Prevención de la enfermedad meningocócica por el serogrupo B mediante una vacuna de cuatro componentes / Prevention of serogroup B meningococcal disease using a four-component vaccine

Introducción: la enfermedad meningocócica es una infección grave causada por Neisseria meningitidis, cuyo serogrupo predominante actualmente es el B, para el que ha sido complejo crear vacunas efectivas y, por tanto, difícil modificar o reducir su morbimortalidad. El objetivo de este trabajo ha sido revisar los datos existentes sobre la nueva vacuna 4 CMenB y sus posibles aportaciones en la prevención de esta infección. Métodos: se realizó una búsqueda de autor dirigida por 12 especialistas relacionados con la Pediatría, Vacunología y Salud Pública, que priorizó 74 publicaciones, para preparar un documento de revisión sobre la vacuna. El documento se trabajó en una reunión presencial y se validó posteriormente mediante correo electrónico. Resultados: la vacuna 4 CMenB, basada en cuatro componentes (NadA, fHbp, NHBA y OMVnz), se ha diseñado mediante Vacunología inversa. El Meningococcal Antigen Typing System muestra una potencial cobertura del 70-80% de las cepas circulantes en Europa. Los ensayos clínicos demuestran que la vacuna es inmunógena y segura en lactantes, niños, adolescentes y adultos, e induce memoria inmunológica. La incidencia de fiebre es similar a la de las vacunas sistémicas si se administra sola, pero resulta mayor cuando se coadministra con ellas, aunque el patrón de fiebre es predecible y autolimitado. Es compatible con la mayoría de las vacunas incluidas en el calendario sistemático español, pudiendo administrarse simultáneamente con las vacunas hexavalente y pentavalente actualmente disponibles, así como con la vacuna antineumocócica conjugada heptavalente. Aún no hay datos disponibles respecto al uso concomitante con la vacuna antimeningocócica C y las vacunas antineumocócicas de amplio espectro. Conclusiones: la vacuna 4 CMenB, por el momento, es la única estrategia disponible para prevenir la enfermedad meningocócica por el serogrupo B (AU)

Introduction: meningococcal disease is an infection caused by Neisseria meningitidis, and those of serogroup B are currently the most predominant. It has been difficult to create effective vaccines for this serogroup in order to modify or reduce its morbidity. The aim of this study was to review existing data on the new vaccine 4 CMenB and its potential contribution to the prevention of this infection. Methods: a panel of 12 experts (from Pediatrics, Public Health and Vaccinology background) conducted a literature search and prioritized 74 publications. A review of the vaccine was then prepared, it was discussed in a meeting and subsequently validated by e-mail. Results: 4 CMenB vaccine, based on four components (NadA, fHbp, NHBA and OMVnz), was designed by reverse Vaccinology. The Meningococcal Antigen Typing System shows a potential of 70-80% coverage of the strains in Europe. Clinical trials show that the vaccine is safe and immunogenic in infants, children, adolescents, and adults, and induces an anamnestic response. The incidence of fever is similar to systemic vaccines administered alone, but higher when coadministered with them, although the fever pattern is predictable and self-limited. It is compatible with the Spanish routine vaccines, and can be administered simultaneously with the currently available hexavalent and pentavalent vaccines, as well as the pneumococcal conjugate vaccine. Conclusions: the 4 CMenB vaccine is the only currently available strategy to prevent meningococcal disease caused by serogroup B

Intramedullary neurenteric cysts of the spine. Case report and review of the literature.

This case of a 68-year-old woman with a low-thoracic intramedullary neurenteric cyst is notable for clinical presentation, cyst location, intraoperative findings, and imaging characteristics. The patient's postoperative course was complicated by neurological deterioration and a neuropathic pain syndrome. Potential causes of these complications are discussed, as are possible ways to reduce the risk of their occurrence.

Somatosensory evoked potential monitoring in anterior thoracic vertebrectomy.

OBJECT: Spine surgeons have used intraoperative cortical and subcortical somatosensory evoked potential (SSEP) monitoring to detect changes in spinal cord function when intraoperative procedures can be performed to prevent neurological deterioration. However, the reliability of SSEP monitoring as applied to anterior thoracic vertebral body resections has not been rigorously assessed. METHODS: The authors retrospectively reviewed hospital charts and operating room records obtained between August 1993 and December 1998 and found that SSEP monitoring was used in 44 surgical procedures involving an anterior approach for thoracic vertebral body resections. There were no patients in whom SSEP changes did not return to baseline during the surgical procedure. Patients in four cases, despite their stable SSEP recordings throughout the procedure, were noted immediately postoperatively to have experienced significant neurological deterioration. The false-negative rate in SSEP monitoring was 9%. Sensitivity was determined to be 0%. CONCLUSIONS: It is important to recognize high false-negative rates and low sensitivity of SSEP monitoring when it is used to record spinal cord function during anterior approaches for thoracic vertebrectomies. The insensitivity of SSEPs for motor deterioration during anterior thoracic vertebrectomies is likely due to the limitation of SSEPs, which monitor only posterior column function whereas motor paths are conveyed in the anterior and anterolateral spinal cord. The authors believe that SSEPs can not be relied on to detect reversible spinal damage during anterior thoracic vertebrectomies.

