The Lung Cancer Prediction Model "Stress Test": Assessment of Models' Performance in a High-Risk Prospective Pulmonary Nodule Cohort.

BACKGROUND: Pulmonary nodules represent a growing health care burden because of delayed diagnosis of malignant lesions and overtesting for benign processes. Clinical prediction models were developed to inform physician assessment of pretest probability of nodule malignancy but have not been validated in a high-risk cohort of nodules for which biopsy was ultimately performed. RESEARCH QUESTION: Do guideline-recommended prediction models sufficiently discriminate between benign and malignant nodules when applied to cases referred for biopsy by navigational bronchoscopy? STUDY DESIGN AND METHODS: We assembled a prospective cohort of 322 indeterminate pulmonary nodules in 282 patients referred to a tertiary medical center for diagnostic navigational bronchoscopy between 2017 and 2019. We calculated the probability of malignancy for each nodule using the Brock model, Mayo Clinic model, and Veterans Affairs (VA) model. On a subset of 168 patients who also had PET-CT scans before biopsy, we also calculated the probability of malignancy using the Herder model. The performance of the models was evaluated by calculating the area under the receiver operating characteristic curves (AUCs) for each model. RESULTS: The study cohort contained 185 malignant and 137 benign nodules (57% prevalence of malignancy). The malignant and benign cohorts were similar in terms of size, with a median longest diameter for benign and malignant nodules of 15 and 16 mm, respectively. The Brock model, Mayo Clinic model, and VA model showed similar performance in the entire cohort (Brock AUC, 0.70; 95% CI, 0.64-0.76; Mayo Clinic AUC, 0.70; 95% CI, 0.64-0.76; VA AUC, 0.67; 95% CI, 0.62-0.74). For 168 nodules with available PET-CT scans, the Herder model had an AUC of 0.77 (95% CI, 0.68-0.85). INTERPRETATION: Currently available clinical models provide insufficient discrimination between benign and malignant nodules in the common clinical scenario in which a patient is being referred for biopsy, especially when PET-CT scan information is not available.

Robotic versus Electromagnetic bronchoscopy for pulmonary LesIon AssessmeNT: the RELIANT pragmatic randomized trial.

BACKGROUND: Robotic-assisted bronchoscopy has recently emerged as an alternative to electromagnetic navigational bronchoscopy for the evaluation of peripheral pulmonary lesions. While robotic-assisted bronchoscopy is proposed to have several advantages, such as an easier learning curve, it is unclear if it has comparable diagnostic utility as electromagnetic navigational bronchoscopy. METHODS: Robotic versus Electromagnetic bronchoscopy for pulmonary LesIon AssessmeNT (RELIANT) is an investigator-initiated, single-center, open label, noninferiority, cluster randomized controlled trial conducted in two operating rooms at Vanderbilt University Medical Center. Each operating room (OR) is assigned to either robotic-assisted or electromagnetic navigational bronchoscopy each morning, with each OR day considered one cluster. All patients undergoing diagnostic bronchoscopy for evaluation of a peripheral pulmonary lesion in one of the two operating rooms are eligible. Schedulers, patients, and proceduralists are blinded to daily group allocations until randomization is revealed for each operating room each morning. The primary endpoint is the diagnostic yield defined as the proportion of cases yielding lesional tissue. Secondary and safety endpoints include procedure duration and procedural complications. Enrolment began on March 6, 2023, and will continue until 202 clusters have been accrued, with expected enrolment of approximately 400 patients by the time of completion in March of 2024. DISCUSSION: RELIANT is a pragmatic randomized controlled trial that will compare the diagnostic yield of the two most commonly used bronchoscopic approaches for sampling peripheral pulmonary lesions. This will be the first known cluster randomized pragmatic trial in the interventional pulmonology field and the first randomized controlled trial of robotic-assisted bronchoscopy. TRIAL REGISTRATION: ClinicalTrials.gov registration (NCT05705544) on January 30, 2023.

Diagnostic Yield vs Diagnostic Accuracy for Peripheral Lung Biopsy Evaluation: Evidence Supporting a Future Pragmatic End Point.

