Congenital toxoplasmosis transmitted from an immunologically competent mother infected before conception

Congenital transmission of Toxoplasma gondii from a mother who was apparently immunologically competent and who had toxoplasmic lymphadenitis 2 months before conception is described. Since no T. gondii-specific serological data were available for this mother from the time her lymph node biopsy specimen was obtained, the specimen was studied by polymerase chain reaction (PCR) to determine whether the T. gondii B1 gene was present. The predictive diagnostic value of histologic findings previously considered to be classic signs of T. gondii lymphadenitis also was studied. This was done by correlation of serological tests diagnostic of acute acquired T. gondii infection and presence of characteristic findings in biopsy specimens from persons without known immunocompromise. Both PCR and review of the characteristic features of her lymph node biopsy specimen confirmed the diagnosis of preconceptual infection in the mother. We also discuss two other cases in which apparently immunologically competent mothers with preconceptually acquired infection transmitted this parasite to their fetuses.

Enteropathogenic E. coli exploitation of host epithelial cells

Enteropathogenic E. coli (EPEC) is a leading cause of neonatal diarrhea worldwide. These organisms adhere to the intestinal cell surface, causing rearrangement in the epithelial cell surface and underlying cytoskeleton, resulting in a structure termed an attaching/effacing (A/E) lesion. A/E lesion formation is thought necessary for EPEC-mediated disease. EPEC secretes several proteins that trigger signal transduction, intimate adherence, and cytoskeletal rearrangements in epithelial cells. Additionally, it produces intimin, an outer membrane product that mediates intimate adherence. Together these various bacterial molecules contribute to the intimate relationship that is formed by EPEC with host epithelial cells which results in A/E lesion formation and diarrhea.

Treatment efficacy: aphasia

This article presents a brief overview of aphasia, followed by a summary of research studies and program evaluation data addressed to answering the question of the efficacy of treatment for aphasia. Selected studies are reviewed in terms of the quality of evidence they present. In addition, a number of questions that remain unanswered are also presented. Several tables, designed to provide clarifying information concerning several aspects of research design (number and types of patients studied, examples of well-designed small-group or single-subject studies, clinical techniques for which efficacy data are available), are included. The conclusion of this review is that, generally, treatment for aphasia is efficacious.

Treatment efficacy: cognitive-communicative disorders resulting from traumatic brain injury in adults

Traumatic brain injuries (TBI) may result in a broad array of cognitive-communicative impairments. Cognitive-communicative impairments are the result of deficits in linguistic and nonlinguistic cognitive functions. The speech-language pathologist functions as a member of the multidisciplinary team of professionals that collaboratively assess and treat individuals with TBI. The role of the speech-language pathologist includes assessment of all aspects of communication, as well as the communicative implications of cognitive deficits, and swallowing; treatment planning and programming, as determined by the individual's stage of recovery; client and family training/counseling; and interdisciplinary consultation. The effectiveness of speech and language intervention for specific cognitive deficits (e.g., attention, memory, executive functions) as well as general issues of social-skills training and early intervention are illustrated by scientific and clinical evidence from group-treatment and single-subject studies as well as case studies.

The Abbreviated Injury Scale. A valuable tool for forensic documentation of trauma

Anatomic trauma scoring systems are fundamental to trauma research. The Abbreviated Injury Scale (AIS) and its derivative, the Injury Severity Score (ISS), are the most frequently used scales. We assessed the applicability of the AIS and the ISS systems for postmortem forensic documentation of trauma. In a prospective study, all trauma autopsies performed between January 1 and June 30, 1993, were coded according to the AIS and ISS method. All cases were reviewed by a consultant in forensic medicine and a traumatologist. Cases were grouped in three categories according to ISS values: 0-14, 16-66, and 75. These categories represent minor, major, and incompatible-with-life injuries, respectively. All autopsy findings in which ISS was < or = 14 were peer-reviewed to establish mechanism and cause of death. In the 6-month period, 279 trauma-related autopsies were studied. Age at death averaged 37.1 +/- 18.7 (mean +/- SD). Eighty-six percent of the victims were male. Penetrating trauma was the mechanism of injury in 67%. ISS was 0-14 in 19 cases, 16-66 in 150 cases, and 75 in 110 cases. In conclusion, AIS and ISS scoring systems are applicable to trauma forensic documentation. Using these methods for coding postmortem findings may help in establishing a database for trauma research, and this information could constitute a major part of continuous quality improvement of trauma management. Low ISS values may serve as a warning, sometimes indicating preventable death.

