NSAID injury to the small intestine

PURPOSE

To identify the clinical and radiologic findings in patients with diaphragm-like strictures in the small bowel.

PATIENTS AND METHODS

We reviewed the histories, radiologic findings, and pathologic findings in two men and two women, all in their sixties, with a history of long-term nonsteroidal antiinflammatory drug (NSAID) or aspirin (ASA) usage and one or more radiologically demonstrated diaphragm-like strictures in the small bowel.

RESULTS

Two patients had long histories of NSAID usage, and two of ASA usage. One NSAID user had a long segment of jejunal involvement, and the other three had short segments of duodenal involvement. The ASA users presented with symptoms of esophageal disease, the small bowel lesions were unexpected, and ASA usage was not initially elicited. In one NSAID user and one ASA user, broader strictures with humps rather than diaphragms were also seen producing a lifesaver-like or bagel-like configuration.

CONCLUSIONS

Multiple diaphragm-like strictures can occur in NSAID injury and are pathognomonic except in the rare patient with ulcerative enteritis complicating celiac disease. Single or few diaphragm-like strictures can occur in NSAID injury and peptic ulceration. ASA should be considered an NSAID with regard to small-bowel toxicity. A careful medication history is required when an unexplained small bowel abnormality is seen radiologically, and a dedicated small bowel examination is required when NSAID injury is suspected.

Guidelines for the investigation of invasive fungal infections in haematological malignancy and solid organ transplantation. British Society for Medical Mycology

Invasive fungal infections are increasing in incidence and now affect as many as 50% of neutropenic/bone marrow transplant patients and 5 to 20% of solid organ transplant recipients. Unfortunately, many of the diagnostic tests available have a low sensitivity. The guidelines presented here have been produced by a working party of the British Society for Medical Mycology in an attempt to optimise the use of these tests. The yield of fungi from blood cultures can be increased by ensuring that at least 20 ml of blood are taken for aerobic culture, by using more than one method of blood culture, and by employing terminal subculture if continuous monitoring systems are used with a five-day incubation protocol. Skin lesions in febrile neutropenic patients should be biopsied and cultured for fungi. The detection of galactomannan in blood or urine is of value in diagnosing invasive aspergillosis only if tests are performed at least twice weekly in high-risk patients. Antigen detection tests for invasive candidiasis are less valuable. Computed tomography scanning is particularly valuable in diagnosing invasive pulmonary fungal infection when the chest radiograph is negative or shows only minimal changes. Bronchoalveolar lavage is most useful in patients with diffuse changes on computed tomography scan. The major advances in the diagnosis of invasive fungal infection in patients with haematological malignancy or solid organ transplantation have been in the use of imaging techniques, rather than in the development of new mycological methods in the routine laboratory.

Pancreaticoduodenal tuberculosis simulating metastatic ovarian carcinoma

A patient from Thailand presented with symptoms suggestive of peptic ulceration. Radiology showed an ulcerated duodenal stricture, a pancreaticoduodenal mass and extensive retroperitoneal lymphadenopathy suggestive of metastatic carcinoma. Tuberculosis was diagnosed only at laparotomy. The incidence of tuberculosis is increasing, and alimentary tuberculosis should be considered in patients from populations at risk presenting with obscure abdominal complaints or unexplained radiologic findings.

Susceptibility testing of Haemophilus influenzae--an international collaborative study in quality assessment

In order to compare the prevalence of antibiotic resistance in different geographical areas, it is necessary to ensure that agreement is achieved between laboratories on the assignment of strains to 'susceptible' and 'resistant' categories. An international quality assessment study, involving 15 laboratories in eight countries, was performed to investigate the standard of performance of the susceptibility testing of Haemophilus influenzae. One hundred and fifty strains of H. influenzae were distributed from the London Hospital Medical College (LHMC) to all laboratories who were asked to test the susceptibility of the strains to ampicillin, chloramphenicol, tetracycline, trimethoprim, cephalosporins and ciprofloxacin. Laboratories were also asked to provide the details of methodology to test the susceptibility. Significant discrepancy between the LHMC and the participating laboratories appeared in the detection of resistance to ampicillin (especially beta-lactamase-negative strains resistant to ampicillin) as well as the assignment of susceptibility and resistance to chloramphenicol, tetracycline and trimethoprim. Often these reflected the use of inappropriate breakpoints which led to erroneous assignment of susceptibility. Other variations including disc content, medium and supplement, inoculum as well as failure to measure zone sizes properly also led to some repeating anomalies.

