Always expect the unexpected: lung abscess due to pseudomonas aeruginosa mimicking pulmonary aspergilloma in acute B-cell leukemia.

We report on a case of Pseudomonas aeruginosa sepsis and consecutive lung abscess in a 13-year-old patient with acute B-cell leukemia. At first, radiographic findings strongly suggested presence of pulmonary aspergilloma and only microbiological testing of the surgically enucleated mass revealed the correct underlying pathogen and confirmed final diagnosis.

Functional trade-offs in white matter axonal scaling.

The brains of large mammals have lower rates of metabolism than those of small mammals, but the functional consequences of this scaling are not well understood. An attractive target for analysis is axons, whose size, speed and energy consumption are straightforwardly related. Here we show that from shrews to whales, the composition of white matter shifts from compact, slow-conducting, and energetically expensive unmyelinated axons to large, fast-conducting, and energetically inexpensive myelinated axons. The fastest axons have conduction times of 1-5 ms across the neocortex and <1 ms from the eye to the brain, suggesting that in select sets of communicating fibers, large brains reduce transmission delays and metabolic firing costs at the expense of increased volume. Delays and potential imprecision in cross-brain conduction times are especially great in unmyelinated axons, which may transmit information via firing rate rather than precise spike timing. In neocortex, axon size distributions can account for the scaling of per-volume metabolic rate and suggest a maximum supportable firing rate, averaged across all axons, of 7 +/- 2 Hz. Axon size distributions also account for the scaling of white matter volume with respect to brain size. The heterogeneous white matter composition found in large brains thus reflects a metabolically constrained trade-off that reduces both volume and conduction time.

Pulmonary interstitial glycogenosis - A systematic analysis of new cases.

BACKGROUND: Pulmonary interstitial glycogenosis (PIG) is a rare paediatric interstitial lung disease of unknown cause. The diagnosis can only be made by lung biopsy. Less than 100 cases have been reported. Clinical features, treatment and outcomes have rarely been assessed systematically in decent cohorts of patients. METHODS: In this retrospective multicentre study, the clinical presentation, radiologic findings, pattern of lung biopsy, extrapulmonary comorbidities, treatment and outcome of eleven children with PIG were collected systematically. RESULTS: 10/11 children presented with respiratory distress immediatly after birth and 8/11 needed invasive ventilation. In 8/11 children extrapulmonary comorbidities were present, congenital heart defects being the most common. 7/11 children received systemic glucocorticoids and of these four showed a clear favorable response. During a median follow-up of 3.0 years (range 0.42-12.0) one child died, while 10 patients improved. Chest CT-scans showed ground-glass opacities (7/10), consolidations (6/10), linear opacities (5/10) and mosaic attenuation (4/10) without uniform pattern. Besides interstitial thickening related to undifferentiated glycogen positive mesenchymal cells all tissue samples showed growth abnormalities with reduced alveolarization. CONCLUSIONS: PIG is associated with alveolar growth abnormalities and has to be considered in all newborns with unexplained respiratory distress. Apparent treatment benefit of glucocorticosteroids needs to be evaluated systematically.

1,3-dinitrobenzene toxicity in the least shrew, Cryptotis parva.

Shrews are abundant in most areas of toxic chemical contamination and bioaccumulate pollutants at much higher rates than sympatric rodent species. As a part of studies to provide information concerning the toxicity of 1,3-dinitrobenzene (DNB) in least shrews (Cryptotis parva), groups of 10 females and 10 males received DNB at 0 (control), 0.7, 2.9, 11.6, and 46.3 microl/L (equivalent mean daily dosage of 0, 0.26, 1.06, 4.26, and 17.0 mg/kg body wt in each sex) in their diet for 14 d. Leukocytosis present at the 0.26 mg/kg body weight/d dosage established the lowest-observed-adverse effect level (LOAEL). Adrenal enlargement was noted at the 1.06 mg/kg body weight/d level. Splenic enlargement and reductions in hematocrit and hemoglobin values occurred at the 4.26 mg/kg body weight/d treatment. Enlargements in the liver and heart and reductions in brown fat weight, granulocyte numbers, and alanine aminotransferase levels were present at high dose levels. Histopathologic examinations showed Kupffer's cell hemosiderosis and suggested testicular damage at the two highest tested doses but failed to confirm brain lesions. Least shrews do not follow standard scaling estimates for lifespan or metabolic rates. The LOAEL calculated from the standard terrestrial screening benchmark equation was higher than our findings, suggesting that these estimates must be viewed with caution.

Neurodevelopmental risks in twin-to-twin transfusion syndrome: preliminary findings.