BACKGROUND: Diagnostic yield and accuracy endpoints have been used inconsistently in the evaluation of advanced diagnostic bronchoscopy devices and techniques, limiting between-study comparisons. In addition, diagnostic accuracy can be adjudicated only after prolonged clinical follow-up, which delays reporting on the performance of novel devices. RESEARCH QUESTION: Will a conservative diagnostic yield definition result in few false-negative initial results to closely approximate diagnostic accuracy and represent a useful outcome for future studies of diagnostic utility? METHODS: Commonly used definitions of diagnostic yield were applied to a prospective data set of consecutive peripheral pulmonary lesions sampled by navigational bronchoscopy from 2017 to 2019. All consider malignancy to be diagnostic but differ in their classification of nonmalignant biopsy findings, which were subcategorized as specific benign, nonspecific benign, or normal lung. Diagnostic yield calculations were also compared with diagnostic accuracy, defined as the proportion of biopsy specimens deemed diagnostic by each definition that were confirmed accurate through 2 years of follow-up. RESULTS: A total of 450 biopsy specimens of lesions were analyzed. The prevalence of malignancy was 60.9% (274 of 450). On initial bronchoscopy pathology, there were 227 malignant diagnoses (50.4%), with a single false positive (0.4%). Among 104 biopsy specimens with specific benign findings, only two were false negative for malignancy (1.9%). There were 119 nonspecific benign biopsy specimens, with 46 false negatives for malignancy (38.7%). The discrepancy between diagnostic yield and accuracy was 0.7% for the conservative definition, which only considered malignant or specific benign findings as diagnostic. INTERPRETATION: A conservative diagnostic yield definition excluding nonspecific benign diagnoses closely approximated diagnostic accuracy through 2 years' follow-up, with a less than 1% discrepancy. Using this conservative yield definition may allow for dissemination of reliable diagnostic utility data without protracted delays needed for follow-up data in this era of rapid technological change in advanced diagnostic bronchoscopy.

Assessing the clinical utility of biomarkers using the intervention probability curve (IPC).

BACKGROUND: Assessing the clinical utility of biomarkers is a critical step before clinical implementation. The reclassification of patients across clinically relevant subgroups is considered one of the best methods to estimate clinical utility. However, there are important limitations with this methodology. We recently proposed the intervention probability curve (IPC) which models the likelihood that a provider will choose an intervention as a continuous function of the probability, or risk, of disease. OBJECTIVE: To assess the potential impact of a new biomarker for lung cancer using the IPC. METHODS: The IPC derived from the National Lung Screening Trial was used to assess the potential clinical utility of a biomarker for suspected lung cancer. The summary statistics of the change in likelihood of intervention over the population can be interpreted as the expected clinical impact of the added biomarker. RESULTS: The IPC analysis of the novel biomarker estimated that 8% of the benign nodules could avoid an invasive procedure while the cancer nodules would largely remain unchanged (0.1%). We showed the benefits of this approach compared to traditional reclassification methods based on thresholds. CONCLUSIONS: The IPC methodology can be a valuable tool for assessing biomarkers prior to clinical implementation.

Robotic versus Electromagnetic Bronchoscopy for Pulmonary LesIon AssessmeNT: the RELIANT pragmatic randomized trial.

Background: Robotic assisted bronchoscopy has recently emerged as an alternative to electromagnetic navigational bronchoscopy for the evaluation of peripheral pulmonary lesions. While robotic assisted bronchoscopy is proposed to have several advantages, such as an easier learning curve, it is unclear if it has comparable diagnostic utility as electromagnetic navigational bronchoscopy. Methods: Robotic versus Electromagnetic Bronchoscopy for Pulmonary LesIon AssessmeNT (RELIANT) is an investigator-initiated, single-center, open label, noninferiority, cluster randomized controlled trial conducted in two operating rooms at Vanderbilt University Medical Center. Each operating room is assigned to either robotic assisted or electromagnetic navigational bronchoscopy each morning, with each OR day considered one cluster. All patients undergoing diagnostic bronchoscopy for evaluation of a peripheral pulmonary lesion in one of the two operating rooms are eligible. Schedulers, patients and proceduralists are blinded to daily group allocations until randomization is revealed for each operating room each morning. The primary endpoint is the diagnostic yield defined as the proportion of cases yielding lesional tissue. Secondary and safety endpoints include procedure duration and procedural complications. Enrolment began on March 6, 2023, and will continue until 202 clusters have been accrued, with expected enrolment of approximately 400 patients by the time of completion in March of 2024. Discussion: RELIANT is a pragmatic randomized controlled trial that will compare the diagnostic yield of the two most commonly used bronchoscopic approaches for sampling peripheral pulmonary lesions. This will be the first known cluster randomized pragmatic trial in the interventional pulmonology field and the first randomized controlled trial of robotic assisted bronchoscopy. Trial registration: ClinicalTrials.gov registration (NCT05705544) on January 30, 2023.

