[The Sister Joseph's nodule-like manifestation of carcinoma of unknown origin: presentation of one case]

The Sister Joseph's nodule represents an umbilical cutaneous metastasis. It is related to one intraabdominal neoplasia habitually. We presents a 71-year-old male, with the Sister Joseph's nodule, detected in the context of unknown origin carcinoma. The fine needle aspiration cytology (FNAC) of the Sister Joseph's nodule showed carcinoma. We comments the usefulness diagnosis of this clinical sign and the poor prognosis that it represents.

Characterization of a reuterin-producing Lactobacillus coryniformis strain isolated from a goat's milk cheese

Lactobacillus coryniformis CECT 5711, a strain isolated from a goat's milk cheese, displayed a broad-spectrum antimicrobial activity; as a consequence, its ability to produce the antagonistic compounds associated to lactic acid bacteria, including bacteriocins, hydrogen peroxide, lactic acid, acetic acid, and reuterin (3-hydroxypropionaldehyde, 3-HPA) was investigated. Production of bacteriocins or hydrogen peroxide by this strain could not be detected. However, in addition to lactic acid and acetic acid, it produced reuterin and cobalamin, a cofactor required for conversion of glycerol to 3-HPA through a glycerol dehydratase. The gene encoding a glycerol dehydratase subunit was detected by PCR and the corresponding amplicon was sequenced. This strain showed a high survival after exposition to conditions simulating those existing in the gastrointestinal tract as well as a notable ability to adhere to intestinal cells, which suggests that its reuterin-producing ability may be used for the host benefit. In addition, the strain showed a strong beta-galactosidase activity. Production of biogenic amines and degradation of mucin could not be detected.

Molecular epidemiology of tuberculosis in the Bata and Malabo districts of Equatorial Guinea

SETTING

Bata and Malabo districts, Equatorial Guinea, 1 March 1999 to 28 February 2001.

OBJECTIVE

To study the molecular epidemiology of tuberculosis (TB).

RESULTS

During the study period, 429 patients were diagnosed with TB in the Bata and Malabo districts. A positive culture was obtained in 206 (48%) TB patients, with RFLP analysis being performed in 185 (89.8%). Ninety-two different patterns were identified. Single patterns were found in 71 strains (38.3%) and the remaining 114 strains (61.6%) were classified into 21 clusters (of 2 to 25 patients). In addition, 37 of the typing strains were resistant to one or more anti-tuberculosis drugs, and 30 were included in clusters (81%), with 21 low level isoniazid (MIC < or = 1 microg/ml) resistance strains in the same cluster. Statistical analysis showed that resistance to anti-tuberculosis drugs (OR 3.1; 95% CI 1.2-7.6; P = 0.014), and positive smear results (4+ grade smear) (OR 4.3; 95% CI 1.5-12; P = 0.005), were significantly more frequent among patients with clustered strains. No epidemiological links were related to clustering.

CONCLUSIONS

The level of clustering (61.6%) observed suggests a high degree of recent transmission and a predominance of determined patterns of Mycobacterium tuberculosis strains among the population of Equatorial Guinea.

African swine fever virus structural protein p54 is essential for the recruitment of envelope precursors to assembly sites

The assembly of African swine fever virus (ASFV) at the cytoplasmic virus factories commences with the formation of precursor membranous structures, which are thought to be collapsed cisternal domains recruited from the surrounding endoplasmic reticulum (ER). This report analyzes the role in virus morphogenesis of the structural protein p54, a 25-kDa polypeptide encoded by the E183L gene that contains a putative transmembrane domain and localizes at the ER-derived envelope precursors. We show that protein p54 behaves in vitro and in infected cells as a type I membrane-anchored protein that forms disulfide-linked homodimers through its unique luminal cysteine. Moreover, p54 is targeted to the ER membranes when it is transiently expressed in transfected cells. Using a lethal conditional recombinant, vE183Li, we also demonstrate that the repression of p54 synthesis arrests virus morphogenesis at a very early stage, even prior to the formation of the precursor membranes. Under restrictive conditions, the virus factories appeared as discrete electron-lucent areas essentially free of viral structures. In contrast, outside the assembly sites, large amounts of aberrant zipper-like structures formed by the unprocessed core polyproteins pp220 and pp62 were produced in close association to ER cisternae. Altogether, these results indicate that the transmembrane structural protein p54 is critical for the recruitment and transformation of the ER membranes into the precursors of the viral envelope.

