Spinal intradural müllerianosis: a case report

Müllerianosis is a term used to indicate lesions composed of an admixture of two or three types of müllerian-derivation glands in heterotopic sites. In this report we describe a case of spinal cord müllerianosis which occurred in a 42-year-old woman. The patient had suffered from catamenial lumbago and sciatica of three years duration before undergoing laminectomy of L2-L3 with excision of a polypoid mass that compressed nerve trunks. At histological examination, the lesion was composed of endocervical, endometrial and tubal glands within a smooth muscle nodule. These features were consistent with a diagnosis of müllerianosis. This is a very uncommon form of presentation of müllerianosis that must be correctly identified since patients can benefit from hormonal therapy.

Urinary sodium, potassium, chloride, calcium, magnesium, phosphate, urate and urea in healthy subjects aged 5-18 years

The determination of urinary electrolytes is helpful in the diagnosis of children with dyselectrolytemia or metabolic acid-base imbalance of unknown origin [1–3]. The urinary excretion of electrolytes has mostly been evaluated by investigating 24-hour urine specimens [4]. The collection of such urine samples is laborious in children without bladder control, in those unable to comply while playing or at school, or in those with acute electrolyte abnormalities. The usefulness of measuring urinary solutes in relation to creatinine in urine has been suggested [5].

Solitary fibrous tumor of the meninges: two new cases and review of the literature

BACKGROUND

Solitary fibrous tumor (SFT), a mesenchymal neoplasm originally described in the pleura has been more recently reported to arise in a number of other sites, including the meninges. Nowadays immunohistochemistry facilitates the otherwise problematic differential diagnosis with regard to other benign and malignant spindle cell neoplasms of the central nervous system.

METHODS

Two recently treated cases of meningeal SFT (one craniospinal, one spinal) are presented and discussed in the light of the present knowledge and a review of the literature.

RESULTS

Total resection was followed by complete recovery and both patients are presently asymptomatic and without evidence of disease. The microscopic and immunohistochemical profiles (CD 34, vimentin positive; S-100, EMA negative) were consistent with those of previously reported cases.

CONCLUSIONS

The majority of SFTs behave in a benign fashion and do not recur unless subtotally resected. Malignant variants may account for up to 37% of SFTs in other locations but have never been reported to occur in the meninges. Meningeal SFTs are to be considered a new pathological entity. Wider use of immunohistochemical screening should enable the determination of their real incidence; larger series and longer follow-up will provide conclusions about their treatment and prognosis.

[Improvement of postinfarct left myocardial contractile function after administration of diltiazem]

BACKGROUND

The impairment of intracellular calcium homeostasis is an important biochemical alteration in stunned and hibernating myocardium. These different forms of viable myocardium frequently occur after myocardial infarction and their recognition may modify the therapeutic program and prognosis. Experimental studies and experiences on male subjects have demonstrated that calcium-channel blockers exert a protective action on myocardial reperfusion injury and reduce infarct size.

OBJECTIVES

The aim of the present study was to evaluate the efficacy of i.v. diltiazem (i.e. a calcium-channel blocker with negative inotropic effect) in enhancing the contractility of viable akinetic myocardium in patients after myocardial infarction.

METHODS

Sixty patients (52 males and 8 females, age 57 +/- 10 years) with the first acute myocardial infarction were evaluated with dobutamine-echocardiography 9 +/- 2 days after admission and on the following day with diltiazem-echocardiography. Diltiazem was administered i.v. using repeated boluses of 0.25 mg/kg up to the maximum dose of 1 mg/kg. Before and during the infusion, left ventricular regional function was scored and the Wall Motion Score Index (WMSI) was calculated; ECG and arterial blood pressure were also monitored. Results were compared with low-dose dobutamine-echocardiography. In a subset of 13 patients who underwent myocardial revascularization (7 coronary artery by-pass graftings and 6 percutaneous transluminal angioplasties), post-procedure echocardiograms were performed to evaluate whether regional left ventricular function had improved.

