Endoprosthetic reconstruction for lower extremity soft tissue sarcomas with bone involvement

BACKGROUND AND OBJECTIVES

Bone resection and endoprosthetic reconstruction (EPR) in the setting of soft tissue sarcoma (STS) management is rare and incurs unique challenges. We aim to report on the surgical and oncological outcomes of this relatively previously undocumented cohort.

METHODS

This is a single-center retrospective review of prospectively collected data for patients who required EPRs following resection of STSs of the lower extremity. Following inclusion criteria, we assessed 29 cases of EPR for primary STS of the lower limb.

RESULTS

The mean age was 54 years (range 18-84). Of the 29 patients, there were 6 total femur, 11 proximal femur, 4 intercalary, and 8 distal femur EPRs. Fourteen of 29 patients (48%) underwent re-operations for surgical complications, with 9 relating to infection (31%). When a matched cohort analysis was performed comparing our cohort to STSs that did not necessitate EPR, a reduced rate of overall survival and metastasis-free survival was found in those requiring EPR.

CONCLUSION

This series identifies a high rate of complication from EPRs performed for STS. Patients should be cautioned about the high rate of infection, surgical complications, and lower overall survival in this setting.

Rupture of a Cyst during Compression at Mammography

The pressure at dedicated mammographic units, indicated by a manometer, shows the pressure in the hydraulic system. The reading of this instrument is misleading because the pressure in the breast caused by the compression plate is considerably lower. Appropriate compression during mammographic examination may, however, rupture cysts.

Calcifications in the Breast in Filaria Loa Infection

A 40-year-old patient underwent mammography for evaluation of a mass. Atypical calcifications were observed in the opposite breast. Two types of calcification were observed: one type was spiral-shaped and the other type rod-shaped. These calcifications were caused by Filaria loa. Parasitic calcifications in the breast are uncommon.

Phase II clinical study of BC-3781, a pleuromutilin antibiotic, in treatment of patients with acute bacterial skin and skin structure infections

This study investigated the potential of the novel systemic pleuromutilin antibiotic BC-3781 to treat patients with an acute bacterial skin and skin structure infection (ABSSSI) caused by a Gram-positive pathogen. Patients were randomized to intravenous BC-3781 100 mg, BC-3781 150 mg, or vancomycin 1 g every 12 h. Response to treatment was assessed daily and at test of cure (TOC). The primary endpoint was the clinical success rate at TOC in the modified intent-to-treat (MITT) and clinically evaluable (CE) analysis populations. Baseline characteristics, including the frequency of methicillin-resistant Staphylococcus aureus (MRSA), were comparable between the different treatment groups. Of 210 patients randomized, 186 (88.6%) patients completed the study. Clinical success at TOC in the CE population occurred in 54 (90.0%) patients in the BC-3781 100-mg group, 48 (88.9%) in the BC-3781 150-mg group, and 47 (92.2%) in the vancomycin group. At day 3, the clinical response rate was similar across the three treatment groups. Six patients discontinued study medication following an adverse event. The incidence rate for drug-related adverse events was lower for patients receiving BC-3781 (34.3% and 39.4% in the 100-mg and 150-mg groups, respectively) than those receiving vancomycin (53.0%). When BC-3781 was used to treat ABSSSIs caused by a Gram-positive pathogen, including MRSA, clinical success rates were comparable to those of the comparator, vancomycin. BC-3781 was generally well tolerated. These results provide the first proof of concept for the systemic use of a pleuromutilin antibiotic for the treatment of ABSSSIs.

The autoreactivity of B cells in hereditary angioedema due to C1 inhibitor deficiency