Risk factors for malignancy in multinodular goitres

BACKGROUND

Multinodular goitre (MNG) is quite often associated with thyroid carcinoma, but the risk factors for malignancy are not well known. The aim is to analyse patients with thyroid carcinoma associated with MNG to determine the clinical risk factors for malignancy.

METHOD

From a series of 672 MNGs we analysed a subgroup of 59 patients presenting with an associated thyroid carcinoma. The variables analysed were age, sex, family history, cervical radiation therapy, residence in areas of endemic goitre, prior thyroid surgery, time of evolution, asymptomatic status, hyperthyroidism, compressive syndromes, intrathoracic prolongation, goitre consistency and cervical adenopathies. These were compared to MNGs not developing malignancy using the Chi-squared test, Student's t test and a logistic regression test.

RESULTS

Of the 59 cases, 37 corresponded to a microcarcinoma (< or =1 cm). The most common histological type was papillary (n=48), followed by follicular (n=6). In 20 cases the carcinoma was multifocal, and capsular involvement was noted in 16 patients, lymph node involvement in five and vascular involvement in another five. The multivariate analysis confirmed the following as independent variables associated with the presence of carcinoma: family history of thyroid pathology (RR=1.6), history of cervical radiation therapy (RR=1.8), recurrent goitre (RR=2.1) and presence of adenopathies on physical exploration (RR=1.6).

CONCLUSION

The risk factors for carcinoma associated with MNG are family history of thyroid pathology, personal history of cervical radiation therapy, prior surgery and presence of cervical adenopathies.

Differentiation of Enterococcus faecium from Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus thermophilus strains by PCR and dot-blot hybridisation

Variations in length and sequence of the 16S/23S spacer region of Enterococcus faecium provided the basis for development of simple PCR and dot-blot hybridisation assays that enabled the differentiation of potentially probiotic Enterococcus faecium strains from Lactobacillus delbrueckii subsp. bulgaricus and Streptococcus thermophilus. Such assays may be useful for differentiation of yoghurt starter cultures and enterococcal strains when they are simultaneously present in probiotic food products.

Study of resistance to anti-tuberculosis drugs in five districts of Equatorial Guinea: rates, risk factors, genotyping of gene mutations and molecular epidemiology

SETTING

Five districts in Equatorial Guinea, March 1999 to February 2001.

OBJECTIVES

To determine tuberculosis drug resistance among new and previously treated cases, the risk factors associated with resistance, and the mutations associated with isoniazid and rifampicin (katG, inhA and rpoB genes) resistance, and to genotype resistant strains.

RESULTS

A positive culture identified as Mycobacterium tuberculosis complex was obtained in 240/499 patients. Susceptibility testing was performed in 236 strains. The overall resistance rate in new cases was 16.9% compared to 41.6% in previously treated cases. Isoniazid resistance was the most frequent (respectively 12.5% and 16.6%) in the two groups, while multidrug resistance was observed in 1.7% and 25% of new and previously treated cases, respectively. Female sex was statistically associated with resistance in new cases. Of 41 isoniazid-resistant strains, 33 (80.5%) had mutations in the inhA gene; none had mutations in the katG gene and eight had no mutations in either gene. All strains had low-level isoniazid resistance. Of eight strains resistant to rifampicin, six had mutations in the rpoB gene. Genotyping defined seven clusters.

CONCLUSIONS

Moderate resistance was found in new cases. Low-level isoniazid resistance predominated among mutations in the inhA gene, with a high percentage of clustering in resistant strains.