Single-beam diode-laser technique for optical path-length measurements

A simple single-beam technique employing radio-frequency modulation of a tunable diode laser with homodyne demodulation is demonstrated as a means of measuring optical path lengths. This technique offers a straightforward method for determining path lengths traversed through optical multipass cells or performing optical range-finding over short (i.e., tens of meters) standoff distances. The radio-frequency phase-sensitive nature of the technique permits narrow-band detection and high signal-to-noise ratios, even when range-finding measurements are made with range resolutions of «1 m. This compares favorably with traditional short-pulse, wide-bandwidth optical range finders.

Optimum detection of multiple vapor materials with frequency-agile lidar

Differential absorption lidar (DIAL) is a well-established technology for estimating the concentration and its path integral CL of vapor materials using two closely spaced wavelengths. The recent development of frequency-agile lasers (FAL's) with as many as 60 wavelengths that can be rapidly scanned motivates the need for detection and estimation algorithms that are optimal for lidar employing these new sources. I derive detection and multimaterial CL estimation algorithms for FAL applications using the likelihood ratio test methodology of multivariate statistical inference theory. Three model sets of assumptions are considered with regard to the spectral properties of the backscatter from either topographic or aerosol targets. The calculations are illustrated through both simulated and actual lidar data.

Fungal infections: a survey of laboratory services for diagnosis and treatment

A questionnaire on the services provided and the methods used for the diagnosis of fungal infections and for the support of antifungal chemotherapy was sent to members of the British Society for Medical Mycology (BSMM) and the British Society for Antimicrobial Chemotherapy (BSAC). Ninety-five responses from general microbiology laboratories in the United Kingdom were analysed, and we compared services provided by laboratories that serve a transplant unit with those offered by other laboratories. We estimate that about 150 cases of cryptococcosis, 500 to 600 of candidaemia, and 300 to 400 of invasive aspergillosis are identified by laboratories in the United Kingdom (UK) each year. The clinical laboratories are aware of the importance of fungal infection, but rely heavily on reference services. In some laboratories, however, the degree of investigation of specimens and the procedures in use are inadequate for diagnosing systemic mycoses and determining the susceptibility of isolates to antifungal agents. The balance between reference and local services requires attention and external quality assurance needs to be applied effectively. In addition, effective methods for the diagnosis of systemic mycoses, and reliable and practicable methods for determining the susceptibility of isolates to antifungal agents, are needed urgently.

Antifungal drug susceptibility testing. Working Party of the British Society for Antimicrobial chemotherapy

This article describes the current situation with regard to intrinsic and acquired resistance to antifungal compounds and progress with the development of standardized methods of susceptibility testing for amphotericin B, flucytosine, and the azoles. Recommendations for testing of isolates from patients destined to receive antifungal drug treatment, or in whom therapeutic failure or relapse is suspected, are presented.

Myeloid progenitor cell regulatory effects of vascular endothelial cell growth factor