Update on Biomarkers for the Stratification of Indeterminate Pulmonary Nodules.

Lung cancer is the leading cause of cancer-related deaths. Early detection and diagnosis are critical, as survival decreases with advanced stages. Approximately 1.6 million nodules are incidentally detected every year on chest CT scan images in the United States. This number of nodules identified is likely much larger after accounting for screening-detected nodules. Most of these nodules, whether incidentally or screening detected, are benign. Despite this, many patients undergo unnecessary invasive procedures to rule out cancer because our current stratification approaches are suboptimal, particularly for intermediate probability nodules. Thus, noninvasive strategies are urgently needed. Biomarkers have been developed to assist through the continuum of lung cancer care and include blood protein-based biomarkers, liquid biopsies, quantitative imaging analysis (radiomics), exhaled volatile organic compounds, and bronchial or nasal epithelium genomic classifiers, among others. Although many biomarkers have been developed, few have been integrated into clinical practice as they lack clinical utility studies showing improved patient-centered outcomes. Rapid technologic advances and large network collaborative efforts will continue to drive the discovery and validation of many novel biomarkers. Ultimately, however, randomized clinical utility studies showing improved patient outcomes will be required to bring biomarkers into clinical practice.

Longitudinal lung cancer prediction convolutional neural network model improves the classification of indeterminate pulmonary nodules.

A deep learning model (LCP CNN) for the stratification of indeterminate pulmonary nodules (IPNs) demonstrated better discrimination than commonly used clinical prediction models. However, the LCP CNN score is based on a single timepoint that ignores longitudinal information when prior imaging studies are available. Clinically, IPNs are often followed over time and temporal trends in nodule size or morphology inform management. In this study we investigated whether the change in LCP CNN scores over time was different between benign and malignant nodules. This study used a prospective-specimen collection, retrospective-blinded-evaluation (PRoBE) design. Subjects with incidentally or screening detected IPNs 6-30 mm in diameter with at least 3 consecutive CT scans prior to diagnosis (slice thickness ≤ 1.5 mm) with the same nodule present were included. Disease outcome was adjudicated by biopsy-proven malignancy, biopsy-proven benign disease and absence of growth on at least 2-year imaging follow-up. Lung nodules were analyzed using the Optellum LCP CNN model. Investigators performing image analysis were blinded to all clinical data. The LCP CNN score was determined for 48 benign and 32 malignant nodules. There was no significant difference in the initial LCP CNN score between benign and malignant nodules. Overall, the LCP CNN scores of benign nodules remained relatively stable over time while that of malignant nodules continued to increase over time. The difference in these two trends was statistically significant. We also developed a joint model that incorporates longitudinal LCP CNN scores to predict future probability of cancer. Malignant and benign nodules appear to have distinctive trends in LCP CNN score over time. This suggests that longitudinal modeling may improve radiomic prediction of lung cancer over current models. Additional studies are needed to validate these early findings.

Shape-Sensing Robotic-Assisted Bronchoscopy vs Digital Tomosynthesis-Corrected Electromagnetic Navigation Bronchoscopy: A Comparative Cohort Study of Diagnostic Performance.