Radiologic evaluation in patients with head injury.

Head injury is common. With many excellent imaging techniques readily available, radiologic evaluation has become critical in the management of patients with head injuries. We review the indications for various imaging studies in patients with head injury. In general, a noncontrast computed tomography of the head is the study of choice for patients with head injury and should be performed whenever there is reasonable suspicion of a serious injury to the brain.

Vertebral arch or posterior spinal tuberculosis.

Posterior spinal tuberculosis or arch tuberculosis is a form of skeletal tuberculosis that selectively involves the vertebral arch. It may mimic skeletal neoplasm clinically and radiographically. Although posterior spinal tuberculosis has been reported in developing countries it has rarely been found in the United States. As a result, there is limited information about this entity in the US literature. We are presenting our experience in a patient born in the United States.

Cervical epidural hematoma after chiropractic manipulation in a healthy young woman: case report.

OBJECTIVE AND IMPORTANCE: Posttraumatic spinal epidural hematoma is an uncommon entity. We present the first report of spinal epidural hematoma occurring after chiropractic manipulation in a healthy young adult without preexisting cervical disease or any obvious predisposing factors. CLINICAL PRESENTATION: The patient presented with radicular and myelopathic symptoms that developed 15 minutes after chiropractic manipulation. Computed tomography and magnetic resonance imaging were performed. They revealed a cervical epidural hematoma. INTERVENTION: The hematoma was evacuated, and all of the patient's neurological symptoms improved over the course of the next 3 days. CONCLUSION: Although cervical spinal epidural hematoma is a rare clinical entity, it must be considered in patients with pain or neurological deficit after cervical trauma.

Giant cell tumour of the seventh cervical vertebra.

A 43-year-old man presented with bubbly expansion and rarefaction of the body of the seventh cervical vertebra. The lesion involved the right side of the vertebral arch and had a soft-tissue component extending mainly anterior to the vertebra. Histopathologic examination of the specimen obtained by open biopsy revealed a giant cell tumour. Giant cell tumours of the spine, excluding the sacrum, are rare. Radiographically, they may be confused with metastatic carcinoma, plasmacytoma, lymphoma, chordoma and even benign lesions, particularly aneurysmal bone cyst and brown tumour of hyperparathyroidism. However, giant cell tumour occurs mainly in younger patients, involves the vertebral body selectively in most cases and has a bubbly appearance associated with rarefaction and expansion of the vertebral body, characteristics that may be helpful in the diagnosis.

Symptomatic cavernous malformations affecting the spine and spinal cord.

Ten cases of symptomatic cavernous malformations affecting the spine and spinal cord were retrospectively reviewed. The cases display a spectrum of pathological findings involving the vertebral body, vertebral body with epidural extension, epidural space without bony involvement, intradural extramedullary space, and intramedullary lesions. Lesions at all locations are identical histologically, electron microscopically, and immunohistochemically. This perspective, in which cavernous malformations are envisioned as a single entity arising at numerous locations, runs contrary to the view found in the neurosurgical literature. In most discussions of cavernous malformations, vertebral body lesions are depicted as separate entities from intradural lesions. Cavernous malformations, also called cavernous hemangiomas, are developmental vascular hamartomas that, by definition, do not grow by mitotic activity. Yet, the expansion of these lesions is well documented both in the literature and among our cases. The therapeutic modalities used in our series included observation, embolization, radiation, and surgical resection alone or in combination. All modalities are effective but must be tailored to the specific needs and condition of the patient. The embryology, methods of treatment, and proposed mechanisms of growth, plus similarities and differences between cavernous malformations at each location, are reviewed. Analogies between spinal and intracranial lesions are presented. On the basis of this series and a review of the literature, we conclude that cavernous malformations represent a single entity regardless of location. Segregation based on location, as is prevalent throughout the neurosurgical literature, hinders an overall understanding of these lesions. Cavernous malformations are more appropriately viewed as a single pathological entity arising in a multitude of locations. The difficulties encountered when managing cavernous malformations at various locations are unique to the location and not the lesion.

Complications of cervical disk surgery.