Vascular endothelial cell growth factor (VEGF) is a ligand for the tyrosine kinase receptor Flk-1/KDR and Flt1 and is considered to be an endothelial cell specific mitogen that plays an important role in angiogenesis. Since Flk-1 mRNA has been detected in primitive and more mature hematopoietic cells, recombinant human VEGF was evaluated for its influence on hematopoiesis, which was assayed as in vitro colony formation by myeloid progenitor cells from human bone marrow. VEGF enhanced colony formation by mature subsets of granulocyte-macrophage and erythroid progenitor cells that had been stimulated with a colony stimulating factor. In contrast, VEGF inhibited colony formation by more immature subsets of granulocyte-macrophage, erythroid and multipotential progenitor cells synergistically stimulated to proliferate with a colony stimulating factor and either steel factor or the ligand for the Flt-3 receptor tyrosine kinase. VEGF produced effects similar to those given above on purified CD34 progenitor cells from bone marrow and VEGF effects were neutralized by VEGF antibodies. However, when assessed for effects on single sorted CD34 cells, VEGF only enhanced or suppressed colony formation by granulocyte-macrophage progenitor cells and the amplitude of the response was less than that observed when populations of these cells were tested. In the single cell assays, VEGF had no effect on colony formation by erythroid or multipotential progenitors. These results suggest that the effects of VEGF, which were not species specific, are mediated by both direct and indirect actions on the progenitors and thereby identify new activities for this important factor.

Gastrocolic fistula secondary to primary gastric lymphoma

Gastrocolic fistula in primary non-Hodgkin's lymphoma (NHL) of the stomach is rare; in a review of the literature we found only four cases, all in association with disseminated (stage IV) disease. We describe the first case of a gastrocolic fistula in a patient with stage IE lymphoma. The diagnosis was suggested by feculent vomiting, and the fistula was located using barium enema and CT scan. Therapy consisted of local resection followed by combination chemotherapy.

Eosinophilic pleural effusion associated with recovery from viral hepatitis A

Pleural effusion represents a rare complication of acute viral hepatitis; only one case has been reported in association with type A viral hepatitis. We report here the second case, in a 24-year-old female nurse who developed a large symptomatic right pleural effusion 9 weeks after the onset of fulminant type A viral hepatitis. Ascites and edema did not develop. The effusion, exudative with an eosinophilic cellular predominance, manifested 2 weeks following recovery from viral hepatitis and resolved spontaneously. Other causes were excluded by investigation. This is the first report of a pleural effusion complicating viral hepatitis during the recovery period; moreover, it is the first case associated with pleural fluid eosinophilia.

Kalman filtering of tunable diode laser spectrometer absorbance measurements

A recursive Kalman time-series filter was applied to absorbance measurements obtained with a tunable diode laser spectrometer. The spectrometer uses frequency modulation spectroscopy and a nearinfrared diode laser operating at 1.604 µm to monitor the CO(2)-vapor concentration in a 30-cm absorption cell. The Kalman filter enhanced the signal-to-noise ratio of the spectrometer by an order of magnitude when an absorbance of 6 × 10(-5) was monitored.

Experimental gene therapy of human colon cancer

BACKGROUND

Gastrin regulates growth of human colon cancer cells by activation of the cyclic adenosine monophosphate (cAMP)-dependent protein kinase A (PKA). Gastrin and 8-Br-cAMP, a membrane-permeable cAMP analog, inhibit growth of HCT116 cells; both stimulate growth of LoVo cells. This dual effect on growth may be explained by relative amounts of the regulatory subunit (RI alpha or RII beta) of PKA within the cancer cells. Antisense oligodeoxynucleotides (ASO) to either RI alpha or RII beta inhibit protein translation of the target mRNA by sequence-specific binding; subsequently, cellular PKA content and the cAMP-mediated growth may be altered. We determined whether ASO to either the RI alpha or RII beta subunit altered the cAMP-mediated growth of HCT116 and LoVo human colon cancer cells.

METHODS

HCT116 cells were treated with RII beta ASO (15 mumol/L, 4 days) and then treated with 8-Br-cAMP (25 mumol/L); tritiated thymidine incorporation was measured after 24 hours, and the cell number was determined on alternate days. Protein and mRNA levels of the RII beta subunit were determined by Western and Northern blotting, respectively. Similar studies with an ASO against the RI alpha subunit were performed on LoVo cells.

RESULTS

RII beta ASO reversed the cAMP-mediated inhibition of growth of HCT116 cells, and RII beta ASO decreased the protein level of the RII beta subunit. RII beta ASO did not alter the basal growth of HCT116 cells. RI alpha ASO reversed the cAMP-mediated stimulation of growth of LoVo cells.

