[Acute neonatal osteomyelitis, an incidental life-changing diagnosis]

Acute neonatal osteomyelitis is a challenging disease and its diagnostic is important to avoid comorbidities. Staphylococcus aureus is the most often involved germ. The diagnostic challenge lies in its pauci-symptomatology in the premature infant in contrast to a more obvious clinical presentation in the term infant or child. The risk factors inherent to prematurity are invasive monitoring, repeated blood sampling, prolonged central catheterization, immature immune response and length of hospital stay. We report the case of an osteomyelitis secondary to staphylococcal sepsis in a preterm infant born at 25 weeks and 3 days of gestational age. The diagnosis was made incidentally on an abdominal x-ray. The low parental compliance for the child's follow-up does not allow us to affirm a future without sequelae even if the elements at our disposal at 8 months suggest a favorable outcome. Acute neonatal osteomyelitis remains a difficult but crucial diagnosis for the future development of the child.

Massive blood loss protocol 'Code Red' at Papworth Hospital: A closed loop audit

Aim

To investigate if the massive blood loss protocol ‘Code Red’ at a specialist cardiothoracic hospital was activated according to local and national guidelines by a closed loop audit.

Methods

Electronic and paper patient care systems were searched in 2015 and 2018 to access records for the ‘Code Red’ activations. Activation of the massive blood loss protocol was compared against the national standards set by The British Committee for Standards in Haematology. The percentage of cases meeting each of the ten standards in the specialist cardiac unit’s Protocol for the Management of Massive Blood Loss in Adults (adapted from the national standards) were evaluated.

Results

‘Code Red’ protocol was activated on 18 occasions in 2015 and nine occasions in 2018, representing just 0.83 and 0.26% of emergency surgeries, respectively. Between 2015 and 2018, there was a 6% increase of ‘Code Red’ cases being appropriately activated, a 26% increase in the prompt notification of the haematology department upon activation, alongside a 30% increase in the timely delivery of blood products, and a 25% decrease in the average amount of blood transferred prior to ‘Code Red’ activation.

Conclusion

There has been an improvement in the standards of care and management of massive blood loss this specialist cardiac centre despite the target timeframe being reduced from 30 to 15min between 2015 and 2018. Preparation for and anticipation of massive blood loss has likely decreased the number of incidences requiring ‘Code Red’ activation, permitting delivery of safe patient care.

Differences in right ventricular-pulmonary vascular coupling and clinical indices between repaired standard tetralogy of Fallot and repaired tetralogy of Fallot with pulmonary atresia

PURPOSE

The purpose of this study was to compare ventricular vascular coupling ratio (VVCR) between patients with repaired standard tetralogy of Fallot (TOF) and those with repaired TOF-pulmonary atresia (TOF-PA) using cardiovascular magnetic resonance (CMR).

MATERIALS AND METHODS

Patients with repaired TOF aged>6 years were prospectively enrolled for same day CMR, echocardiography, and exercise stress test following a standardized protocol. Sanz's method was used to calculate VVCR as right ventricle (RV) end-systolic volume/pulmonary artery stroke volume. Regression analysis was used to examine associations with exercise test parameters, New York Heart Association (NYHA) class, RV size and biventricular systolic function.

RESULTS

A total of 248 subjects were included; of these 222 had repaired TOF (group I, 129 males; mean age, 15.9±4.7 [SD] years [range: 8-29 years]) and 26 had repaired TOF-PA (group II, 14 males; mean age, 17.0±6.3 [SD] years [range: 8-29 years]). Mean VVCR for all subjects was 1.54±0.64 [SD] (range: 0.43-3.80). Mean VVCR was significantly greater in the TOF-PA group (1.81±0.75 [SD]; range: 0.78-3.20) than in the standard TOF group (1.51±0.72 [SD]; range: 0.43-3.80) (P=0.03). VVCR was greater in the 68 NYHA class II subjects (1.79±0.66 [SD]; range: 0.75-3.26) compared to the 179 NYHA class I subjects (1.46±0.61 [SD]; range: 0.43-3.80) (P<0.001).

