Hand-assisted laparoscopic splenectomy for a splenic hamartoma: two case reports

We present two patients, each with a hamartoma of the spleen. These cases were thought to be well indicated for a hand-assisted laparoscopic approach and subsequent treatment was successful. Focal lesions of the spleen should be removed intact to allow a complete histological examination and to avoid peritoneal dissemination in case of malignancy. In these patients, the hand-assisted laparoscopic approach makes it possible to remove an unmorcellated organ and has the advantages of the laparoscopic technique. It can be considered as one of the suitable methods of surgical treatment.

Treatment with anti-TNF? does not induce reactivation of latent Salmonella enterica serovar Typhimurium infection in C3H/HeN mice

Therapy with tumour necrosis factor-alpha (TNFalpha)-blocking agents is successful in treating inflammatory disorders, but carries an increased risk of manifest and reactivating infection with intracellular bacteria. In a mouse model of latent Salmonella typhimurium infection, neutralization of TNFalpha did not result in reactivation of infection, suggesting only a minor role for TNFalpha during latency of persistent Salmonella infection.

[Effect of genetic polymorphisms on the susceptibility to and course of infectious diseases]

The highly variable susceptibility to and course of infectious diseases are caused by variable environmental factors and by genetic differences in both the pathogens and the host. The genetic variability of the host is determined mainly by polymorphisms in genes that play a role in processes such as adhesion, specific and non-specific immunity, antigen presentation, and inflammation. These variations are important, for example, in infections with HIV or respiratory syncytial virus. It is important to combine genetic knowledge with knowledge about the functional properties of variant genes. Applications of knowledge about genetic variability can be found in the development of vaccines and therapeutic agents, prognostics, and the treatment of individual patients.

No association between interleukin-18 gene polymorphisms and haplotypes in Dutch sarcoidosis patients

Previously, an association between susceptibility to sarcoidosis and a polymorphism in the interleukin (IL-18) gene (IL-18 -607A/C) has been reported in Japanese. The aim of the present study was to validate this association in a clinically well-characterized population of Dutch Caucasians. Three other polymorphisms at positions -656, -137, and 1248 were included in order to extend the mapping of the IL-18 gene and to enable the construction of haplotypes. Polymorphisms were determined using sequence-specific primers (SSPs) and polymerase chain reaction (PCR). A total of 236 individuals was studied (133 patients and 103 controls). No significant differences were observed in the distribution of the -607 and the other polymorphisms between Dutch sarcoidosis patients and controls. However, significant differences in IL-18 -607 genotype and allele frequency distributions were found between the Dutch and the Japanese. From the investigated IL-18-promoter polymorphisms, we were able to deduce four haplotypes. No differences were observed in haplotype frequencies between Dutch sarcoidosis patients and controls. In conclusion, IL-18 polymorphisms do not appear to influence the susceptibility to sarcoidosis in Dutch Caucasians. Important differences in allele frequencies were observed between Japanese and Dutch sarcoidosis patients and controls.

Pneumonia caused by Mycobacterium kansasii in a series of patients without recognised immune defect

The clinical and epidemiological characteristics of 17 patients diagnosed with Mycobacterium kansasii pneumonia within a limited geographical region over a period of 10 years are described. An in-depth evaluation of the innate and adaptive immune systems was performed for five available patients. A comparison was made of the genetic fingerprint patterns of the isolates obtained by restriction fragment length polymorphism (RFLP) analysis, with the major polymorphic tandem repeat (MPTR) as a probe. Predisposing factors consisted of smoking, airway abnormalities, substance abuse, diabetes or poor general condition, but in two patients no risk factor was identified. In the five patients tested, no abnormalities or deficiencies were detected in the innate or adaptive type-1 immunity. All M. kansasii isolates had identical MPTR RFLP patterns, although no epidemiological connection could be established, and these were identical to those of clinical isolates from Australian patients. These data do not support the theory that defects in the innate or adaptive type-1 immunity have a role in the pathogenesis of invasive M. kansasii infections. The identical fingerprint patterns of the isolates suggested the existence of a virulent strain of M. kansasii.

Linkage of myostatin pathway genes with knee strength in humans

This study was the first to explore the potential role of the myostatin (GDF8) pathway in relation to muscle strength and estimated muscle cross-sectional area in humans using linkage analysis with a candidate gene approach. In young male sibs (n = 329) 11 polymorphic markers in or near 10 candidate genes from the myostatin pathway were genotyped. Muscle mass was estimated by anthropometric measurements, and maximal knee strength was evaluated using isokinetic dynamometers (Cybex NORM). Single-point nonparametric variance components and linear quantitative trait locus regression linkage analysis methods were used. Linkage patterns were observed between knee extension and flexion peak torque with markers D2S118 (GDF8), D6S1051 (CDKN1A), and D11S4138 (MYOD1), and a maximum LOD score of 2.63 (P = 0.0002) was observed with D2S118. The ratios of peak torque over muscle and bone area of the midthigh of the lower contraction velocity (60 degrees/s) showed more frequently significant LOD scores than the torques at high velocity (240 degrees/s). Although myostatin is physiologically more related to muscle mass through possible effects of hyperplasia and hypertrophy than it is to strength, only two estimated muscle cross-sectional areas were marginally linked (LOD 1.06 and 1.07, P = 0.01) with marker D2S118 near GDF8 (2q32.2). The present results gave suggestive evidence that the myostatin pathway might be important for strength phenotypes, and GDF8, CDKN1A, and MYOD1 are potential candidate regions for a further and denser mapping with respect to these phenotypes.

