An outbreak of severe respiratory tract infection caused by human metapneumovirus in a residential care facility for elderly in Utrecht, the Netherlands, January to March 2010

Binary file ES_Abstracts_Final_ECDC.txt matches

An outbreak of severe respiratory tract infection caused by human metapneumovirus in a residential care facility for elderly in Utrecht, the Netherlands, January to March 2010

Recognition of infections with human metapneumovirus (HMPV) among institutionalised elderly is rising. When HMPV was found to be the causative agent of an outbreak of pneumonia in a residential care facility for elderly in the Netherlands, an elaborate outbreak investigation was set up, including active surveillance for new cases. From clinical cases, defined by fever (> 38°C) and symptoms of respiratory tract infections, respiratory samples for analyses of viral pathogens by real-time Reverse Transcriptase Polymerase Chain Reaction (rRT-PCR) and blood samples for determination of HMPV-specific IgM and IgG antibody titres were taken. Five staff members and 18 residents fulfilled the clinical case definition. Of those, five residents tested positive for HMPV by rRT-PCR. The combination of rRTPCR and serology identified nine confirmed cases, six probable cases, six possible cases and ruled out two persons as cases. Among residents, the outbreak of HMPV had an attack rate, ranging from 5% for laboratory- confirmed cases, to 13% for clinical cases. This outbreak investigation shows that HMPV is a potential serious pathogen for institutionalised elderly.

Exposing the third chromosome of Burkholderia cepacia complex strains as a virulence plasmid

The Burkholderia cepacia complex (Bcc) consists of 17 closely related species of opportunistic bacterial pathogens, which are particularly problematic for cystic fibrosis patients and immunocompromised individuals. Bcc genomes consist of multiple replicons, and each strain sequenced to date has three chromosomes. In addition to genes thought to be essential for survival, each chromosome carries at least one rRNA operon. We isolated three mutants during a transposon mutagenesis screen that were non-pathogenic in a Caenorhabditis elegans infection model. It was demonstrated that these mutants had lost chromosome 3 (c3), and that the observed attenuation of virulence was a consequence of this. We constructed a c3 mini-replicon and used it to cure c3 from strains of several Bcc species by plasmid incompatibility, resulting in nine c3-null strains covering seven Bcc species. Phenotypic characterization of c3-null mutants revealed that they were attenuated in virulence in multiple infection hosts (rat, zebrafish, C. elegans, Galleria mellonella and Drosophila melanogaster), that they exhibited greatly diminished antifungal activity, and that c3 was required for d-xylose, fatty acid and pyrimidine utilization, as well as for exopolysaccharide production and proteolytic activity in some strains. In conclusion, we show that c3 is not an essential chromosomal element, rather a large plasmid that encodes virulence, secondary metabolism and other accessory functions in Bcc bacteria.

Elastic exciton-exciton scattering in photoexcited carbon nanotubes

We report on original nonlinear spectral hole-burning experiments in single wall carbon nanotubes that bring evidence of pure dephasing induced by exciton-exciton scattering. We show that the collision-induced broadening in carbon nanotubes is controlled by exciton-exciton scattering as for Wannier excitons in inorganic semiconductors, while the population relaxation is driven by exciton-exciton annihilation as for Frenkel excitons in organic materials. We demonstrate that this singular behavior originates from the intrinsic one-dimensionality of excitons in carbon nanotubes, which display unique hybrid features of organic and inorganic systems.

Streptococcus pneumoniae exposure is associated with human metapneumovirus seroconversion and increased susceptibility to in vitro HMPV infection

It remains largely unknown which factors determine the clinical outcome of human metapneumovirus (HMPV) infections. The aim of the present study was to analyse whether exposure to bacterial pathogens can influence HMPV infections. From 57 children, serum samples and colonization data for Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus and Streptococcus pneumoniae were collected at 1.5, 6, 14 and 24 months of age. Seroconversion rates to HMPV were determined and related to bacterial carriage. Frequent nasopharyngeal carriage (≥2 times in the first 2 years of life) of S. pneumoniae, but not of the other three pathogens, was associated with increased seroconversion rates of infants to HMPV at the age of 2 years (frequently vs. less exposed, 93% vs. 59%; p <0.05). Subsequently, the susceptibility of well-differentiated normal human bronchial epithelial cells (wd-NHBE) pre-incubated with bacterial pathogens to in vitro HMPV infection was evaluated. Pre-incubation of wd-NHBE with S. pneumoniae resulted in increased susceptibility to infection with HMPV-enhanced green fluorescent protein (EGFP), as determined by enumeration of EGFP-positive cells. This was not the case for cells pre-incubated with H. influenzae, M. catarrhalis on S. aureus. We conclude that exposure to S. pneumoniae can modulate HMPV infection.

Upper lip Basal cell carcinoma reconstruction based on anatomical characteristics using skin-mucosa double opposing v-y advancement flap

BACKGROUND

Upper lip defects less than one-fourth of total upper lip length are typically closed directly, but larger defects require reconstruction. Established techniques, such as the Abbe/Estlander flap, often require multiple procedures. This report discusses a single-step method, involving a skin-mucosa double opposing V-Y advancement flap, which was utilized to reconstruct the upper lip after basal cell carcinoma extirpation.

METHODS

The patient is a 54-year-old woman who presented with a 2.5-cm basal cell carcinoma in the right upper lip. Two parallel V-Y flaps were designed, on "parallel" planes of the skin and mucosa, and were advanced following wedge resection of tumor and portion of the adjacent orbicularis oris muscle. Skin/mucosa flap edges were brought to create a new skin-vermilion border, which was then sutured onto existing skin-vermilion border edges.

RESULTS

The patient was evaluated 6 months after the operation, and examination showed well-healed flaps with excellent aesthetic and functional results. There was a thin, marginal scar, where reconstructed vermilion (medial) edge was sutured to native vermilion.

CONCLUSIONS

It was considered that this method could reconstruct anatomical features and function of the lip precisely. It seems that within certain limits (probably between one-fourth and one-third of total upper lip length), skin-mucosa double opposing V-Y advancement flaps appear to be the preferred method for upper lip reconstruction.