Hemopoietic stem cell transplantation in refractory rheumatoid arthritis is not a contraindication for reconstructive surgery

Hemopoietic stem cell transplantation (HCST) is an experimental therapy that may produce prolonged remissions in patients with rheumatoid arthritis (RA) resistant to other treatments. Prosthetic articular replacement is often required in severe long-lasting disease. There is a well-founded concern regarding the feasibility and safety of reconstructive surgery after HSCT and as yet no published data on the subject. We report a patient with RA of 9 years' duration resistant to conventional treatments plus femoral head necrosis, who underwent prosthetic hip replacement with no post-surgical complications one year after HSCT, with a sustained response.

Fulminant hepatic failure and liver transplantation: experience of Virgen de la Arrixaca Hospital

INTRODUCTION

For patients with fulminant hepatic failure who show a poor evolution despite medical treatment, liver transplantation is an option, with survival rates of greater than 50%. The ideal time to perform the transplant is controversial, as it must not be done too soon (when the liver disease is still reversible) or too late (when the patient is in an irreversible clinical situation).

PATIENTS AND METHODS

Retrospective review of the clinical histories of 34 patients admitted to our hospital with a diagnosis of fulminant hepatic failure included 26 who underwent transplantation. The most frequent cause was viral (n=10, 38%); with no etiology established in 11 cases (42%). Thirteen patients had preoperative complications, the most frequent being renal insufficiency. As for degree of AB0/DR compatibility, 13 cases were identical (40%), 17 compatible (51%), and the other three incompatible (9%).

RESULTS

Thirty-three transplants were performed in 26 patients: four were retransplants due to chronic rejection, two for primary graft failure, and one for hyperacute rejection. The overall mortality rate was 46% (12 patients). The most frequent cause of death was infection (50%). The overall actuarial survival rate was 68% at 1 year, 63% at 3 years, and 59% at 5 years. The factors associated with a poor prognosis were renal and respiratory insufficiency, a grade D electroencephalogram, and encephalopathy grades III and IV, the last being the only prognostic factor identified in the multivariate analysis. The prognostic factors for mortality were a grade D electroencephalogram, encephalopathy grades III and IV and respiratory insufficiency, the last being the only prognostic factor identified in the multivariate analysis.

CONCLUSION

Good results of transplantation for the management of fulminant hepatic failure depends on optimal selection of transplant candidates, which means identifying them early, reducing the waiting time, and excluding factors associated with a poor prognosis.

Role of liver transplantation in the management of metastatic neuroendocrine tumors

INTRODUCTION

In the majority of patients transplanted for unresectable liver metastases, long-term results are disappointing because of early tumor recurrence. Due to its biologically less aggressive nature, neuroendocrine metastases (NM) may represent a good indication for liver transplantation (LT).

PATIENTS AND METHODS

Between January 1996 and May 2000, five patients with NM were transplanted. The primary tumors were located in the pancreas (n=4) and the small bowel (n=1). In three cases there were symptoms related to hormone production: two carcinoids, and one gastrinoma. The management of primary tumors was sequential in three patients with the tumor being resected before LT (one Whipple procedure and two left pancreatectomies). In two patients the resections of the primary tumors and the LT were simultaneous namely one bowel resection and one left pancreatectomy. All patients were treated with chemotherapy.

RESULTS

Two patients developed recurrent disease succumbing at 15 months (nonfunctioning NE pancreatic head tumor) and 17 months (carcinoid of the pancreatic tail) post-LT. Another patient died at 3 months post-LT due to technical complications. The other two patients are alive and free of recurrence.

CONCLUSION

Despite the promising results obtained with LT for NM, our experience indicates that patients must be carefully selected. Perhaps the use of more aggressive chemotherapeutic protocols combined with an individualized approach will improve the results.

[Usefulness of transesophageal echocardiography in monitoring pulmonary artery catheter progression in a case of tricuspid annuloplasty]

A 47-year-old man with mitral and aortic valve prostheses and a tricuspid valve annuloplasty required emergency substitution of both valves because of infectious endocarditis on the aortic valve prosthesis. The tricuspid ring initially impeded insertion of the pulmonary artery catheter toward the right ventricle. With the aid of transesophageal echocardiographic visualization, the catheter could be maneuvered to reach the pulmonary artery without damage to valvular or prosthetic structures. Transesophageal echocardiography, a monitoring technique with specific indications, is becoming increasingly useful as an aid in procedures related to cardiac surgery.