CONCLUSION

Non-invasive determination of VVCR using CMR is feasible in children and adolescents. VVCR showed association with NYHA class, and was worse in subjects with repaired TOF-PA compared to those with repaired standard TOF. VVCR shows promise as an indicator of pulmonary artery compliance and cardiovascular performance in this cohort.

[Non-specific interstitial pneumonia : a rare clinical entity in adolescents]

Non-specific Interstitial Pneumonia (NSIP) is an anatomo-clinical entity within the group of Diffuse Infiltrative Pulmonary Diseases (DPID). It is very rarely found in pediatrics. Main symptoms are dry cough and dyspnea. Bronchoalveolar lavage and biology are non specific. The thoracic CT scan suspects the diagnosis, but histological examination of a lung biopsy remains the reference examination and makes the diagnosis highly probable according to the ATS / ERS criteria. An autoimmune assessment should be performed because NSIPs are often associated with connective tissue disease or may even be the first sign of connectivitive tissues diseases. The treatment of the acute phase is mainly based on the administration of corticosteroids and the prognosis is generally good. In this article, we describe the management of NSIP, based on a pediatric clinical case.

Developmental Ethanol-Induced Sleep Fragmentation, Behavioral Hyperactivity, Cognitive Impairment and Parvalbumin Cell Loss are Prevented by Lithium Co-treatment

Developmental ethanol exposure is a well-known cause of lifelong cognitive deficits, behavioral hyperactivity, emotional dysregulation, and more. In healthy adults, sleep is thought to have a critical involvement in each of these processes. Our previous work has demonstrated that some aspects of cognitive impairment in adult mice exposed at postnatal day 7 (P7) to ethanol (EtOH) correlate with slow-wave sleep (SWS) fragmentation (Wilson et al., 2016). We and others have also previously demonstrated that co-treatment with LiCl on the day of EtOH exposure prevents many of the anatomical and physiological impairments observed in adults. Here we explored cognitive function, diurnal rhythms (activity, temperature), SWS, and parvalbumin (PV) and perineuronal net (PNN)-positive cell densities in adult mice that had received a single day of EtOH exposure on P7 and saline-treated littermate controls. Half of the animals also received a LiCl injection on P7. The results suggest that developmental EtOH resulted in adult behavioral hyperactivity, cognitive impairment, and reduced SWS compared to saline controls. Both of these effects were reduced by LiCl treatment on the day of EtOH exposure. Finally, developmental EtOH resulted in decreased PV/PNN-expressing cells in retrosplenial (RS) cortex and dorsal CA3 hippocampus at P90. As with sleep and behavioral activity, LiCl treatment reduced this decrease in PV expression. Together, these results further clarify the long-lasting effects of developmental EtOH on adult behavior, physiology, and anatomy. Furthermore, they demonstrate the neuroprotective effects of LiCl co-treatment on this wide range of developmental EtOH's long-lasting consequences.

[Hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations in children]

Hereditary hemorrhagic telangiectasia is a constitutional vascular dysplasia characterized by chronic epistaxis, mucocutaneous and visceral telangiectasias and arteriovenous malformations. Apart from family screenings, the disease is rarely diagnosed during the pediatric age given the late advent of typical clinical symptoms. Nevertheless, arteriovenous malformations are sometimes already present at a young age with significant morbidity risk. Therefore, it is important to establish an early diagnosis. We describe two pediatric cases of hereditary hemorrhagic telangiectasia and pulmonary arteriovenous malformations with divergent clinical presentation.