Transaxial gunshot injuries

OBJECTIVE

To define the clinical characteristics of gunshot injuries across the truncal midline (transaxial injuries).

DESIGN

A retrospective case-control study

MATERIALS AND METHODS

Analysis of a consecutive series of 223 patients with gunshot injuries to the torso treated at one trauma center. Sixty-three patients with transaxial injuries were compared to 148 patients with unilateral bullet trajectories.

MAIN RESULTS

The incidence of cardiac (8%), vascular (17%), and spinal (29%) injuries and the mortality rate (29%) were significantly higher among the 63 patients with transaxial injuries compared with 148 patients with unilateral injuries. Initial operative access to the wrong visceral cavity (10%), missed injuries (14%), and early reoperations (19%) were also more common in the transaxial group.

CONCLUSIONS

A transaxial bullet trajectory identifies a distinct injury pattern associated with a high incidence of major visceral damage, intraoperative misadventures, and very high mortality.

Eye manifestations of congenital toxoplasmosis

PURPOSE

To determine the natural history of treated and untreated congenital toxoplasmosis and impact of this infection on vision.

METHODS

In this prospective, longitudinal study, 76 newborns were treated with pyrimethamine and sulfadiazine for approximately one year, and 18 individuals not treated during their first year of life entered the study after age 1 year (historical patients).

RESULTS

Chorioretinal scars were the most common eye finding in all patients and were most common in the periphery (58% of treated and 82% of historical patients). Macular scars were present in 54% of the treated patients; 41% were bilateral. Macular scars were present in 76% of the historical patients; 23% were bilateral. Visual acuity in the presence of macular lesions ranged from 20/20 to 20/400. Of the patients followed up from the newborn period and treated, 29% had bilateral visual impairment, with visual acuity for the best eye of less than 20/40. Causes for this visual impairment in eyes with quiescent lesions included macular scars, dragging of the macula secondary to a peripheral lesion, retinal detachment, optic atrophy, cataract, amblyopia, and phthisis. There were recurrences in both treated (13%, 7/54) and previously untreated historical patients (44%, 8/18). The total, median, and range of years of follow-up during which recurrences were observed were, for treated patients, 189 years (total), five years (median), and three to ten years (range) and, for historical, untreated patients, 160 years (total), 11 years (median), and three to 24 years (range). New lesions occurred in previously normal retinas and also contiguous to older scars. Active lesions appeared to become quiescent within ten to 14 days after beginning pyrimethamine and sulfadiazine therapy.

CONCLUSION

Many children with congenital toxoplasmosis have substantial retinal damage at birth and consequent loss of vision. Nonetheless, vision may be remarkably good in the presence of large macular scars. Active lesions become quiescent with treatment.

Pelvic abscesses: transvaginal US-guided drainage with the trocar method

The effectiveness of the trocar technique of catheter placement for transvaginal sonographically guided drainage of pelvic abscess was assessed in seven women who presented with pelvic pain, fever, and presumed pelvic abscess. Endovaginal ultrasound was performed to document fluid collection before drainage. All procedures were performed in less than 1 hour, without complications. Catheters were left in place for 1-3 days. Catheter placement was curative in six of seven patients (86%).

A pathogenic bacterium triggers epithelial signals to form a functional bacterial receptor that mediates actin pseudopod formation

Enteropathogenic E. coli (EPEC) belongs to a group of bacterial pathogens that induce actin accumulation beneath adherent bacteria. We found that EPEC adherence to epithelial cells mediates the formation of fingerlike pseudopods (up to 10 microm) beneath bacteria. These actin-rich structures also contain tyrosine phosphorylated host proteins concentrated at the pseudopod tip beneath adherent EPEC. Intimate bacterial adherence (and pseudopod formation) occurred only after prior bacterial induction of tyrosine phosphorylation of an epithelial membrane protein, Hp90, which then associates directly with an EPEC adhesin, intimin. These interactions lead to cytoskeletal nucleation and pseudopod formation. This is the first example of a bacterial pathogen that triggers signals in epithelial cells which activates receptor binding activity to a specific bacterial ligand and subsequent cytoskeletal rearrangement.

Anuria and acute renal failure caused by multiple bladder calculi

A rare case of multiple bladder stones (more than 300) is described. Acute renal failure and anuria complicated by urosepsis were the presenting symptoms.

Corpus cavernosum as an emergency vascular access in dogs

RATIONALE AND OBJECTIVES

We investigated the feasibility of using the corpus cavernosum as an emergency vascular access in dogs with severe hypovolemia.