BACKGROUND: Electromagnetic navigational bronchoscopy has been the dominant bronchoscopic technology for targeting small peripheral lesions and now includes digital tomosynthesis-electromagnetic navigational bronchoscopy (DT-ENB), allowing near-real-time intraprocedural nodule visualization. Shape-sensing robotic-assisted bronchoscopy (ssRAB), with improved catheter stability and articulation recently became available. Although the diagnostic performance of these two methods seems higher than that of legacy systems, data remain limited. We sought to compare the diagnostic yield of these two novel platforms after their introduction at our institution. RESEARCH QUESTION: Does the diagnostic yield of ssRAB differ significantly from that of DT-ENB in patients undergoing biopsy of peripheral pulmonary lesions (PPLs)? STUDY DESIGN AND METHODS: This retrospective comparative cohort study analyzed prospectively collected data on consecutive procedures performed with DT-ENB and ssRAB in their first 6 months of use at our institution. Biopsies were considered diagnostic if histopathologic analysis revealed malignancy or specific benign features that readily explained the presence of a PPL. Nonspecific inflammation, normal lung or airway, and atypia not diagnostic of malignancy were considered nondiagnostic. RESULTS: SSRAB was used to biopsy 143 PPLs in 133 patients and DT-ENB was used to biopsy 197 PPLs in 170 patients. Diagnostic yield was 77% for ssRAB (110 of 143 PPLs) and 80% (158 of 197 PPLs) for DT-ENB (OR, 0.8; 95% CI, 0.5-1.4; P = .4). Median lesion diameters were 17 and 19 mm, respectively. No difference in diagnostic yield was found after adjustment for lesion size, bronchus sign, peripheral vs middle third location, and sex. Pneumothorax complicated 1.5% of ssRAB and 1.8% of DT-ENB procedures (P = .86). INTERPRETATION: SSRAB and DT-ENB showed comparable diagnostic yields and safety profiles in this comparative cohort study.

18F-FSPG PET imaging for the evaluation of indeterminate pulmonary nodules.

BACKGROUND: 18F-fluorodeoxyglucose (FDG) PET/CT is recommended for evaluation of intermediate-risk indeterminate pulmonary nodules (IPNs). While highly sensitive, the specificity of FDG remains suboptimal for differentiating malignant from benign nodules, particularly in areas where fungal lung diseases are prevalent. Thus, a cancer-specific imaging probe is greatly needed. In this study, we tested the hypothesis that a PET radiotracer (S)-4-(3-[18F]-fluoropropyl)-L-glutamic acid (FSPG) improves the diagnostic accuracy of IPNs compared to 18F-FDG PET/CT. METHODS: This study was conducted at a major academic medical center and an affiliated VA medical center. Twenty-six patients with newly discovered IPNs 7-30mm diameter or newly diagnosed lung cancer completed serial PET/CT scans utilizing 18F-FDG and 18F-FSPG, without intervening treatment of the lesion. The scans were independently reviewed by two dual-trained diagnostic radiology and nuclear medicine physicians. Characteristics evaluated included quantitative SUVmax values of the pulmonary nodules and metastases. RESULTS: A total of 17 out of 26 patients had cancer and 9 had benign lesions. 18F-FSPG was negative in 6 of 9 benign lesions compared to 7 of 9 with 18F-FDG. 18F-FSPG and 18F-FDG were positive in 14 of 17 and 12 of 17 malignant lesions, respectively. 18F-FSPG detected brain and intracardiac metastases missed by 18F-FDG PET in one case, while 18F-FDG detected a metastasis to the kidney missed by 18F-FSPG. CONCLUSION: In this pilot study, there was no significant difference in overall diagnostic accuracy between 18F-FSPG and 18F-FDG for the evaluation of IPNs and staging of lung cancer. Additional studies will be needed to determine the clinical utility of this tracer in the management of IPNs and lung cancer.

Risk stratification of indeterminate pulmonary nodules.