Local colorectal cancer recurrence: pelvic MRI evaluation

Surveillance of colorectal cancer is currently based on dosage of tumoral markers, colonoscopy and multidetector row computed tomography. However, pelvic magnetic resonance imaging (MRI) and PET-CT are two second-line useful imaging modalities to assess colorectal cancer local recurrence (LR). The anatomical information derived from MRI combined to the functional information provided by diffusion-weighted imaging currently remain of value. Pelvic MRI is accurate not only for detection of pelvic colorectal recurrence but also for the prediction of absence of tumoral invasion in pelvic structures, and it may thus provide a preoperative road map of the recurrence to allow for appropriate surgical planning. As always, correlation of imaging and clinical findings in the multidisciplinary forum is paramount. MRI can also be used to follow-up LR treated with radiofrequency ablation. The aim of this review is to discuss clinical practice and application of MRI in the assessment or pelvic recurrence from colorectal cancer.

[Clinical case of the month. Idiopathic mediastinal fibrosis]

Fibrosing mediastinitis is a rare condition characterized by an excessive growth of dense fibrous tissue within the mediastinum. The etiology of the disease is most often a fungal infection and may in some cases be idiopathic. We present the case of a patient with chronic obstructive pulmonary disease (COPD) suffering from fibrosing mediastinitis of undetermined origin and in whom the diagnosis was established by histopathological analysis after mediastinoscopy.

MR enterography in children with Crohn disease: results from the Belgian pediatric Crohn registry (Belcro)

INTRODUCTION

Magnetic Resonance enterography (MRE) is an imaging modality avoiding ionizing radiation and the discomfort associated with enteroclysis. The results of MRE at diagnosis in the patients of the Belgian pediatric Crohn registry (Belcro) are compared to endoscopical and histological results.

METHODS

Results of MRE, endoscopy and histology were obtained from the medical charts and assigned to one of the following segments: jejunum, ileum, ascending colon, transverse colon, descending colon or rectosigmoid. MRE images were reviewed in a blinded way by 4 radiologists with specific interest in pediatric MRE.

RESULTS

From the Belcro registry, twenty-two patients underwent a MRE during their work-up for Crohn disease. The results of endoscopy, histology and MRE were concordant (either all negative or positive) in the ileum in 16/18 patients and in the rectosigmoid, descending colon, transverse colon and ascending colon in resp 9, 8, 8 and 8/22 patients. In the non-concordant cases (MRE colon negative but endoscopy and/or histology positive), MRE could not reflect the subtle endoscopic or histologic lesions such as erosions that were described.In 4 cases where ileocaecal valve intubation was impossible ileal MRE findings were abnormal. MRE detected ileal stenosis, jejunal lesions and fistula in resp 4/22, 3/22 en 2/22 patients. The 100% and 75% interobserver agreement was resp 50-82% and 773-100% according to the different intestinal segments.

CONCLUSIONS

MRE is a promising imaging modality avoiding radiation in Crohn disease. It should probably become the technique of first choice for the evaluation of extensive small bowel disease in children with Crohn disease.

Investigation of a spatiotemporal cluster of verotoxin-producing Escherichia coli O157 infections in eastern England in 2007

An outbreak of verotoxin-producing Escherichia coli O157 (VTEC O157) infections linked to an open farm occurred in eastern England in April and May 2007. This paper describes the investigation and highlights the importance of multidisciplinary collaboration for successful control of such outbreaks. There was a temporal cluster of 12 confirmed symptomatic cases of VTEC O157 and one asymptomatic carrier, from five families. The investigation revealed that four of these cases formed part of an outbreak involving two families who visited an open farm. The phenotypic and genotypic characteristics of the isolates from the two families and the putative farm animal contacts were indistinguishable, indicating that the animals were the source of the primary infections. No epidemiological link could be established between the remaining three families affected and the open farm or people having visited the farm. Control measures included improved hand washing facilities on the farm, information for visitors and staff, restricted access and suspended petting and feeding of animals, and thorough cleaning and disinfection of affected areas.