The common complications of cervical disk surgery using the posterior and the anterior approach are discussed. The advantages and disadvantages of diskectomy with and without fusion are also presented. Complications of cervical disk surgery are a function of the type of procedure, the specific anatomic approach, and the experience of the surgeon. Although the posterior approach may be used for posterolateral or lateral herniated disks and foramenal osteophytes, the anterior approach is safer for central herniated disks and osteophyte formation. At The Mount Sinai Hospital, anterior-approach cervical diskectomy, whether with or without fusion, is preferred to the posterior approach for all herniations.

Combined approach for excision of cervical nerve tumors with dural extension.

Tumors of the cervical plexus are rare. Often these tumors are found on routine exam as asymptomatic masses. We present our experience in managing four patients with tumors with dural extension. Three of these lesions were neurilemomas and one was a meningioma. Symptoms and signs included weakness and hypoesthesia. Evaluation included complete neurologic examination with electromyography (EMG). Magnetic resonance imaging (MRI) was the best diagnostic tool to see tumor extent into the epidural and intradural space. Computed tomography (CT) or plain x-rays were used to evaluate the degree of destruction of the cervical spine. The surgical removal of these tumors was performed by a two-team approach. A posterior laminectomy was combined with an anterior neck exploration. Follow-up shows persistent upper extremity weakness in two patients, hypesthesia in three patients, and anesthesia of the anterior chest wall in two patients. Patients with these lesions should be informed of the potential neurologic consequences of removal.

Predicting outcome in brain-injured patients. Using the Glasgow Coma Scale in primary care practice.

The Glasgow Coma Scale provides a quick and simple way to assess the level of consciousness of a brain-injured patient and to predict that patient's social outcome. The information provided by such prediction of prognosis can help primary care physicians choose the appropriate therapeutic regimen and also allows investigators to compare alternative regimens.

Head and neck trauma in taxicabs. A growing urban problem.

The passage of mandatory seat belt legislation has markedly decreased the incidence of head and neck trauma to passengers in private automobiles. However, taxicabs are exempt from seat belt laws in many states. Seat belts, which are included as standard equipment by automobile manufacturers, are often made inaccessible by taxicab operators. We present five cases of head and neck trauma sustained by passengers in taxicabs in which seat belts were not accessible. Injuries included laryngeal fractures, maxillofacial trauma, and severe trauma to the cervical spine. All injuries could have been avoided by the use of an accessible safety belt. The nationwide scope of this problem and strategies for modification of existing laws for better protection of passengers in cars for hire are presented.

Osseous lesions of the cervical spine.

Osseous lesions of the cervical spine present a spectrum of histopathology varying from benign to highly malignant tumors. Vertebral body resection and reconstruction are possible at all levels of the cervical spine. This affords decompression of the spinal cord even with anterior or anterolateral masses. Resection of the posterior arch or vertebral body should be followed by internal fixation with Halifax clamps, Roy-Camille plates, or Ransford rods posteriorly with a bony fusion or by Caspar plates, strut grafts, or acrylic anteriorly. Restoration of spinal alignment must be carefully planned to correct any structural deficits. In those patients who are not considered as surgical candidates, steroids, chemotherapy, or radiation remain effective alternatives in attempting to relieve pain or reverse neurologic deficits. Earlier awareness and evaluation for this group of patients will afford relief of pain, reversal of neurological deficits, stabilization of the cervical spine, and early immobilization.

Paranasal sinus disease with intracranial extension: aspergillosis versus malignancy.

Aspergillus is a fungus with world-wide distribution and a common endogenous contaminate of the upper respiratory tract. It has become an increasingly recognized pathogen in the paranasal sinuses. In its pathologic state it presents in one of several forms that may represent a continuum of the disease: allergic, noninvasive, invasive, and fulminant. The progression and prognosis of these disease depends on the location and immunologic status of the patient. This case represents the fourth reported case of a nonimmunologic compromised patient with intracranial extension of aspergillosis. The patient presented with unilateral pansinusitis and radiographic evidence of orbital and anterior cranial fossa invasion. This case illustrates the difficulty of establishing the diagnosis of invasive aspergillosis and differentiating it from neoplastic entities. Radiographs and photomicrographs will be presented to establish this premise.

Middle fossa facial schwannoma removed via the intracranial extradural approach: case report and review of the literature.

A case of an intracranial facial schwannoma originating from the geniculate ganglion in a patient without neurofibromatosis is presented. Preoperative diagnosis and determination of site of origin along the facial nerve course is stressed through analysis of radiographic and clinical features. The tumor was completely removed using an intracranial, extradural approach.

Thoracic disc disease. Clinical manifestations and surgical treatment.

Thoracic disc herniation in an uncommon spinal entity. The authors discuss three variations in the presentation of the disease and point out the importance of being able to recognize both the thoracic prolapsed disc and the symptomatic degenerated nonherniated disc. The seven cases that are reported demonstrate the unique presentations of this disease and the techniques for treatment. Utilization of the anterior transthoracic approach for the excision of the herniated disc is emphasized.