Exogenously acquired Clostridium septicum gas gangrene--a case report

We report on a 72-year-old woman suffering from gas gangrene of the right leg, which developed 3 days after getting injured while gardening. Due to rapid microbiological diagnosis-direct microscopical examination of muscle biopsies revealed numerous grampositive rods-, immediately performed amputation of the leg and antibiotic treatment with penicillin and metronidazole the patient survived. From the muscle biopsies Clostridium septicum, which is found ubiquitously, was isolated in pure culture.

Localization and regulation of the cdk-activating kinase (Cak1p) from budding yeast

Eukaryotic cell cycles are controlled by the activities of cyclin-dependent kinases (cdks). The major cdk in budding yeast, Saccharomyces cerevisiae, is Cdc28p. Activation of Cdc28p requires phosphorylation on threonine 169 and binding to a cyclin. Thr-169 is phosphorylated by the cdk-activating kinase (CAK), Cak1p, which was recently identified as the physiological CAK in budding yeast. Here we present our further characterization of yeast Cak1p. We have found that Cak1p is dispersed throughout the cell as shown by immunofluorescence; biochemical subcellular fractionation confirmed that most of the Cak1p is found in the cytoplasm. Cak1p is a monomeric enzyme in crude yeast lysates. Mutagenesis of potential sites of activating phosphorylation had little effect on the activity of Cak1p in vitro or in vivo. Furthermore, Cak1p contains no posttranslational modifications detectable by two-dimensional isoelectric focusing. We found that Cak1p is a stable protein during exponential growth but that its expression decreases considerably when cells enter stationary phase. In contrast, Cak1p levels oscillate dramatically during meiosis, reflecting regulation at both the transcriptional and post-translational level. The localization and regulation of Cak1p are in contrast to those of the known vertebrate CAK, p40(MO15).

Transcriptional regulation of the SMK1 mitogen-activated protein kinase gene during meiotic development in Saccharomyces cerevisiae

Meiotic development (sporulation) in Saccharomyces cerevisiae is characterized by an ordered pattern of gene expression, with sporulation-specific genes classified as early, middle, mid-late, or late depending on when they are expressed. SMK1 encodes a mitogen-activated protein kinase required for spore morphogenesis that is expressed as a middle sporulation-specific gene. Here, we identify the cis-acting DNA elements that regulate SMK1 transcription and characterize the phenotypes of mutants with altered expression patterns. The SMK1 promoter contains an upstream activating sequence (UASS) that specifically interacts with the transcriptional activator Abf1p. The Abf1p-binding sites from the early HOP1 and the middle SMK1 promoters are functionally interchangeable, demonstrating that these elements do not play a direct role in their differential transcriptional timing. Timing of SMK1 expression is determined by another cis-acting DNA sequence termed MSE (for middle sporulation element). The MSE is required not only for activation of SMK1 transcription during middle sporulation but also for its repression during vegetative growth and early meiosis. In addition, the SMK1 MSE can repress vegetative expression in the context of the HOP1 promoter and convert HOP1 from an early to a middle gene. SMK1 function is not contingent on its tight transcriptional regulation as a middle sporulation-specific gene. However, promoter mutants with different quantitative defects in SMK1 transcript levels during middle sporulation show distinct sporulation phenotypes.

Surgical repair of Achilles tendon rupture. Comparison of surgical with conservative treatment

Achilles tendon suture combined with a triceps surae tendon tip-over graft was performed in 314 patients with acute rupture of the Achilles tendon between 1980 and 1991. Analysis of these cases showed a low tissue complication rate compared with that reported in the literature. An average of 8.1 years after repair, 223 patients were examined using Holz's scale of clinical assessment after Achilles tendon repair. The results were 'good' in 87.4%, 'fair' in 11.2% and 'poor' in 1.4%. The re-rupture rate was very low (0.4%). These results are better than the re-rupture rate after surgical repair with solely end-to-end suture or after conservative immobilizing or conservative functional treatment. In conclusion, these data show that the fascial reinforcement is a valuable complement to the tendon suture.