Investigation of a spatiotemporal cluster of verotoxin-producing Escherichia coli O157 infections in eastern England in 2007

An outbreak of verotoxin-producing Escherichia coli O157 (VTEC O157) infections linked to an open farm occurred in eastern England in April and May 2007. This paper describes the investigation and highlights the importance of multidisciplinary collaboration for successful control of such outbreaks. There was a temporal cluster of 12 confirmed symptomatic cases of VTEC O157 and one asymptomatic carrier, from five families. The investigation revealed that four of these cases formed part of an outbreak involving two families who visited an open farm. The phenotypic and genotypic characteristics of the isolates from the two families and the putative farm animal contacts were indistinguishable, indicating that the animals were the source of the primary infections. No epidemiological link could be established between the remaining three families affected and the open farm or people having visited the farm. Control measures included improved hand washing facilities on the farm, information for visitors and staff, restricted access and suspended petting and feeding of animals, and thorough cleaning and disinfection of affected areas.

[Diffusion-weighted MR imaging of liver pathology: principles and clinical applications]

Due to ongoing technological advances, the range of clinical applications for diffusion-weighted MR imaging has expanded to now include abdominal pathology. Current applications for liver pathology include two main directions. First, oncologic imaging with detection, characterization and follow-up of lesions. Second, evaluation of diffuse liver diseases, including hepatic fibrosis. The diagnostic impact and role of diffusion-weighted MR imaging remain under investigation, but appear promising. Because of its short acquisition time, sensitivity, and additional information it provides, diffusion-weighted MR imaging should be included in routine liver imaging protocols.

[Unilateral pulmonary agenesis, aplasia and dysplasia]

Unilateral pulmonary anomalies are rare events of unknown etiology and large clinical variability. Neonatal history does not allow for a reliable prognosis. Interdisciplinary mangament includes prenatal diagnostics and obstetrics, genetics, neonatology, pediatric cardiology and surgery as well as pediatric orthopedics. Neonatal history and long-term follow-up in three patients are presented here including a discussion of prenatal diagnostics and the embryo-genetic basics of lung development. In three term neonates the diagnoses of unilateral pulmonary agenesis, aplasia and dysplasia, respectively, were based on angiography, MRI and bronchoscopy. Neonatal presentation and long-term consequences were studied in the context of the current literature. Neonatal complications ranged from mild repiratory distress to pulmonary failure requiring mechanical ventilation. One patient developed scoliosis on long-term follow-up. Cardiac failure or pulmonary hypertension did not occur during follow-up, in one case lung malformation was accompanied by VACTER-association. Unilateral lung malformation is frequently associated with other, singular or complex anomalies (e.g., renal and vascular). A possible relationship to disrupted regulation of embryo-genetic factors such as T-BOX genes, PITX2 and growth factors ( FGF10), which regulate ASYMMETRICAL pulmonary morphogenesis is discussed. Disruptive unilateral pulmonary malformations may serve as a model for embryological lung development and other anomalies (e.g., congenital diaphragmatic hernia, unilateral hypoplasia and CCAM). Prenatal diagnosis is characterized by unilateral hyperechogenicity of the affected lung. Neonatal presentation is determined by mediastinal shift which may be corrected by tissue-expander implantation. Associated anomalies require cytogenetic analysis and sequencing of currently known mutations. Long-term follow-up by echocardiography and pulmonary function testing is mandatory in these patients.

Pulmonary embolism in a trauma patient with liver and orthopedic injuries

We report the case of a 41-year-old man admitted for lower limb and liver trauma following a car accident. Surgical repair of a tibial fracture was performed under general anesthesia 5 days after admission while the liver injury was managed conservatively. At the time of tourniquet inflation, the patient presented a pulmonary embolism. Low-molecular-weight heparin administration had been delayed for 72 hours after admission due to the liver injury. Risk factors for bleeding and thromboembolism in trauma patients with liver injury are discussed.

Radiofrequency ablation for recurrent pelvic cancer

OBJECTIVE

Local recurrence of pelvic cancer is a therapeutic challenge. The purpose of the study was to evaluate radiofrequency ablation (RFA, intra-operative or CT-guided) for the treatment of pelvic recurrence in patients not eligible for curative surgical resection.