Patients with hereditary angioedema (HAE) tend to produce autoantibodies and have a propensity to develop immunoregulatory disorders. We characterize the profile of autoantibodies in a group of HAE patients and investigate their memory B cells' phenotype and activation status. We studied the activity status phenotype, Toll-like receptor (TLR)-9 expression and total phosphotyrosine in B cells isolated from HAE patients. Additionally, the following autoantibodies were assessed in the serum of 61 HAE patients: anti-nuclear, rheumatoid factor, anti-cardiolipin, anti-tissue transglutaminase, anti-endomysial, anti-Saccharomyces cerevisiae, anti-thyroid and anti-neutrophil cytoplasmic antibodies. In 47·5% of HAE patients we detected at least one of the tested autoantibodies. Expression of CD69, CD5 and CD21 was found to be significantly higher on memory B cells from HAE patients compared to healthy controls (4·59 ± 4·41 versus 2·06 ± 1·81, P = 0·04, 8·22 ± 7·17 versus 3·65 ± 3·78, P = 0·05, 2·43 ± 0·54 versus 1·92 ± 0·41, P = 0·01, respectively). Total phosphotyrosine in B cells from HAE patients was significantly higher compared to healthy controls (4·8 ± 1·1 versus 2·7 ± 1·3, P = 0·0003). Memory B cells isolated from the HAE group contained higher amounts of TLR-9 compared to healthy controls (8·17 ± 4·1 versus 4·56 ± 1·6, P = 0·0027). Furthermore, the expression of TLR-9 in memory B cells from HAE patients with autoantibodies was significantly higher than the control group (10 ± 4·7 versus 4·56 ± 1·6, P = 0·0002) and from that in HAE patients without autoantibodies (10 ± 4·7 versus 5·8 ± 0·9, P = 0·036). HAE patients have enhanced production of autoantibodies due most probably to the increased activation of B cells, which was found to be in association with a high expression of TLR-9.

Abundance of IFN-? and IFN-? mRNA in blood of resistant and susceptible chickens infected with Marek?s disease virus (MDV) or vaccinated with turkey herpesvirus; and MDV inhibition of subsequent induction of IFN gene transcription

The effects of the very virulent RB-1B strain of Marek's disease virus (MDV) and turkey herpesvirus (HVT), a vaccinal strain, on abundance of IFN mRNA in the blood were investigated. MDV and HVT infection did not change the circulating level of IFN-gamma mRNA 1 and 7 days p.i., but they increased IFN-alpha mRNA levels slightly in genetically susceptible (to tumour development) B(13)/B(13) chickens. The total number of circulating leukocytes was unchanged and increase in message was accompanied by an increase in circulating CD8alpha(+) and MHC Class II(+) cells. On the contrary, both viruses slightly increased IFN-gamma transcripts and decreased IFN-alpha transcripts in genetically resistant B(21)/B(21) chickens. Further, oncogenic MDV was able to block the response to inactivated Newcastle disease virus, a potent inducer of IFN, in both chicken lines. The inhibiting effect on transcription was present for both IFN at days 1 and 7 p.i. in susceptible B(13)/B(13) chickens, but only at day 7 p.i. in resistant B(21)/B(21) chickens. By contrast, non-oncogenic HVT did not interfere with induction of either message at one day p.i. and MDV had a more suppressive effect than HVT on IFN gene transcription 7 days p.i. in B(21)/B(21) chickens. Thus, the strong ability of MDV to block induction of IFN gene transcription detected in the blood as soon as one day after infection in susceptible chickens, as opposed to resistant chickens, not only causes immunosuppression but also may be related to the virus's oncogenicity.

Apoptosis-inducing factor mediates microglial and neuronal apoptosis caused by pneumococcus

Streptococcus pneumoniae is the major cause of bacterial meningitis and it damages the hippocampus by inducing neuronal apoptosis. The blocking of caspases provides only partial protection in experimental meningitis, which suggests that there is an additional apoptotic pathway. A trigger of this pathway is the bacterium itself, as exposure of microglia or neurons to live pneumococci induces rapid apoptosis. In this study, apoptosis was not associated with the activation of caspases-1-10 and was not inhibited by z-VAD-fmk, a broad-spectrum caspase inhibitor. Rather, apoptosis was attributed to damage to mitochondria, which was followed by the release of apoptosis-inducing factor (AIF) from the mitochondria, large-scale DNA fragmentation, and hypodiploidy. Furthermore, intracytoplasmatic microinjection of AIF-specific antiserum markedly impaired pneumococcus-induced apoptosis. These findings indicate that AIF may play a central role in brain cell apoptosis and bacterial pathogenesis.

