Clinicopathogenetic significance of chromosomal abnormalities in patients with blastic peripheral B-cell lymphoma. Kiel-Wien-Lymphoma Study Group

So far, reproducible histomorphologic and immunological criteria to distinguish clinicopathologic subtypes of blastic peripheral B-cell non-Hodgkin's lymphoma (BBCL), especially centroblastic (cb) and immunoblastic (ib) lymphomas, for daily diagnostic use are still lacking. Therefore, we correlated the cytogenetic findings in 126 patients with BBCL with histopathologic diagnoses. Subclassification of cb and ib lymphomas relied on the criteria defined in the updated Kiel classification; these subtypes are also listed in the Revised European-American Lymphoma (REAL) classification and in a preliminary report on the newly established World Health Organization classification, to investigate their clinical significance. Moreover, we performed a multivariate analysis to compare the prognostic significance of cytogenetic findings with the International Index. There were significant differences in the frequency of chromosome aberrations between different BBCL subtypes: t(8;14) was predominantly present in Burkitt's lymphomas, t(14;18) in centroblastic lymphomas, deletions in 8q and 14q, changes of 4q and losses of chromosome 10 in immunoblastic lymphomas; t(11;14) was restricted to blastoid mantle cell lymphomas and associated with a poor prognosis. In cb lymphomas, deletions in 1q42-qter, duplications in 1q23-32, trisomy 5, and changes of 15q were identified as independent prognostic factors. In ib lymphomas, changes of 7q and 8q had stronger impact on survival than the International Index. These findings underline that Burkitt's, cb, ib, and blastoid mantle-cell lymphoma are biologically distinct and clinically relevant entities and that cytogenetic findings can be helpful to subtype BBCL.

Scanning small angle X-ray scattering analysis of human bone sections

Scanning small-angle X-ray scattering (scanning SAXS) was applied for the first time on bone to compare results from SAXS directly with those from other position-sensitive methods, such as light and polarized light microscopy, back-scattered electron imaging, and radiographic imaging. Since scanning SAXS is a nondestructive method of investigation, images from all these techniques could be obtained from the same bone sections. Thus, it could be shown that both the collagen and the mineral crystals were predominantly aligned parallel to the trabeculae and, therefore, to principle stress directions. Moreover, the mean crystal thickness as determined by scanning SAXS was found to be different at various positions inside the trabecular and cortical structure. Finally, it could be shown that scanning SAXS is suitable for detecting local changes in bone material, e.g., due to fluoride treatment.

Pharmacologic intervention during the acute bleeding episode

The risk of recurrent variceal bleeding after an acute episode of bleeding has been controlled in significant with rebleeding rates as high as 80% between one and two years. Pharmacologic therapy has a definite role in the prevention of recurrent variceal bleeding and should be started as soon as the acute bleeding event has been controlled. Serial hemodynamic measurements are critical for success. Non-selective beta-blocker therapy is a reasonable first line approach followed by the addition of a long-acting nitrate for patients not achieving a 20% reduction in the hepatic venous pressure gradient. Most patients will require combination pharmacotherapy or combined endoscopic therapy with pharmacotherapy.

Pharmacological prevention of rebleeding

Pharmacologic therapy used during acute variceal bleeding may control the bleeding episode, minimized transfusion requirements, and prevent early rebleeding. Several options for pharmacologic therapy exist in this setting and include: vasopressin in combination with nitroglycerin, terlipressin, somatostatin, and octreotide. Metoclopramide and domperidone may also be useful but require additional study. At present, octreotide, administered intravenously as soon as variceal bleeding is suspected, is favored.

[Drugs in the physician's bag for emergency conditions]

The list of drugs for the physician's bag depends on several factors, including practice location, conditions most likely to be found, costs and availability of drugs, organization of the emergency medicine in the region, shelf life and climatic vulnerability of certain drugs, population age, and size and design of the bag. Most of the drugs carried should be in an injectable form. However, the non-injectable drugs with relatively rapid systemic onset may be also included. Separation of drugs in the bag according to their usage may help in providing an organized treatment. For example, one could separate drugs for treatment of the following emergencies: cardiovascular, altered mental status, respiratory, gastrointestinal, bleeding, infections, and toxicological emergencies. The list of drugs needed for medical emergencies when physician makes house-calls is presented with short notes on their usage. Oncologic, toxicologic and pediatric emergencies are commented.