METHOD

Charts of all patients treated for pelvic recurrence by RFA between March 2004 and March 2005 were reviewed.

RESULTS

Eight patients (two females) had RFA for inoperable local recurrence [rectal adenocarcinoma (six) and sarcoma (two)]. Surgical resection of the primary tumour had been performed at a median age of 50.2 (36.7-61.6) years. Recurrence occurred after a median of 49.5 (11.7-63.5) months. The mean size of the recurrence was 33.4 (20-45) mm. RFA was given on a median number of two occasions (1-3). Complications occurred in six patients including minor pain [pelvic (six); sciatic nerve irritation (four)]; ureteric obstruction requiring stenting (two) and colo-vesical fistula (one), requiring ileal urinary diversion. After a median follow-up of 18.2 months (11-32), six patients were still alive. Patients, who had experienced pain prior to RFA were pain-free. Five patients showed evidence of further tumour growth but were asymptomatic.

CONCLUSION

Radiofrequency ablation is a feasible therapeutic option for recurrent pelvic cancer. It allows good symptom control in patients with pain but morbidity is high.

[Pineapple juice as a negative oral contrast agent in magnetic resonance cholangiopancreatography]

PURPOSE

The quality of magnetic resonance cholangiopancreatography (MRCP) images is frequently degraded by high signal from the gastrointestinal tract on heavily T2W images. The purpose of this study is to evaluate pineapple juice (PJ) as an oral negative contrast agent in MRCP.

MATERIALS AND METHODS

Results from MRCP in 50 patients with PJ and 50 patients with paramagnetic contrast (ferumoxsil-Lumirem) were compared. Reviewers were blinded to the type of contrast agent. Exam quality was recorded with regards to signal suppression in the stomach, duodenum and proximal small bowel and with regards to pancreatic duct and biliary ducts visualization. In vitro, the signal characteristics of several commercially available brands of PJ were assessed using T1W, T2W and MRCP sequences. Signal intensity was correlated with the manganese concentration measured using atomic absorption spectrometry. Finally, the reviewers compared the taste of PJ and ferumoxsil.

RESULTS

On MRCP sequences, results were similar with regards to signal suppression in the stomach, duodenum and proximal small bowel with PJ and ferumoxsil. Visualization of the pancreatic duct, intrahgepatic bile ducts and CBD was similar with PJ and ferumoxsil. The signal intensity of commercially available brands of PJ on T2W and MRCP sequences correlated well with the measured manganese concentration on spectroscopy. Variations in manganese concentration were observed, with values ranging from 3.65 to 27.24 mg/L. The reviewers noted that PJ tasted "good" or "very good" and that ferumoxsil tasted "bad" or "very bad".

CONCLUSION

Ingestion of PJ provides effective signal suppression in the GI tract on MRCP, similar to paramagnetic contrast agents. Because manganese concentration is highly variable in commercially available PJ brands, a brand with high manganese concentration should be selected.

[Autoimmune pancreatitis mimicking an intra-ductal papillary mucinous neoplasm of the pancreas: an original case]

In recent years, autoimmune pancreatitis (AIP) has been increasingly recognized. It can be associated with diabetes mellitus and other systemic autoimmune diseases, or with bile ducts lesions, which are also responsive to steroid therapy as pancreatic lesions. We report the case of a 34-year-old man with a history of a first acute pancreatitis, attributed to an intraductal papillary-mucinous neoplasm of the pancreas (IPMN) with segmental involvement of the main pancreatic duct. A spleno-pancreatectomy was performed, and pathological examination of the specimen diagnosed autoimmune pancreatitis. A treatment with corticosteroids was carried out. To our knowledge, this is the first reported case of AIP mimicking IPMN of the main pancreatic duct.