Molecular characterization of the human ABO blood group orthologus system in pigs

The selection and use of animals with blood group 0 in the process of transplanting pig organs or tissues into humans can positively contribute to the control of acute immune rejection due to differences in blood groups. Exon-specific PCRs for the porcine blood group A transferase gene against genomic DNA from either blood group A or 0 animals resulted in the amplification failure of the A0 blood group gene exon 8 from blood group 0 animals. To characterize the genetic abnormality in the genome of blood group 0 animals, we screened bacterial artificial chromosome (BAC) clones from a Korean native pig BAC library which had the blood group 0 allele, and carried out shotgun sequencing. The analysis showed that the 0 allele has a large deletion between exon 7 of the A0 blood group gene and the neighbouring SURF6. We also showed that the ABO blood group antigens in humans and the A0 blood group antigens in pigs are coded by mutations within the orthologous glycosyltransferase gene. In addition, we developed a multiplex genotyping method for the porcine A0 blood group gene.

Use of the parabiotic model in studies of cutaneous wound healing to define the participation of circulating cells

Previous experimental studies to assess the contribution of blood-borne circulating (BBC) cells to cutaneous wound healing have relied on discontinuous pulsing of labeled BBC elements or bone marrow transplant protocols. Such approaches do not allow the examination of stable BBC cells that have matured in a physiologically normal host. We have used a parabiotic murine model for cutaneous wound healing to evaluate the relative contribution of stable populations of peripheral blood cells expressing the green fluorescent protein (GFP) transgene in otherwise normal animals. Circulating cells (mature and immature) expressing the GFP transgene were easily detected and quantified in wounds of GFP- parabiotic twins during all evaluated stages of the healing response. Using multiple antibody probes, the relative contribution of various subsets of BBC cells could be comparatively assessed. In early wounds, some cells expressing mesenchymal epitopes were documented to be of hematopoietic origin, indicating the utility of this model in assessing cell plasticity in the context of tissue regeneration and repair. Application of this approach enables further investigation into the contribution of peripheral blood in normal and abnormal healing responses.

Incidental positive internal mammary lymph nodes: a multiple international institutional investigation

The internal mammary lymph node is the second most frequent site of nodal metastasis. With an increase in breast free flap reconstruction utilization of the internal mammary vessels, identification of these internal mammary lymph node metastases will become more prevalent. A chart review documented 75 free transverse rectus abdominis myocutaneous flaps cases performed at Kaiser Bellflower from 1998 to 2004. Between March 2000 and January 2006 there were 157 autologous breast reconstructions (122 DIEP flaps, 10 GAP flaps, 15 SIEA flaps, 7 free transverse rectus abdominis flaps, and 1 SCIA flap) using internal mammary vessels as the recipient site at the Chang Gung Memorial Hospital. A literature review was conducted to survey the current protocols in the surgical, oncological, and radiological communities. A population of 232 patients with breast reconstruction via free flaps was identified. The age range was 29 to 65 years. With the exception of the five cases presented, no other incidence of positive internal mammary lymph nodes was identified. Failure to account for the status of the internal mammary lymph nodes may risk understaging and preclude appropriate treatment stratification. With more frequent utilization of the internal mammary vessels, discussions regarding breast reconstruction should take this new oncological focus into consideration.

Institutional Review of Free TRAM Flap Breast Reconstruction

INTRODUCTION

A 10-year experience with breast reconstruction in a university hospital was recently reviewed. The purpose of this study was to determine the subtypes of breast reconstructive procedures and to evaluate the frequency and change in technique over time of free TRAM (transverse rectus abdominis muscle) flap breast reconstruction performed at one institution. Trends in the development of the procedure over this period were also reviewed.

MATERIALS & METHODS

Between November 1994 and September 2004, a 10-year retrospective chart review was conducted. The indications for mastectomy and reconstruction were determined. The median age was 48 (range 31-66). The range of follow-up was 2 to 71 months, with a median of 19.5 months. The mean follow-up was 23.5 months. Outcome data were grouped into 2 consecutive 5-year periods (period 1: 1994-1998; period 2: 1999-2004) and evaluated for changes over time in techniques and outcome. Statistical analysis (Decision Analyst, Inc., STATS Statistics software, version 1.1, 1998) was performed using the difference between 2 proportions module to assess the probability of a significant difference in the data for period 1 and period 2 parameters.

RESULTS

Over a 10-year period, 117 patients underwent breast reconstruction. This consisted of 12 pedicle procedures (11.3%), including 1 bipedicle flap (0.9%) and 2 bilateral pedicle procedures (1.8%). There were 3 latissimus dorsi pedicle flaps (2.8%). Sixteen patients (15.1%) received tissue expander or implant reconstructions. Of the 117 patients, 79 underwent free flap breast reconstruction. Of the 79 free-flap patients, 22 (27.8%) had bilateral procedures, for a total of 101 free flaps performed in these 79 patients. Fifty-two patients underwent immediate reconstruction (65.8%) and 25 were delayed (31.6%) reconstructions using either deep inferior epigastric artery perforator (DIEP) flaps (4 = 3.9%) or free TRAM flaps (97 = 96.0%). A muscle-sparing technique was used in 43 of the 97 free TRAM flaps (44.3%). The preferred vascular inflow was the internal mammary artery, which was used in 66 out of 101 flaps (65.3%). The rate of anastomotic revision (arterial and venous) was 4.9%. The majority of cases used a 2.5-mm venous coupler (65.3%). In 2 of the free TRAM cases, there was insufficient volume to establish the patients preexisting volume. Therefore, at the patient's request, immediate implants were used to augment the reconstruction. The average hospital stay was 8.13 days, and the average intensive care stay was 4.59 days. When assessed for trends over time, we noted a reduction in our hospital length of stay and our ICU length of stay.