PURPOSE OF REVIEW: Lung cancer remains the leading cause of cancer-related death in the United States, with poor overall 5-year survival. Early detection and diagnosis are key to survival as demonstrated in lung cancer screening trials. However, with increasing implementation of screening guidelines and use of computed tomography, there has been a sharp rise in the incidence of indeterminate pulmonary nodules (IPNs). Risk stratification of IPNs, particularly those in the intermediate-risk category, remains challenging in clinical practice. Individual risk factors, imaging characteristics, biomarkers, and prediction models are currently used to assist in risk stratifying patients, but such strategies remain suboptimal. This review focuses on established risk stratification methods, current areas of research, and future directions. RECENT FINDINGS: The multitude of yearly incidental and screening-detected IPNs, its management-related healthcare costs, and risk of invasive procedures provides a strong rationale for risk stratification efforts. The development of new molecular and imaging biomarkers to discriminate benign from malignant lung nodules shows great promise. Yet, risk stratification methods need integration into the diagnostic workflow and await validation in prospective, biomarker-driven clinical trials. SUMMARY: Novel biomarkers and new imaging analysis, including radiomics and deep-learning methods, have been developed to optimize the risk stratification of IPNs. While promising, additional validation and clinical studies are needed before they can be part of routine clinical practice.

Cross-Sectional Geometry and Scaling in the Baculum of Cuban Hutias (Rodentia: Capromyidae).

Bacula from 61 individual hutia (Rodentia) from five species were studied. The purpose was to investigate cross-sectional geometry as an indicator of mechanical behavior in order to answer questions around the origin and maintenance of the mammalian baculum. From images of the apical and basal cross sections, the following variables were calculated: perimeter, cross-sectional area, maximum second moment of area, and polar moment. An allometric analysis showed that these variables were related to body size. The orientation of the maximum second moment of area was analyzed by means of circular statistics. This orientation was transverse in both the apical and basal cross sections. Values for the second moment of area and polar moment, obtained from the predicted value of the allometric equations, showed that either the bending moment or the twisting moment of the baculum must be relatively low in hutias, compared with those of the radius in the same species. The results of the second moment of area predict that the main bending stress acting on the baculum is transverse. At the same time, shear stress would not be negligible. Anat Rec, 303:1346-1353, 2020. © 2019 American Association for Anatomy.

Globally important islands where eradicating invasive mammals will benefit highly threatened vertebrates.

Invasive alien species are a major threat to native insular species. Eradicating invasive mammals from islands is a feasible and proven approach to prevent biodiversity loss. We developed a conceptual framework to identify globally important islands for invasive mammal eradications to prevent imminent extinctions of highly threatened species using biogeographic and technical factors, plus a novel approach to consider socio-political feasibility. We applied this framework using a comprehensive dataset describing the distribution of 1,184 highly threatened native vertebrate species (i.e. those listed as Critically Endangered or Endangered on the IUCN Red List) and 184 non-native mammals on 1,279 islands worldwide. Based on extinction risk, irreplaceability, severity of impact from invasive species, and technical feasibility of eradication, we identified and ranked 292 of the most important islands where eradicating invasive mammals would benefit highly threatened vertebrates. When socio-political feasibility was considered, we identified 169 of these islands where eradication planning or operation could be initiated by 2020 or 2030 and would improve the survival prospects of 9.4% of the Earth's most highly threatened terrestrial insular vertebrates (111 of 1,184 species). Of these, 107 islands were in 34 countries and territories and could have eradication projects initiated by 2020. Concentrating efforts to eradicate invasive mammals on these 107 islands would benefit 151 populations of 80 highly threatened vertebrates and make a major contribution towards achieving global conservation targets adopted by the world's nations.

Molecular phylogenetic analysis of nuclear genes suggests a Cenozoic over-water dispersal origin for the Cuban solenodon.

The Cuban solenodon (Solenodon cubanus) is one of the most enigmatic mammals and is an extremely rare species with a distribution limited to a small part of the island of Cuba. Despite its rarity, in 2012 seven individuals of S. cubanus were captured and sampled successfully for DNA analysis, providing new insights into the evolutionary origin of this species and into the origins of the Caribbean fauna, which remain controversial. We conducted molecular phylogenetic analyses of five nuclear genes (Apob, Atp7a, Bdnf, Brca1 and Rag1; total, 4,602 bp) from 35 species of the mammalian order Eulipotyphla. Based on Bayesian relaxed molecular clock analyses, the family Solenodontidae diverged from other eulipotyphlan in the Paleocene, after the bolide impact on the Yucatan Peninsula, and S. cubanus diverged from the Hispaniolan solenodon (S. paradoxus) in the Early Pliocene. The strikingly recent divergence time estimates suggest that S. cubanus and its ancestral lineage originated via over-water dispersal rather than vicariance events, as had previously been hypothesised.

