[Profile of HIV infected patients among blood donors in Abidjan, Côte d'Ivoire (1992-1999)]

The FonSIDA is a private clinic created in 1992 within the premises of the National Blood Transfusion Center of Abidjan (CNTS), the largest city in Côte d'Ivoire. It provides medical and psychological follow-up for blood donors which are diagnosed as HIV-infected. This Centre provides blood for transfusions in Abidjan and the surrounding area, which from 1992 to 1999 collected 263,398 blood units. In this period, 5574 subjects were detected HIV-positive. Among those, 1766 (32%) HIV infected blood donors came back to be tested for confirmation of HIV diagnosis. Since then, only 9% of the 5574 donors have been seen at least twice a year for medical and psychological follow-up. Women were more compliant than men in the FonSIDA Clinic: they constituted 62% of the 409 patients who were followed-up (p < 0.001). 53% of men had sex with prostitutes the year before HIV diagnosis. 67% of women stated voluntary abortion at least once. In the same period the systematic use of condoms was reported by only 7% of women and 5% of men. 22% of women and 28% of men reported having two or more sexual partners in the year before HIV diagnosis. The main aim of every blood center is to improve blood safety, particularly in developing countries. The appropriate counseling towards blood donors and especially those detected HIV positive can contribute to reduce new HIV infections in high HIV prevalence cities. Rate of compliance of HIV-infected patients to follow-up has risen to 11% in 1992-1994 to 60% in 1997-1999 and will contribute to reach this aim.

[Bacillary angiomatosis in an adult infected with HIV-1 at an early stage of immunodepression in Abidjan, Côte d'Ivoire]

Human immunodeficiency virus (HIV)-associated bacillary angiomatosis has rarely been described in Africa. We report here the first case in Côte d'Ivoire. Although in industrialised countries bacillary angiomatosis has been described in patients with low CD4 count, this episode occurred in the first year following HIV-seroconversion in an adult patient with more than 500 CD4 cells per cubic millimetre. Symptoms rapidly and totally disappeared under erythromycin treatment, although with a relapse two years after the end of the first episode. In Africa where people living with HIV often present chronic cutaneous lesions, bacillary angiomatosis may be under-diagnosed. Bacillary angiomatosis must be systematically considered in face of lesions similar to Kaposi's sarcoma. Improving knowledge on symptoms of bacillary angiomatosis in Africa should lead to better treatment and a better estimation of its true frequency which may be underestimated.

Primary culture of porcine mammary epithelial cells as a model system for evaluation of milk protein expression

Porcine mammary epithelial cells were isolated to culture on collagen gel followed by gel floating treatment to evaluate differentiation under the culture conditions of serum-free medium, supplemented with combinations of insulin, hydrocortisone, and prolactin. After the culture period, the mammary cells attached to the collagen gels were recovered to observe expression of beta-casein, beta-lactoglobulin, and lactoferrin by reverse transcriptase polymeric chain reaction method. Expression of beta-casein was observed in the presence of insulin, hydrocortisone, and prolactin whereas transcription of beta-lactoglobulin and lactoferrin occured irrespective of hydrocortisone and prolactin. Immunoblot analysis demonstrated synthesis and secretion of lactoferrin in the fraction of recovered cells and the culture medium.

Severe complications of ulcerative colitis after high-dose prednisolone and azathioprine treatment

We report a rare case of ulcerative colitis (UC) associated with methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa infections in multiple organs, and with compressive fracture from osteoporosis after the administration of high-dose prednisolone and azathioprine. A 25-year-old man had been treated with high-dose prednisolone for UC. He suddenly experienced severe lumbago, which prevented him from walking. Plain X-ray demonstrated compressive fractures of the thoracic and the lumbar vertebrae, which were thought to be due to osteoporosis as a side effect of the high-dose prednisolone. At this admission, in another hospital, he also had a bloody discharge from the rectum, and azathioprine was started; however, the patient's condition still did not show any improvement. The total doses of azathioprine and prednisolone he had received were 3150 mg and more than 15,000 mg, respectively. Considering the presence of the serious complications, surgical intervention was the treatment selected. Culture study revealed MRSA in the feces and nasal cavity, and P. aeruginosa in the feces and urine. Vancomycin hydrochloride and gentamicin were administered, and were effective, with a subsequent negative culture study. Subtotal colectomy with mucus fistula was performed. After the operation, culture studies remained negative. Major steroid side effects such as bone fracture and osteoporosis should be considered as an indication for surgery in UC patients. MRSA and P. aeruginosa are a menace, especially for UC immunosuppressed patients on steroid or immunosuppressive therapy. When these bacteria are detected, there should be prompt and adequate antimicrobial therapy against the organisms and the immunosuppressive therapy should be immediately discontinued. We conclude that surgical therapy should be considered in the earlier stage for patients with intractable UC, rather than continuing long-term administration of steroid or azathioprine, which may lead to serious complications.

