Treatment of hereditary amyotrophic lateral sclerosis

Currently, only four molecules can be prescribed for amyotrophic lateral sclerosis (ALS), of which only one is approved worldwide for this indication, riluzole. Although progress in the therapeutic field remains unsatisfactory, we have to notice that genetics have undergone impressive improvements over the last three decades and, by extension, our knowledge of ALS cases linked to a pathogenic mutation that accounts for 10% of all cases (either sporadic or familiar) and is currently called hereditary ALS (hALS). In many neurological diseases treatment targeting pathogenic genes have significatively improved the natural profile of the disease: this is perfectly illustrated for familial amyloid neuropathy and spinal muscular atrophy. Because of these findings and the urgent need to find a cure for ALS, many trials have focused on familial ALS targeting the four most important genes linked to the disease: C9orf72, SOD1, TARDBP and FUS. We propose in this review an update on the perspectives of treatment that may be available in mid-term in hALS and will discuss in the last part the potential consequences for asymptomatic relatives of patients with a hALS and for ALS patients.

1142. A multicenter cohort study to identify differences between methicillin-susceptible and methicillin-resistant Staphylococcus aureus infections in pediatrics in Bogotá, Colombia, 2014-2018

Background

The epidemiology of methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) S. aureus in pediatrics has changed in recent years. MRSA infections have been reported to be more severe than MSSA.

Methods

Multicenter retrospective cohort, in 6 pediatric hospitals in Bogotá, Colombia, between January 1, 2014, and December 31, 2018, 1 isolate was included for patient from the same origin. Infections were classified into: SSTI, osteoarticular, bacteremia, or pneumonia.The objective is to establish differences between clinical, laboratory, and outcomes of MSSA and MRSA infections, according to origin of the infection in a pediatric population from Bogotá, Colombia.

Results

551 patients were included; 211 (38%) MRSA and 340 (62%) MSSA, in total 703 cultures. Figure 1. Some risk factors were statistically associated with MSSA: Heart disease (3.3% Vs. 0.5%) neurologic disease (5.9% vs. 2.4%),

surgery in last 6 months (11% vs. 5%), use of vascular or external devices (3% vs 11%) and previous hospitalization >3 days (11% vs 17%) Table 2. In 84/159 (52%) cases, bacteremia was associated with osteoarticular infection (OI), 19/159 (13%) with pneumonia, 21/159 (13%) with SSTI, 14/159 (9%) with other foci, 21/159 (13%) were primary. Independently of the origin, PICU admittance was more frequent in MRSA (52% vs. 28), as well as mechanical ventilation (MV) (30% vs. 13%) and inotropic support (IS )(38% vs 17%). Of 136 osteoarticular infections, 59 (43,4%) were MRSA and 77 (56,6%) MSSA. MRSA isolates required more than 3 surgical procedures (45% vs 24%), more PICU admittance (36% vs. 12%) and IS (27% vs. 5%). Complicated pneumonia was more frequently associated to MRSA in comparison with MSSA (57% vs. 23%). In pneumonia, MRSA also was significantly associated with PICU. (74%vs 50%), MS (61%vs 32%), and VS (52% vs 27%). SSTI was not associated with greater severity or worse outcome (PICU, MV, IS) according to S. aureus susceptibility.

Conclusion

MRSA was associated with more severe course in bacteremia, OI and pneumonia. It is interesting that some classically risk factors associated with MRSA infections were found to be related to MSSA. In general, with SSTI exception, MRSA increase risk of PICU, mechanical support and inotropic support in a pediatric population in Bogotá, Colombia.

Disclosures

Ivan Felipe Gutiérrez Tobar, n/a, Pfizer and MSD (Advisor or Review Panel member, Research Grant or Support, Speaker’s Bureau, Has received support from Pfizer and MSD for participation in congresses and has received conference payments from Pfizer)Pfizer and MSD (Speaker’s Bureau, Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Sandra Beltran, n/a, Pfizer (Other Financial or Material Support, Has received support from Pfizer for participation in congresses)

1176. Experience with PCV10 Implementation in Colombia and More Severe Course of Pneumococcal Pneumonia in children: A Multicenter Study, 2008 – 2019 (Neumocolombia Network)

Background

Pneumococcal conjugate vaccines (PCV) have decreased pneumonia in children. Colombia introduced massive vaccination with PCV10 in 2012.

Methods

Pneumococcal pneumonia cases from 10 hospitals part of an active surveillance network for invasive pneumococcal disease were included. Two periods were compared, pre-PCV10: 2008-2012 and post-PCV10: 2014-2019. The objective was to compare characteristics and outcomes before and after PCV10.

