Clinical application of ultrashort echo-time MRI for lung pathologies in children.

Lung magnetic resonance imaging (MRI) is considered to be challenging, because the low proton density of the tissue, fast signal decay, and respiratory artefacts hamper adequate image quality. MRI of the lungs and thorax is increasingly used in the paediatric population, because it is a radiation-free alternative to chest CT. Recently, ultrashort echo-time (UTE) sequences have been introduced into clinical MRI protocols, in order to improve the contrast-to-noise ratio due to reduced susceptibility artefacts and to depict structural alterations comparable to CT. The purpose of this review is to provide an overview of various clinical conditions and pathologies in the paediatric chest depicted by an UTE sequence, the so-called three-dimensional (3D) Cones sequence, in comparison with conventional MRI sequences. Besides describing typical features of cystic fibrosis, we present UTE application in other more or less common paediatric lung pathologies, for instance, interstitial pneumopathies, pulmonary infections, and congenital pulmonary malformations.

Multicentre reference values for cardiac magnetic resonance imaging derived ventricular size and function for children aged 0-18 years.

AIMS: Cardiovascular magnetic resonance (CMR) imaging is an important tool in the assessment of paediatric cardiac disease. Reported reference values of ventricular volumes and masses in the paediatric population are based on small cohorts and several methodologic differences between studies exist. We sought to create steady-state free precession (SSFP) CMR reference values for biventricular volumes and mass by combining data of previously published studies and re-analysing these data in a standardized manner. METHODS AND RESULTS: A total of 141 healthy children (68 boys) from three European centres underwent cine-SSFP CMR imaging. Cardiac structures were manually contoured for end-diastolic and end-systolic phases in the short-axis orientation according to current standardized CMR post-processing guidelines. Volumes and masses were derived from these contours. Age-related reference curves were constructed using the lambda mu sigma method. Median age was 12.7 years (range 0.6-18.5). We report biventricular volumes and masses, unindexed and indexed for body surface area, stratified by age groups. In general, boys had approximately 15% higher biventricular volumes and masses compared with girls. Only in children aged <6 years old no gender differences could be observed. Left ventricle ejection fraction was slightly higher in boys in this study population (median 67% vs. 65%, P = 0.016). Age-related reference curves showed non-linear relations between age and cardiac parameters. CONCLUSION: We report volumetric SSFP CMR imaging reference values for children aged 0-18 years old in a relatively large multi-centre cohort. These references can be used in the follow-up of paediatric cardiac disease and for research purposes.

Characterization of epitope specificities of reference antibodies used for the quantification of the birch pollen allergen Bet v 1.

BACKGROUND: Accurate allergen quantification is needed to document the consistency of allergen extracts used for immunotherapy. Herein, we characterize the epitope specificities of two monoclonal antibodies used in an ELISA for the quantification of the major birch pollen allergen Bet v 1, established as a reference by the BSP090 European project. METHODS: The ability of mAbs 5B4 and 6H4 to recognize Bet v 1 isoforms was addressed by immunochromatography. The capacity of each mAb to compete with patients' IgE for binding to Bet v 1 was measured by ELISA inhibition. Epitope mapping was performed by pepscan analysis, site-directed mutagenesis, and hydrogen/deuterium exchange-mass spectrometry. RESULTS: The 5B4 epitope corresponds to a peptide sequence (I56-K68) overlapping with the binding sites of patients' serum IgEs. Mutation of residues P59, E60, and K65 abolishes 5B4 binding to Bet v 1 and reduces the level of IgE recognition. In contrast, 6H4 recognizes a conformational epitope lying opposite to the 5B4 binding site, involving residues located in segments I44-K55 and R70-F79. Substitution of E45 reduces the binding capacity of 6H4, confirming that it is critical for the interaction. Both mAbs interact with >90% of Bet v 1 content present in the birch pollen extract, while displaying a weak cross-reactivity with other allergens of the PR-10 family. CONCLUSIONS: MAbs 5B4 and 6H4 recognize structurally distinct epitopes present in the vast majority of Bet v 1 isoforms. These results support the relevance as a reference method of the Bet v 1-specific quantitative ELISA adopted by the European Pharmacopoeia.

Cardiac function after repair of tetralogy of fallot: how are the atria performing? pilot study by cardiac magnetic resonance imaging.