Cervical spine motion with direct laryngoscopy and orotracheal intubation. An in vivo cinefluoroscopic study of subjects without cervical abnormality

BACKGROUND

Cervical spine kinetics during airway manipulation are poorly understood. This study was undertaken to quantify the extent and distribution of segmental cervical motion produced by direct laryngoscopy and orotracheal intubation in human subjects without cervical abnormality.

METHODS

Ten patients without clinical or radiographic evidence of cervical spine abnormality underwent laryngoscopy using a #3 Macintosh blade while under general anesthesia and neuromuscular blockade. Cervical motion was recorded with continuous lateral fluoroscopy. The intubation sequence was divided into distinct stages and the corresponding fluoroscopic images were digitized. Segmental motion, occiput through C5, was calculated for each stage using the digitized data.

RESULTS

During exposure and laryngoscope blade insertion, minimal displacement of the skull base and rostral cervical vertebral bodies was observed. Visualization of the larynx created superior rotation of the occiput and C1 in the sagittal plane, and mild inferior rotation of C3-C5. C2 maintained nearneutral posture. This pattern of displacement resulted in extension at each motion segment, with the most significant motion produced at the occipitoatlantal and atlantoaxial joints (mean = 6.8 degrees and 4.7 degrees, respectively). Intubation created slight additional superior rotation at the occiput and C1, without substantial alteration in the posture of C2-C5. After laryngoscope removal, position trended toward baseline at all levels, although exact neutral posture was not regained.

CONCLUSIONS

This investigation quantifies the behavior of the normal cervical spine during direct laryngoscopy with a Macintosh blade. With this maneuver, the vast majority of cervical motion is produced at the occipitoatlantal and atlantoaxial joints. The subaxial cervical segments (C2-C5) are displaced only minimally. This study establishes a highly reliable and reproducible method for analyzing cervical motion in real time.

Cytogenetic findings in 175 patients indicate that items of the Kiel classification should not be disregarded in the REAL classification of lymphoid neoplasms

Cytogenetics have proved to be a valuable tool for classifying systemic lymphatic neoplasms, as this technique allows different stem line aberrations and clonal developments to be distinguished. This study was designed to analyze how far groups defined according to common cytogenetic features correlated with their position in either the Kiel (KC) or the REAL classification. Cytogenetic analyses were performed on material from 175 patients with lymphoid neoplasms (LN). Samples were prepared from peripheral blood and bone marrow in acute lymphoblastic leukemia (ALL), from bone marrow in multiple myeloma (MM), and from lymph node biopsies in lymphomas. The results of this study support the inclusion of ALL, MM, and extranodal lymphomas into a comprehensive classification, because their chromosomal aberrations were always characteristic for LN. From the cytogenetic point of view, a subgroup of ALL appears as a leukemic manifestation of lymphoblastic lymphoma. MM have structural aberrations of chromosomes 1, 11, and 14 and secondary aberrations of chromosomes 3, 6, 7, 12, 13, and 18, all of which are characteristic for lymphatic disease. The groups with follicle center cell lymphoma and mantle cell lymphoma correlate well with our results both in the low-grade subtype and in the blastic variant type, the majority of cases demonstrating t(14; 18) and its variants and t(11; 14), respectively. In contrast, the group of diffuse large B-cell (DLB) lymphomas proved to be heterogeneous on the basis of our cytogenetic results. Accordingly, we would suggest keeping the immunoblastic lymphoma (IB) subtype defined by the KC. IB demonstrates no stem line aberration in common with any other group and seems to be characterized by stem line aberrations involving chromosomes 3 and 6. As some DLB lymphomas have a t(14;18) or variant translocations involving chromosome 18, they should either be separated as a subgroup or included into the group of follicle center lymphomas.

Glycine receptor antagonism. Effects of ACEA-1021 on the minimum alveolar concentration for halothane in the rat

BACKGROUND

Glycine and glutamate binding sites are allosterically coupled at the N-methyl-D-aspartate (NMDA) receptor complex. Previous studies have shown that antagonism of glutamate at the NMDA receptor reduces the minimum alveolar concentration (MAC) for volatile anesthetics. 5-Nitro-6,7-dichloro-2,3-quinoxalinedione (ACEA-1021) is a competitive antagonist at the glycine recognition site of the NMDA receptor. The purpose of this study was to determine whether glycine receptor antagonism also reduces volatile anesthetic requirements in the rat.