The purpose of this study was to determine the neurodevelopmental risks in patients with twin-to-twin transfusion syndrome, a rare but serious complication of monochorionic twin gestations. From a total sample of 94 twins with twin-to-twin transfusion syndrome, admitted during 1989 and 1993, 49 patients survived and 40 patients were followed to a mean age of 24 months. Neurological status and psychomotor development (Denver and Griffiths Developmental Tests) were determined. Parameters of the neonatal period were evaluated for their potential prediction. Of the 40 tested patients 18 showed a normal psychomotor development. Thirteen patients exibited a specific delay in language development and/or showed minor neurological dysfunctions. Nine twins had severe psychomotor retardation in combination with cerebral palsy. Major neurological sequelae were found, more common in recipients than in donors (6/19 vs 3/21). Correspondingly, neonatal ultrasound showed more pathological results (especially periventricular leucomalacia) in recipients. Neither anaemia nor polycythaemia at birth can predict developmental outcome. Apart from a high prenatal mortality rate, both twins, donators as well as recipients, are highly at risk for brain damage of different aetiology, associated with abnormal neonatal cerebral ultrasound.

Changes in rat spinal cord gene expression after inflammatory hyperalgesia of the joint and manual therapy.

CONTEXT: Mobilization of a joint affects local tissue directly but may also have other effects that are mediated through the central nervous system. OBJECTIVE: To identify differential gene expression in the spinal cords of rats with or without inflammatory joint injury after manual therapy or no treatment. METHODS: Rats were randomly assigned to 1 of 4 treatment groups: no injury and no touch (NI/NT), injury and no touch (I/NT), no injury and manual therapy (NI/MT), and injury and manual therapy (I/MT). We induced acute inflammatory joint injury in the rats by injecting carrageenan into an ankle. Rats in the no-injury groups did not receive carrageenan injection. One day after injury, rats received manual therapy to the knee of the injured limb. Rats in the no-touch groups were anesthetized without receiving manual therapy. Spinal cords were harvested 30 minutes after therapy or no touch, and spinal cord gene expression was analyzed by microarray for 3 comparisons: NI/NT vs I/NT, I/MT vs I/NT, and NI/NT vs NI/MT. RESULTS: Three rats were assigned to each group. Of 38,875 expressed sequence tags, 755 were differentially expressed in the NI/NT vs I/NT comparison. For the other comparisons, no expressed sequence tags were differentially expressed. Cluster analysis revealed that the differentially expressed sequence tags were over-represented in several categories, including ion homeostasis (enrichment score, 2.29), transmembrane (enrichment score, 1.55), and disulfide bond (enrichment score, 2.04). CONCLUSIONS: An inflammatory injury to the ankle of rats caused differential expression of genes in the spinal cord. Consistent with other studies, genes involved in ion transport were among those affected. However, manual therapy to the knees of injured limbs or to rats without injury did not alter gene expression in the spinal cord. Thus, evidence for central nervous system mediation of manual therapy was not observed.

Role of osteopathic manipulative treatment in altering pain biomarkers: a pilot study.

CONTEXT: Underlying mechanisms explaining the effects of osteopathic manipulative treatment (OMT) are poorly defined. The authors evaluate various nociceptive (pain) biomarkers that have been suggested as important mediators in this process. OBJECTIVE: To determine if OMT influences levels of circulatory pain biomarkers. METHODS: In a prospective, blinded assessment, blood was collected from 20 subjects (10 with chronic low back pain [LBP], 10 controls without chronic LBP) for 5 consecutive days. On day 4, OMT was administered to subjects 1 hour before blood collection. Blood was analyzed for levels of beta-endorphin (betaE), serotonin (5-hydroxytryptamine [5-HT]), 5-hydroxyindoleacetic acid (5-HIAA), anandamide (arachidonoylethanolamide [AEA]), and N-palmitoylethanolamide (PEA). A daily questionnaire was used to monitor confounding factors, including pain and stress levels, sleep patterns, and substance use. RESULTS: Increases from baseline in betaE and PEA levels and a decrease in AEA levels occurred immediately posttreatment. At 24 hours posttreatment, similar biomarker changes from baseline were observed. A decrease in stress occurred from baseline to day 5. The change in PEA from baseline to 24 hours posttreatment correlated with the corresponding changes in stress. Subgroup analysis showed that subjects with chronic LBP had significantly reduced 5-HIAA levels at 30 minutes posttreatment (P=.05) and 5-HT levels at 24 hours posttreatment (P=.02) when compared with baseline concentrations. The increase in PEA in subjects with chronic LBP at 30 minutes posttreatment was two times greater than the increase in control subjects. CONCLUSION: Concentrations of several circulatory pain biomarkers were altered after OMT. The degree and duration of these changes were greater in subjects with chronic LBP than in control subjects without the disorder.