CONCLUSIONS

The regulatory subunits of PKA are potential targets to alter growth of human colon cancer cells. Gene therapy directed to alter specific steps in signal transduction pathways may provide new therapeutic strategies.

Development of an internal quality assessment scheme in a clinical bacteriology laboratory

AIM

To develop an internal quality assessment (IQA) scheme in a clinical bacteriology laboratory.

METHODS

Over 24 months, 1230 diagnostic specimens, representing 0.42% of laboratory workload, were anonymised and resubmitted for analysis. Six hundred and twenty one (48.7%) of these gave positive culture results; 44 fecal and upper respiratory specimens were "spiked" (artificially inoculated) to increase the proportion of positive samples.

RESULTS

Discrepancies between IQA and clinical sample results occurred in 188 cases (14.8%): 76.6% of these were in culture results, 13.3% in microscopy performance, and 10.1% in clerical recording. The culture discrepancy rate for each positive sample was lowest for wound (17.5%) and urine (18.1%) specimens, and highest for faeces (34.9%) and upper respiratory (37.7%) samples. Discrepancies in several areas responded to staff training and improvement in technical methods.

CONCLUSIONS

An IQA programme of this type assesses the reproducibility of tests within a diagnostic laboratory when analysing common specimen types and organisms. It permits blind assessment of many areas of diagnostic work that are not readily amenable to other quality assurance methods, and it raises the awareness of all staff to the importance of quality in every aspect of specimen and data processing.

Venous intravasation of barium: CT findings

Portal venous barium and air intravasation occurred during an air contrast enema in a man with ulcerative colitis. Abdominal plain radiography and CT subsequently showed increased hepatic density. Computed tomography also showed colonic intramural and pericolic nodal or venous barium, increased splenic density, and pulmonary arterial barium. The patient's course was benign because little barium embolized beyond the liver into the systemic circulation.

Neutropenic enterocolitis associated with Clostridium tertium

A 15 year old boy being treated for relapsed acute lymphoblastic leukaemia developed severe diarrhoea and abdominal pain which worsened despite empirical antibiotic treatment. A right hemicolectomy was performed. The caecum and ascending colon showed changes typical of neutropenic enterocolitis. Clostridium tertium was isolated from faeces, blood cultures, and from the resected gut wall, with no evidence of other organisms capable of causing such a condition. As far as is known, this is the first reported case in which neutropenic enterocolitis has been associated with well documented C tertium infection, an organism previously described as a cause of bacteraemia in neutropenic patients.

Antibodies to meningococcal class 1 outer membrane proteins in South African complement-deficient and complement-sufficient subjects

Inhibition assays were used to investigate human serum antibodies to the meningococcal class 1 outer membrane proteins. We adapted the whole-cell enzyme-linked immunosorbent assay technique to determine the ability of sera to inhibit the binding of murine subtyping monoclonal antibodies. Serum samples from 33 South African subjects with a deficiency in the sixth component of complement as well as serum samples from various groups of complement-sufficient subjects were investigated. Subjects were subdivided according to whether they were (i) convalescent from Neisseria meningitidis infections, (ii) nonconvalescent, or (iii) controls. Preliminary subtyping investigations had shown that P1.2 was present on 36% of meningococcal clinical isolates from Cape Province, South Africa. Assays with the anti-P1.2 antibodies showed the presence of high antibody levels in many deficient sera and moderately elevated levels in some sera from the complement-sufficient convalescent patients. P1.2, P1.4, P1.15, and P1.16 are epitopes situated on loop 4 of the class 1 outer membrane proteins, whereas P1.7 is on loop 1. Inhibition assays showed that human sera that inhibited binding by P1.2 monoclonal antibodies tended to inhibit the other monoclonal antibodies directed to loop 4 epitopes. This suggests that the epitopes recognized by the human antibodies are not exactly the same as the epitopes recognized by the murine monoclonal antibodies and raises the possibility of the importance of other epitopes.