Results

370 cases were included. Serotype 1(15, 11.2%) and 14 (33, 24.6%) were the most frequent in Pre-PCV10, with only 4(3%) 19A and 1(0.7%) serotype 3. Post-PCV10, serotype 1 decreased to 6(3.1%), 14 to 15(7.8%), while 19A increased to 58(30.2%), serotype 3 to 32(16.7%) and 6A to 7(3.6%) (p = < 0.001), (Graph 1). Complicated pneumonia (CN) also increased (13.4% to 31,8%) (p< 0,001). Pre-PVC10, 44% of CN were due to PCV10 serotypes; with no PCV13 serotypes cases. Post-vaccine period, PCV10 explained only 8.2% and PCV13 60.6%(p < 0.001) of CN. Comparing PICU requirement among predominant serotypes on each period; 23.5% of serotypes 14 and 27.2% of serotypes 1 were admitted, while 59.4% of serotypes 3, 56.9 % of 19A and 42.8% of 6A required PICU. The median of hospitalization increased from 8(5.5-15) to 12 (7-22) days (p < 0.001), as well as the frequency of PICU, 32.8% to 51.6 %, (p = 0.001). Penicillin prescription was similar (17.2% -15.7%), with decrease in ampicillin use (28.4% - 3.6%) and increase ampicillin-sulbactam (0.7% to 24%), and ceftriaxone / clindamycin (0.7% to 5.7%) in post-PCV10. The duration of empirical antibiotic treatment was 7(4-11) and increased to 10(6-17) (p = < 0.001). Lethality showed a slight, non-significant increase between periods 7.5% vs. 9.9% (p = 0.57). (Table1)

Graph 1. Serotype distribution 2008 - 2019

Year 2012, PCV10 introduced 2 + 1 schedule.

Table 1. Outcomes in the Pre-PCV10 and Post-PCV10 Period

Conclusion

PCV10 significantly decreased vaccine serotypes, with increase in PCV13 serotypes. 19A, 3 and 6A the predominant serotypes had greater severity including PICU admission, CN and more resistance, with an increase in the use of broad-spectrum antibiotics and longer hospitalization. The current data support national and regional evidence on the importance of replacing PCV10 to a higher valence that include 19A, as PCV13, with the aim of reducing the circulation, particularly of this serotype.

Disclosures

Ivan Felipe Gutiérrez Tobar, n/a, Pfizer and MSD (Advisor or Review Panel member, Research Grant or Support, Speaker’s Bureau, Has received support from Pfizer and MSD for participation in congresses and has received conference payments from Pfizer)Pfizer and MSD (Speaker’s Bureau, Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Cristina Mariño Drews, n/a, Pfizer (Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Sandra Beltran, n/a, Pfizer (Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Aura Lucia Leal Castro, MD, Pfizer and MSD (Research Grant or Support, Speaker’s Bureau, Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Aura Lucia Leal Castro, n/a, Pfizer and MSD (Research Grant or Support, Speaker’s Bureau, Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Jaime alberto Patiño-Niño, n/a, Pfizer (Research Grant or Support, Speaker’s Bureau, Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Martha Isabel Alvarez-Olmos, n/a, Pfizer (Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Rocio Barrero Barreto, n/a, Pfizer and MSD (Other Financial or Material Support, Has received support from Pfizer and MSD for participation in congresses and has received conference payments from Pfizer) Fabio Espinosa, n/a, MSD (Research Grant or Support, Other Financial or Material Support, Has received support from MSD for other research.) Nicolas Ramos, n/a, Pfizer (Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Vivian Marcela Moreno Mejia, n/a, Pfizer (Research Grant or Support)

496. Comparison of Severe COVID 19 and Influenza Infections in Pediatric Patients Requiring PICU in Bogota, Colombia

Background

COVID 19 infection represents a global threat and now a frequent cause of hospitalization in pediatrics. COVID 19, as well as Influenza virus could have a severe course. There are few studies, and no local or regional information comparing severe disease between COVID 19 and Influenza virus in children.

Methods

Confirmed COVID 19 between March 2020 to October 2021 and influenza infections from Jan-2017 to dec-2019 were included. Asymptomatic or ambulatory COVID 19 infections were excluded. The main objective was to compare clinical, laboratory and outcome characteristic of PICU admitted patients.

Results

71 patients were included, 32(45,1%) with COVID 19 and 39 (54,9%) influenza virus. COVID 19 patients were older than influenza patients: 67 (20,5-143) vs. 10 (2- 46) p=0.0002. The majority of influenza patients were younger than two years, with different distributions in COVID 19 patients. Figure 1. Respiratory distress was more frequent in influenza (92,3% vs. 62,5%) p=0.002, but exanthema (28,1% vs 2,6%), shock (68,7% vs. 7,7%) and central nervous system manifestations (40,6% vs. 7,7%) were significantly more common in COVID19 than in Influenza respectively. COVID 19 had lower platelets and lymphocyte counts than inlfuenza. There were no differences in treatment, nor deceased either, but Influenza patients had slightly longer hospital stays 12 (7 – 23) vs. 9.5 (6–15.5) p=0.1592 than COVID 19 (Table 1).