RESULTS

Low-dose dobutamine and diltiazem enhanced regional left ventricular contractility in 28 and 31 patients, respectively; both tests were positive in 26 cases. Conversely, dobutamine-test was negative in 32 patients and diltiazem in 29, with concordance in 27. A good correlation was found between diltiazem and dobutamine WMSI at the basal evaluation (r = 0.91; p < 0.000) as well as during the pharmacological test (r = 0.86; p < 0.000). In patients who underwent myocardial revascularization, the same good correlation was found between diltiazem-WMSI and WMSI evaluated after the procedure (r = 0.91; p < 0.000).

CONCLUSIONS

Acute i.v. administration of diltiazem about ten days after myocardial infarction may enhance the contractility of viable akinetic ventricular wall segments, as evaluated with echocardiography. The results of this study may have some physiopathological and therapeutical implications that could lead to reconsidering the use of calcium-channel blockers, particularly diltiazem, in selected patients after myocardial infarction.

Neurophysiological evaluation with multimodality evoked potentials in craniostenosis and craniofacial stenosis

Multimodality evoked potentials (somatosensory and acoustic) have been recorded before surgery in children selected for surgical treatment for different kinds of craniostenosis and craniofacial stenosis. Evoked potentials were found to be deranged on at least one recording in 50% of cases, suggesting a significant incidence of neurophysiological alterations in these patients. No correlation was found between evoked potentials' derangements and clinical status, radiological findings, or different kinds of craniostenosis; moreover, a significant correlation was found between neurophysiological alterations and the age of the children. These preliminary data might define the possible role of neurophysiological tests in the presurgical evaluation of craniostenosis and craniofacial stenosis.

A delayed complication with steel wire osteosynthesis

We treated a 6-year-old child for hyperteleorbitism. We performed a facial bipartition steel wire osteosynthesis of the frontal bone. After 7 years we observed two episodes of pneumococcal meningitis, which were treated with intravenous antibiotic, resulting in a prompt recovery. The computed tomographic scan and nuclear magnetic resonance image showed the steel wire included in the frontal sinus and in contact with the dura mater. Removal of the wire and suture of the dura allowed prompt recovery.

Transesophageal echocardiographic color Doppler evaluation of pulmonary vein flow during ventricular pacing

Hemodynamic changes induced by ventriculo-atrial retroconduction has been considered an important factor in pacemaker syndrome. The contraction of atrial muscles, when the mitral valve is closed, induces a reverse systolic flow into the pulmonary veins, because the outlet of the pulmonary vein in the left atrium is not protected by a valve. The profile of the pulmonary vein forward flow of 25 patients was examined using transesophageal echocardiography (TEE) technique. Doppler evaluation of velocity-time integrals of forward flow (fVTI) and reverse flow (rVTI) was measured both during sinus rhythm or fully automatic (DDD) pacing, and ventricular demand pacing (VVI) accompanied by ventriculoatrial (VA) retroconduction or atrioventricular (AV) dissociation. The mean fVTI was reduced from 21.1 cm +/- 6.2 cm in DDD or sinus rhythm (SR) to 16.4 cm +/- 6.6 cm in VVI (p < 0.001). The mean rVTI was increased from 1.4 cm +/- 0.8 cm in DDD or SR to 4.3 cm +/- 1.8 cm in VVI (p < 0.001). The degree of such alterations varied considerably from patient to patient and this may explain the variability of clinical symptoms reported for pacemaker syndrome. It has not been possible to establish a direct correlation between the magnitude of hemodynamic changes and the severity of the symptoms observed because all the patients were in sequential stimulation or in SR and were temporarily submitted to VVI stimulation during the echocardiographic examination.