[Pain therapy in pediatric oncology]

Malignancy-related pain is of similar frequency in children and adolescents as in adults. In children too evaluation of pain intensity, character and location is the basis for individually adapted pain therapy. The choice of medication is determined by the pathophysiological cause and the intensity of the pain. In addition to non-opioid analgesics, tramadol is used for moderate, and morphine for severe, pain. In the case of neuropathic pain, coanalgesics are employed. If oral treatment with morphine is no longer possible, pain pumps for continuous parenteral treatment must be used in children too. Provided the appropriate medical care is possible, parenteral treatment with potent opioids can also be applied at home. In children, every effort must be made to make painful diagnostic and therapeutic measures as painfree as possible.

Presence of mycobacterial DNA in sarcoidosis

In 11 of 35 clinically proven cases of sarcoidosis, we detected DNA sequences coding for the mycobacterial 65-kDa antigen. In four cases, the sequences were homologous to Mycobacterium avium; seven sequences were related to other nontuberculous Mycobacteria. The insertion sequence 1110, characteristic for Mycobacterium avium, was present in three cases. The insertion sequence 6110 of the Mycobacterium tuberculosis complex (M tuberculosis, africanum, bovis, BCG) was not detectable in any of the 11 cases, ruling out the presence of members of the Mycobacterium tuberculosis complex. Therefore, it seems reasonable to speculate about a mycobacterial cause in some cases of sarcoidosis.

Elderly veterans receiving care at a Veterans Affairs Medical Center while enrolled in Medicare-financed HMOs. Is the taxpayer paying twice?

Elderly veterans who visit our Veterans Affairs (VA) Medical Center primary care clinic often mention they are enrolled in HMOs. Approximately 20% of patients hospitalized at our facility report health insurance coverage. Of 1,000 hospitalizations during a 6-month period in which veterans reported insurance coverage, 337 involved elderly veterans. Of these 337 hospitalizations, 218 (65%) were for 174 veterans who stated they were enrolled in a Medicare-financed HMO. The VA's Medical Care Cost Recovery Program deemed only 46 (21%) of the hospitalizations billable and received reimbursement for 20 (9%). Thus, the VA is providing costly services already paid for by the Health Care Financing Administration under prepaid capitation contracts, and recovers minimal reimbursement from the HMOs.

The CDK-activating kinase CAK1 can dosage suppress sporulation defects of smk1 MAP kinase mutants and is required for spore wall morphogenesis in Saccharomyces cerevisiae

Mitogen-activated protein (MAP) kinase pathways are evolutionarily conserved kinase cascades that are required for the response of eukaryotic cells to a wide variety of environmental stimuli. MAP kinase pathways are also required for the execution of developmental and differentiative programs in a variety of cell and tissue types. SMK1 encodes a developmentally regulated MAP kinase in yeast that is required for spore wall morphogenesis. Cyclin-dependent kinase-activating kinases (CAKs) phosphorylate a conserved threonine residue in the activating loop of cyclin-dependent kinases. CAK1 encodes the major CAK activity in yeast and is required for cell cycle progression. The work presented here demonstrates that CAK1 functions positively in the spore wall morphogenesis pathway. First, CAK1 has been isolated as a dosage suppressor of a conditional smk1 mutant that is defective for spore wall morphogenesis. Second, CAK1 mRNA accumulates during spore development contemporaneously with SMK1 mRNA. Third, cak1 mutant strains have been isolated that are able to complete meiosis I and II but are specifically defective in assembly of the spore wall. These results show that cell cycle progression and morphogenetic pathways can be regulated by a single gene product and suggest mechanisms for coordinating these processes during development.

Decarboxylation of malonyl-(acyl carrier protein) by 3-oxoacyl-(acyl carrier protein) synthases in plant fatty acid biosynthesis

In order to identify regulatory steps in fatty acid biosynthesis, the influence of intermediate 3-oxoacyl-(acyl carrier proteins) (3-oxoacyl-ACPs) and end-product acyl-ACPs of the fatty acid synthase reaction on the condensation reaction was investigated in vitro, using total fatty acid synthase preparations and purified 3-oxoacyl-ACP synthases (KASs; EC 2.3.1.41) from Cuphea lanceolata seeds. KAS I and II in the fatty acid synthase preparations were assayed for the elongation of octanoyl- and hexadecanoyl-ACP respectively, and the accumulation of the corresponding condensation product 3-oxoacyl-ACP was studied by modulating the content of the reducing equivalentS NADH and NADPH. Complete omission of reducing equivalents resulted with either KAS in the abnormal synthesis of acetyl-ACP from malonyl-ACP by a decarboxylation reaction. Supplementation with NADPH or NADH, separately or in combination with recombinant 3-oxoacyl-ACP reductase (EC 1.1.1.100), led to a decrease in the amount of acetyl-ACP and a simultaneous increase in elongation products. This demonstrates that the accumulation of 3-oxoacyl-ACP inhibits the condensation reaction on the one hand, and induces the decarboxylation of malonyl-ACP on the other. By carrying out similar experiments with purified enzymes, this decarboxylation was attributed to the action of KAS. Our data point to a regulatory mechanism for the degradation of malonyl-ACP in plants which is activated by the accumulation of the fatty acid synthase intermediate 3-oxoacyl-ACP.