Conclusion

COVID 19 and influenza severe infections can have some differences including age of presentation. Inlfuenza main manifestation requiring UCIP is respiratory distress, while COVID19 can have other presentations including shock and central nervous manifestation. Lower lymphocyte counts as well as lower platelets were significantly more common in COVID 19 patients. Although there are no unique characteristics of each infection, some particularities could guide clinician to the etiology of the infection.

Disclosures

Ivan Felipe Gutiérrez Tobar, n/a, Pfizer and MSD (Advisor or Review Panel member, Research Grant or Support, Speaker’s Bureau, Has received support from Pfizer and MSD for participation in congresses and has received conference payments from Pfizer)Pfizer and MSD (Speaker’s Bureau, Other Financial or Material Support, Has received support from Pfizer for participation in congresses) Sandra Beltran, n/a, Pfizer (Other Financial or Material Support, Has received support from Pfizer for participation in congresses)

Network approach identifies Pacer as an autophagy protein involved in ALS pathogenesis

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a multifactorial fatal motoneuron disease without a cure. Ten percent of ALS cases can be pointed to a clear genetic cause, while the remaining 90% is classified as sporadic. Our study was aimed to uncover new connections within the ALS network through a bioinformatic approach, by which we identified C13orf18, recently named Pacer, as a new component of the autophagic machinery and potentially involved in ALS pathogenesis.

METHODS

Initially, we identified Pacer using a network-based bioinformatic analysis. Expression of Pacer was then investigated in vivo using spinal cord tissue from two ALS mouse models (SOD1^G93A and TDP43^A315T) and sporadic ALS patients. Mechanistic studies were performed in cell culture using the mouse motoneuron cell line NSC34. Loss of function of Pacer was achieved by knockdown using short-hairpin constructs. The effect of Pacer repression was investigated in the context of autophagy, SOD1 aggregation, and neuronal death.

RESULTS

Using an unbiased network-based approach, we integrated all available ALS data to identify new functional interactions involved in ALS pathogenesis. We found that Pacer associates to an ALS-specific subnetwork composed of components of the autophagy pathway, one of the main cellular processes affected in the disease. Interestingly, we found that Pacer levels are significantly reduced in spinal cord tissue from sporadic ALS patients and in tissues from two ALS mouse models. In vitro, Pacer deficiency lead to impaired autophagy and accumulation of ALS-associated protein aggregates, which correlated with the induction of cell death.

CONCLUSIONS

This study, therefore, identifies Pacer as a new regulator of proteostasis associated with ALS pathology.

Typical bulbar ALS can be linked to GARS mutation

Background: Amyotrophic lateral sclerosis is the most frequent motor neuron disorders (MND) in adults. The role of genetic factors is worldwide accepted, and currently, more than 30 genes have been linked to this disease. Genetics was also the matter of numerous studies in distal hereditary motor neuropathies (dHMN). GARS is classically linked to a predominant dHMN and, until now, no mutation has been described in GARS in other MND. Case Report: We report the case of a 70-year-old woman who developed a classical bulbar ALS phenotype. Owing to his familial history of ALS, a genetic screening was performed excluding the main genes linked to ALS and revealing a heterozygous missense mutation in GARS gene with a high probability of pathogenicity. Conclusion: This first description of mutation in GARS in ALS, extends once more the genetic overlap between ALS and other MND.

Staging amyotrophic lateral sclerosis: A new focus on progression

Amyotrophic lateral sclerosis (ALS) is a heterogenous motoneuronal neurodegenerative condition with a panel of phenotypes exhibiting different clinical patterns. Two compounds are currently available for the treatment of ALS but the majority of trials have failed to show a positive effect on prognosis. One of the explanations which could be put forward involves the way efficacy is evaluated: clinicians agree that the ALSFRS-revised scale used in all trials does not fit with highlighting a positive effect. So, the development and validation of new tools allowing a reliable assessment of ALS has become a key issue in clinical research. Over the last three years, two functional scales (the King's College and MiToS staging systems) have been proposed. These scales rely on two different approaches to ALS: an anatomical and prognostic concept, and loss of autonomy. Both scales propose five stages. We will discuss below the contribution of these two scales to clinical evaluation and the questions which remain to be resolved in the future.

Interventions for infantile haemangiomas of the skin: abridged Cochrane systematic review and GRADE assessments

BACKGROUND

Infantile haemangiomas (IH) are soft swellings of the skin that occur in 3-10% of infants. When haemangiomas occur in high-risk areas or when complications develop, active intervention is necessary.