Rapid growth of residual colonic tumor after incomplete mucosal resection

We report an 89-year-old man with colon cancer that developed rapidly after an incomplete endoscopic mucosal resection (EMR), and discuss the adverse effect of this maneuver on the tumor biology. A sessile polyp, 15 mm in size, was detected at the hepatic flexure. EMR was performed immediately. Histological examination showed well differentiated adenocarcinoma with an adenomatous component invading the submucosal layer. There was vascular invasion (positive on elastica van Gieson staining) and the surgical margin was positive for cancer. A right hemicolectomy was performed. The surgical specimen showed the residual tumor, 22 mm in diameter. The relevant histopathological findings of the surgical specimen were: well differentiated adenocarcinoma, with partly mucinous carcinoma and a tubular adenomatous component, depth muscularis propria (mp), lymph node (LN) (0/9). Most of the submucosally invasive cancer was resected by the initial EMR, but the small residual tumor showed rapid growth within only 3 months after the EMR. It was assumed that the residual tumor cells had acquired more malignant characteristics after EMR. In regard to EMR we propose that: (1) except for patients who are at high risk for a major operation, EMR should be avoided for carcinoma with massive submucosal invasion, (2) colonic resection should be performed immediately when histology shows a positive surgical margin for carcinoma, and (3) patients operated after an incomplete EMR should be watched very carefully for the detection of recurrence.

Endoscopic resection for submucosally invasive colorectal cancer: is it feasible?

BACKGROUND

Recent advances in colonoscopy have resulted in an increasing number of endoscopic resections of colorectal neoplasms. However, endoscopic resection of submucosal invasive cancer remains a controversial issue.

METHODS

The subjects for this study were the surgically treated patients with submucosal invasive colorectal cancer. These patients were classified into two groups: those with versus those without preoperative endoscopic resection. Clinicopathologic features and prognosis were compared and analyzed.

RESULTS

Fifty patients underwent surgery for submucosally invasive colorectal cancer. Numbers of patients with and without preoperative endoscopic resection were 22 and 28, respectively. In 36.4% of the patients, endoscopic resections were incomplete. Two patients in whom the preoperative endoscopic resections had revealed a positive cancer margin, had nodal metastasis. One of these patients also developed hepatic metastasis. Endoscopic findings such as diameter and shape were not indicative of either lymphatic or vascular invasion. There were no morbidities or mortalities associated with endoscopic resection or surgery.

CONCLUSIONS

Preoperative endoscopic resection for colorectal submucosal cancer is feasible, provided the resection is complete. The indications for surgical treatment should be determined after pathologic examination.

Appendico-ileo-vesical fistula

Appendico-vesical fistula is a rare condition. In total, 109 cases, most secondary to appendicitis, have been reported in the English-language literature. We report the first case, to our knowledge, of appendico-ileo-vesical fistula secondary to appendiceal diverticulitis. An enterovesical fistula was diagnosed by urine culture, cystoscopy, and computed tomography. The locations of enteric opening sites were demonstrated by barium enema and colonoscopy. Ileocecal resection and fistulectomy with primary reconstruction were performed. We believe that accurate pre- and intra-operative diagnosis is essential for cure. This case demonstrates the importance of barium enema and colonoscopic examinations in the diagnosis and treatment of complicated enterovesical fistula.

Clear demonstration of carcinoma of the ampulla of Vater with ultrasonography

We present a non-icteric case, in which an ampullary polypoid lesion was clearly demonstrated by ultrasonography, suggesting carcinoma of the ampulla of Vater. The lesion was a 3 cm in diameter, spherical tumor with a polypoid surface, and internal hyperechogenicity. The patient underwent a curative pylorus-preserving pancreaticoduodenectomy.

Vectorcardiographic evaluation of myocardial infarct size: departure parameters are superior to conventional spatial parameters

To determine whether the departure parameters derived from a "departure loop" of a vectorcardiogram are more accurate than conventional spatial parameters in evaluating myocardial infarct size, 74 patients with first-onset myocardial infarction (MI) were studied. The correlation between the departure parameters (amplitudes in scalar leads of the departure loop) and the percent defect volume of thallium myocardial scintigrams (%DV) was compared with that of the spatial parameters (magnitude, azimuth, and elevation of the original QRS loop). In anteroseptal MI, the amplitude of a 20-msec vector in the z-axis and the azimuth of a 30-msec vector (H30) were significantly correlated with %DV (r=0.783, p<0.001 and r=0.572, p<0.05). In anteroseptal MI with involvement of the lateral wall, the amplitude of a 30-msec vector in the x-axis and H30 showed significant correlation with %DV (r=0.802, p<0.001 and r=0.772, p<0.01). In inferior and inferoposterior MI, the amplitude of a 30-msec vector in the y-axis and the elevation of a 30-msec vector were significantly correlated with %DV (r=0.920, 0.891, p<0.001 and r=0.871, 0.678, p<0.01, respectively). In conclusion, the departure parameters are more accurate than the spatial parameters for evaluation of myocardial infarct size.