CONCLUSION

The experience with free tissue breast reconstruction reveals predominant use of the TRAM flap. This is justified by the reliability of this flap and the advances in achieving esthetic breast reconstruction. Additionally, we have begun performing DIEP free-flap reconstructions. Our clinical practice has evolved concurrent with standards of care, as noted by the increase in use of muscle-sparing techniques and the reduction in the use of dextran. We do not routinely use therapeutic anticoagulation in our cases. Our hospital length of stay and average intensive care length of stay have also decreased over time, consistent with a system-wide effort to increase the efficiency of healthcare delivery.

Effect of loteprednol etabonate nasal spray suspension on seasonal allergic rhinitis assessed by allergen challenge in an environmental exposure unit

BACKGROUND

Loteprednol etabonate (LE) is a novel soft steroid that was designed to improve the benefit/risk ratio of topical corticosteroid therapy. This study assesses the clinical efficacy and safety of three different doses of LE nasal spray in seasonal allergic rhinitis (SAR).

METHODS

In this single-center, double-blind, placebo-controlled, parallel-group trial 165 subjects with SAR to grass pollen received daily single doses of either 100, 200, 400 microg LE nasal spray, or placebo for 14 days. The patients underwent three 4-h allergen challenges with grass pollen in an environmental exposure unit at a screening visit (baseline) and on days 7 and 14 of treatment. Standardized nasal symptom scores were obtained every 20 min. Nasal flow, nasal secretions, and FEV(1) were measured every hour during allergen challenges.

RESULTS

After 14 days of treatment, patients who received 400 microg LE had significantly lower total nasal symptom scores compared with those receiving placebo (P = 0.007). LE400 reduced rhinorrhea, nasal congestion, nasal itching, the amount of nasal secretions, and improved nasal flow as compared with placebo (P < 0.05). LE100 and LE200 were not significantly different from placebo. All treatments were well tolerated.

CONCLUSIONS

Loteprednol 400 microg once daily is superior to placebo and the only effective dose tested in improving nasal symptoms and objective parameters in patients with SAR.

Drug susceptibility and its genetic basis in epidemic Vibrio cholerae O1 in Vietnam

The drug susceptibility and genes responsible for the drug resistance of Vibrio cholerae O1 isolated in Vietnam in 1995, 2000 and 2002 were studied. The strains isolated in 1995 were resistant to streptomycin and harboured the class I integron which contained the aadA1 gene responsible for streptomycin resistance. The strains isolated in 2000 were devoid of a class I integron but were multiple-drug resistant and harboured SXT constin, with several drug-resistant genes. The genes responsible for streptomycin resistance were strA and strB. The strains isolated in 2002 were sensitive to all drugs examined, and the organisms were devoid of both class I integron and SXT constin. Cholera outbreaks in the three periods examined (1995, 2000 and 2002) were apparently due to different categories of V. cholerae O1.

S-layer protein transport across the cell wall of Corynebacterium glutamicum: in vivo kinetics and energy requirements

Corynebacteria are Gram-positive bacteria with a very peculiar cell envelope structure as it is constituted of an inner membrane and an outer membrane-like structure. Protein secretion in Corynebacterium glutamicum was studied in vivo, using the S-layer protein PS2 as a model. We show that different variants of PS2 protein are exported through the whole cell envelope with a half-life ranging between 2 and 4 min, by a two-step mechanism. The first step, which is over after about 1.5 min, is ATP- and proton motive force-dependent and may correspond to translocation across the inner membrane via the 'Sec' machinery. The second step, across the cell wall and the outer mycolate layer, is rapid but independent of energy sources. This very efficient secretion process across the mycolate layer raises the question of the existence in this layer of a specific machinery.

Association of calnexin with mutant peripheral myelin protein-22 ex vivo: a basis for "gain-of-function" ER diseases

Schwann cell-derived peripheral myelin protein-22 (PMP-22) when mutated or overexpressed causes heritable neuropathies with a previously unexplained "gain-of-function" endoplasmic reticulum (ER) retention phenotype. In wild-type sciatic nerves, PMP-22 associates in a specific, transient (t(1/2 ) approximately equal to 11 min), and oligosaccharide processing-dependent manner with the lectin chaperone calnexin (CNX), but not calreticulin nor BiP. In Trembler-J (Tr-J) sciatic nerves, prolonged association of mutant PMP-22 with CNX is found (t(1/2) > 60 min). In 293A cells overexpressing PMP-22(Tr-J), CNX and PMP-22 colocalize in large intracellular structures identified at the electron microscopy level as myelin-like figures with CNX localization in the structures dependent on PMP-22 glucosylation. Similar intracellular myelin-like figures were also present in Schwann cells of sciatic nerves from homozygous Trembler-J mice with no detectable activation of the stress response pathway as deduced from BiP and CHOP expression. Sequestration of CNX in intracellular myelin-like figures may be relevant to the autosomal dominant Charcot-Marie-Tooth-related neuropathies.

[Study of terminally ill patients' needs in an university hospital]

Within the framework of a project to create a Mobile Palliative Care Unit, in May 2000 we conducted an evaluation of the needs of patients undergoing palliative care in a university hospital centre. Thanks to the use of a standardised questionnaire, a team of doctors and nurses for each service was able to describe the symptoms, treatments and social and family situations as well as assess the eventual outcome of the patients hospitalised in their service who were in an advanced or terminal phase. In total, the study included 52 cases (5.5% of available beds). 81% of patients reported suffering from physical discomfort and 70% from psychological distress. A specific treatment for the disease in question was maintained in 28% of the cases. In 24% of the cases, the patient had social problems. Among all of the patients, 31% were on the waiting list to be transferred to a different location.