OBJECTIVE

To update a Cochrane Review assessing the interventions for the management of IH in children.

METHODS

We searched for randomized controlled trials in CENTRAL, MEDLINE, Embase, LILACS, AMED, PsycINFO, CINAHL and six trials registers up to February 2017. We included 28 trials (1728 participants) assessing 12 interventions.

RESULTS

We downgraded evidence from high to moderate/low for issues related to risk of bias and imprecision. Oral propranolol (3 mg kg^-1 daily) probably improves clinician-assessed clearance vs placebo [risk ratio (RR) 16·61, 95% confidence interval (CI) 4·22-65·34; moderate quality of evidence (QoE)]; we found no evidence of a difference in terms of serious adverse events (RR 1·05, 95% CI 0·33-3·39; low QoE). We found the chance of reduction of redness may be improved with topical timolol maleate (0·5% gel applied twice daily) when compared with placebo (RR 8·11, 95% CI 1·09-60·09; low QoE). We found no instances of bradycardia or hypotension for this comparison.

CONCLUSIONS

Our key results indicate that oral propranolol and topical timolol maleate are more beneficial than placebo in terms of clearance or other measures of resolution, or both, without an increase in harm.

Interventions for infantile haemangiomas of the skin

BACKGROUND

Infantile haemangiomas (previously known as strawberry birthmarks) are soft, raised swellings of the skin that occur in 3% to 10% of infants. These benign vascular tumours are usually uncomplicated and tend to regress spontaneously. However, when haemangiomas occur in high-risk areas, such as near the eyes, throat, or nose, impairing their function, or when complications develop, intervention may be necessary. This is an update of a Cochrane Review first published in 2011.

OBJECTIVES

To assess the effects of interventions for the management of infantile haemangiomas in children.

SEARCH METHODS

We updated our searches of the following databases to February 2017: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, LILACS, and CINAHL. We also searched five trials registries and checked the reference lists of included studies for further references to relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of all types of interventions, versus placebo, active monitoring, or other interventions, in any child with single or multiple infantile haemangiomas (IHs) located on the skin.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome measures were clearance, a subjective measure of improvement, and adverse events. Secondary outcomes were other measures of resolution; proportion of parents or children who consider there is still a problem; aesthetic appearance; and requirement for surgical correction. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics.

MAIN RESULTS

We included 28 RCTs, with a total of 1728 participants, assessing 12 different interventions, including lasers, beta blockers (e.g. propranolol, timolol maleate), radiation therapy, and steroids. Comparators included placebo, an active monitoring approach, sham radiation, and interventions given alone or in combination.Studies were conducted in a number of countries, including China, Egypt, France, and Australia. Participant age ranged from 12 weeks to 13.4 years. Most studies (23/28) included a majority of females and different types of IHs. Duration of follow-up ranged from 7 days to 72 months.We considered most of the trials as at low risk of random sequence generation, attrition bias, and selective reporting bias. Domains such as allocation concealment and blinding were not clearly reported in general. We downgraded evidence for issues related to risk of bias and imprecision.We report results for the three most important comparisons, which we chose on the basis of current use. Outcome measurement of these comparisons was at 24 weeks' follow-up.Oral propranolol versus placeboCompared with placebo, oral propranolol 3 mg/kg/day probably improves clinician-assessed clearance (risk ratio (RR) 16.61, 95% confidence interval (CI) 4.22 to 65.34; 1 study; 156 children; moderate-quality evidence) and probably leads to a clinician-assessed reduction in mean haemangioma volume of 45.9% (95% CI 11.60 to 80.20; 1 study; 40 children; moderate-quality evidence). We found no evidence of a difference in terms of short- or long-term serious adverse events (RR 1.05, 95% CI 0.33 to 3.39; 3 studies; 509 children; low-quality evidence), nor in terms of bronchospasm, hypoglycaemia, or serious cardiovascular adverse events. The results relating to clearance and resolution for this comparison were based on one industry-sponsored study.Topical timolol maleate versus placeboThe chance of reduction of redness, as a measure of clinician-assessed resolution, may be improved with topical timolol maleate 0.5% gel applied twice daily when compared with placebo (RR 8.11, 95% CI 1.09 to 60.09; 1 study; 41 children;low-quality evidence). Regarding short- or long-term serious cardiovascular events, we found no instances of bradycardia (slower than normal heart rate) or hypotension in either group (1 study; 41 children; low-quality evidence). No other safety data were assessed, and clearance was not measured.Oral propranolol versus topical timolol maleateWhen topical timolol maleate (0.5% eye drops applied twice daily) was compared with oral propranolol (via a tablet taken once per day, at a 1.0 mg/kg dose), there was no evidence of a difference in haemangioma size (as a measure of resolution) when measured by the proportion of patients with a clinician-assessed reduction of 50% or greater (RR 1.13, 95% CI 0.64 to 1.97; 1 study; 26 participants; low-quality evidence). Although there were more short- or long-term general adverse effects (such as severe diarrhoea, lethargy, and loss of appetite) in the oral propranolol group, there was no evidence of a difference between groups (RR 7.00, 95% CI 0.40 to 123.35; 1 study; 26 participants; very low-quality evidence). This comparison did not measure clearance.None of our key comparisons evaluated, at any follow-up, a subjective measure of improvement assessed by the parent or child; proportion of parents or children who consider there is still a problem; or physician-, child-, or parent-assessed aesthetic appearance.