Non-CF bronchiectasis: does knowing the aetiology lead to changes in management?

The aim of the current study was to review the aetiology of non-cystic fibrosis (CF) bronchiectasis from two tertiary paediatric respiratory units in order to determine how often making a specific aetiological diagnosis leads to a change in management, and to assess the contribution of computed tomography (CT) in determining the underlying diagnosis. The case records of all patients who were diagnosed as having bronchiectasis by CT, currently being seen at the Royal Brompton Hospital and Great Ormond Street Hospital for Children (London, UK), were reviewed. All patients had undergone extensive investigations, and the underlying aetiology and the area of pulmonary involvement (as seen on CT) were recorded. A total of 136 patients were identified; there were 65 young males and the group median (range) age was 12.1 yrs (3.1-18.1). Immunodeficiency, aspiration and primary ciliary dyskinesia accounted for 67% of the cases. In 77 (56%) children, the identification of a cause led to a specific change in management. There was no association between aetiology and the distribution of CT abnormalities. In conclusion, immunodeficiency and other intrinsic abnormalities account for the majority of cases of non-cystic fibrosis bronchiectasis seen in the current authors' units. Computed tomography scans do not contribute towards identifying the aetiology and, most importantly, a specific aetiological diagnosis frequently leads to a change in management.

[Anesthetic gas contamination in the operating room--an unsolved problem? Results of our own studies]. / Narkosegasbelastung im OP--ein ungelöstes Problem? Ergebnisse eigener Untersuchungen.

Ambient air concentrations of nitrous oxide (N2O) and volatile anesthetics were assessed under routine conditions in a total of 41 surgical suites located at seven Vienna hospitals. Continuous measurements were performed by means of infrared trace gas analyzers throughout a period of approximately 450 h. Additional analyses of ventilation facilities (if installed) revealed no essential deficiencies; however, anesthetic gas scavenging (AGS) systems yielded insufficient flow rates in 32% (less than 25 l/min). In surgical suites without mechanical ventilation or scavenging systems (2 out of 41), maximum occupational threshold limits (i.e., 100 ppm N2O; 5 ppm halothane) were exceeded continuously and to considerable degrees throughout the duration of anesthesia. During measurements conducted in operating rooms (ORs) in otolaryngology departments, extreme peaks (greater than 2600 ppm N2O, greater than 150 ppm halothane) of several minutes duration were documented when open-circuit anesthesia was performed. In the general surgical ORs equipped with modern ventilation facilities ambient air contamination was lowest, time-weighted average (TWA) values ranging from 8 to 15 ppm (mean 11 +/- 3 ppm) for N2O and 0.1 to 0.6 ppm (mean 0.3 +/- 0.2 ppm) for the halogenated anesthetic. Despite good ventilation and scavenging in the gynecological ORs, distinctly higher concentrations (mean 83 +/- 49, range 24-211 ppm N2O; mean 0.75 +/- 0.3, range 0.3 to 1.3 ppm volatile agent) were measured in cases where anesthesia was delivered by mask. TWA values exceeding currently established maximum workplace concentrations were found in an unscavenged but ventilated urological OR. At present, short-term concentration peaks seem to be inevitable even under optimal OR ventilation conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

MRI-Based evaluation of locus and extent of neurotoxic lesions in monkeys.

To minimize the variability in the extent of lesions made by injections of the excitotoxin ibotenic acid in rhesus monkeys, we developed and validated an MRI-based method to determine the efficacy of the injections soon after surgery. T2-weighted MR images were obtained 6-11 days after surgery from 17 brain hemispheres of monkeys that had received bilateral lesions of either the hippocampal formation (HF), perirhinal cortex, or parahippocampal cortex. The extent of lesion estimated from the hypersignal that appeared in and outside of the targeted area on these MR images was compared with the extent of damage assessed histologically after survival periods ranging from 120-370 days. Highly significant correlations (r values between 0.85-0.99) were found between these two measures for several regions in the medial temporal lobe. Based on this finding, lack of hypersignal in the targeted area of some Ss was followed by successful reinjection of the neurotoxin to create more complete cell loss prior to the postoperative phase of the study. We also assessed the relationship between a postoperative reduction in HF volume, measured from T1-weighted MR images, and the extent of damage determined histologically in 14 hemispheres of monkeys with bilateral excitotoxic HF lesions. The HF volume decreases sharply after surgery until 40-50 days postoperatively, after which there is only a minor further decrease. Based on this finding, we obtained T1-weighted MR images at least 44 days but in most cases close to 1 year after surgery. A highly significant positive correlation (r = 0.95, P < 0.001) was found between neuronal damage and volume reduction, with nearly complete neuronal damage (96-99%) corresponding to a volume reduction of 68-79%. These MRI-based methods thus provide an accurate in vivo evaluation of the locus and extent of neurotoxic lesions. Application of these methods can ensure that each animal in the experiment is used effectively.