Measurement of the Lambdab0 lifetime using semileptonic decays

We report a measurement of the Lambda(b)(0) lifetime using a sample corresponding to 1.3 fb(-1) of data collected by the D0 experiment in 2002-2006 during run II of the Fermilab Tevatron collider. The Lambda(b)(0) baryon is reconstructed via the decay Lambda(b)(0)-->micronuLambda(c)(+)X. Using 4437+/-329 signal candidates, we measure the Lambda(b)(0) lifetime to be tau(Lambda(b)(0))=1.290(-0.110)(+0.119)(stat)(-0.091)(+0.087)(syst) ps, which is among the most precise measurements in semileptonic Lambda(b)(0) decays. This result is in good agreement with the world average value.

Imagerie des pathologies thoraciques chez le patient VIH au stade sida

The imaging features of infectious and non-infectious pathologies in HIV patients with AIDS (less than 200 CD4/mm3) are illustrated. Opportunistic infections, tumors and vascular pathologies have variable appearances based on the degree of immunosuppression and patient compliance with opportunistic infection prophylaxis. Because of advances in retroviral treatments and wider use of anti-infectious prophylaxis, thoracic pathologies in AIDS patients are less frequent but must nonetheless be recognized, and diagnosis should be suggested in patients with unknown serologic status.

[External phased-array MR imaging preoperative assessment of rectal cancer]

The main problem associated with rectal cancer treatment is tumor recurrence. Randomized controlled studies have shown that adjuvant preoperative radiation therapy is effective for reducing local recurrence. These studies have also demonstrated that there are groups of rectal cancer patients with differing degrees of risk for local recurrence. At one end of the spectrum is the low-risk group: patients with superficial rectal cancer, who can be treated with surgery alone. At the other end is the high-risk group: patients with a close or involved resection margin at total mesorectal excision, the very advanced tumors that require a longer course of chemotherapy and radiation therapy, and extensive surgery. Paramount for this selection and differentiated treatment is a reliable preoperative test that can be used to distinguish these groups of patients. In this review article, we will discuss the role of high-resolution phased array MRI among the other imaging modalities such as endorectal MRI, endorectal US, and CT. We will also discuss and illustrate MR imaging results in terms of T stage, circumferential resection margin, locally advanced rectal cancer, and N stage.

[How I investigate... The coronary arteries in 2007: contributions of CT coronary angiography]

Cardiac imaging has always been a challenge because of the continuous movement of the heart. Cardiac computed tomography (CT) has undergone an accelerated progression over the past decade, due to the combination of the high-speed rotation of the X-ray tube, the ECG-gating technique and the infra-millimeter spatial resolution. Multidetector CT allows visualisation of the coronary artery lumen and the detection of coronary stenosis after intravenous injection of contrast medium. Studies have demonstrated a high negative predictive value of CT coronary angiography (CTCA). CTCA may be reasonably used for the assessment of symptomatic patients, especially in the setting of equivocal treadmill or functional testing. Also, CTCA allows assessment of coronary bypass graft patency and recognition of aberrant coronary arteries. Limitations in the use of this technique exist: atrial fibrillation and other cardiac arrhythmias remain a contraindication; severe calcifications are the most frequent reason for impaired assessment of coronary arteries. High radiation doses prohibit the use of this test as a screening tool for asymptomatic patients.

Ciliated hepatic foregut cyst with extensive squamous metaplasia: report of a case

Ciliated hepatic foregut cysts (CHFC) are rare cystic lesions of the liver composed of a ciliated pseudostratified columnar epithelium with mucous cells, connective tissue, and smooth muscles bundles. We report the first case of CHFC with extensive squamous metaplasia without dysplasia or carcinoma. A unilocular, avascular, hypoechoic 60-mm liver lesion located in segment IV was detected by ultrasonography in a 31-year-old woman. The cyst was surgically removed and was lined mainly by a regular squamous epithelium without keratin formation. After extensive sampling, a ciliated pseudostratified columnar epithelium with some alcian blue-positive goblet cells was identified. The lesion was totally examined and there was no epithelial dysplasia or carcinoma. Squamous epithelium is very rare in hepatic foregut cysts and may degenerate into squamous carcinoma. Squamous epithelium is also described in biliary cysts. When squamous epithelium is identified in a liver cyst, an extensive sampling is recommended to identify possible foci of squamous carcinoma and to classify more precisely the histological type of the lesion. Because some cases of squamous carcinoma have been described in CHFC, surgical removal of the lesion may be more appropriate than close follow-up or sclerosing therapy.