Immune status assessment by abundance of IFN-alpha and IFN-gamma mRNA in chicken blood

Avian diseases, including such viral infection as infectious bursal disease, infectious anemia, and Marek's disease, often cause immunosuppression, leading to more severe infection, problems with secondary infection, and inadequate responses to vaccination. Immunosuppression thus causes serious economic losses in commercial poultry production. To date, methods for assessing immune status have been too slow to be of practical help. Reasoning that immunosuppression should be reflected by reduced production of interferons (IFN) in response to a viral antigen, we have developed competitive nucleic acid hybridization microtiter plate assays for chicken IFN-alpha (ChIFN-alpha) and ChIFN-gamma mRNA. To evaluate the assay, chickens were challenged with inactivated Newcastle disease virus (iNDV). Whole blood samples were collected at various times subsequently and preserved with a cationic detergent. Later, total RNA was extracted, and mRNA for both ChIFN-alpha and ChIFN-gamma was measured. Both rose from undetectable levels to reach a peak by 4 h, remained high for about 3 days, and fell to undetectable levels by day 5. Results were similar in chickens aged between 1 and 28 days. In later experiments, blood was collected 4 h after viral challenge. When chickens were immunosuppressed by administering 4-5 mg cyclophosphamide (CY) daily for 3 days and challenged with iNDV, they transcribed less ChIFN-alpha and ChIFN-gamma mRNA, and their antibody response was impaired. Our results suggest that suspected immunosuppression in a commercial flock could be assessed within 2-3 days by challenging birds with iNDV and measuring the amounts of ChIFN-alpha and ChIFN-gamma mRNA in blood obtained 2-4 h later.

The rationale and design of the CPCRA (Terry Beirn Community Programs for Clinical Research on AIDS) 058 FIRST (Flexible Initial Retrovirus Suppressive Therapies) trial

The CPCRA (Terry Beirn Community Programs for Clinical Research on AIDS) 058 FIRST (Flexible Initial Retrovirus Suppressive Therapies) trial is a large, long-term, randomized, prospective comparison of three different antiretroviral strategies in highly active antiretroviral therapy-naïve, HIV-1-infected persons. The trial was designed as a flexible framework upon which other studies could be added to answer more limited, but still important, questions. This article presents the study design, discusses the challenges we have faced in implementing the trial, and describes our preliminary experiences. Control Clin Trials 2001;22:176-190

Slovene smart card and IP based health-care information system infrastructure

Slovenia initiated a nation-wide project to introduce smart cards in the health sector in 1995 and its full-scale deployment started in September 2000. Although the basic aim of the project was to support insurance related procedures, the system was designed in a flexible and open manner to present an infrastructure for the whole health sector. The functionality of the current system is described in this paper along with lessons learned so far. The upgrade of the system is outlined, with emphasis on technical details, the objective being to provide a real-time EDI based environment for a general set of applications in the medical sector, supported by the flexibility and security of modern smart card technologies. Integration with similar systems in other EU countries is discussed.

Clinical isolates of Streptococcus pneumoniae that exhibit tolerance of vancomycin

The ability of Streptococcus pneumoniae to escape lysis and killing by vancomycin, a property termed "tolerance," has recently been noted in a laboratory strain of the species. Vancomycin tolerance in clinical isolates represents a potential new health risk. We determined the prevalence of vancomycin and penicillin tolerance among 116 clinical isolates of pneumococci by monitoring lysis and viability after exposure to the respective antibiotic for 4 hours. Eight percent of the strains were tolerant to penicillin and 3% were tolerant to vancomycin. The 3 vancomycin-tolerant isolates also had a high ratio of minimum bactericidal concentration to minimum inhibitory concentration, in contrast to nontolerant strains. They were of serotype 9V and had reduced susceptibility to penicillin. Only 1 was also tolerant to penicillin. Growth rate and ability to divide were not affected in the 3 vancomycin-tolerant strains, and they all lysed with deoxycholate, which indicates autolysin production. Vancomycin tolerance among clinical isolates of pneumococci will necessitate tracking to determine the magnitude of the evolving health risk, since tolerance may contribute to treatment failure (in particular, cases of meningitis, in which bactericidal activity is critical for eradication) and since it may also be a favored background for acquisition of resistance of vancomycin.