The osmoregulatory pathway represses mating pathway activity in Saccharomyces cerevisiae: isolation of a FUS3 mutant that is insensitive to the repression mechanism

Mitogen-activated protein (MAP) kinase cascades are conserved signal transduction pathways that are required for eukaryotic cells to respond to a variety of stimuli. Multiple MAP kinase pathways can function within a single cell type; therefore, mechanisms that insulate one MAP kinase pathway from adventitious activations by parallel pathways may exist. We have studied interactions between the mating pheromone response and the osmoregulatory (high-osmolarity glycerol response [HOG]) pathways in Saccharomyces cerevisiae which utilize the MAP kinases Fus3p and Hog1p, respectively. Inactivating mutations in HOG pathway kinases cause an increase in the phosphotyrosine content of Fus3p, greater expression of pheromone-responsive genes, and increased sensitivity to growth arrest by pheromone. Therefore, the HOG pathway represses mating pathway activity. In a HOG1+ strain, Fus3p phosphotyrosine increases modestly and transiently following an increase in the extracellular osmolarity; however, it increases to a greater extent and for a sustained duration in a hog1-delta strain. Thus, the HOG-mediated repression of mating pathway activity may insulate the mating pathway from activation by osmotic stress. A FUS3 allele whose gene product is resistant to the HOG-mediated repression of its phosphotyrosine content has been isolated. This mutant encodes an amino acid substitution in the highly conserved DPXDEP motif in subdomain XI. Other investigators have shown that the corresponding amino acid is also mutated in a gain-of-function allele of the MAP kinase encoded by the rolled locus in Drosophila melanogaster. These data suggest that the DPXDEP motif plays a role in the negative regulation of MAP kinases.

[Traumatic damage to the lower cervical spine--a diagnostic problem?]

Even today fractures and dislocations of the lower cervical spine are usually not recognized, or the interpretation of the results of the diagnostic procedures is not correct. These diagnostic failures are often caused by an incomplete representation of the cervical spine in the conventional radiograms, particularly in the lateral projection. Beyond that, the interpretation of the results of the neurological examination of patients with motoric or sensoric deficits after spine injury can be incorrect. Ignorance of the distribution of the segmental innervation of the upper extremities could lead to the wrong diagnosis of paraplegia in a tetraplegic patient. Two patients with injuries of the lower cervical spine are reported, in whom these problems led to an incorrect diagnosis. With regard to these cases we propose a standard diagnostic procedure for the clinical and radiological emergency examination of patients with neurological deficits after spine injury. The technical possibilities of obtaining correct radiographs of the lower cervical spine are described in detail.

[Role of intramedullary nailing in pseudarthrosis and malalignment]

Intramedullary stabilization can provide fast bone consolidation in cases of delayed fracture healing and hypertrophic non-unions. The indication for intramedullary nailing must be exactly adapted to the individual situation. An analysis of our own cases revealed bony healing in hypertrophic non-unions of femoral shaft fractures in 93% and in 94% of tibial shaft fractures after reamed intramedullary nailing. In selected cases of axial or rotational deformities or length discrepancy of the femur and the tibia, a correction osteotomy can be performed with intramedullary nailing. If it is necessary to expose the non-union and in axial or rotational deformities a rotation-stabilizing plate can be applied in addition to the intramedullary nail.

Narcolepsy in a 2-year-old boy

This report describes the prospective follow-up of a 2-year-old child with narcolepsy. The initial clinical diagnosis was confirmed by the onset of cataplexy when the child was 5 years old. He does not have the HLA genotype characteristic of narcolepsy or an identifiable brain lesion, although he has megalencephaly and mild learning difficulties. Treatment with dietary tyrosine supplements who are to young to use stimulants safely. The morbidity of narcolepsy is high and early diagnosis is therefore important, as treatment is effective.