[Migraine and MIDAS (MIDASELA) in Colombian hospital workers]

AIMS

The aim of this study was to determine the prevalence of migraine and its implications in the occupational and outside employment/daily activities of the workers at a regional hospital in the Cundiboyacense Plateau in Colombia.

PATIENTS AND METHODS

The available members of the house staff at this institution were interviewed by applying the neuroepidemiological protocol drawn up by the World Health Organization (WHO); general doctors performed the initial screening and the determination of neurological disease was carried out by a clinical neurologist, both in patients who were positive and negative for neurological disease. Quality of life was evaluated by means of the MIDAS (Migraine Disability Assessment) survey, MIDASELA (in Spanish for Latin America); the analysis was performed using the EPI 6.04 software application.

RESULTS

A total of 238 people were studied: 188 females and 50 males; the prevalence of migraine was 22.5% (15.5% by the WHO protocol and 7% false negatives), with predominance in females (OR: 5.49; p< 0.005). In the MIDASELA questionnaire, 47.2% of the patients had a 50% alteration in their productivity, with regard to their occupational and outside employment/daily activities. A minimum number of patients (3.8%) were unable to work because of migraine, as compared to the figures for outside employment/daily activities (29.7%) or those involving leisure/family (66.4%). The average work, outside employment/daily and family time lost per patient because of migraine was 0.3, 2 and 5.2 days, respectively.

CONCLUSION

A sub register in the prevalence of migraine could be reported in places where the WHO protocol is used. This pathology will have to be taken well into account in Colombian hospital workers due to its individual, occupational, family, social and economic impact. It is necessary to introduce health policies and programmes aimed at evaluating, controlling and treating this type of pathology in an appropriate manner, in order to improve the quality of life of those whose job it is to look after and improve that of the other Colombians.

Heterologous production of bacteriocins by lactic acid bacteria

Over the last two decades, bacteriocins produced by lactic acid bacteria (LAB) have been the subject of considerable research and industrial interest due to their potential as food biopreservatives. The development of heterologous expression systems for such antimicrobial compounds may offer a number of advantages over native systems, such as facilitating the control of bacteriocin gene expression or achieving higher production levels. In addition, the heterologous production by food-grade LAB offers an attractive method for overcoming some of the adverse situations that may affect the effectiveness of some bacteriocins in food systems. Construction of multibacteriocinogenic strains or acquisition of antimicrobial properties by industrial strains are further objectives that can be achieved through the use of heterologous gene expression systems. The development of new biotechnological tools and recent advances in LAB genetics account for the escalating number of studies dealing with heterologous production of bacteriocins by such hosts. This paper reviews the literature published on the subject and compares the different experimental strategies that have been used up to the present for this purpose.

Repression of African swine fever virus polyprotein pp220-encoding gene leads to the assembly of icosahedral core-less particles

African swine fever virus (ASFV) polyprotein pp220, encoded by the CP2475L gene, is an N-myristoylated precursor polypeptide that, after proteolytic processing, gives rise to the major structural proteins p150, p37, p34, and p14. These proteins localize at the core shell, a matrix-like virus domain placed between the DNA-containing nucleoid and the inner envelope. In this study, we have examined the role of polyprotein pp220 in virus morphogenesis by means of an ASFV recombinant, v220i, containing an inducible copy of the CP2475L gene regulated by the Escherichia coli repressor-operator system. Under conditions that repress pp220 expression, the virus yield of v220i was about 2.6 log units lower than that of the parental virus or of the recombinant grown under permissive conditions. Electron microscopy revealed that pp220 repression leads to the assembly of icosahedral particles virtually devoid of the core structure. Analysis of recombinant v220i by immunoelectron microscopy, immunoblotting, and DNA hybridization showed that mutant particles essentially lack, besides the pp220-derived products, a number of major core proteins as well as the viral DNA. On the other hand, transient expression of the CP2475L gene in COS cells showed that polyprotein pp220 assembles into electron-dense membrane-bound coats, whereas a mutant nonmyristoylated version of pp220 does not associate with cellular membranes but forms large cytoplasmic aggregates. Together, these findings indicate that polyprotein pp220 is essential for the core assembly and suggest that its myristoyl moiety may function as a membrane-anchoring signal to bind the developing core shell to the inner viral envelope.