AUTHORS' CONCLUSIONS

We found there to be a limited evidence base for the treatment of infantile haemangiomas: a large number of interventions and outcomes have not been assessed in RCTs.Our key results indicate that in the management of IH in children, oral propranolol and topical timolol maleate are more beneficial than placebo in terms of clearance or other measures of resolution, or both, without an increase in harms. We found no evidence of a difference between oral propranolol and topical timolol maleate with regard to reducing haemangioma size, but we are uncertain if there is a difference in safety. Oral propranolol is currently the standard treatment for this condition, and our review has not found evidence to challenge this. However, these results are based on moderate- to very low-quality evidence.The included studies were limited by small sample sizes and risk of bias in some domains. Future trials should blind personnel and participants; describe trials thoroughly in publications; and recruit a sufficient number of children to deduce meaningful results. Future trials should assess patient-reported outcomes, as well as objective outcomes of benefit, and should report adverse events comprehensively. Propranolol and timolol maleate require further assessment in RCTs of all types of IH, including those considered problematic, as do other lesser-used interventions and new interventions. All treatments should be compared against propranolol and timolol maleate, as beta blockers are approved as standard care.

Clinical practice guideline. Integral Care Guidelines for the prevention, early detection and treatment of pregnancy, childbirth and puerperium complications: Section on toxoplasmosis in pregnancy

Tooplasma infection, an aspect included in the Integral Care Guidelines for prevention, early detection and treatment of complications during pregnancy developed and sponsored by the Department of Science, Technology and Innovation, Colciencias and the Ministry of Health and Social Protection; was selected to develop recommendations that may contribute to its prevention diagnostic and treatment. Guidelines were developed through systematic review of literature, two panels of evaluation, gradation of evidence: SIGN (Scottish Intercollegiate Guidelines Network), discussion panel with users and patients, external evaluation and socioeconomical evaluation of the impact of recommendations. The Toxoplasma gondii infection that occurs during pregnancy may cause serious complications for the fetus and important sequelae for the newborn. A clinical guideline based on the best available scientific evidence, with emphasis on Colombian references, was performed. Experts in parasitology, neonatology and infectious diseases (adult and pediatric) developed the recommendations. It is suggested that the recommendations included in this guideline be followed by healthcare professionals in pregnancy care programs nationwide, with the purpose of lowering the morbidity and mortality related to this disease. Specific recommendations for diagnosis during the first trimester of the pregnancy, recommendations for prevention in noninfected women, identification of fetal or newborn infection and recommendations for treatment in those given cases are included.

Neisseria meningitidis and Streptococcus pneumoniae as leading causes of pediatric bacterial meningitis in nine Mexican hospitals following 3 years of active surveillance

OBJECTIVES

Meningococcal meningitis is reported as a rare condition in Mexico. There are no internationally published studies on bacterial causes of meningitis in the country based on active surveillance. This study focuses on finding the etiology of bacterial meningitis in children from nine Mexican Hospitals.

METHODS

From January 2010 to February 2013, we conducted a three years of active surveillance for meningitis in nine hospitals throughout Mexico. Active surveillance started at the emergency department for every suspected case, and microbiological studies confirmed/ruled out all potentially bacterial pathogens. We diagnosed based on routine cultures from blood and cerebrospinal fluid (not polymerase chain reaction or other molecular diagnostic tests), and both pneumococcal serotyping and meningococcal serogrouping by using standard methods.

RESULTS

Neisseria meningitidis was the leading cause, although 75% of cases occurred in the northwest of the country in Tijuana on the US border. Serogroup C was predominant. Streptococcus pneumoniae followed Neisseria meningitides, but was uniformly distributed throughout the country. Serotype 19A was the most incident but before universal implementation of the 13-valent pneumococcal conjugate vaccine. Other bacteria were much less common, including Enterobacteriaceae and Streptococcus agalactiae (these two affecting mostly young infants).