[Value of microvascular, free flap transplantation in treatment of open tibial fracture]

Between 1986 and 1994, 71 cases of open fractures of the lower leg were treated by transplantation of a free, microvascular flap. Of these, 68 flaps were successful and the complication rate was low. Because of better vascularity subsequent bone reconstruction was shown to be more effective.

[Revision operations after failed arthrodeses of the upper ankle joint]

Although non-union of ankle arthrodesis is reported to be a common problem there is sparse literature regarding technique and results of revision arthrodesis in this difficult situation. We performed revision arthrodesis in 22 cases, either by means of a resection-compression revision arthrodesis or a tibiotalar sliding graft. According to our experience a subtle operation technique with cancellous bone grafting and particular attention to soft tissue can achieve bone healing with good functional results in about 90% of cases.

DNA binding properties of the Saccharomyces cerevisiae DAT1 gene product

The DAT1 gene of Saccharomyces cerevisiae encodes a DNA binding protein (Dat1p) that specifically recognizes the minor groove of non-alternating oligo(A).oligo(T) tracts. Sequence-specific recognition requires arginine residues found within three perfectly repeated pentads (G-R-K-P-G) of the Dat1p DNA binding domain [Reardon, B. J., Winters, R. S., Gordon, D., and Winter, E. (1993) Proc. Natl. Acad. Sci. USA 90, 11327-1131]. This report describes a rapid and simple method for purifying the Dat1p DNA binding domain and the biochemical characterization of its interaction with oligo(A).oligo(T) tracts. Oligonucleotide binding experiments and the characterization of yeast genomic Dat1p binding sites show that Dat1p specifically binds to any 11 base sequence in which 10 bases conform to an oligo(A).oligo(T) tract. Binding studies of different sized Dat1p derivatives show that the Dat1p DNA binding domain can function as a monomer. Competition DNA binding assays using poly(I).poly(C), demonstrate that the minor groove oligo(A).oligo(T) constituents are not sufficient for high specificity DNA binding. These data constrain the possible models for Dat1p/oligo(A).oligo(T) complexes, suggest that the DNA binding domain is in an extended structure when complexed to its cognate DNA, and show that Dat1p binding sites are more prevalent than previously thought.

Cured of acute lymphoblastic leukaemia but lost for words

A thirteen-year-old boy with nominal aphasia caused by simple partial status epilepticus is described. The aphasia disappeared with intravenous diazepam and has improved on oral carbamazepine. His epilepsy is probably secondary to the cranial irradiation and intrathecal methotrexate that he received as treatment for his Acute Lymphoblastic Leukaemia at the age of nine.

[Surgical therapy of Achilles tendon rupture]

From 1980 to 1991, 314 patients with acute rupture of the Achilles tendon were treated operatively in the "Berufsgenossenschaftliche Unfallklinik Tübingen" with suture of the tendon combined with a triceps surae tendon tip-over graft and subsequent cast immobilization for 6 weeks. Analysis of these cases revealed a significant reduction of severe soft tissue complications (3.2%), which were all controllable and a very low rerupture rate (0.3%) compared with the results obtained in the relevant literature. In 223 of these patients postoperative assessment according to the scale of Holz was carried out an average of 8.1 years after injury. The results were assessed as good in 87.4%, satisfactory in 11.2% and poor in 1.4%. Compared with conservative treatment with immobilization these results are significantly better than reported in the literature. The number of patients with Achilles tendon rupture who have received conservative functional treatment with a newly developed boot is still so small that reliable statistical statements are not yet possible. Therefore, operative therapy with an established procedure should still be regarded as the method of choice for treatment of Achilles tendon rupture; the tip-over graft is a valuable complement to the tendon suture.

Urticaria pigmentosa and acute lymphoblastic leukaemia

Childhood urticaria pigmentosa is generally considered to have a good prognosis with the majority of cases undergoing spontaneous resolution. However, there have been a number of reports of haematological malignancies occurring in association with urticaria pigmentosa. We describe a child with extensive urticaria pigmentosa and a congenital cardiac anomaly who developed acute lymphoblastic leukaemia and suggest a possible common aetiology.