Extradural haematomas: how many deaths can be avoided? Protocol for early detection of haematoma in minor head injuries

Since 1988 in the referral area of the Neurosurgical Unit of Cesena, Italy, a protocol for prevention of deterioration in minor head injury was adopted. Adult patients admitted to any hospital with a GCS score of 15 and 14 (transient) without neurological deficit are submitted to skull x-ray: if a fracture is present the patient is sent for CT to the nearest regional Center. In children skull x-ray is not routinely performed and the patients are admitted for observation to the nearest regional hospital. To assess the effects of such a protocol on morbidity and mortality of extradural haematoma (EDH), from June 1989 to September 1991 a consecutive series of 95 patients harbouring a significant acute EDH was collected. Mean age was 31 years; in 70% trauma was caused by a road traffic accident. The patients were divided into 3 categories: a) Clinical deterioration: mean GCS at surgery was 7.7; out of 27 patients, 12 had anysocoria and 3 bilaterally fixed pupils; the outcome showed only two deaths, one related to the EDH and the other to cardiac arrythmia. Most of the patients deteriorated either during transport after being recognized as at risk or already in Neurosurgery allowing rapid surgical treatment. b) Impaired consciousness (18 cases) and c) Minor head injury (50 cases) are groups of patients treated without morbidity and mortality. If we compare these results with those of a previous study of our group done in 1980-86, there is a statistically significant difference concerning both mortality and morbidity. Our protocol proved therefore to be adequate in preventing most deaths that occurred following clinical deterioration in an apparently low risk patient.

[Simplified determination of proteinuria in children using a single urine sample]

In children and adolescents the evaluation of proteinuria is cumbersome because of the need to obtain timed urine collections. The protein/creatinine ratio (using a Coomassie blue binding technique and a kinetic Jaffe reaction, respectively) measured in 134 pediatric patients with renal disease aged 2 months to 16 years correlated closely with the overnight urine protein excretion rates using the statistical approach suggested by Bland and Altman to compare methods of measuring some quantity. The upper limit of urinary protein/creatinine ratio measured in 252 healthy children and adolescents aged 4 to 19 years was shown to be 19 mg/mmol. No age-related differences in urinary protein excretion were noted in healthy subjects. The random urine protein/creatinine ratio provides an accurate assessment of quantitative protein excretion and avoids errors and difficulties associated with timed urine collection.

Management of low-risk head injuries in an entire area: results of an 18-month survey

All patients admitted following a minor head injury (GCS is without neurological deficits) during an 18 month period in an entire area were submitted to the same diagnostic and therapeutic protocol. Adult patients were x rayed and in the cases with skull fracture (even asymptomatic), a computed tomographic (CT) scan was performed. Children (below the age of 14) did not routinely receive skull X-rays but were admitted to one of the five regional hospitals where a CT scanner was available 24 hours per day. Neuroradiologic investigations (carried out in over 600 patients) showed posttraumatic lesions in 201 cases; 113 of these patients were transferred to the neurosurgical center. There were 49 patients with extradural hematomas, 41 with brain contusions, 17 with depressed skull fractures, and six with subdural hematomas. Of these 113, 40 patients were operated on (mainly extradural hematomas); surgical indications were based on appearance of clinical deterioration, lesion volume, presence of midline shift, and/or compressed third ventricle and basal cisterns. In eight cases there was a clinical deterioration to a GCS of 13 or less; in all of these patients, the CT diagnosis (and transfer to a neurosurgical center, preceded the onset of deterioration. All patients admitted to such a center had a good outcome, but a survey of deaths related to head injury in the area revealed two fatalities following minor head injury. The only avoidable death was a patient with multiple brain contusions who developed sudden brain swelling on day 12 post-trauma. We conclude that, even if management mortality is not zero, our protocol is sufficiently safe for the treatment of minor head injury.

Intracranial lesions of surgical interest in minor head injuries in paediatric patients

Among 62 children and adolescents (1-16 years) admitted over a period of 3 years (1987-1989) with a minor head injury, 33 (53%) were found to harbour intracranial lesions of surgical interest. The most frequent lesion found was extradural haematoma (17 cases), followed by cerebral contusion (7 cases), depressed fracture (4 cases), depressed fracture with underlying contusion (3 cases) and pneumocephalus (2 cases). A skull fracture was present in 88% of patients with an intracranial lesion and in 50% of patients without lesions. Fifteen patients underwent surgery for an extradural haematoma or a depressed fracture. All had a good recovery. No correlation was found between age and Glasgow Coma Score on the one hand, and the incidence of both the presence of intracranial lesions and the necessity of surgical treatment on the other. The only important risk factor proved to be a skull fracture, which had occurred significantly more often in patients with intracranial lesions than in those without any.