CONCLUSIONS

Meningococcal meningitis is endemic in Tijuana, Mexico, and vaccination should be seriously considered in that region. Continuous universal vaccination with the 13-valent pneumococcal conjugate vaccine should be nationally performed, and polymerase chain reaction should be included for bacterial detection in all cultures - negative but presumably bacterial meningitis cases.

Urinary neutrophil gelatinase-associated lipocalin after kidney transplantation: is it a good biomarker to assess delayed graft function?

Delayed graft function (DGF) is a common complication after transplantation. Its incidence is increased among patients receiving a graft from an expanded-criteria donor. Urinary neutrophil gelatinase-associated lipocalin (uNGAL), an acute kidney injury marker, could in the first days after transplantation be an early marker of DGF. We collected urine samples from 38 renal transplant recipients on days 1, 3, 6, and 10 post-transplantation, and months 1 and 6 creatinine to determine uNGAL, serum creatinine, Cystatin C, and albumin/creatinine ratio. We divided the patients into 2 groups, based on whether they developed DGF. We observed that mean uNGAL concentrations, Cystatin C, serum creatinine, and albumin/creatinine ratio were significantly lower in the non-DGF cohort on all measured days. uNGAL at day 3 showed a positive correlation with serum creatinine at day 10 (R = 0.58; P < .00) and day 30 (R = 0.57; P = .016) as well as with the length of hospital stay (r = 0.47; P < .00). Receiver operating characteristic analyses performed to assess the potential of uNGAL to predict DGF showed an area under the curve for day 3 of uNGAL of 0.917 (confidence interval [CI], 0.79-1.00; P = .00), with an optimal cutoff level of 124 ng/mL, sensitivity of 80% (CI, 62%-97%), and specificity of 83% (62%-104%; P = .001). In the first days after transplantation, uNGAL could be an early marker of DGF, providing additional information to standard biomarkers and potentially helping clinicians to take early measures to mitigate DGF.

Bird mortality related to collisions with ski–lift cables: do we estimate just the tip of the iceberg?

Collisions with ski–lift cables are an important cause of death for grouse species living close to alpine ski resorts. As several biases may reduce the detection probability of bird carcasses, the mortality rates related to these collisions are generally underestimated. The possibility that injured birds may continue flying for some distance after striking cables represents a major source of error, known as crippling bias. Estimating the crippling losses resulting from birds dying far from the ski–lift corridors is difficult and it is usually assessed by systematic searches of carcasses on both sides of the ski–lifts. Using molecular tracking, we were able to demonstrate that a rock ptarmigan hen flew up to 600 m after striking a ski–lift cable, a distance preventing its detection by traditional carcasses surveys. Given the difficulty in conducting systematic searches over large areas surrounding the ski–lifts, only an experiment using radio–tagged birds would allow us to estimate the real mortality rate associated with cable collision.

Vertebrate host protective immunity drives genetic diversity and antigenic polymorphism in Schistosoma mansoni

Schistosomes are gonochoric blood parasites with a complex life cycle responsible for a disease of considerable medical and veterinary importance in tropical and subtropical regions. Understanding the evolution of schistosome genetic diversity is clearly of fundamental importance to interpreting schistosomiasis epidemiology and disease transmission patterns of this parasite. In this article, we investigated the putative role of the host immune system in the selection of male genetic diversity. We demonstrated the link between genetic dissimilarity and the protective effect among male worms. We then compared the proteomes of three male clones with different genotypes and differing by their capacity to protect against reinfection. The identified differences correspond mainly to antigens known or supposed to be involved in the induction of protective immunity. These results underline the role played by host immune system in the selection of schistosome genetic diversity that is linked to antigenic diversity. We discuss the evolutionary consequences in the context of schistosome infection.

Schistosome monogamy: who, how, and why?

Schistosomes represent a unique animal model for comparative analyses of monogamy. Indeed, schistosomes are classified at the lowest taxonomical level of monogamous species and lack complex social interactions, which could alter our understanding of their unusual mating system. Elements discussed here include the fact that monogamy in schistosomes could be an ancestral state between hermaphroditism and polygyny or polygynandry and the occurrence of mate changes. In addition, hypotheses are proposed to explain monogamy in schistosomes (e.g. female dispersion, the need for paternal care, oviposition site limitation or aggressiveness, and mate guarding). We also propose future experimental and analytical approaches to improve our understanding of the schistosomes' mating system.

Hürthle cell thyroid carcinoma metastatic to the sigmoid colon

Prognosis of differentiated thyroid cancer is favorable in the majority of cases. However, distant metastases occur in 10-15% of cases, predominantly in lungs and bones, especially in older patients exhibiting poorly differentiated forms or advanced stages. We report a case history of Hürthle cell thyroid carcinoma metastasized to the sigmoid colon. To the best of our knowledge, this location has never been described before. This case history illustrates the difficulties of diagnosis and treatment in patients whose metastases do not concentrate radioiodine. The interest of different imaging modalities, including fluoro-deoxy-glucose positron emission tomography scan and somatostatin receptor scintigraphy, is discussed.