Evaluación de la calidad del procedimiento de biopsia selectiva del ganglio centinela en pacientes con cáncer de mama, en un hospital comarcal / Assessment of the quality of selective sentinel lymph node biopsy in patients with breast cancer in a district hospital

Objetivo. Evaluar la calidad del procedimiento de la biopsia selectiva del ganglio centinela en la Unidad de Patología Mamaria de un hospital comarcal, sin servicio de Medicina Nuclear. Material y métodos. Se diseñó un estudio descriptivo, retrospectivo, en el que se incluyeron 104 pacientes con cáncer de mama no avanzado. El día previo a la cirugía se les realizó una linfogammagrafía en el hospital de referencia. Como instrumento de gestión, se empleó la guía clínica de autoevaluación de la Sociedad Española de Senología y Patología Mamaria. Estudiamos la eficacia en la detección del ganglio centinela, la sensibilidad y la media de ganglios centinelas axilares aislados por paciente. Se evaluaron tanto los resultados globales obtenidos por la Unidad de Mama, como los obtenidos individualmente por cada uno de los 3 cirujanos que la integran. Resultados. Se cumplieron los 3 criterios esenciales de la guía de autoevaluación, siendo: la detección del ganglio centinela del 94,2%, la sensibilidad acreditada del 93,2%, y la media de ganglios centinela axilares extraídos de 1,66 ± 0,84. Estos criterios también se cumplieron a nivel individual, por cada uno de los 3 cirujanos que integran la unidad. La aplicación de la guía de autoevaluación nos dio una puntuación global de 33 sobre 71 puntos, siendo el nivel de calidad ii el más prevalente. Conclusiones. En nuestra unidad, la aplicación de la guía publicada por la Sociedad Española de Senología y Patología Mamaria para evaluar los aspectos esenciales y básicos de la biopsia selectiva del ganglio centinela en cáncer de mama nos ha permitido confirmar que realizamos el procedimiento con suficiente garantía de calidad, y además, promover aspectos de mejora (AU)

Objective. To assess the quality of selective sentinel lymph node biopsy in the Breast Diseases Unit of a district hospital without a Nuclear Medicine service. Methods and material. A retrospective, descriptive study was conducted in 104 patients with nonadvanced breast cancer. The day before surgery, the patients underwent lymph node mammography in the referral hospital. The self-evaluation clinical guideline of the Spanish Society of Senology and Breast Pathology was used as part of the management protocol. We studied the efficacy of sentinel lymph node detection, the sensitivity of the procedure, and the mean number of axillary sentinel lymph nodes isolated per patient. Both the overall results obtained by the Breast Diseases Unit and the results obtained individually by each of the 3 surgeons working in the unit were evaluated. Results. The 3 main criteria of the self-evaluation guideline were fulfilled, namely: sentinel lymph node detection in 94.2%, the sensitivity ratio in 93.2% and the mean number of sentinel lymph nodes removed, 1.66 ± 0.84. These criteria were also fulfilled by each of the 3 surgeons working in the unit. The score of the self-assessment guideline was 33 out of 71 points, with level ii being the most prevalent level of quality. Conclusions. In our unit, application of the guidelines published by the Spanish Society of Senology and Breast Pathology to evaluate essential and basic aspects of selective sentinel lymph node biopsy in breast cancer demonstrated that quality criteria are being met in our unit, and allowed us to promote quality improvements (AU)

Repercusión del estado nutricional en el desarrollo dentario y esqueletal de escolares de Tucumán, Argentina: año 2004 / Impact of nutritional status on dental and skeletal development of school Tucumán, Argentina: 2004