Reactive lymphoid hyperplasia of the liver characterized by an angiofollicular pattern mimicking Castleman's disease

A case of reactive lymphoid hyperplasia of the liver exhibiting a characteristic angiofollicular pattern is reported. A hepatic nodular lesion was discovered by abdominal echography during clinical follow-up of abnormal liver function tests. It was diagnosed as hepatocellular carcinoma because of its hypervascularity when observed by angiography, and surgically resected. Grossly, the lesion was well-demarcated and measured 2 cm in diameter. Microscopically, the nodule was composed of lymph follicles with germinal centers, and the hyalinized inter-follicular space contained abundant hyalinized vasculature and plasma cells. The surrounding liver tissue exhibited chronic inflammation with some peculiar angiofollicular structures mimicking Castleman's disease. An immunohistochemical study revealed that the angiofollicular structure had the same characteristics as a lymph follicle with a germinal center, and that the plasma cells proliferating in the inter-follicular space had polyclonal immunophenotypes. These histological and immunohistochemical findings indicated that the angiofollicular structure observed was a kind of reactive lymph follicle, and that this hepatic lesion was reactive lymphoid hyperplasia rather than Castleman's disease or an inflammatory pseudotumor.

P wave changes in body surface potential maps due to increasing heart rate during exercise in normals

Exercise-induced changes in P maps were investigated in normal subjects (n = 20) in order to clarify the basic changes in P maps caused by exercise in patients with ischemic heart disease or by exercise-induced dysfunction of the left ventricle in patients with various heart diseases. Maps were obtained using an 87 lead-point system (HPM-6500, Chunichi-Denshi Corporation) and were recorded at rest and at heart rates up to 140/min in 20/min steps under graded bicycle ergometric exercise. P waves were divided into 3 phases (initial, middle and terminal) by locating the maximum. Maps were characterized by the distribution pattern of the positive and negative potentials in each frame. Peak voltages increased proportionally to the increase in heart rate. We observed a decrease in P wave duration concomitant with the increase in heart rate. Time from P onset to peak voltage increased slightly. We believe these findings to be due to the acceleration of sympathetic nerve tone accompanying exercise. We observed 2 patterns: type A showed the relatively short middle and terminal phases, and type B a prolongation of the middle phase and a shortening of the terminal phase. We consider the differences between types A and B to be partly due to individual differences in the degree of increase in pulmonary air volume and sympathetic nerve tone influence on the atria. In evaluating the exercise-induced P map changes, special consideration should be paid to the changes due to increase in heart rate.

Serum beta-enolase in acute myocardial infarction

The enzyme beta-enolase (alpha beta and beta beta forms) is present in skeletal and heart muscle and catalyses the glycolysis of 2-phosphoglycerate to phosphoenolpyruvate. The enzyme was measured in serum samples from patients with acute myocardial infarction, angina pectoris, congestive heart failure, and idiopathic cardiomyopathy. Serum concentrations of beta-enolase were significantly increased in acute myocardial infarction but not in the other cardiovascular diseases. Activity peaked approximately 12 to 14 hours after an acute attack of chest pain, and then gradually decreased as the patient recovered. The rise and fall in beta-enolase concentration were faster and steeper than those of creatine kinase activity, particularly in patients in whom activities of both these enzymes were less high. The assay of beta-enolase, which is highly specific and sensitive, has considerable advantages for the early diagnosis of myocardial infarction and the diagnosis of a second episode of myocardial infarction because beta-enolase concentration increases very early and rapidly and clears quickly. These data imply that serum beta-enolase may be a more effective marker for early myocardial infarction, particularly in milder cases, than measurement of creatine kinase activity.

Asthma: the yoga perspective. Part II: Yoga therapy in the treatment of asthma

The integral yoga approach to asthma (and other psychosomatic disorders) is briefly outlined as meeting all of the requirements for an optimal, holistic, somatopsychic therapy (as outlined in Part I), including correction of distorted posture and faulty breathing habits, teaching a system of general muscle relaxation, techniques for the release of suppressed emotion and for reducing anxiety and self-conscious awareness, as well as special methods for the expectoration of mucus. Yoga practices are described in detail and the available psychophysiological research on yoga practice, as well as clinical-therapeutic studies on yoga as asthmatic therapy, are reviewed. It can therefore be concluded that yoga therapy is most effective with asthma.