Subclinical Hypothyroidism in HIV-Infected Patients Is Not an Autoimmune Disease

AIMS AND METHODS

A study of 350 HIV+ patients in our region showed that 16% suffered from hypothyroidism. Twenty-two HIV+ hypothyroid patients (10 with subclinical hypothyroidism, 12 with low FT4 levels (LT4) (confirmed by a dialysis equilibrium assay) and 22 HIV+ euthyroid controls receiving highly active anti-retroviral therapy were included in an additional study.

RESULTS

No goiter or anti-thyroid antibodies were detected. Use of stavudine was more frequent in the LT4 subgroup (p < 0.01) and subclinical hypothyroidism group (p = 0.04). Use of didanosine (OR, 12.5, p < 0.01) and ritonavir (OR, 33.0, p < 0.01) was more frequent in the LT4 subgroup, with a greater didanosine cumulative dose (616.7 mg [180.0, 1,260.0] vs. 263.7 [63.0, 948.0], p = 0.01). Reverse T3, binding protein levels, the TSH response to thyrotropin-releasing hormone, urinary iodine, plasma selenium and thiocyanate levels did not differ. IFNgamma levels were lower in the subclinical hypothyroidism group (pg/ml) (9.1 [0.0, 22.7] vs. 19.5 [0.0, 40.9], p = 0.03).

CONCLUSION

None of the investigated mechanisms are able to explain the occurrence of hypothyroidism in HIV patients receiving highly active anti-retroviral therapy except the anti-retroviral treatment. In light of the absence of autoimmunity, the normal adenohypophysis and thyroid responses to thyrotropin-releasing hormone, central hypothyroidism is suspected and could explain LT4 and high TSH levels. Underlying mechanisms need further exploration.

[Inaugural unilateral adrenal hematoma of an antiphospholipid syndrome]

INTRODUCTION

A primary antiphospholipid syndrome is a very rare cause of adrenal haemorrhage.

OBSERVATION

A 51 year-old man presented with a unilateral adrenal haemorrhage, enhanced by the prescription of Synacthène during the 4 days that preceded. There was no adrenal deficiency but the immunological control revealed the presence of anti-phospholipid antibodies. After 2 years of follow-up, adrenal controls have not shown any underlying tumour or endocrine insufficiency.

COMMENTS

Adrenal involvement is described in the anti-phospholipid syndrome and may present in the form of adrenal deficiency in the case of occasionally only microscopic bilateral haemorrhages. Furthermore, Synacthène is known to induce adrenal haemorrhages although this complication remains rare. Moreover, any unilateral adrenal haemorrhage requires subsequent follow-up for several months or even years in order to eliminate any underlying tumour and to control the absence of any adrenal deficiency if the involvement is bilateral.

Prévalence des marqueurs biologiques de la maladie cœliaque dans une cohorte d’enfants et d’adolescents diabétiques de type I

The aim of this study was to determine the prevalence of celiac disease (CD) markers in a French cohort of 84 children type 1 diabetics. Detection of antitransglutaminase (AtTG), antiendomysium (AEA) and antigliadin (AGA) antibodies was performed. Group 1 included 81 (96.4%) diabetic patients with negative antibodies. Group 2 included 3 patients (3.6%) with positive serological markers: 1 AGA-AEA-AtTG and 1 AEA-AtTG with proved histological diagnosis and 1 AGA positive with negative histology. No statistically significant difference was observed between the groups with regard to age, duration of diabetes, familial target stature, and ratios Height/Age and Weight/Height. Presence of CD serological markers was related to a lower level of HbA1c. Prevalence of CD serological markers is important in this French cohort but lower than other countries.

Linezolid versus vancomycin in the treatment of known or suspected resistant gram-positive infections in neonates

BACKGROUND

Gram-positive infections caused by susceptible and resistant strains of Staphylococcus aureus, coagulase-negative staphylococci and enterococci are increasing problems in neonates. Linezolid, a new oxazolidinone, is active against these pathogens and has recently been approved by the Food and Drug Administration for treating Gram-positive infections in pediatric patients.

OBJECTIVE

To compare the clinical efficacy and safety of intravenous and oral linezolid with vancomycin (10 to 15 mg/kg every 6 to 24 h) in neonates (age 0 to 90 days).

METHODS

Hospitalized infants with known or suspected hospital-acquired pneumonia, complicated skin or skin structure infections, bacteremia or other infections (e.g. pyelonephritis, abdominal abscess) were eligible. Test-of-cure clinical response was evaluated at follow-up.