METHODS

Five male mongrel dogs were brought to hypovolemic shock by withdrawal of blood through an internal jugular venous line. Using the corpus cavernosum as a venous access, normal saline was injected through a 23-gauge needle at the highest possible rate. Cavernosography was performed under fluoroscopy to verify the accurate position of the needle tip. Blood volumes were measured using 125I-labeled human serum albumin.

RESULTS

Before the dogs were bled, their mean systolic blood pressure was 121.4 (mean) +/- 5.2 (standard error) mm Hg and their mean blood volume was 1,835.2 +/- 139.7 ml. The mean volume of blood removed from the dogs was 710.0 +/- 67.8 ml. The mean systolic pressure during shock was 40.8 +/- 2.2 mm Hg. After fluid resuscitation, the mean systolic pressure recovered to 114.6 +/- 4.6 mm Hg and their mean blood volume increased to 1,763.2 +/- 112.7 ml. The mean rate of saline infusion into the corpus cavernosum was 50.2 +/- 0.7 ml/min.

CONCLUSION

The results of this study demonstrate the feasibility of using the corpus cavernosum as an alternative route for fluid resuscitation in severely hypovolemic dogs.

Complications of laparoscopic cholecystectomy: imaging and intervention

Cholecystectomy is the most common abdominal operation done in the United States, with more than half a million cholecystectomies performed annually. Recently, there has been a trend to perform laparoscopic, rather than open, cholecystectomy. The introduction of any new technique involves a learning curve for surgeons, and several complications may occur with this procedure. Radiologists may be called on to help diagnose and manage injuries occurring after laparoscopic cholecystectomy. This article will review the complications of laparoscopic cholecystectomy, emphasizing the role of imaging in both diagnosis and nonsurgical management of these injuries.

Delayed embolization of a shotgun pellet from the chest to the middle cerebral artery

Embolization of metallic missiles into the cerebral circulation is a rare occurrence. Most of the cases reported were due to gunshot wounds and shotgun wounds to the neck and face. Embolization from injuries sustained to the chest are extremely rare. We report a case of delayed pellet embolization to the middle cerebral artery resulting from a shotgun injury to the left chest.

Is a history of depressive symptoms associated with an increased risk of infertility in women?

Researchers have reported an association between self-reported antidepressant use and increased risk of ovulatory infertility but could not control for confounding by the drug indication. We evaluated the role of depressive symptoms in the development of infertility. We recontacted a population-based sample of Pawtucket Heart Health Program (PHHP) health survey respondents to perform this case-control study. Self-reported infertility was defined as an inability to conceive after 12 months of unprotected intercourse. Controls were women who reported at least one pregnancy. The index age for infertile women was the age at which they first experienced fertility problems, and for the fertile women it was the age of their first pregnancy. History of depressive symptoms was based on self-report before the index age. Women with a history of depressive symptoms were nearly twice as likely to report infertility relative to women without a history of depressive symptoms before the index age after controlling for potential confounders (90% confidence interval: 0.9-3.2). Our data suggest that depressive symptoms as well as the drugs used to treat these conditions may play an important role in the pathogenesis of infertility. The association between depressive symptoms and infertility should be explored further.

Immunization with anti-neutrophil cytoplasmic antibody (ANCA) induces the production of mouse ANCA and perivascular lymphocyte infiltration

Wegener's granulomatosis (WG) is a granulomatous necrotizing vasculitis associated with the presence of ANCA, predominantly directed against proteinase 3 (PR3). The titres of ANCA correlate with disease activity and titre increases may precede disease exacerbations. Previously, we have shown that it is possible to induce autoimmune disease (systemic lupus erythematosus (SLE) and anti-phospholipid syndrome) in naive mice following active immunization with human autoantibodies, namely anti-DNA and anti-cardiolipin, respectively. The mice developed first anti-autoantibodies and, after about 4 months anti-anti-autoantibodies (Ab3), simulating auto-antibodies (Ab1) in their binding activities, and their presence was associated with the development of disease manifestations, characteristic of the human disease. So far, there is no good animal model for WG. In the current study we have immunized mice with human ANCA with the aim of inducing experimental WG. In two separate studies 30 mice were immunized in their footpads with autoantigen-purified IgG fraction (ANCA) from the sera of two patients with untreated WG, emulsified in Freund's complete adjuvant, followed 3 weeks later by ANCA injection in PBS. In the first experiment mice immunized with ANCA developed sterile microabscesses in the lungs after 8 months, and died after 8-15 months. In the second experiment, mice immunized with ANCA developed after 4 months mouse ANCA, with specificity both to PR3 and to myeloperoxidase, as well as anti-endothelial autoantibodies (AECA), as shown by radioimmunoprecipitation. Pathologically, the immunized mice developed proteinuria but not haematuria, and histological sections of the lungs demonstrated mononuclear perivascular infiltration, while diffuse granular deposition of immunoglobulins was noted in the kidneys. Our results point to a pathogenic role of ANCA in WG, and confirm the importance of the idiotypic network in the etiopathogenesis of autoimmune conditions.