Metal versus plastic spacers: an in vitro and in vivo comparison

This study compared the metal Nebuchamber with the polycarbonate Volumatic spacer in vivo as well as in vitro. Seventeen asthmatic patients were evaluated in a crossover placebo-controlled double-blind study. Bronchodilation, heart rate and serum potassium levels were measured at baseline and 15 min after administration of salbutamol. Cumulative dose-response curves (200, 400, 800 and 1600 microg) were constructed. The Andersen Cascade Impactor was used to compare the aerodynamic particle size distribution. The FEV(1) measurements showed highly significant differences between placebo and the two active preparations (P<0.001), but not between the two active preparations (P=0.433). The serum potassium levels also showed highly significant differences between placebo and the two active preparations (P=0.009), but not between the two active preparations (P=0.532). Only 1600 microg salbutamol dose raised the heart rate significantly, but the difference between the two active preparations was not significant. The in vitro deposition study revealed no significant differences in the delivered dose or in the fine particle dose (P>0.05). In conclusion, there are no significant differences between the Volumatic and Nebuchamber either in vivo or in vitro.

Mismatched wear couple zirconium oxide and aluminum oxide in total hip arthroplasty

A patient complained about a squeaking noise in his total hip arthroplasty. Clinical evaluation revealed good function, and there were no signs of loosening on the radiograph. Physiotherapy did not alter this phenomenon, and ultimately a revision was performed 42 months after the first surgery. The analysis of the retrievals revealed that a zirconium oxide ceramic head had been paired with a monolithic alumina ceramic cup. The cup showed large deviations from an ideal sphere but minor wear signs. The head exhibited heavy local damage in the articulation zone. This damage might have been caused by the observed unsatisfactory fit between cup and ball, resulting in high stress concentrations and increased wear of the zirconium head. The characteristics of the zirconium and aluminum ceramics pairing might have worsened the process. The combination of implants used in this retrieved wear couple was never approved. To prevent such problems, components of different manufacturers should never be mixed and matched unless explicitly stated.

Novel Salmonella enterica serovar Typhimurium protein that is indispensable for virulence and intracellular replication

Upon contact with host cells, the intracellular pathogen Salmonella enterica serovar Typhimurium promotes its uptake, targeting, and survival in intracellular niches. In this process, the bacterium evades the microbicidal effector mechanisms of the macrophage, including oxygen intermediates. This study reports the phenotypic and genotypic characterization of an S. enterica serovar Typhimurium mutant that is hypersusceptible to superoxide. The susceptible phenotype is due to a MudJ insertion-inactivation of a previously undescribed Salmonella gene designated sspJ that is located between 54.4 and 64 min of the Salmonella chromosome and encodes a 392-amino-acid protein. In vivo, upon intraperitoneal injection of 10(4) to 10(7) bacteria in C3H/HeN and 10(1) to 10(4) bacteria in BALB/c mice, the mutant strain was less virulent than the wild type. Consistent with this finding, during the first hour after ingestion by macrophage-like J774 and RAW264.7 cells in vitro, the intracellular killing of the strain carrying sspJ::MudJ is enhanced fivefold over that of wild-type microorganisms. Wild-type salmonellae displayed significant intracellular replication during the first 24 h after uptake, but sspJ::MudJ mutants failed to do so. This phenotype could be restored to that of the wild type by sspJ complementation. The SspJ protein is found in the cytoplasmic membrane and periplasmic space. Amino acid sequence homology analysis did reveal a leader sequence and putative pyrroloquinoline quinone-binding domains, but no putative protein function. We excluded the possibility that SspJ is a scavenger of superoxide or has superoxide dismutase activity.

[Long iliac artery occlusions: Feasibility, short- and mid-term outcome]

PURPOSE

It was the aim of the following study to determine the feasibility of the recanalization of long occlusions in iliac arteries and to establish its patency rate.

MATERIAL AND METHODS

We retrospectively evaluated the data of 23 patients (15 male and 8 female) with occlusions of the iliac arteries with a mean length of 12 cm (range: 9-15 cm). The occlusions were situated either in the common iliac artery (CIA) (n = 3), in the external iliac artery (EIA) (n = 12) or in both CIA and EIA (n = 7). In one patient three vessels, the common femoral artery included, were involved. The recanalization procedure was performed with wire and catheter from retrograde and, in case of a failure, from antegrade in a cross-over technique.