The atria of the heart function as reservoir, conduit, and active pump and are critical for ventricular filling and cardiac output. We sought to evaluate right (RA) and left atrial (LA) function in patients after tetralogy of Fallot (TOF) repair by using cardiovascular magnetic resonance. Twelve TOF patients, age 16.7 ± 6.1 years, weight 50.9 ± 14.9 kg, were compared to 10 healthy volunteers, age 18.8 ± 6.8 years, weight 52.3 ± 20.8 kg. Both atria and both ventricles were imaged in short-axis planes by Steady State Free Precession. Volume changes and all derived atrial functional parameters were calculated from the volume/time curves obtained after segmentation on the cine images. Blood flow across the AV valves was used to define ventricular diastolic dysfunction. TOF patients showed similar maximal RA volume compared to controls, but increased volumes at mid-diastole (p < 0.05), resulting in a decreased cyclic volume change and atrial filling fraction (p < 0.01), and a decreased passive emptying volume and fraction (p < 0.01). In patients with diastolic dysfunction, conduit volume was increased (p < 0.05), and active emptying volume and fraction tended to be increased, respectively. No significant changes were found in LA, except for a decreased passive emptying fraction (p < 0.05). RA function and particularly reservoir function are impaired in TOF patients. The RA conduit/reservoir ratio is increased and reflects the lost of the ability of the atrium to fill the ventricle by pulsatile flow.

Combining phosphate and bacteria removal on chemically active filter membranes allows prolonged storage of drinking water.

A chemically active filtration membrane with incorporated lanthanum oxide nanoparticles enables the removal of bacteria and phosphate at the same time and thus provides a simple device for preparation of drinking water and subsequent safe storage without using any kind of disinfectants.

A 12-year-old girl with absent radial pulse: arterial thoracic outlet syndrome with subclavian artery aneurysm and thrombosis of the brachial artery.

Brachial arterial occlusion is rare in children and adolescents. Once a traumatic cause is excluded, the differential diagnosis consists of a variety of rare conditions. We report the case of a 12-year-old girl whose presenting symptoms--an absent radial pulse and Raynaud's phenomenon of the right hand--could be easily mistaken for a vasculitis. She was found to have arterial thoracic outlet syndrome with right subclavian artery compression and aneurysm formation caused by an anomalous first rib and consecutive thromboembolic occlusion of the brachial artery. The diagnosis and differential diagnosis of this condition are reviewed.

Accuracy of linear intraoral measurements using cone beam CT and multidetector CT: a tale of two CTs.

OBJECTIVES: The aim was to compare the accuracy of linear bone measurements of cone beam CT (CBCT) with multidetector CT (MDCT) and validate intraoral soft-tissue measurements in CBCT. METHODS: Comparable views of CBCT and MDCT were obtained from eight intact cadaveric heads. The anatomical positions of the gingival margin and the buccal alveolar bone ridge were determined. Image measurements (CBCT/MDCT) were performed upon multiplanar reformatted data sets and compared with the anatomical measurements; the number of non-assessable sites (NASs) was evaluated. RESULTS: Radiological measurements were accurate with a mean difference from anatomical measurements of 0.14 mm (CBCT) and 0.23 mm (MDCT). These differences were statistically not significant, but the limits of agreement for bone measurements were broader in MDCT (-1.35 mm; 1.82 mm) than in CBCT (-0.93 mm; 1.21 mm). The limits of agreement for soft-tissue measurements in CBCT were smaller (-0.77 mm; 1.07 mm), indicating a slightly higher accuracy. More NASs occurred in MDCT (14.5%) than in CBCT (8.3%). CONCLUSIONS: CBCT is slightly more reliable for linear measurements than MDCT and less affected by metal artefacts. CBCT accuracy of linear intraoral soft-tissue measurements is similar to the accuracy of bone measurements.

Pectus excavatum: echocardiography and cardiac MRI reveal frequent pericardial effusion and right-sided heart anomalies.

AIMS: In patients with pectus excavatum (PEX), echocardiographic assessment can be difficult. There are little data on the impact of the chest deformity on echocardiographic findings and comparison of data obtained by echocardiography (echo) with cardiac magnetic resonance imaging (CMR) in PEX. METHODS AND RESULTS: In a prospective study, cardiac anomalies in PEX were analysed by echo and compared with CMR in consecutive patients with PEX referred for echo. If they agreed to participate, the patients were referred for CMR and included if the pectus index was ≥3.0 by CMR. Also, clinical data and electrocardiogram tracings were analysed. There were 18 patients (13 females; 72%), with a mean age of 53±16 years; mean pectus index was 4.7 (range: 3-7.3). Echo showed haemodynamically insignificant pericardial effusion in six patients (33%), tricuspid valve prolapse in five (28%), right ventricular (RV) localized wall motion anomalies (WMA) in five (28%) and diminished RV systolic function in two (11%); no patient had RV dilatation. CMR demonstrated cardiac displacement to the left in 9 patients (50%); minimal pericardial effusion was seen in 10 patients (56%; P value=0.13 compared with echo), RV localized WMA in 6 (44%; P value=1.0), diminished RV systolic function in 8 (44%; P=0.07), and RV dilatation in 5 (28%; P=0.06). A completely normal cardiac examination was found in six patients by echo (33%) and in 2 (11%) using CMR. Although some signs of arrhythmogenic RV cardiomyopathy (ARVC) were present, no patient fulfilled the ARVC criteria. CONCLUSION: In severe PEX, haemodynamically insignificant pericardial effusion, tricuspid valve prolapse and other RV anomalies possibly due to RV displacement are frequent as demonstrated by both CMR and echo. The cardiac assessment by echo and CMR did show discrepancies; however, they were not significant.