El objetivo fue determinar el estado nutricional de niños y asociar la edad cronológica al estado madurativo esqueletal y dentario. Para determinar el estado nutricional de los escolares se usó la tabla de crecimiento normal de peso para talla de niños y niñas argentinos (Lejarraga y col, 1977). El estado madurativo esqueletal se relevó mediante radiografía carpal las que fueron comparadas con las del Atlas de Desarrollo Esqueletal de Greulich and Pyle. La edad dentaria se determinó mediante radiografías retroalveolares de canino inferior y comparadas con la Tabla de fases del desarrollo dental adaptado de Haavikko. No se encontraron diferencias significativas entre la edad cronológica, edad dentaria y ósea entre los grupos. ANOVA P= 0,76; P=0,17; P=0,50, respectivamente. Para este grupo de pacientes, la edad ósea de los niños desnutridos es significativamente inferior que la edad cronológica (Test de Kruskal-Wallis) P=0,021. En los niños eutróficos, la edad dentaria fue significativamente inferior que la cronológica (Kruskal- Wallis) P= 0,03

The objective was to determine children nutritional status and to associate chronological age to the skeletal and dental maduration status. In order to determine nutritional status of students, it was used a table for normal growing and development of weight and height for argentine children (Lejarraga, 1977). Skeletal madurative state was obtained using a wrist radiography which were compared with others included in the Atlas of Skeletal Development of the Hand and Wrist of Greulich and Pyle. Dental age was determined using dental radiograph of lower canine and compared with standards in the Table of dental Development Stages of Haaviko No significant difference was found between chronological, dental and skeletal age between groups. ANOVA P=0,76; P=0,17; P=0,50 respectively. For this population, skeletal age of malnourished children is significativelly lower than chronological age. For eutrophic children, dental age appeared significativelly lower than chronological age

Úlcera vulvar aguda / Acute vulvar ulcer

La ulceración vulvar puede ocurrir como un proceso primario o secundario en una gran variedad de situaciones: infecciones, enfermedades autoinmunitarias e inflamatorias y dermatosis, neoplasias y entidades de etiología desconocida. El diagnóstico se basa en criterios positivos: aparición brusca de una o varias ulceraciones profundas y grandes, necrotizantes y muy dolorosas en mujeres jóvenes, generalmente vírgenes, precedidas de fiebre en ocasiones asociadas a amigdalitis. Son necesarios estudios microbiológicos, histológicos e inmunológicos específicos para establecer el diagnóstico. Se describe un caso de una mujer de 18 años con las características clínicas típicas de la úlcera vulvar aguda y se discuten los principales diagnósticos diferenciales

Vulvar ulceration can occur as the primary or secondary event in a wide variety of processes:infections, autoimmune and/or inflammatory diseases and dermatoses, neoplasms and entities ofunknown etiology. Diagnosis relies on positive criteria: acute onset of one or several deep, large, necrotizing and extremely painful ulcerations in young women, usually virgins, preceded by fever sometimes associated with tonsillitis. Specificmicrobiological, histological, immunological, andother investigations are often required to establish a diagnosis.The case of an 18-year-old woman with typicalclinical features of acute vulvar ulcer is reported.The main differential diagnoses are discussed

Idiomarina fontislapidosi sp. nov. and Idiomarina ramblicola sp. nov., isolated from inland hypersaline habitats in Spain.

Two bacterial strains, F23T and R22T, have been isolated from hypersaline habitats in Málaga (S. Spain) and Murcia (E. Spain). The novel strains, similar to previously described Idiomarina species, are slightly curved rods, Gram-negative, chemo-organotrophic, strictly aerobic and motile by a single polar flagellum. Both strains produce catalase and oxidase. They hydrolyse aesculin, gelatin, casein, Tween 20, Tween 80 and DNA but not starch or tyrosine. The strains differ from the hitherto described Idiomarina species in their capacity to produce extracellular polysaccharides and their different patterns of carbon sources and antimicrobial susceptibility. They are moderate halophiles capable of growing in NaCl concentrations of 0.5 to 25 % w/v, the optimum being 3-5 % w/v. Cellular fatty acids are predominantly iso-branched. The main fatty acids in strain FP23T are 15 : 0 iso (26.75 %), 16 : 1omega7c (11.33 %) and 16 : 0 (11.73 %) whilst 15 : 0 iso (24.69 %), 17 : 0 iso (12.92 %) and 17 : 1omega9c (11.03 %) are predominant in strain R22T. The DNA G + C composition is 46.0 mol% in strain FP23T and 48.7 mol% in strain R22T. Phylogenetic analyses indicate conclusively that the two strains belong to the genus Idiomarina. DNA-DNA hybridization revealed that they represent novel species. In the light of the polyphasic evidence accumulated in this study, it is proposed that they be classified as novel species of the genus Idiomarina, with the names Idiomarina fontislapidosi sp. nov. (type strain F23T = CECT 5859T = LMG 22169T) and Idiomarina ramblicola sp. nov. (type strain R22T = CECT 5858T = LMG 22170T).