Hepatitis C virus core protein inhibits human T lymphocyte responses by a complement-dependent regulatory pathway

Complement proteins are involved in early innate immune responses against pathogens and play a role in clearing circulating viral Ags from the blood of infected hosts. We have previously demonstrated that hepatitis C virus (HCV) core, the first protein to be expressed and circulating in the blood of infected individuals, inhibited human T cell proliferative response through interaction with the complement receptor, globular domain of C1q receptor (gC1qR). To investigate the mechanisms of HCV core/gC1qR-induced inhibition of T cell proliferation, we examined the effect of core protein on the early events in T cell activation. We found that HCV core inhibited phosphorylation of extracellular signal-regulated kinase (ERK) and mitogen-activated ERK kinase (MEK). HCV core-induced impairment of ERK/MEK mitogen-activated protein kinase resulted in the inhibition of IL-2 and IL-2Ralpha gene transcription, which led to the inhibition of IL-2 production and high-affinity IL-2R expression. Importantly, the ability of anti-gC1qR Ab treatment to reverse HCV core-induced inhibition of ERK/MEK phosphorylation reveals that the interaction between HCV core and gC1qR is linked to the interference of ERK/MEK mitogen-activated protein kinase activation. These results imply that HCV core-induced blockage of intracellular events in T cell activation by a complement-dependent regulatory pathway may play a critical role in the establishment of HCV persistence during the acute phase of viral infection.

Study of mycoloyl transferase transport across the cell envelope of Corynebacterium glutamicum

PS1 is a major exported protein of Corynebacterium glutamicum homologous to mycobacterial antigen 85. It is largely associated with the mycolic acid-containing cell wall and acts as a mycoloyl transferase. The transport of PS1 to the cell wall is slow and occurs through two energetically distinct steps: the first one, which includes processing by signal peptidase, is rapid and inhibited by sodium azide or carbonyl cyanide m-chlorophenylhydrazone. This step is probably associated with translocation across the cytoplasmic membrane. The kinetics of the second step depend on the size of the polypeptide chain to be transported but neither ATP nor proton motive force is required. This step may correspond to the diffusion of PS1 across the cell wall to its final location.

Forgoing life-sustaining treatments: how the decision is made in French pediatric intensive care units

OBJECTIVES

The decision to forgo life support is frequently made in pediatric intensive care units (PICUs). A group of experts is currently preparing recommendations for guidelines concerning this decision-making process in France. We have performed a prospective study to help the experts. This study documents how children die in French PICUs and how the decision to limit life support is made.

DESIGN

A multicenter, prospective, cross-sectional study.

SETTING

Thirty-three multidisciplinary PICUs in university hospitals.

PATIENTS

All consecutive deaths were recorded over a 4-month period. Children who died after a medical decision to forgo life-sustaining treatment were included in group 1 and children who died from other causes were included in group 1.

MAIN RESULTS

A total of 264 consecutive children died, 40.1% from group 1 and 59.8% from group 2. Patients of both groups were primarily admitted for acute respiratory failure (group 1, 50.8%; group 2, 52.6%). Neurologic emergencies were more frequent in patients in group 1, whereas patients with cardiovascular failures were more frequent in group 2. When there was a question of whether to pursue life-sustaining treatment, the parents' opinions were recorded in 72.1% of cases. A specific meeting was called to make this decision in 80.1% of cases. This meeting involved the medical staff in all cases. Parents were aware of the meeting in 10.7% of cases. The conclusion of the meeting was reported to the parents in 18.7% of cases and documented in the patient's medical record in 16% of cases. Experts who were not members of the PICU staff were invited to give their opinion in 62.2% of cases.

CONCLUSIONS

The decision to forgo life-sustaining treatment is frequently made for children dying in French PICUs. Guidelines must be available to help the medical staff reach this decision. Knowledge of the decision-making process in French PICUs provides the experts with information needed to elaborate such recommendations.

[Evaluation of plain abdominal radiography prescriptions in a university hospital center]

OBJECTIVES

The aim of this study was to evaluate the prescription, impact and diagnostic utility of plain abdominal radiography in a University Hospital.

METHODS

Plain abdominal radiography series performed over 15 consecutive days were evaluated for quality and agreement with the patient's clinical status. Agreement between the final diagnosis and the radiographic findings were also compared. Contribution of plain abdominal radiography to final diagnosis was assessed on the basis of the conclusions on the hospital discharge report or from those drawn from a telephone survey. The same relationship was also assessed in terms of clinician status (medical student, resident physician, senior physician).

RESULTS

The series included 175 radiography series (11.6 per day). In 86% of the cases, the choice of views was adapted to the clinical context. In 14% it was not. The quality of the x-rays was found to be unsatisfactory in 17%, good in 63% and excellent in 20%. The radiography was considered to be contributive to the final diagnosis in 13% of the cases and non-contributive in 87%. Clinician status was not correlated with the degree of usefulness for final diagnosis. Finally, the prescription was in agreement with standard guidelines in 28% of the cases and not in agreement in 72%.

CONCLUSION

Plain abdominal radiographs are neither sensitive nor specific, frequently misleading, and costly per specific and correct diagnosis. Better physician awareness is required to limit the number of unnecessary examinations.

Roles of two homotetrameric kinesins in sea urchin embryonic cell division

To improve our understanding of the roles of microtubule cross-linking motors in mitosis, we analyzed two sea urchin embryonic kinesin-related proteins. It is striking to note that both of these proteins behave as homotetramers, but one behaves as a more compact molecule than the other. These observations suggest that these two presumptive motors could cross-link microtubules into bundles with different spacing. Both motors localize to mitotic spindles, and antibody microinjection experiments suggest that they have mitotic functions. Thus, one of these kinesin-related proteins may cross-link spindle microtubules into loose bundles that are "tightened" by the other.

Anesthetic management of the patient undergoing head and neck cancer surgery

The head and neck cancer patient should be in the best possible medical condition before facing surgery, bearing in mind the status of the tumor and the urgency of the procedure. Careful assessment of the patient's upper airway will enable the anesthesiologist to select an appropriate course of action to secure the airway before the operation begins. In many cases, the patient can be safely intubated after the induction of general anesthesia. In other situations, the patient may require an examination of the airway while awake with the aid of sedation and topical analgesia to determine the safest intubation technique. If the patient has evidence of a difficult airway, a flexible fiberoptic-guided intubation may be indicated to secure the airway in the awake patient patient before general anesthesia is induced. Some patients with severe airway obstruction or large, bulky supraglottic tumors usually undergo an initial tracheostomy with local anesthesia to secure the airway. Following surgery, extubation of the patient's trachea requires careful attention and may have to be performed over a jet-ventilating stylet.