Effect of different quantities of a sugared clear fluid on gastric emptying and residual volume in children: a crossover study using magnetic resonance imaging.

BACKGROUND: Gastric emptying in the first 2 h after 7 ml kg(-1) of sugared clear fluid has recently been investigated in healthy children using magnetic resonance imaging (MRI). This study aims to compare gastric volume and emptying half-life during 1 h after 3 or 7 ml kg(-1) sugared clear fluid intake. METHODS: Fourteen healthy volunteer children aged 11.1 (8.2-12.5) yr were investigated prospectively after administration of 3 and 7 ml kg(-1) diluted raspberry syrup in a randomized order, after overnight fasting (baseline). Gastric content volume (GCV(w)) was assessed with a 1.5 Tesla MRI scanner in a blinded fashion. Data are presented as median (range) and compared using the Wilcoxon test. RESULTS: Baseline GCV(w) was 0.39 (0.04-1.00) and 0.34 (0.07-0.75) before intake of 3 and 7 ml kg(-1) syrup, respectively (P=0.93). GCV(w) was 0.45 (0.04-1.55)/1.33 (0.30-2.60) ml kg(-1) 60 min after ingestion of 3/7 ml kg(-1) syrup (P=0.002). Thus GCV(w) had declined to baseline after 3 ml kg(-1) (P=0.39) but not after 7 ml kg(-1) (P=0.001) within 60 min. T(1/2) was 20 (10-62)/27 (13-43) min (P=0.73) after 3/7 ml kg(-1). CONCLUSION: In healthy volunteer children, residual GCV(w) 1 h after intake of 3 ml kg(-1) syrup is significantly smaller than that after 7 ml kg(-1) and within the range of baseline.

Residual gastric contents volume does not differ following 4 or 6 h fasting after a light breakfast - a magnetic resonance imaging investigation in healthy non-anaesthetised school-age children.

BACKGROUND: While American Society of Anesthesiologists and European Society of Anaesthesiology guidelines recommend 6 h pre-anaesthetic fasting for food and non-clear fluids in children, some institutions allow shorter fasting times of 4 h. Aim of this pilot study was to compare weight-indexed residual gastric contents volumes (GCV(w)) after 4 vs. 6 h after a light breakfast, using magnetic resonance imaging (MRI) in healthy volunteer children not scheduled for anaesthesia. METHODS: Four vs. 6 h (F(4) /F(6)) of food fasting were simulated in a crossover study. After overnight fasting (baseline), each child ingested a light breakfast (cereal flakes, milk products) on two separate days. Additional clear fluid (7 ml/kg raspberry syrup) was given either after 2 (F(4) ) or 4 h (F(6) ), followed by half-hourly MRI acquisition for 2 h. MRI was obtained on a 1.5 Tesla scanner as 5 mm axial images (FIESTA) and volumes were traced manually by one blinded observer. Data are given as median (range) or mean ± standard deviation. RESULTS: Eighteen healthy volunteers aged 9.0 (6.8-12.2) years participated. GCV(w) for F(4) and F(6) at baseline was 0.50 ± 0.27 and 0.76 ± 0.48 ml/kg (P = 0.07), respectively, GCV(w) after 4 and 6 h was 0.72 ± 0.85 and 0.47 ± 0.25 ml/kg (P = 0.88). T(1/2) after syrup intake was 30.8 ± 12.2 and 28.3 ± 5.7 min (P = 0.47) for F(4) and F(6) , respectively. CONCLUSION: Residual gastric contents volumes at a hypothetical anaesthesia start were similar for 4 and 6 h food fasting in healthy volunteer school-age children.

Gastric emptying after overnight fasting and clear fluid intake: a prospective investigation using serial magnetic resonance imaging in healthy children.