METHODS

In experiment 1, Sprague-Dawley rats were anesthetized with halothane in 50% O2-balance N2 and their lungs mechanically ventilated. They were randomly assigned to one of three groups according to the dose of ACEA-1021 administered (0, 20, or 40 mg/kg intravenously; n = 6). The bolus dose of ACEA-1021 was followed by a continuous intravenous infusion of vehicle or ACEA-1021 at 14 mg.kg-1.h-1. Halothane MAC was then determined by the tail-clamp method. In experiment 2, awake rats were randomly assigned to groups according to the same dosages of ACEA-1021 as in experiment 1. Arterial CO2 tension and mean arterial pressure were recorded before and 5 and 30 min after the start of the infusion. The infusion was then stopped, and the time to recovery of the righting reflex was recorded.

RESULTS

In experiment 1, ACEA-1021 decreased halothane MAC (mean +/- SD) in a dose-dependent manner (control, 0.95 +/- 0.15 vol%; ACEA-1021 20 mg/kg, 0.50 +/- 0.14 vol%; ACEA-1021 40 mg/kg, 0.14 +/- 0.16 vol%; P < 0.01). In experiment 2, arterial CO2 tension was increased by ACEA-1021 (control, 38 +/- 3 mmHg; ACEA-1021 20 mg/kg, 43 +/- 3 mmHg; ACEA-1021 40 mg/kg, 48 +/- 2 mmHg; P < 0.01). Mean arterial pressure was not affected by any dose of ACEA-1021. The righting reflex was abolished in rats receiving ACEA-1021 40 mg/kg only and recovered 30 +/- 7 min after discontinuation of the infusion.

CONCLUSIONS

Halothane MAC reduction by glycine receptor antagonism was greater than that previously observed for antagonism of glutamate at the NMDA or AMPA receptor. In rats receiving ACEA-1021 only, minimal hemodynamic depression and moderate hypoventilation were observed. Antagonism of glycine at the NMDA receptor recognition site offers a potential mechanism of action of anesthesia.

Bovine spongiform encephalopathy surveillance in Argentina

Bovine spongiform encephalopathy (BSE) is a new disease of cattle first described in the United Kingdom in November 1986. BSE belongs to the scrapie-related group of diseases. The epidemiological studies performed in the United Kingdom demonstrate that the BSE epidemic was caused by feeding cattle with ruminant-derived protein contaminated by a scrapie-like agent. Until June 1994, the disease had been detected in indigenous cattle in Ireland, Switzerland and France. Three cases reported in Germany, two in the Sultanate of Oman, and single cases in the Falkland Islands (Islas Malvinas), Denmark, Portugal and Canada occurred in animals imported from the United Kingdom. Several countries have implemented surveillance programmes analysing the risk factors involved in the epidemic. An analysis of risk factors conducted in Argentina shows that it is highly unlikely that BSE or scrapie exist in the country, or will arise via feed in the future. As a continuation of the analysis of risk factors, a surveillance programme was implemented in the field and in abattoirs. Specialised personnel were trained in the clinical, histopathological and biochemical detection of the disease through a network of laboratories which covered 85% of the total cattle population and 100% of the high-risk group (dairy cows over five years of age). By using a statistical procedure with reference to the bovine population in nine provinces, 1,019 brains from animals belonging to the high-risk group were selected and studied by histopathological and biochemical analyses for BSE detection. The results were negative in all cases. It can be concluded from this analysis (with a sensitivity of detection of 2.95 per 1,000, and 95% statistical confidence) that Argentina may be regarded as BSE-free, and that the importation of infected animals or by-products may represent the sole potential source of introduction of BSE infection into the country in the future.