Assessing drug sensitivity of Plasmodium vivax to halofantrine or choroquine in southern, central Vietnam using an extended 28-day in vivo test and polymerase chain reaction genotyping

Chloroquine-resistant Plasmodium vivax malaria is emerging in Oceania, Asia, and Latin America. We assessed the drug sensitivity of P. vivax to chloroquine or halofantrine in two villages in southern, central Vietnam. This area has chloroquine-resistant Plasmodium falciparum but no documented chloroquine-resistant P. vivax. Standard dose chloroquine (25 mg/kg, over 48 hours) or halofantrine (8 mg/kg, 3 doses) was administered to 29 and 25 patients, respectively. End points were parasite sensitivity or resistance determined at 28 days. Of the evaluable patients, 23/23 100% (95% confidence interval [CI] 85.1-100) chloroquine and 21/24 (87.5%) (95% CI 67.6-97.3) halofantrine-treated patients were sensitive. Three halofantrine recipients had initial clearance but subsequent recurrence of their parasitemias. Genotyping of the recurrent and Day 0 parasitemias differed, suggesting either new infections or relapses of liver hypnozoites from antecedent infections. Among these Vietnamese patients, P. vivax was sensitive to chloroquine and halofantrine. Genotyping was useful for differentiating the recurrent vivax parasitemias.

Response to interferon alpha treatment and disappearance of cryoglobulinaemia in patients infected by hepatitis C virus

BACKGROUND

Mixed cryoglobulinaemia is closely associated with hepatitis C virus (HCV) infection.

AIM

To assess in a prospective open study the efficiency of interferon alpha treatment of cryoglobulinaemia, as reflected by the disappearance of cryoglobulins and clinical manifestations of the disease, and to analyse the factors predictive of a response to interferon.

METHOD

Eighty seven consecutive patients with chronic hepatitis C treated for the first time with interferon at a dose of 3 x 10(6) international units three times a week for six months were studied. Forty three patients had cryoglobulins, which were responsible for clinical manifestations in 12.

RESULTS

At the end of interferon treatment, cryoglobulins had disappeared in 39% of the patients. A clinical improvement (except for neuropathies) was observed in all patients. Six months after interferon treatment was stopped, the same rate of response (normal alanine aminotransferase values and undectable HCV RNA) was observed in patients with or without cryoglobulins. Only 14% of patients still had undetectable cryoglobulins, and all of them also had undetectable serum HCV RNA. The disappearance of cryoglobulins was found less frequently in patients with clinical symptoms than in asymptomatic ones, but the difference was not significant. Sustained responders were more often men, infected by genotype 2 or 3, with a lower pretreatment viral load.

CONCLUSION

The presence of cryoglobulins does not seem to affect the response to interferon in HCV infected patients. The improvement in cryoglobulinaemia is strongly associated with a virological response, reinforcing the hypothesis of a direct role for HCV in the pathogenesis of this disease.

Effect of diabetes and aminoguanidine therapy on renal advanced glycation end-product binding

BACKGROUND

Advanced glycation end-products (AGEs) have been implicated in the pathogenesis of diabetic nephropathy, and aminoguanidine (AG) has been shown to decrease the accumulation of AGEs in the diabetic kidney.

METHODS

This study investigates changes in AGE binding associated with diabetes in the rat kidney using in vitro and in vivo autoradiographic techniques. Male Sprague-Dawley rats were randomized into control and diabetic groups with and without AG treatment and were sacrificed after three weeks. Frozen kidney sections (20 microm) were incubated with [125I]-AGE-RNase or [125I]-AGE-BSA. To localize the AGE binding site, in vivo autoradiography was performed by injection of 15 microCi of [125I]-AGE-BSA into the abdominal aorta of the rat.

RESULTS

Low-affinity binding sites specific for AGEs in the renal cortex (IC50 = 0.28 microm) were detected by in vitro autoradiography. There was a significant increase in [125I]-AGE binding in the diabetic kidney, which was prevented by AG treatment. Emulsion autoradiography revealed that binding was localized primarily to proximal tubules in the renal cortex. Renal AGE levels, as assessed by fluorescence or by radioimmunoassay, were increased after three weeks of diabetes. This increase was attenuated by AG therapy.

CONCLUSIONS

AGE binding sites are present within the proximal tubules of the kidney and appear to be modulated by endogenous AGE levels. It remains to be determined if these binding sites represent receptors involved in clearance of AGEs or are linked to pathogenic pathways that lead to the development of diabetic nephropathy.

Descriptive epidemiological survey on a given day in all palliative care patients hospitalized in a French university hospital

We conducted a descriptive study on a given day on all inpatients requiring palliative care in a French university hospital. In each department, a collaborative team made up of physicians and nurses identified and described the clinical signs, the treatment protocols, the social and family characteristics and the outcome for each patient using a standardized questionnaire. Study subjects were inpatients in the hospital and presented advanced or terminal-stage life-threatening conditions. Two-hundred-and-forty-five patients were included in the study. These patients represented 13% of the total number of inpatient beds available in the hospital on the day of the survey. Sixty-six per cent of study subjects suffered from physical discomfort and 80% suffered psychologically. Patients still received specific treatment for their condition in 45% of cases. Social problems were identified principally in medium- or long-term care department inpatients who made up 36% of the total inpatient population. A request for transfer to another care structure had been completed for 24% of patients. Assistance from the Palliative Care Unit's support team had been requested in 25% of cases, mainly to provide psychological support for the patient and the health care providers. These results have led us to reconsider the general organization of palliative care in the health care system.