Monocyte deactivation and its reversal in a patient with chemotherapy-induced leukopenia and severe systemic infection.

BACKGROUND: Serious infections constitute a major problem for patients with cancer, and new approaches must be found in dealing with these. The pathophysiology of neutropenic infection is not well understood, although there is some evidence that, as in sepsis in the primarily immunocompetent host, a pro- and an antiinflammatory phase can be discriminated. In the recent literature is described a series of nonneutropenic patients with sepsis in whom interferon-gamma was successfully administered during the immunoparalytic phase, a concept that might possibly be extended to immunocompromised hosts. PROCEDURE: A 14-year-old patient with RAEB-T/hypoplastic M2 and chemothera py-induced neutropenia developed a severe infection and continued to deteriorate clinically despite maximum supportive measures, including broad antibacterial and antifungal coverage. On the basis of monocyte de-activation this patient was considered to be in the immunoparalytic phase of sepsis and consequently treated with 60 microg/m(2) of interferon-gamma per day for 10 days. RESULTS: The patient made a rapid clinical recovery, and biochemical markers of infection improved promptly. At the same time, the fraction of activated monocytes normalized rapidly and stably. We hypothesize that treatment with interferon-gamma effected this rapid restoral of monocyte activation and that monocyte reactivation might have contributed to the patient's prompt recovery from his severe infection. Interferon-gamma treatment was well tolerated. CONCLUSIONS: Immunostimulation with interferon-gamma might prove to be a valuable adjuvant treatment for patients with chemotherapy-induced neutropenia during the rare scenario of infection with immunoparalysis.

Cross-facial nerve grafting for facial reanimation: effect on normal hemiface motion.

Reinnervation of the paralyzed hemiface with a cross-facial nerve graft (CFNG) required division of facial nerve branches on the normal hemiface to serve as axon donors. There is therefore concern about whether any impairment of normal hemiface motion occurs in the postoperative period. To minimize the likelihood of donor-side impairment, donor branches are chosen from the bucco-zygomatic region which was extensive cross branching, as opposed to be the single temporal or marginal mandibular branches. This study chose to determine quantitatively if this practice does, in fact, adversely affect the normal side hemiface motion governed by these branches, viz., eye closure, pucker, and smile. Since surgical procedures near the facial nerve (such as superficial parotidectomy) may leave the patient with transient facial weakness, even in the absence of nerve transection, the hypothesis was that hemiface motion would be impaired on the donor side during the early postoperative period (first month) secondary to edema and/or neuropraxia. However, based on the clinical observation that donor-side facial motion is not demonstrably impaired late after surgery, a further hypothesis was that any early facial motion is not demonstrably impaired late after surgery, a further hypothesis was that any early facial motion impairment would return to normal by 3 months postoperatively. Seven patients underwent sural CFNG as a primary or secondary component of their facial animation procedure. Their facial motion was quantified preoperatively and in serial postoperative examinations using the Maximal Static Response Assay (MSRA) of facial motion. Careful selection of redundant bucco-zygomatic branches of the facial nerve on the normal side for CFNG did not ultimately ( > or = 3 months postoperative) impair the important motions of eye closure, smile, or pucker. Early postoperative ( < or = 1 month) weakness of the smile was seen on both X and Y axes, indicating that both the risorius and zygomatic muscles were transiently weakened. The ability to elevate the lower eyelid was unaffected at any postoperative time point. Movement of the normal hemiface did not appear to be permanently affected by CFNG when a careful choice of redundant bucco-zygomatic donor branches was made.

Infectious complications in children with acute lymphoblastic leukemia and T-cell lymphoma--a rationale for tailored supportive care.