[A case of popliteal pterygium syndrome. Considerations of timing and method of therapy]

A case of popliteal pterygium syndrome is presented and the various possibilities of treatment so far reported in the literature are discussed. The medical history of the 22-year-old male patient shows that there is no uniform concept in its therapy and that even multiple operations, which dealt only with the skin contracture and the shortened achilles tendon, were not successful. An extensive neurolysis of the sciatic nerve, its transposition into deeper muscle layers and slow extension of the knee joint with a dynamic splint did improve the patient's condition and this seems to be the concept to follow even in patients with multiple previous operations. For children with popliteal pterygium syndrome, an evaluation of the severity of contracture in degrees would be useful and a conservative treatment with splints should be begun within the first months after birth. In case of no response to conservative therapy, an operation becomes necessary. Surgery consists of the transposition of the sciatic nerve into deeper layers with simultaneous excision of fibrotic tissue, flap transfer or Z-plasty and postoperative extension of soft tissue in the knee by splinting and physiotherapy.

Hypertonic saline prehydration in patients undergoing transurethral resection of the prostate under spinal anaesthesia

Thirty-three patients undergoing elective transurethral resection of the prostate were allocated randomly to receive either 0.9% isotonic saline 7 ml kg-1 (16 patients), or 3% hypertonic saline 7 ml kg-1 (17 patients) as a preload before spinal anaesthesia. After spinal anaesthesia, the incidence of systolic arterial pressure < 75% of control value was greater in the normal saline group than in the hypertonic saline group. Also, the mean dose of phenylephrine required to maintain arterial pressure > 75% of the baseline value was significantly greater in the normal saline group than in the hypertonic saline group.

A comparison of epidural tramadol and epidural morphine for postoperative analgesia

The present study compared epidural tramadol with epidural morphine for postoperative analgesia in 20 patients undergoing major abdominal surgery. Intraoperatively, the patients were anaesthetized by a balanced technique of general anaesthesia combined with lumbar epidural lidocaine. In ten of the patients 100 mg tramadol diluted in 10 ml normal saline was also injected epidurally, while 4 mg epidural morphine was used in the other ten patients. In all patients, the visual analogue pain score, PaO2, PaCO2 and respiratory rate were monitored every hour for the first 24 hr postoperatively. In both the tramadol and morphine groups, the mean hourly pain scores ranged from 0.2 +/- 0.6 to 1.4 +/- 2.5 throughout the period of observations. However, the mean PaO2 was decreased postoperatively in the epidural morphine group, while no change was observed in the epidural tramadol group. The maximal decrease of PaO2 in the epidural morphine group was observed at the tenth hour postoperatively, when it decreased to 72.8 +/- 10.3 mmHg. This was not associated with any increase in PaCO2 or a decrease of respiratory rate, suggesting that hypoxaemia rather than hypercarbia or decreased respiratory rate may be an earlier indicator of respiratory rate, suggesting that hypoxaemia rather than hypercarbia or decreased respiratory rate may be an earlier indicator of respiratory depression in patients breathing room air without oxygen supplementation. The absence of clinically relevant respiratory depression following epidural tramadol compared with epidural morphine may be attributed to the different mechanisms of their analgesic action. The results suggest that epidural tramadol can be used to provide prolonged postoperative analgesia without serious side effects.

Preliminary evaluation of a simple method for detection of bovine tuberculosis: the glutaraldehyde test

The glutaraldehyde test (GT) is performed by mixing whole blood with a 1.25% glutaraldehyde solution. Gelification time is shorter in tuberculous cattle. This test was performed in blood samples obtained from: (a) 48 cattle with bacteriologically confirmed tuberculous lesions; (b) 61 animals with no evidence of tuberculosis at the time of slaughterhouse inspection, 14 of which had hydatid cysts; (c) 260 tuberculin-negative apparently healthy animals, and (d) 21 cattle, also tuberculin-negative but serologically positive for brucellosis. Sensitivity for detecting tuberculosis was 85.4% (41 of 48 animals). The test was negative in 298 out of 307 healthy animals (97.1% specificity). This specificity decreased when the test was applied in animals with evidence of diseases other than tuberculosis. This simple, rapid and inexpensive method could play a complementary role to the tuberculin test for detecting tuberculous cattle, especially in endemic areas with scarce resources and facilities.