Kidney transplant function and histological clearance of virus following diagnosis of polyomavirus-associated nephropathy (PVAN)

Polyomavirus-associated nephropathy (PVAN) is managed by reduced immunosuppression with or without antiviral therapy. Data from 55 patients with biopsy-proven PVAN were analyzed for adverse outcomes and influence of baseline variables and interventions. During 20+/-11 months follow-up, the frequencies of graft loss, major and any functional decline were 15%, 24% and 38%, respectively. Repeat biopsies were performed in 45 patients with persistent PVAN in 47%. Low-dose cidofovir, IVIG and cyclosporine conversion were used in 55%, 20% and 55% of patients. No single intervention was associated with improved outcome. Of the variables examined, only degree of interstitial fibrosis at diagnosis was associated with kidney function decline. In contrast, donor source, interstitial fibrosis, proportion of BKV positive tubules and plasma viral load at diagnosis were all associated with failure of histological viral clearance. This retrospective, nonrandomized analysis suggests that: (i) Graft loss within 2 years of PVAN diagnosis is now uncommon, but ongoing functional decline and persistent infection occur frequently. (ii) Low-dose cidofovir, IVIG and conversion to cyclosporine do not abrogate adverse outcomes following diagnosis. (iii) Fibrosis at the time of diagnosis predicts subsequent functional decline. Further elucidation of the natural history of PVAN and its response to individual interventions will require prospective clinical trials.

Essential mixed cryoglobulinemia type II

We report a rare case of essential mixed cryoglobulinemia type II with membrano-proliferative glomerulonephritis (MPGN) type I in which HCV was not found. Long-term history of palindromic rheumatism, skin leukocytoclastic vasculitis attacks and micro-normocytic anemia preceded the appearance of cryoglobulinemia. Cryoprecipitate consisted of monoclonal IgMk-RF and polyclonal IgG (essential mixed type II). The newly appreciated cryoglobulinemia was associated with Coombs positive hemolytic anemia. The MPGN in this case had a benign course and responded to complex simple therapies including prevention of exposure to cold, low antigen content diet, treatment of provoking factors such as UTI, and maximal dose of ACE inhibitor. Responsiveness of skin vasculitis to colchicine therapy was restored after a two-month colchicine withdrawal period and therefore corticosteroid and immunosuppressive therapy was postponed.

Characterization of gastric mucosal membranes. IX. Fractionation and purification of K+-ATPase-containing vesicles by zonal centrifugation and free-flow electrophoresis technique

Methods are described for purification of a vesicular membrane fraction of hog gastric mucosa using differential centrifugation, density gradient separation on zonal rotors and free-flow electrophoresis. As a result a fraction is obtained enriched 40-fold in terms of K(+)-ATPase and free of any other enzyme marker other than K(+)-activated p-nitrophenyl phosphatase. The 5'-nucleotidase and basal Mg(2+)-ATPase are clearly separated from the latter enzymes. Osmotic shock, Triton X-100 treatment or K+ ionophores increased the K(+)-ATPase activity in isotonic conditions, but K(+)-p-nitrophenyl phosphatase is not affected by these treatments, nor is the ATPase activity in the presence of NH4+. The results suggest that the electrophoretic fraction contains a major population of tight vesicles, whose permeability to K+ is rate limiting for the ATPase activity but not for the p-nitrophenyl phosphatase activity. It is concluded that K+ site for the ATPase is internal whereas the K+ site for the p-nitrophenyl phosphatase is external, hence, the K+ site must be mobile across the membrane.