Infections still remain a major cause of therapy-associated morbidity and death in patients with malignant diseases. To further lower the risk of serious and long-lasting infections by additional supportive measures, detailed information on the frequency and characteristic features of infections is needed. Therefore, patient data from 112 children with acute lymphoblastic leukemia and T-cell lymphoma who were treated according to the COALL-05-92 protocol in our department were analyzed for differences in the frequency and origin of febrile episodes in relation to age, immunological type of leukemia, treatment in group assessed as being at high or low risk of relapse, actual occurrence of relapse, and course of chemotherapy. At the time of diagnosis, low-risk patients more commonly presented with febrile episodes than high-risk patients. In total, patients developed a fever in 313 (24%) of 1,307 evaluated chemotherapy cycles. Febrile episodes were associated with microbiologically or clinically documented infections in 60% of all cases, while in 40% the fever was of unknown origin. Gram-positive pathogens had a markedly higher incidence than gram-negative or fungal ones. The incidence of febrile episodes during therapy appeared to be correlated with certain chemotherapeutic drug combinations. The highest rate was found after high-dose cytarabine and asparaginase causing a long period of leukopenia. However, after other chemotherapy courses with a similar duration of leukopenia the incidence of febrile episodes was significantly lower, suggesting that specific interactions of different chemotherapeutic agents with the immune response might be an important factor in development of infections. Individual factors might also account for an increased incidence of infections, since the number of high-risk patients with recurrent infections was significantly higher than expected on the basis of statistical evaluation. In conclusion, our findings suggest that the risk of infections during chemotherapy may not only be influenced by leukopenia, but that drug-specific effects of the various chemotherapeutic agents and individual factors may also be important contributory factors. These observations must be further expanded in prospective studies so that new tailored supportive care protocols can be elaborated.

Cough frequency in children with stable asthma: correlation with lung function, exhaled nitric oxide, and sputum eosinophil count.

BACKGROUND: A study was undertaken to assess the correlation between cough frequency in asthmatic children with lung function and two non-invasive markers of airway inflammation. METHODS: Thirty two children of median age 12.0 years (interquartile range (IQR) 9.5-13.4) with stable asthma were recruited. They underwent spirometric testing, exhaled nitric oxide (eNO) measurement, sputum induction for differential cell count, and ambulatory cough monitoring over 17 hours and 40 minutes. Coughing episodes were counted both as individual spikes and as clusters. RESULTS: Complete cough frequency data were available in 29 children (90%) and their median forced expiratory volume in 1 second (FEV1) and eNO were 88.5% (IQR 79.5-98) and 23.9 ppb (IQR 11.4-41.5), respectively. The median number of cough episodes was 14 (IQR 7.0-24.0) which was significantly higher than that of normal children (6.7 (IQR 4.1-10.5), p<0.001). Sputum induction was successful in 61% of the subjects; the median induced sputum eosinophil count was 0.05% (IQR 0-9.0). Cough frequency was found to have a significant positive correlation with eNO (Spearman's r =0.781, p<0.001) but not with FEV1 or sputum eosinophil count (r =-0.270, p=0.157; r =0.173, p=0.508, respectively). CONCLUSIONS: Children with stable asthma have increased cough frequency compared with normal controls and cough frequency was greater during the day than at night. Cough may be a more sensitive marker of airway inflammation than simple spirometry.

Additive effects of infection and neutropenia on the induction of granulocytopoietic activity in vivo.

BACKGROUND: Granulocyte-colony stimulating factor (G-CSF) is a potent stimulator of granulocytopoiesis and granulocyte function. It has been used in the treatment of children with neutropenic infection; in this context, it was expected to shorten aplasia and limit the severity of infection. Clinical trials, however, have demonstrated conflicting results as to whether these aims can be met. Recently, the use of other, less lineage specific growth factors, such as interleukin (IL)-11 and stem cell factor (SCF), has also been discussed. The dynamics of growth factors and growth factor-regulating proteins during neutropenic infection, particularly in youngsters, are not well understood. METHODS: Serial blood samples from children and adolescents with infection during chemotherapy-induced neutropenia were assayed for C-reactive protein, white blood cell count, IL-11, SCF, G-CSF, IL-10, IL-4, IL-lalpha, and IL-1beta. RESULTS: Although no correlation could be demonstrated between endogenous IL-11 or SCF levels, infection, and leukocyte counts, endogenous G-CSF levels were increased during both aplasia and infection. However, only the additive effects of infection and neutropenia led to maximally stimulated endogenous G-CSF levels. CONCLUSIONS: The elevated G-CSF levels in a majority of patients during severe neutropenic infection may explain why a therapeutic benefit of G-CSF treatment cannot be demonstrated in all cases. There remains, however, a subgroup of patients in whom infection and cytopenia do not yield a good G-CSF response. This latter group should be identified, because they might derive some benefit from adjuvant growth factor therapy. The authors predict that the efficacy of G-CSF in the treatment of patients with neutropenic fever might depend on each individual's ability to initiate the necessary cytokine production.