[Indications, technique and results of muscle flaps in decubitus ulcers of the pelvic region in paraplegic patients]

Over a period of 10 years 57 pelvic pressure sores of 47 para- and tetraplegic patients were covered operatively with a muscle flap at the Co-Operative Trade Association Hospital for Accidents, at Tübingen, Germany. 39 patients with 49 muscle flap-covered decubiti were seen in a follow-up examination. Despite many postoperative complications--not uncommon for septic patients--there was a high rate of complete healing (94%) of the pressure sores within a short period of rehabilitation. Indeed one cannot prove the superiority of the muscle flaps over cutaneous and fasciocutaneous flaps because of the missing statistical comparability and correlation capability of the results with other studies. In our opinion muscle flaps in the pelvic area seem to be advantageous to cutaneous and fasciocutaneous flaps.

SMK1, a developmentally regulated MAP kinase, is required for spore wall assembly in Saccharomyces cerevisiae

Mitogen-activated protein (MAP) kinases comprise a family of conserved, eukaryotic enzymes that mediate responses to a wide variety of extracellular stimuli. In yeast, different signal transduction pathways utilize distinct MAP kinase family members. We have identified a new yeast MAP kinase gene (named SMK1) that is required for the completion of sporulation. Molecular and cytologic markers indicate that meiotic development proceeds normally in homozygous smk1-delta 1 diploids through meiosis II. However, light and electron microscopy show that smk1 asci are defective in organizing spore wall assembly. Consistent with a defect in spore wall assembly, smk1-delta 1 mutant asci display enhanced sensitivities to enzymatic digestion, heat shock, and exposure to ether. SMK1 mRNA, which is not detectable in vegetative cells, is derepressed at least 200-fold just prior to prospore enclosure. We propose that the SMK1 MAP kinase participates in a developmentally regulated signal transduction pathway that coordinates cytodifferentiation events with the transcriptional program.

Familial hemophagocytic lymphohistiocytosis associated with disseminated T-cell lymphoma: a report of two siblings

Two siblings with evidence of disseminated T-cell lymphoma at the time of diagnosis of familial hemophagocytic lymphohistiocytosis (FHL) are reported, an association which has not been described previously. The first child with typical clinical and laboratory features of FHL died shortly after admission, before diagnosis could be established. Retrospective analysis of autoptic tissue revealed marked hemophagocytosis as well as morphological and immunohistochemical features suggestive of disseminated T-cell lymphoma. In the second child, FHL was diagnosed in time. Subsequent histologic investigation of bone marrow biopsies displayed a focal infiltration by T-cell lymphoma. DNA hybridization studies provided evidence of a monoclonal T-cell receptor beta chain gene rearrangement. Following conventional chemotherapeutic induction for FHL, the patient received an allogeneic bone marrow transplant (BMT) from a related healthy donor. Currently, 17 months after BMT, the boy is in unmaintained remission from FHL and T-cell lymphoma. The current pathogenetic concepts for FHL and a possible relationship between T-cell lymphoma and FHL are discussed.

DNA of Mycobacterium tuberculosis in formalin-fixed, paraffin-embedded tissue in tuberculosis and sarcoidosis detected by polymerase chain reaction

Infection with Mycobacterium tuberculosis is a major cause of death worldwide. Identification of mycobacteria in tissue sections is usually easily achieved by acid-fast stains, but this method sometimes gives unsatisfactory results. The authors therefore compared conventional staining techniques and polymerase chain reaction (PCR) for mycobacterial DNA sequences in 24 selected tissue samples from patients with tuberculosis. In all samples, either positive or negative with acid-fast stain, mycobacterial DNA fragments were detected. In addition, tissue samples from patients with clinically proven sarcoidosis were included as controls. Surprisingly, strong signals for mycobacterial DNA were found in 2 of 15 cases. Polymerase chain reaction is a useful technique in the demonstration of mycobacterial DNA fragments in patients with clinically suspected tuberculosis who have acid fast stain-negative histology. An epithelioid granulomatous reaction in the lung, negative by acid-fast stain and positive for mycobacterial DNA by PCR, however, does not permit a diagnosis of tuberculosis, because a positive result can also be obtained in cases of sarcoidosis. In some cases of sarcoidosis, the causal agent might be either cell wall defective mycobacteria or persistent intracellular DNA from mycobacteria.