IDEC-C2B8 anti-CD20 (rituximab) immunotherapy in patients with low-grade non-Hodgkin's lymphoma and lymphoproliferative disorders: evaluation of response on 48 patients

This study focused on the efficacy of IDEC-C2B8 (chimeric anti-CD20) immunotherapy relative to specific subtypes of low-grade lymphoproliferative disorders/non-Hodgkin's lymphomas (LPD/NHL). Forty-eight patients with resistant or relapsed disease completed the IDEC-C2B8 infusion schedule of 375 mg/m2/wk x 4 wk. The LPD/NHL subtypes included: (a) follicular centre cell lymphoma (FCC) in 22 patients; (b) mantle cell lymphoma (MCL) in 10; (c) 1 diffuse large cell lymphoma (DLCL); and (d) the category of small lymphocytic lymphoma/chronic lymphocytic leukaemia (SLL/CLL) and related disorders in 15 patients. No patient obtained a complete remission. Ten patients (21%) achieved partial remission: 6 FCC, 2 MCL, 1 DLCL and 1 patient from the SLL/CLL group. Twenty-eight patients had stable disease and 10 progressed during immunotherapy. In patients with CLL and MCL in leukaemic phase, there was no correlation between the marked decrease in circulating neoplastic cells following antibody infusions and amelioration of the tumour burden. The results suggest that the subtype of LPD/NHL and the intensity of CD20 on the tumour cells influence the effectiveness of IDEC-C2B8. The antibody was most efficacious against FCC lymphoma. The efficacy (at the dose schedule of 375 mg/m2/wk x 4) against MCL and SLL/CLL appeared to be limited, however.

A review of the present status of lymphatic filariasis in Vietnam

Establishing the current status of an infectious disease forms the starting point of any attempt at parasite control. Although data on the prevalence and distribution of lymphatic filariasis exist for Vietnam from the early 1900s, the present situation regarding the disease is less well-known. Here, we review the results of recent surveys conducted by the Institute of Malariology, Parasitology and Entomology, Hanoi, to update the existing information on filariasis epidemiology and distribution for this country. The present results are from surveys carried out on some 135,000 individuals in 24 provinces of Vietnam. The highest prevalences of microfilaraemia (primarily Brugia malayi ) are observed in lowland areas of the Red River Delta and in Quang-binh Province where the survey results show microfilaraemia (mf) prevalences in the range of 0.9-5.5%. The most common type of chronic clinical manifestation is shown to be leg elephantiasis. A significant finding is that an overall decrease in mf prevalence was observed to occur in five communities which were surveyed twice over an 11-21-year period, even though no interventions were carried out between the two surveys. The changes are probably caused by environmental changes, such as increased standards of housing and drainage. Studies on the effect of selective chemotherapy and mass chemotherapy using diethylcarbamazine showed reductions in community mf prevalences of 69 and 72-88%, respectively. Furthermore, cats do not appear to represent significant reservoirs of infection. These findings of geographical restriction of infection, effective and well-tolerated drug therapy, low significance of animal reservoirs, together with the existence of an effective national health network, suggest a good prognosis for the control of filariasis in this country.

Evaluation of the injured wrist on the field and in the office

The wrist is a common site of injury in sports, both acute and chronic. Evaluation of wrist injuries requires knowledge of anatomy kinematics, attention to the mechanism of injury, the intensity of training, and a focus on the physical examination for specific injuries.

[Access to health care for destitute persons at Public Assistance Hospitals in Paris]

All legal French residents are entitled to health care. The 1992 regulatory measures, which create a contractual agreement between the government and public medical institutions, aim at facilitating access to health care by resolving the financial obstacles to accessing health care. The Assistance Publique-Hôpitaux de Paris (AP-HP) has set up a medical reception center in several hospitals since 1993. This system is integrated in the general structure of each hospital: in some cases, there is a single and centralized unit; in other cases, all departments of the hospital, including the emergency room, are involved in caring for destitute patients. Whatever the type of the structure may be, social workers are a key element to helping the patients recover their social rights. Thirty to seventy-percent of patients visiting these centers regain access to social and health care coverage. The epidemiological survey of the active file of patients revealed that 70% are male, more than 50% are non-French nationals, half of which do not have legal immigration status in France. Homeless people represent 40 to 80% of the population. The average age is around 35. The number of medical visits varies greatly from one hospital to another and range from 20 to 60 per month. The reasons for visiting the center and the identified medical disorders are strongly related to the patients' life conditions and vary significantly with the risk factors related to the social and economic situation. The frequency of some diseases (psychiatric disorders, tuberculosis, infections by the HIV and HCV) is higher in this population than in general population. Delayed visits to the medical center represents a severity factor. The hospitals' mission statement is not only to ensure that patients facing a precarious social and professional situation have equal access to health care, but also to help such patients recover their social rights, facilitate their integration in the society and fight against social exclusion.

A comprehensive knowledge-based system for laboratory hematology

The Coulter FACULTY knowledge-based systems, Professor Petrushka for peripheral blood interpretation, Professor Fidelio for flow cytometry immunophenotyping and Professor Belmonte for bone marrow reporting, have been installed in several hospitals in Spain, Portugal and the United Kingdom. In Spain and Portugal, the systems are part of the IZASA-Coulter CITOTECA workstation, which includes a video camera for capturing microscopic images and a networkable laboratory information system supporting color reports. At the Royal Hospitals Trust (St. Bartholomew's Hospital and The Royal London Hospital, London, UK), networked workstations are available and the system is used daily to generate bone marrow reports in the hematology laboratories. There have been considerable benefits from adopting Coulter FACULTY for bone marrow reporting, including faster turnaround time, improved quality of the reports and cost savings.

Fast separation of underivatized carbohydrates by coelectroosmotic capillary electrophoresis

A method for the rapid quantitative analysis of underivatized acidic sugars, monosaccharides and disaccharides using coelectroosmotic capillary electrophoresis was developed. Indirect UV detection at 254 nm using sorbate as background electrolyte was employed for monitoring the analytes. A highly alkaline pH value of the electrolyte system was chosen in order to achieve an electrophoretic mobility of the saccharides towards the anode. A dynamic reversal of the electroosmotic flow and, by this means, a codirectional movement of the negatively charged analytes and the electroosmotic flow is accomplished by employing a polycationic surfactant (hexadimethrine bromide), which is added to the background electrolyte. To further improve the resolution of specific carbohydrates, acetone is used as organic modifier. A practical application of the developed method for the fast determination of fructose, glucose, and sucrose in various soft drinks is provided.