BACKGROUND: Current guidelines recommend preoperative fasting of 2 h for clear fluids, which is often exceeded in routine clinical practice. Existing data on residual gastric volumes in children do not consider fluid intake within <2 h and rely on the aspiration of gastric contents via a gastric tube. This study evaluated the emptying of clear fluids from the stomach using magnetic resonance imaging (MRI). METHODS: Healthy volunteers aged 6-14 years were asked to fast overnight. MRI scans to assess gastric volumes were obtained before and immediately after drinking 7 ml kg(-1) of diluted raspberry syrup and then every 30 min up to 120 min. Volumes were determined by a blinded investigator and indexed gastric fluid/air volumes (GFV(w)/GAV(w)) and half-life (t(1/2)) of GFV(w) course after clear fluid intake were calculated. RESULTS: Sixteen children, median age 9.2 (range 6.4-12.8) years, were investigated. Median (range) GFV(w) was 0.62 (0.15-0.97) ml kg(-1) before and 6.68 (4.77-7.78) ml kg(-1) immediately after fluid intake, and 2.92 (0.43-5.04), 1.27 (0.28-3.62), 0.42 (0.07-2.49), and 0.32 (0.04-1.13) ml kg(-1) 30, 60, 90, and 120 min thereafter. Median GFV(w) declined exponentially (t(1/2)=26.1 min). Median individual t(1/2) was 23.6 (range 17.9-47.8) min. GAV(w) showed considerable intra- and inter-individual variation. CONCLUSIONS: In healthy school children, gastric emptying after ingestion of clear fluid occurs with a median half-life time of <30 min but with considerable inter-individual variation.

[Periorbital ecchymosis--trauma or tumor?]. / Säugling mit Brillenhämatom - Trauma oder Tumor?

We report about an 11 month old patient, who presented with progressive supraorbital swelling, periorbital ecchymosis, hepatosplenomegalia and B-symptoms. Neuroblastoma was subsequently diagnosed based on the clinical history, physical examination, laboratory tests and imaging findings. Neuroblastoma is the second most frequent solid tumor in infancy. Clinical symptoms are not specific. The so called "raccoon eyes", as seen in our patient, result from osseous metastasis to the orbits and skull. Periorbital swelling may initially be misinterpreted as child abuse. Prognosis of neuroblastoma depends on various factors including initial tumor staging, tumor biology and the child's age.

Selective inhibition of trypsins by insect peptides: role of P6-P10 loop.

PMP-D2 and HI, two peptides from Locusta migratoria, were shown to belong to the family of tight-binding protease inhibitors. However, they interact weakly with bovine trypsin (K(i) around 100 nM) despite a trypsin-specific Arg at the primary specificity site P1. Here we demonstrate that they are potent inhibitors of midgut trypsins isolated from the same insect and of a fungal trypsin from Fusarium oxysporum (K(i)

Complexation of two proteic insect inhibitors to the active site of chymotrypsin suggests decoupled roles for binding and selectivity.

The crystal structures of two homologous inhibitors (PMP-C and PMP-D2v) from the insect Locusta migratoria have been determined in complex with bovine alpha-chymotrypsin at 2.1- and 3.0-A resolution, respectively. PMP-C is a potent bovine alpha-chymotrypsin inhibitor whereas native PMP-D2 is a weak inhibitor of bovine trypsin. One unique mutation at the P1 position converts PMP-D2 into a potent bovine alpha-chymotrypsin inhibitor. The two peptides have a similar overall conformation, which consists of a triple-stranded antiparallel beta-sheet connected by three disulfide bridges, thus defining a novel family of serine protease inhibitors. They have in common the protease interaction site, which is composed of the classical protease binding loop (position P5 to P'4, corresponding to residues 26-34) and of an internal segment (residues 15-18), held together by two disulfide bridges. Structural divergences between the two inhibitors result in an additional interaction site between PMP-D2v (position P10 to P6, residues 21-25) and the residues 172-175 of alpha-chymotrypsin. This unusual interaction may be responsible for species selectivity. A careful comparison of data on bound and free inhibitors (from this study and previous NMR studies, respectively) suggests that complexation to the protease stabilizes the flexible binding loop (from P5 to P'4).

Ingested pins causing perforation.

We report two children who underwent endoscopic removal of ingested foreign bodies which had perforated the stomach, one of which had migrated into the thorax.

Solution structure of a conformationally constrained Arg-Gly-Asp-like motif inserted into the alpha/beta scaffold of leiurotoxin I.