Prognostic factors in thymic epithelial neoplasms

OBJECTIVES

The primary thymic epithelial neoplasms (PTENs) are uncommon tumours with a broad spectrum of both biological and morphological features. The aim of this study is to analyse the prognostic factors that influence survival.

METHODS

Forty-four patients with a complete follow-up were analysed. Nine patients (20.5%) were asymptomatic, the most common symptoms in the rest being myasthenia gravis and dyspnoea. All the patients underwent surgery, 30 cases (68.2%) receiving total thymectomy and the rest a partial resection or biopsy. Marino-Müller's histological classification showed the mixed type to be the most common (52.3%). Clinical staging was done according to the Masaoka classification, which gave the most common stage as stage III (34.1%).

RESULTS

Twelve patients died during a mean follow-up of 8.2 +/- 3.5 years. The accumulated survival rate was 77% at 5 years and 60% at 10 years. Analysis of the survival curves shows significant differences (P<0.05) when considering surgical technique, clinical staging and histological subtype. The multivariate analysis shows the only parameters with prognostic significance in PTENs to be clinical staging and histological type (P<0.001).

CONCLUSIONS

The most important prognostic factors in PTENs are Masaoka's clinical staging and Marino-Müller's histological subtype.

Long-term outcome and predictor variables in the treatment of acquired esotropia with botulinum toxin

PURPOSE

To determine the long-term results of botulinum therapy in acquired esotropia and to identify predictors of a satisfactory outcome.

METHODS

Sixty-eight children (age range, 8-64 months) with acquired esotropia were enrolled in a prospective study. Botulinum toxin A was injected in the two medial recti. Motor and sensory statuses were evaluated at 1 and 2 weeks; 3, 6, and 12 months; and every year after the last injection. Univariate and multivariate logistic regression analyses were performed to relate motor and sensory outcome to variables recorded as potential predictors.

RESULTS

After an average follow-up of 4.8 years since the last injection, motor success was obtained in 36 children with one injection (52.9%), increasing to 48 (70.6%) and 60 (88.2%) children after two and three injections, respectively. Forty-eight (70.6%) patients had at least peripheral fusion (category 1 binocularity) and 32 (47.1%) had stereoacuity of at least 400 seconds of arc (category 2 binocularity). Higher hypermetropia, less severe amblyopia, and a smaller angle of esotropia were the best predictors of motor success. Minimal amblyopia and favorable motor alignment were associated with better binocularity outcome.

CONCLUSIONS

Botulinum is an effective long-term treatment of acquired esotropia. It is especially useful in children with high hypermetropia, minimal amblyopia, and small esotropic deviation.

Antibiotic prophylaxis in incisional hernia repair using a prosthesis

Antibiotic prophylaxis in clean surgery with implantation of prosthetic material is widely accepted, although there are no studies on its use in abdominal incisional hernia repair. The objective was to evaluate antibiotic chemoprophylaxis in incisional herniorrhaphy with the implantation of prosthetic material. A prospective non-randomized study (1990-1998) was conducted to analyse 216 patients undergoing surgery for abdominal incisional hernia who required a prosthesis (polypropylene) in the reconstruction and who met the criteria for clean surgery. Risk factors were observed in 31.5%, the most frequent being diabetes and obesity. The incisional hernia was located mostly in the abdominal midline and in 64.4% measured over 10 cm. Antibiotic prophylaxis was administered in 140 patients (64.8%) via the systemic route, the antibiotics being first- or second-generation cephalosporins or amoxicillin-clavulanic acid. Surgical wound infection occurred in 39 patients (18.1%), 19 who had received antibiotic prophylaxis (13.6%) and 20 who had not (26.3%). In multivariate analysis using logistic regression, the variables with statistical significance for local septic infection were antibiotic prophylaxis and number of risk factors. We can conclude therefore that antibiotic chemoprophylaxis is useful in abdominal incisional herniorrhaphy surgery with implantation of prosthetic material for reducing local septic complications.