Haematological validation of a computer-based bone marrow reporting system

AIMS

To prove the safety and effectiveness of "Professor Belmonte", a knowledge-based system for bone marrow reporting, a formal evaluation of the reports generated by the system was performed.

METHODS

Three haematologists (a consultant, a senior registrar, and a junior registrar), none of whom were involved in the development of the software, compared the unedited reports generated by Professor Belmonte with the original bone marrow reports in 785 unselected cases. Each haematologist independently graded the quality of Belmonte's reports using one of four categories: (a) better than the original report (more informative, containing useful information missing in the original report); (b) equivalent to the original report; (c) satisfactory, but missing information that should have been included; and (d) unsatisfactory.

RESULTS

The consultant graded 64 reports as more informative than the original, 687 as equivalent to the original, 32 as satisfactory, and two as unsatisfactory. The senior registrar considered 29 reports to be better than the original, 739 to be equivalent to the original, 15 to be satisfactory, and two to be unsatisfactory. The junior registrar found that 88 reports were better than the original, 681 were equivalent to the original, 14 were satisfactory, and two were unsatisfactory. Each judge found two different reports to be unsatisfactory according to their criteria. All 785 reports generated by the computer system received at least two scores of satisfactory or better.

CONCLUSIONS

In this representative study, Professor Belmonte generated bone marrow reports that proved to be as accurate as the original reports in a large university hospital. The haematology knowledge contained within the system, the reasoning process, and the function of the software are safe and effective for assisting haematologists in generating high quality bone marrow reports.

Simulation of the enzyme reaction mechanism of malate dehydrogenase

A hybrid numerical method, which employs molecular mechanics to describe the bulk of the solvent-protein matrix and a semiempirical quantum-mechanical treatment for atoms near the reactive site, was utilized to simulate the minimum energy surface and reaction pathway for the interconversion of malate and oxaloacetate catalyzed by the enzyme malate dehydrogenase (MDH). A reaction mechanism for proton and hydride transfers associated with MDH and cofactor nicotinamide adenine dinucleotide (NAD) is deduced from the topology of the calculated energy surface. The proposed mechanism consists of (1) a sequential reaction with proton transfer preceding hydride transfer (malate to oxaloacetate direction), (2) the existence of two transition states with energy barriers of approximately 7 and 15 kcal/mol for the proton and hydride transfers, respectively, and (3) reactant (malate) and product (oxaloacetate) states that are nearly isoenergetic. Simulation analysis of the calculated energy profile shows that solvent effects due to the protein matrix dramatically alter the intrinsic reactivity of the functional groups involved in the MDH reaction, resulting in energetics similar to that found in aqueous solution. An energy decomposition analysis indicates that specific MDH residues (Arg-81, Arg-87, Asn-119, Asp-150, and Arg-153) in the vicinity of the substrate make significant energetic contributions to the stabilization of proton transfer and destabilization of hydride transfer. This suggests that these amino acids play an important role in the catalytic properties of MDH.

Effects of earplugs on catecholamine and cortisol excretion in noise-exposed textile workers

To investigate physiological and psychological effects of industrial noise, a survey was performed on 50 female workers exposed to machinery noise [93-100 dB(A)] (noise group) and 25 female workers in less-noisy environments [71-75 dB(A)] (control group) in a textile factory in Vietnam. Urine was collected for analysis of catecholamines and cortisol. The subjects were also asked to fill out a questionnaire. Each subject was examined over 2 working days. The workers in the noise group were asked to put earplugs in their ears during the working hours of the 2nd day. On the 1st day without earplugs, urinary excretion of catecholamines in the noise group were greater than those in the control group. Cortisol in urine showed a similar tendency. Differences in catecholamine excretion between the noise group and the control group decreased on the 2nd day when the earplugs were used for attenuation of noise level in the noise group. Frequency of subjective fatigue symptoms was lower on the 2nd day than that on the 1st day in noise group, while the control group showed almost no day-difference. The results indicate that the catecholamine response to noise in workers was reduced through the use of earplugs.

Multiparameter case studies using knowledge-based systems in hematology

Knowledge-based systems in diagnostic medicine are often used for teaching medical decision making. We have extended the educational value of our suite of hematology decision support systems (peripheral blood analysis, flow cytometry immunophenotyping and DNA analysis, and bone marrow morphology) by creating case studies in a hypertext format. The case studies use the knowledge-based system screens as a background. Digitized images of blood and bone marrow smears from the teaching cases can be accessed on-line. The case studies, which are designed primarily for technologists and physicians, emphasize the proper multiparameter approach to hematopathology diagnosis.

Chronic lymphocytic leukemia with an interfollicular architecture: avoiding diagnostic confusion with monocytoid B-cell lymphoma

Certain low grade B-cell lymphoproliferative disorders can be mistaken for each other morphologically, particularly when there is partial lymph node involvement. We encountered two cases of chronic lymphocytic leukemia, in which the interfollicular growth pattern and the pale appearance of the neoplastic proliferation in the lymph nodes led to a misclassification as monocytoid B-cell lymphoma. The correct diagnosis was established, however, when the lymph node morphology was carefully reexamined, with the knowledge of the clinical history, peripheral blood findings, and bone marrow data. The immunophenotype of the neoplastic cells in the peripheral blood (CD5, CD23, weak fluorescence intensity of surface immunoglobulin and CD22) and the lymph node immunohistochemistry (weak L26 staining, strong MT1 positivity) confirmed the diagnosis of chronic lymphocytic leukemia. These two cases demonstrate the necessity of a systematic approach to lymph node morphology and the utility of a multiparameter approach in the diagnosis of lymphoproliferative disorders.

Are normative expert systems appropriate for diagnostic pathology?