Combination therapy with cyclosporine and methotrexate in severe rheumatoid arthritis. The Methotrexate-Cyclosporine Combination Study Group

BACKGROUND

Patients with severe rheumatoid arthritis who are treated with methotrexate frequently have only partial improvement.

METHODS

In a six-month randomized, double-blind trial, we compared combination therapy with cyclosporine (2.5 to 5 mg per kilogram of body weight per day in two divided doses at 12-hour intervals) and methotrexate (at the maximal tolerated dose) with methotrexate and placebo in 148 patients with rheumatoid arthritis who had residual inflammation and disability despite partial but substantial responses to prior methotrexate treatment. The primary outcome measure was the change in the number of tender joints.

RESULTS

The mean (+/- SD) dose of cyclosporine at the final treatment was 2.97 +/- 1.02 mg per kilogram per day. As compared with the placebo group, the patients in the treatment group had a net improvement in the tender-joint count of 25 percent, or 4.8 joints (95 percent confidence interval, 0.7 to 8.9; P = 0.02), and in the swollen-joint count of 25 percent, or 3.8 joints (95 percent confidence interval, 1.3 to 6.3; P = 0.005); improvement in overall disease activity as assessed by the physician (19 percent, P < 0.001) and the patient (21 percent, P < 0.001); and improvement in joint pain (23 percent, P = 0.04) and in the degree of disability (26 percent, P < 0.001). The mean erythrocyte sedimentation rate increased by 4.2 mm per hour in the cyclosporine group and decreased by 4.8 mm per hour in the placebo group (P = 0.006). Thirty-six patients (48 percent) in the cyclosporine group and 12 patients (16 percent) in the placebo group (P < 0.001) met the 1993 criteria for improvement of the American College of Rheumatology (more than 20 percent improvement in the numbers of both swollen and tender joints and improvement in three of five other variables). Seventeen patients in the cyclosporine group and 12 patients in the placebo group were withdrawn from the study; 2 patients in the cyclosporine group died, 1 from viral pneumonia and the other in a motor vehicle accident. Serum creatinine concentrations increased by a mean of 0.14 +/- 0.27 mg per deciliter (12 +/- 24 mmol per liter) in the cyclosporine group and by 0.05 +/- 0.19 mg per deciliter (4 +/- 17 mmol per liter) in the placebo group (P = 0.02).

CONCLUSIONS

In a six-month study, patients with severe rheumatoid arthritis and only partial responses to methotrexate had clinically important improvement after combination therapy with cyclosporine and methotrexate. Side effects were not substantially increased. Long-term follow-up of patients treated with this combination is needed.

Chlamydomonas reinhardtii thioredoxins: structure of the genes coding for the chloroplastic m and cytosolic h isoforms; expression in Escherichia coli of the recombinant proteins, purification and biochemical properties

Based on known amino acid sequences, probes have been generated by PCR and used for the subsequent isolation of cDNAs and genes coding for two thioredoxins (m and h) of Chlamydomonas reinhardtii. Thioredoxin m, a chloroplastic protein, is encoded as a preprotein of 140 amino acids (15,101 Da) containing a transit peptide of 34 amino acids with a very high content of Ala and Arg residues. The sequence for thioredoxin h codes for a 113 amino acid protein with a molecular mass of 11,817 Da and no signal sequence. The thioredoxin m gene contains a single intron and seems to be more archaic in structure than the thioredoxin h gene, which is split into 4 exons. The cDNA sequences encoding C. reinhardtii thioredoxins m and h have been integrated into the pET-3d expression vector, which permits efficient production of proteins in Escherichia coli cells. A high expression level of recombinant thioredoxins was obtained (up to 50 mg/l culture). This has allowed us to study the biochemical/biophysical properties of the two recombinant proteins. Interestingly, while the m-type thioredoxin was found to have characteristics very close to the ones of prokaryotic thioredoxins, the h-type thioredoxin was quite different with respect to its kinetic behaviour and, most strikingly, its heat denaturation properties.