A monoclonal antibody, AC7, directed against the RGD-binding site of the GPIIIa subunit of the platelet fibrinogen receptor, interacts with activated platelet. The H3 region (H3, RQMIRGYFDV sequence) of the complementarity-determining region 3 heavy chain of AC7 inhibits platelet aggregation and fibrinogen binding to platelet. H3 contains the arginine, glycine and aspartate residues, but in an unusual order. The solution structure of the decapeptide has been studied by proton NMR. The NMR data suggested a helical equilibrium. To test whether the helical structure of H3 was biologically relevant, a conformationally constrained peptide with the RGD-like motif was designed. The sequence of a scorpion toxin (leiurotoxin I) has been modified in order to constrain the H3 sequence in a rigid helical conformation. The structure of leiurotoxin I consists of a beta-sheet and an alpha-helix, linked by three disulfide bridges. The structural feature of the chimeric peptide (H3-leiurotoxin) has been determined by standard two-dimensional NMR techniques. H3-Leiurotoxin structure closely resembles that of leiurotoxin I.

Structural and functional analysis of peptidyl oligosaccharyl transferase inhibitors.

The peptide cyclo(hex-Amb(1)-Cys(2))-Thr(3)-Val(4)-Thr(5)-Nph(6)-NH2 was previously shown to be a slow, tight-binding inhibitor (Ki = 37 nM) of the yeast oligosaccharyl transferase (OT) [Hendrickson et al. (1996) J. Am. Chem. Soc. 118, 7636-7637]. This enzyme catalyzes the transfer of a carbohydrate moiety to an asparagine residue in the consensus sequence Asn-Xaa-Thr/Ser. Herein we present a study of the contribution of the residues in positions 1, 3, 4, and 5 to OT binding. Replacement of the threonine (residue 3) by valine or (S)-2-aminobutyric acid dramatically reduced the potency of the inhibitor while, surprisingly, the incorporation of an additional methylene into the side chain of residue 1 [(S)-2,3-diaminobutyric acid changed to ornithine] had very little effect. Variants with acidic, basic, hydrophilic/polar, and hydrophobic side chains in positions 4 and 5 were also evaluated for both yeast and porcine liver OT inhibition. This aspect of the study reveals that basic (lysine) and acidic (glutamic acid) residues are detrimental to the binding, whereas hydrophobic (valine) and polar/hydrophilic (threonine) residues are both well tolerated. The kinetic behavior of substrate analogs [cyclo(hex-Asn(1)-Cys(2))-Thr(3)-Xaa(4)-Yaa(5)-Nph-NH2] corresponding to inhibitors of weak, medium, and strong potency was also examined in order to provide insight into the nature of these inhibitors.

Inhibition of neuronal high voltage-activated calcium channels by insect peptides: a comparison with the actions of omega-conotoxin GVIA.

The whole cell variant of the patch clamp technique was used to investigate the actions of two novel insect peptides on high voltage-activated Ca2+ currents in cultured dorsal root ganglion (DRG) neurones. The insect peptides (PMP-D2 and PMP-C) were isolated originally from insect brains and fat bodies, and have been found to have similar three-dimensional structures to the N-type Ca2+ channel inhibitor omega-conotoxin GVIA (omega-CgTx GVIA). High voltage-activated Ca2+ currents were activated from a holding potential of -90 mV by depolarizing step commands to 0 mV. Extracellular application of synthetic PMP-D2 or PMP-C (1 microM) attenuated high voltage-activated Ca2+ currents. The effects of PMP-C were strongly dependent on the frequency of current activation, but inhibition was apparent and reached a steady state after 20 steps when currents were evoked for 30 msec at 0.1 Hz. The actions of the two insect peptides overlapped both with each other and with omega-CgTx GVIA, suggesting that N-type Ca2+ current was predominantly sensitive to these peptides. Low voltage-activated T-type current and 1,4-dihydropyridine sensitive L-type Ca2+ currents were insensitive to 1 microM PMP-D2 and PMP-C, which indicates a degree of selectivity. The presence of a fucose group on PMP-C abolished the ability of this peptide to attenuate high voltage-activated Ca2+ currents, which may reflect a mechanism by which peptide function could be regulated in insects. The electrophysiological data are supported by studies on 45Ca2+ influx into rat cerebrocortical synaptosomes. Both PMP-D2 (10 microM), PMP-C (10 microM) and omega-CgTx GVIA (1 microM) attenuated a proportion of 45Ca2+ influx into the synaptosomes, but additive effects of these peptides were not observed. We conclude that these naturally occurring peptides obtained from invertebrate preparations have inhibitory effects on N-type Ca2+ channels. Although the peptides have related three-dimensional structures, they have distinct amino acid sequences and appear to have different mechanisms of action to produce inhibition of mammalian neuronal high voltage-activated Ca2+ channels.