Conceptual models for diagnostic reasoning proposed in the medical literature are presented to stimulate discussion about the issue of the appropriateness of probabilistic knowledge-based systems for medical diagnosis. Evidence is presented to corroborate the authors' view that diagnosis is a problem-solving task, rather than a decision-making task. In the authors' opinion, probabilistic reasoning is better suited to situations dealing with choices for clinical intervention, rather than to those dealing with determining the correct diagnosis. A critique is given of a diagnostic Bayesian expert system for lymph node pathology. In empirical studies, diagnostic Bayesian systems have been shown to typically list the correct diagnosis as the program's first choice 60% to 70% of the time. One reason for this undistinguished level of diagnostic performance is that Bayesian systems are not designed to represent and use knowledge the same way that an expert does.

Balloon dissection facilitated laparoscopic extraperitoneal hernioplasty

BACKGROUND

With the goals of minimizing perioperative morbidity and obtaining direct inguinal access without transgressing the peritoneal cavity, we developed a balloon dissection device to facilitate laparoscopic extraperitoneal hernioplasty.

PATIENTS AND METHODS

We have performed balloon facilitated dissection on 113 patients (105 males) on an outpatient basis. Some patients were repaired under regional anesthesia. A total of 150 hernias have been repaired: 72 indirect, 70 direct, 3 scrotal, 2 sliding, 2 spigelian, and 1 femoral.

RESULTS

Mean operating time was 60 minutes. All patients were ambulatory on discharge. Half reported minimal or no immediate postoperative pain. Over 80% had only minimal irritation or discomfort on the third postoperative day. Nearly 60% returned to work within 2 weeks. None required hospital readmission for an immediate complication of hernioplasty. With a mean follow-up of 6.3 months, only three recurrences are reported. Except for one persistent neuropathy which resolved after staple removal, there were no significant complications.

CONCLUSIONS

We conclude that balloon dissection facilitates laparoscopic extraperitoneal hernioplasty and obviates the need for general anesthesia. Our approach minimizes perioperative pain. It can be done on an outpatient basis and permits prompt return to full activity including physical work.

Potential diagnostic pitfalls caused by blood film artifacts in prolymphocytic leukaemia. Observations in two cases

The diagnosis of lymphoproliferative disorders is based on a combined evaluation of the clinical, immunological and morphological findings. Cytological details may vary with the quality of the smear. We report two cases of prolymphocytic leukaemia in which cytoplasmic hairs or protrusions were observed when the films were not dried quickly. In one case the artifacts led to an initial erroneous interpretation of hairy cell leukaemia 'variant'. The cytoplasmic outline was smooth in both cases when the smears were immediately fan-dried. The findings underscore the necessity of high standards of excellence, even for the simple technique of blood film preparation, in order to avoid undesirable artifacts which may result in diagnostic misinterpretation.

Multiparameter interpretative reporting in diagnostic laboratory hematology

Accurate diagnosis and classification of hematologic malignancies (acute leukemias and chronic lymphoproliferative disorders) requires a multiparameter approach including peripheral blood analysis, bone marrow examination, and immunophenotyping. We have designed knowledge-based computer systems for interpretation of the hemogram and peripheral blood smears, analysis of flow cytometric immunophenotyping panels, and morphologic assessment of bone marrow specimens. The 3 modules share a relational database which includes pertinent clinical history in addition to the laboratory results. The bone marrow module automatically writes a complete interpretative report with a final diagnosis by searching all of the databases for appropriate clinical, peripheral blood, and immunophenotyping information. The ability of the 3 modules to interact, and the quality of the interpretative reports were tested on 100 consecutive patients with leukemia. The final diagnosis made by the bone marrow system agreed with the hospital diagnosis in 94 cases and the authors' interpretation in 99 of 100 cases.

A knowledge-based system for the interpretation of flow cytometry data in leukemias and lymphomas

Flow cytometry immunophenotyping and analysis of DNA ploidy and proliferative activity have become extremely helpful techniques for diagnosing and subclassifying hematopoietic cell populations in a modern, full-service hematopathology laboratory. The number of physicians with special training in the interpretation of these studies is limited. A knowledge-based computer system has been designed to aid in the interpretation of immunophenotyping and DNA flow cytometry results in hematopoietic disease. The system, known as "Professor Fidelio," is a heuristic classification system that reasons on the basis of defined diagnostic patterns. In this study, Fidelio was tested as a stand-alone system on 366 specimens from two large tertiary medical centers. Fidelio's interpretation was considered to be appropriate in all cases. In 300 of 366 (82%) specimens, the system's interpretation agreed with the diagnosis of record. Many of the disagreements could be traced to errors in the recording of the original diagnosis and minor differences in diagnostic criteria between Fidelio's knowledge base and the criteria in use at the medical centers. When used in a stand-alone mode, Fidelio's interpretation was less specific than the diagnosis of record in certain lymphoproliferative disorders that require morphologic information for subclassification. Professor Fidelio is one module in a workstation for the diagnostic hematology laboratory. This workstation is designed for interpretive reporting, education, and database functions for clinical research. Clinical and morphologic information are shared between Fidelio and the other modules for peripheral blood analysis, bone marrow morphology, and lymph node interpretation by means of a relational database. The system will be useful in hospitals that lack individuals specially trained in flow cytometry.(ABSTRACT TRUNCATED AT 250 WORDS)

An unusual pattern of lymph node involvement in mycosis fungoides simulating neoplastic follicles

We describe an unusual pattern of lymph node involvement in a case of mycosis fungoides. The neoplastic proliferation formed pale nodules composed of small, irregular lymphoid cells, features that, on routine paraffin sections, suggested neoplastic follicles and a B-cell phenotype. The correct diagnosis was established by immunohistochemical studies that demonstrated a T-cell phenotype. Polymerase chain reaction for rearrangement of the T-cell receptor gamma gene confirmed that the proliferation was monoclonal. This case demonstrates that both architectural pattern and cytologic features may be unreliable in predicting immunologic phenotype. Immunologic marker studies and careful attention to the clinical history are vital to classify lymphoproliferative disorders correctly.