Multimodality evoked potentials in HIV infected subjects: a longitudinal study

18 subjects with symptomless HIV infection were investigated with multimodal evoked potentials for possible CNS involvement and again after an 8-12 month interval. 13 subjects showed neuropsychological changes, which were confirmed at the second examination. The 5 subjects found normal remained so at the second examination. On WAIS assessment the only patient to earn pathological scores was the one with the greatest evoked potentials changes. Thus the evoked potentials procedure proved capable of identifying early CNS involvement by HIV infection.

[Psychotherapy in comparison: have all really earned a prize?]

The aim of the project is a comprehensive analysis of psychotherapeutic outcome research from a differential perspective. All controlled psychotherapy outcome studies which have been published until 1983 (n = 897) were carefully analyzed with an especially developed assessment-manual. Special importance was laid on those features of the results that throw some light on the comparative effects and prescriptive criteria of the therapies under investigation and their preconditions in the experimental design, measurement and statistical analysis of the respective study. The procedure is described in detail. It results in a comprehensive report on the research which has been done and the results that have been found for each psychotherapy method. An example of such a report is given.

Intracranial tumors during the 1st year of life

Twenty-eight patients with intracranial tumors symptomatic during the 1st year of life were managed from January 1970 to March 1988. Supratentorial location (19 cases) was dominant over the infratentorial. The most common histological type was astrocytoma; choroid plexus papilloma and ependymal tumors followed in frequency. Twenty-two infants (78.6%) had associated hydrocephalus. Macrocrania, vomiting, delayed milestones, and behavioral disturbances were the chief clinical manifestations. Four patients were admitted in extremely deteriorated condition and died preoperatively. Twenty cases underwent surgery for tumor removal with a 1-month mortality rate of 20%. Tumor excision provided permanent relief of hydrocephalus in the majority of the surviving cases. Five patients received conventional radiotherapy. Stereotactic brachytherapy yielded an excellent result in 1 case. Overall 13 cases are currently alive; 6 of them have survived longer than 6 years. Fourteen of the 15 patients who were dead at follow-up succumbed within 1 year after diagnosis.

Monoclonal antibodies to human kidney gamma-glutamyltransferase

Eight hybridoma clones secreting large amounts of monoclonal antibodies against purified human kidney gamma-glutamyltransferase (GGT) were isolated and produced in ascites. None of them inhibits the catalytic activity of GGT. They all bind to the heavy subunit of this dimeric enzyme. Immunoblot analysis showed that these antibodies react with the catalytically active GGT. The monoclonal antibodies also recognize the heavy subunit of the human liver enzyme. This is of interest, as serum GGT is known to originate from the liver. None of the monoclonals reacts with GGTs from rat or pig kidney. After identification of epitopes specificities, the antibodies will be used for the development of immunoassays of GGT especially in human serum.

Metastatic spread of benign intracranial meningioma

A case of benign meningioma of the superior sagittal sinus is reported, which recurred three times during a period of six years. At the time of the first recurrence the overlying bone was eroded and the tumor grew subcutaneously; the second recurrence was associated with a pulmonary metastatic deposit of extraordinary size. The literature dealing with remote extracranial spread of meningiomas is briefly reviewed.

Tropolone: a lipid solubilizing agent for cationic metals

Lipid soluble agents which chelate radioactive cations have several potential uses in nuclear medicine including: brain imaging, labeling of blood elements, and identifying fatty infiltration of organs. A tropolone-gallium complex has been characterized by the determination of in vitro partition ratios correlated with in vivo organ distribution in the rat. Partition ratios were determined for gallium-67 citrate, indium-114m chloride, and iron-59 chloride cations complexed with tropolone in chloroform + water, octanol + water, olive oil + water, and olive oil + plasma two-phased systems. Tropolone proved to be highly effective in the lipid solubilization of these metal cations. Distribution studies in animals of these cations complexed with tropolone demonstrated an increased concentration of these cation complexes in tissues of high lipid content when compared with appropriate controls.