RESULTS

Recanalization succeeded in all patients. Technical success defined as residual stenosis < 30 % was seen in 20 of 23 patients. Early reocclusions were seen in four patients, in three of whom, the stent dilatation had been incomplete. Late reocclusions were observed in three patients, one of whom had already had early reocclusion. The reason was stent breakage in one, stent dehiscence in the second and restenosis in the third patient. All of the patients with reocclusion either early or late, had received covered stents. In four patients restenosis developed within 30 months: It was successfully treated by ballon dilatation or stent. Embolism during the recanalization procedure was observed in six patients. Embolism was observed on the ipsilateral side in five, and on the contralateral side in one patient. In each patient who had experienced embolism, balloon dilatation had been performed before stent implantation.

CONCLUSION

1) There is some evidence that the recanalization of long iliac artery occlusions is feasible. 2) The main reason for early and late reocclusions is either rest stenosis or restenosis. 3) Covered stents should only be used in selected cases. 4) Primary stenting is the treatment of choice in order to prevent embolism.

Recombinant Lactobacillus plantarum inhibits house dust mite-specific T-cell responses

Recent evidence suggests that chronic exposure to lactobacilli, which are part of the normal intestinal flora, inhibits the development of allergic disorders. Allergy is mediated by Th2 cells, which produce high levels of IL4 and IL5, and suppressive effects of lactic acid bacteria on the development of allergy have been attributed to their Th1-inducing properties. On the other hand, lactic acid bacteria have also been shown to suppress autoimmune disorders which are mediated by Th1 cells producing high levels of IFNgamma. To study this apparent discrepancy, the immunomodulatory potential of lactobacilli was evaluated using recombinants that express an immunodominant T-cell epitope of Der p 1 of house dust mites. Mucosal immunization of C57BL/6 J mice with such recombinants resulted in the induction of T cells which produced low amounts of IFNgamma. Immunization with the house dust mite peptide followed by treatment with recombinant Lactobacillus plantarum resulted in the inhibition of both IFNgamma and IL5 production. The effect on IFNgamma production was shown to be a non-specific effect of L. plantarum. The effect on IL5 production, however, was only observed when the recombinant expressing the Der p 1 peptide, but not the control recombinant, was used for treatment. Neither of the recombinants had an effect on the antibody response. Taken together, these data suggest that recombinant L. plantarum may be a suitable candidate for the treatment of allergic disorders.

Multifocal osteomyelitis caused by nontuberculous mycobacteria in patients with a genetic defect of the interferon-gamma receptor

We describe three patients with multifocal osteomyelitis caused by Mycobacterium avium and a family history of one or more first degree family members diagnosed with various clinical presentations of infections with nontuberculous mycobacteria. There was a significant delay in the diagnosis and they had a protracted course of their illness, which responded only slowly to prolonged multi-drug treatment. In one patient, additional treatment with interferon-gamma (IFN-gamma) was necessary. Macrophages of these patients had decreased in vitro responsiveness to IFN-gamma. Genomic sequencing revealed that these patients and their affected family members were heterozygous for a previously described dominant negative mutation in the gene encoding the IFN-gamma binding receptor-1 chain. The clinical presentations of the infections with nontuberculous mycobacteria in these families, with spread limited to skin, bone and lymph nodes, is discussed in the light of the immune mechanisms that are responsible for the clearance of otherwise poorly pathogenic environmental mycobacteria.

Estimated risk of HIV transmission by blood transfusion in Kenya

BACKGROUND

During the past decade, developing countries have received limited support for blood safety programmes. The Kenya Ministry of Health did a collaborative multicentre assessment to establish the risk of HIV transmission by transfusion in Kenya, to promote awareness of blood safety issues in this country with a mature HIV epidemic, and to identify methods to reduce the risk of HIV transmission by blood transfusion in Kenya.

METHODS

For 12 weeks, from April to July 1994, we collected information and blood samples from all blood donors, and pretransfusion samples were collected from all recipients in six government hospitals in Kenya. Blood donations were collected and screened for HIV according to standard practice in the hospital laboratories. Test results at a reference laboratory were compared with those of the hospital laboratories and risk of transfusion-associated HIV transmission was calculated.

FINDINGS

The prevalence of HIV among blood donors was 6.4% (120 of 1877) and varied by hospital (range 2-20%). HIV test results were available for 1290 donor-recipient pairs. Of these, 26 HIV-positive donations were given to HIV-negative patients. We estimate that 2.0% of transfusions transmitted HIV. Problems in the hospitals that contributed to transfusion risk included inconsistent refrigeration, data entry errors, equipment failure, and lack of a quality-assurance programme.

INTERPRETATION

A high proportion of blood transfusions transmitted HIV in this high-prevalence area of Africa, primarily because of erroneous laboratory practices. On the basis of these results, the Kenya Ministry of Health introduced a number of practical and inexpensive interventions to improve national blood safety.