known to carry melanoma lesions; (b) 95 occult lesions were visualized in 61 patients of the same group; and (c) 32 lesions were visualized in 15 of 63 patients without diagnosed lesions. The melanomic nature of 101 of 127 radioimaged occult lesions was confirmed by clinical criteria and/or by additional laboratory investigations. These results indicate that immunoscintigraphy with radiolabeled F(ab')2 fragments of MoAb 225.28S can provide clinically useful information. Analysis of the variables influencing the outcome of immunoscintigraphy with 99mTc- and 111In-labeled F(ab')2 fragments of MoAb 225.28S confirmed the role of size, anatomic site, and level of high molecular weight melanoma associated antigen in melanoma lesions. Such analysis also showed, for the first time, the influence (a) of the isotope used to radiolabel the antibody fragments and (b) of the clinical stage of the patients. The present study has shown good agreement in the results obtained by the 10 nuclear medicine departments, suggesting that immunoscintigraphy with radiolabeled F(ab')2 fragments of MoAb 225.28S is a reliable procedure.

Sudden deafness in children

The authors present a report of 38 cases of sudden deafness (SD), observed in the Bambino Gesù Hospital in Rome. Twenty-six cases were due to infective causes, such as mumps, meningitis, measles, varicella or to physical trauma. The other 12 cases were defined as idiopathic (ISD) on the basis of their anamnestic and clinical findings. The etiological, prognostic and therapeutic aspects are discussed.

Reliability of cerebral radioisotopic angiography and of directional Doppler C.W. in the diagnosis of cerebrovascular insufficiency

The diagnostic value of radioisotopic cerebral angioscintigraphy (R.A.) and of Doppler CW (D.C.W.) techniques to identify stenosis of the internal carotid artery in its extracranial course was studied in 97 patients with ischaemic lesions (50 T.I.A. and 47 Complete Stroke). The results of R.A. and D.C.W. were compared with those of contrast carotid-angiography (C.A.). C.A. revealed stenosis above 50% or complete occlusion in 22% of cases, whereas D.C.W. and R.A. showed flow reduction in 27% and 48% of the cases respectively. In T.I.A., C.A. positivity went down to 8%; D.C.W. to 16%; and R.A. to 34%. In "Complete Stroke" positivity was 36% for C.A.; 41% for D.C.W.; and 62% for R.A. There was a high number of false positive findings with D.C.W. (8) but even more with R.A. (27). False negative findings occurred only in two cases with R.A. These data confirm the diagnostic value of these two noninvasive techniques to identify haemodynamically carotid stenosis. The use of both methods can reduce error due to false negativity. The rather marked frequency of false positivity, particularly with reference to R.A. doesn't affect the diagnostic value of the two methods.

Immune complexes in uveitis

We determined the incidence of immune complex increases, the nature of immune complexes, and the correlation between the immune complex level and clinical uveitis status in patients with chronic iridocyclitis and chronic diffuse uveitis. Ten of 16 patients with chronic iridocyclitis had increased levels of immune complexes, and this correlated with disease activity. Immune complexes were detected in ten of 12 patients with chronic diffuse uveitis. These complexes have a molecular weight of approximately 2 X 10(6) daltons. The antibody component of immune complex is IgG; however; the antigenic component of the immune complexes is unclear.

"Normal" pressure hydrocephalus in chronic inflammatory diseases: a clinical and laboratory study

A review of the 21 cases of "normal" pressure hydrocephalus (N.P.H.) identified by means of radioisotope cisternography, seems to support the basic views of Adams et al. (1965) that a chronic inflammatory disease is an important cause of N.P.H. The clinical and laboratory date made it possible to identify a substantial number of cases affected by N.P.H. in the course of a chronic inflammatory disease; of particular interest were those affected by syphilis. In this connection it seems possible that the symptoms of classical neurosyphilis may be very similar to those often seen in patients with N.P.H.