RESULTS

Sixty-three neonates, randomized 2:1 to linezolid (n = 43) or vancomycin (n = 20) were included in the intent-to-treat group. Clinical cure rates at follow-up in the intent-to-treat group were higher, but not significantly different, for linezolid vs. vancomycin (78% vs. 61%; P = 0.196). Corresponding cure rates in clinically evaluable patients were 84% vs. 77% (P = 0.553) for linezolid and vancomycin, respectively. Pathogen eradication rates were as follows in the linezolid and vancomycin groups, respectively: S. aureus (67% vs. 60%; P = 0.850); coagulase-negative staphylococci (88% vs. 100%; P = 0.379); and enterococci (71% vs. 0%; P = 0.168). Results for hematology and chemistry assays were similar between treatment groups. Fewer linezolid-treated neonates had drug-related adverse events than vancomycin-treated neonates (12% vs. 32%; P = 0.058).

CONCLUSIONS

Linezolid is well-tolerated and as effective as vancomycin in the treatment of resistant Gram-positive infections in neonates.

A case of tuberculous sinusitis without concomitant pulmonary disease

This case report highlights the difficulty of diagnosing tuberculous sinusitis in the absence of pulmonary foci. Although extrapulmonary localisations of tuberculosis are rare in immunocompetent patients, it is important to consider this diagnosis, since therapeutic delay usually results in an unfavourable outcome. Acid-fast bacilli are sometimes difficult to detect in pathological specimens. Consequently, the diagnosis is usually based on the following criteria: (i) the absence of clinical response to usual antibiotics, (ii) the presence of caseous granulomatous inflammatory lesion on histopathology, and (iii) identification of Mycobacterium tuberculosis by the polymerase chain reaction assay confirmed by bacteriological culture. The diagnosis of tuberculosis is finally confirmed by the efficacy of antituberculous treatment. The differential diagnosis is Wegener's disease.

Iliac muscle abcess and staphylococcal metastatic infection in a diabetic patient

We report the case of a 44-year-old obese diabetic woman admitted for fever. Blood cultures grew Staphylococcus Aureus and antibiotherapy was started. Iliac abscess was diagnosed and surgical drainage done. Clinical evolution was marked by metastatic dissemination: sacroiliac osteolysis, right shoulder osteoarthritis, spondylitis of the third lumbar vertebra and pulmonary localizations. This case-report shows diagnosis and treatment difficulties of an iliac muscle abscess with metastatic localization in a diabetic patient.

Glenohumeral instability: evaluation with MR arthrography

Magnetic resonance arthrography is superior to other imaging techniques in evaluation of the glenohumeral joint. Normal variants that can be diagnostic pitfalls include the anterosuperior sublabral foramen, the Buford complex, and hyaline cartilage under the labrum. Anteroinferior dislocation is the most frequent cause of anterior glenohumeral instability and produces a constellation of lesions (anteroinferior labral tear, classic and osseous Bankart lesions, Hill-Sachs lesion). Variants of anteroinferior labral tears include anterior labroligamentous periosteal sleeve avulsion and glenoid labral articular disruption. Anterior glenohumeral instability can also involve tears of the anterior or anterosuperior labrum or the glenohumeral ligaments. Posterior glenohumeral instability can involve a posterior labral tear, posterior capsular stripping or laxity; fracture, erosion, or sclerosis and ectopic ossification of the posterior glenoid fossa; reverse Hill-Sachs lesion; McLaughlin fracture; or posterosuperior glenoid impingement. Superior labral anterior and posterior lesions involve the superior labrum with varying degrees of biceps tendon involvement.

An education model for otitis media care field-tested in Latin America

The World Health Organization has designated the teaching of otitis media management skills a "priority" status. Effective treatment of ear disease requires that the physician be both informationally educated as well as physically trained to use otoscopy. Little is known about how well this education can be provided in a short time and in a foreign country. To more objectively assess teaching effect, results of an education session for rural Mexican pediatric primary-care providers who were given an intensive otitis media lecture and otoscopy skills workshop in 1990 were evaluated. To test immediate cognitive impact, an anonymous written examination was given both before and after the teaching session. Average test scores after the educational sessions improved 24% (p < 0.001) over baseline scores before the sessions. To evaluate long-term impact on clinical practice, a follow-up telephone survey 2 years later was conducted. The use of an otoscope to diagnose otitis media had increased from 40% to 93% of respondents. We conclude that pediatric primary-care providers in rural Mexico possess a baseline level of knowledge about otitis media that can be significantly enhanced with one educational session. Further, this teaching effort produces an impact on practice pattern that lasts at least 2 years.