The administration of foot and mouth disease vaccine with oil adjuvant and its influence on the diagnosis of bovine tuberculosis

The possible influence of vaccination with oil adjuvanted foot and mouth disease vaccines on the tuberculin response was investigated in 32 normal guinea pigs and 190 non-tuberculous bovines. Circulating anti-Mycobacterium bovis IgG antibodies were analysed by an enzyme-linked immunosorbent assay (ELISA), in order to determine the effect of the vaccination on the humoral response against mycobacteria in cattle. Control animals were either nonvaccinated or injected with aluminium hydroxide adjuvanted vaccine. Administration of foot and mouth disease vaccine had no apparent influence on the tuberculin responses of either guinea pigs or cattle, nor did it influence the level of anti-M. bovis antibodies in cattle.

Reciprocal cellular and humoral immune responses in bovine tuberculosis

A sandwich ELISA for the detection of gamma interferon showed higher sensitivity and specificity than an indirect ELISA for mycobacterial antibodies in the diagnosis of bovine tuberculosis. Circumstantial evidence of an inverse relationship between cellular and humoral immune responses to Mycobacterium bovis was found in cattle with natural infection.

Further evaluation of an indirect enzyme-linked immunosorbent assay for the diagnosis of bovine tuberculosis

The sensitivity and specificity of an ELISA for the detection of bovine IgG anti-Mycobacterium bovis antibodies were 73.6% and 94.1%, respectively, as determined in 53 bacteriologically confirmed tuberculous cattle and 101 healthy cattle from a tuberculosis-free area. In addition, the results of ELISA and tuberculin tests in 149 cattle were compared with those of subsequent necropsy studies. Both tests failed to detect 2 animals with tuberculous lesions and positive culture; 3/12 cattle with M. bovis isolation and no lesions, and 2/7 with atypical mycobacterial infection reacted to tuberculin, but none had antibodies; in 128 cattle with neither lesions nor mycobacterial isolation, 6 were tuberculin reactors and 7 others had antibodies. Negative results were obtained by ELISA in 21/22 paratuberculous cattle. Antibodies were not detected in 88.9% to 96.4% of 697 cattle from two tuberculin negative herds of an endemic area. In a herd with proved M. bovis infection, distribution of seropositive animals in tuberculin and non-tuberculin reactors was similar. Antibody responses to cutaneous tuberculin stimuli were observed in 4 experimentally infected cattle, but only in 2/10 healthy controls after repeated PPD stimuli. Nine controls which had either received a single tuberculin dose or none showed no increase in antibody levels. The low sensitivity of this ELISA limits its usefulness as a diagnostic tool for bovine tuberculosis eradication campaigns. However, it could be helpful in epidemiological surveillance if its efficiency to identify infected herds is demonstrated.

[Evaluation of four antigens for the detection of anti-Mycobacterium bovis antibodies by enzyme immunoassay]

An enzyme-linked immunosorbent assay (ELISA) for the diagnosis of bovine tuberculosis through the detection of specific seric antibodies has recently been developed in our laboratory. In order to assess its reproducibility and select the most adequate antigen, four bovine PPDs from different sources were evaluated in parallel: PPD M. bovis strain AN5, CEPANZO standard (CPZ), PPD M. bovis strain AN5, European Economic Community standard (EEC), PPD M. bovis strain AN5, prepared from non heated bacilli, killed by phenol (P) and PPD. M. bovis BCG strain prepared at the Pasteur Institute, Paris (BCG). Sera from 22 healthy cattle from tuberculosis free area and 20 bacteriologically confirmed tuberculous animals were employed in simultaneous assays. Antibody mean and standard deviations from healthy cattle expressed as optical density (OD) values were 45 +/- 22 when CPZ was used as antigen, 24 +/- 10 with EEC, 103 +/- 56 with P and 56 +/- 20 with BCG. Mean O.D. from tuberculous cattle were 588 +/- 158, 510 +/- 234, 782 +/- 138 and 441 +/- 189 with antigens CPZ, EEC, P and BCG respectively. A close correlation was observed when results obtained with EEC and P were compared with that of CPZ (r: 0.97 and 0.94 respectively). A lower specificity was achieved when BCG was used as antigen being also lower its correlation with the results obtained with CPZ (r: 0.87). It is concluded that our ELISA would achieve similar sensitivity and specificity if CPZ, EEC and P were used as antigens. On the other hand, BCG would not be suitable for this assay.