Correlación entre patrón respiratorio y morfología cráneo-facial / Correlation between respiratory pattern and cranio-facial morphology

lntroducción - El crecimiento posnatal de ciertas estructuras cráneo-faciales está asociado aI desarrollo de Ias funciones vitales: respiración y deglución. El objetivo de este estudio fue comparar Ia morfología cráneo-cervical de dos grupos de pacientes, uno con respiración normal y otro formado por respiradores bucales. Además, relacionar el patrón respiratorio con Ias anomalias morfológicas y Ias de maloclusión, encontradas. Método - Un total de 105 ninos de entre 8 y 12 afios, de ambos sexos, fueron incluidos en este estudio. De ellos, cincuenta y dos respiradores bucales y cincuenta y tres sin trastomos en Ia función respiratoria. Se utilizaron teleradiografias de perfil, Ias que fueron analizadas aI azar por dos profesionales calibrados. Las medidas estudiadas fueron: Posición deI hueso Hioides, Profundidad cráneo-vertebral anterior, Profundidad cráneo-maxilar posterior, ángulo 6 de Handelman, Ángulo formado por los planos palatino y mandibular con respecto a Ia apófisis Odontoides, Ángulo base de cráneo y Ángulo Plano Palatino-Plano de Frankfort. Resultados - El análisis de los resultados con el test t revela que existe diferencia significativa entre respiradores bucales y respiradores nasales respecto de: Posición deI Hioides (p=0,016), Profundidad cráneo-cervical anterior (P=0,035), y ángulo PP-B.Cráneo (p=0,0000). Conclusión - No se encontró asociación entre patrón respiratorio y maloclusión (clasificación de Angle) (p=0,98); ni entre patrón respiratorio y sexo (p=0,23). En este estudio se encontró relación entre el patrón respiratorio anormal y algunas alteraciones en Ia morfología cráneo-cervical

Garcin syndrome resulting from a giant cell tumor of the skull base in a child.

Garcin syndrome is characterized by a progressive ipsilateral involvement of cranial nerves, culminating in paralysis of all or at least seven of them, without sensory or motor long-tract disturbance, with no intracranial hypertension, and with osteoclastic involvement in the skull base on radiographic computed tomography. Giant cell tumor is a primary bone tumor rarely affecting the skull base. An 8-year-old female presented with a 3-month history of increasingly worsening right otalgia, tinnitus, hearing loss, right facial numbness, and diplopia. She was admitted with a 2-week history of swallowing difficulties, voice change, and right shoulder pain. Neurologic examination disclosed unilateral paralysis of the right fifth through twelfth cranial nerves, with no other abnormal neurologic findings. Skull radiographic computed tomography revealed lytic lesions in the right temporal petrous portion. Computed tomographic scan indicated a destructive mass involving the right greater wing of the sphenoid bone and temporal petrous apex. Magnetic resonance imaging demonstrated a tumor arising from the temporosphenoidal region, infiltrating neither the brain nor the brainstem. No hydrocephalus was observed. Biopsy revealed giant cell tumor. Posterior treatment consisted of radiotherapy. At an 8-year follow-up, the patient was well but with functional sequelae. There is no magnetic resonance imaging evidence of tumor growth. No other giant cell tumor presenting as Garcin syndrome is known to have been reported.