Competitive DNA hybridization in microtitre plates for chicken anaemia virus

Unlabelled chicken anaemia virus (CAV) DNA probe, produced by PCR, was immobilized onto nitrocellulose discs that then were fitted into microtitre plate wells in order to develop a competitive, non-radioactive hybridization test for detection of CAV. The discs were hybridized with either DNA extracts of buffy coats or dilutions of CAV DNA (for standard curves), followed by hybridization with biotin-labelled CAV DNA probe in excess of the immobilized, capture probe. Thus, CAV from sample DNA extracts and standard DNA preparations competed with the biotin-labelled CAV DNA probe for the immobilized, capture probe, decreasing subsequent colour development by an avidin-biotin-alkaline phosphatase detection system. Standard curves were log linear from 5-100 ng viral DNA with r(2)> or =0.91. Tests were considered positive at 2 SD less than mean absorbence of samples from uninfected chickens, and ranged from 52 to 108 microm viral DNA or 2 to 4.2x10(10)virions microg(-1)buffy coat DNA. Blood samples from chickens infected and not infected with CAV at one day of age were tested for evidence of infection until 28 days of age by viral isolation, competitive hybridization in microtitre plates, dot-blots, enzyme-linked immunosorbent assay (ELISA), and in situ hybridization on blood smears. None of the tests was positive for uninfected chickens. Viral isolation from buffy coats, though expensive and lengthy, was the most sensitive method. It detected virus in buffy coat from each infected chicken, while competitive hybridization detected 72% of infected chickens, in situ hybridization 69%, dot-blots 67%, and ELISA 36%. Sensitivity of competitive hybridization was 0.78, and its specificity was 1.00. Three chickens must be sampled from an infected flock for a 90% chance of detecting a positive chicken at the 0.025 one-tailed level of significance, assuming 100% prevalence.

Regulation of growth inhibition at high temperature, autolysis, transformation and adherence in Streptococcus pneumoniae by clpC

The ClpC ATPase is a subfamily of HSP100/Clp molecular chaperones-regulators of proteolysis. By screening a library of loss of function mutants for the ability to survive treatment with penicillin, we identified the gene clpC. The corresponding protein was identified as a ClpC ATPase, sharing strong peptide sequence identity with ClpC of Bacillus subtilis, Listeria monocytogenes and Lactococcus lactis. Northern blot experiments showed that expression of clpC was induced in response to high temperature (40-42 degrees C) versus 37 degrees C, suggesting that ClpC is a heat shock protein. Insertional duplication mutagenesis of clpC resulted in increased tolerance to high temperature; a result in contrast to other bacterial Clp proteases. The clpC-deficient mutant formed long chains and failed to undergo lysis after treatment with penicillin or vancomycin. The effect of the clpC mutation extended to deficiency of adherence to the human type II alveolar cells. Finally, the clpC disruption resulted in decreased genetic transformation. Western blot analysis demonstrated that the mutant failed to express pneumolysin and the choline-binding proteins LytA, CbpA, CbpE, CbpF, CbpJ. These results suggest that the heat shock protein ClpC plays an essential complex pleiotropic role in pneumococcal physiology, including cell growth under heat stress, cell division, autolysis, adherence and transformation.

Laboratory evaluations of methylated soy oil and monoterpenes as mosquito larvicides

The larvicidal toxicities of methylated soy oil (MSO) and surfactant combinations were compared to 2 commercially available oil larvicides (Golden Bear Oil 1111 and Bonide) in standard laboratory bioassays of 4th-stage larvae of Culex pipiens Linn. The dose lethal to 50% of the test organisms (LD50) and the dose lethal to 95% of the test organisms (LD95) values are presented as microliters (microl) per beaker (treatment surface area of 54 cm2). The 2 surfactant-MSO mixtures differed significantly in their toxicity to Cx. pipiens larvae; 2% Pyroter CPI-40 in MSO was more toxic than 2% Pluronic L121 in MSO (LD50 = 3.8 microl per 54 cm2 and 11.3 microl per 54 cm2, respectively). The 2 most active larvicides were Golden Bear Oil (LD50 = 3.6 microl per 54 cm2) and the 2% Pyroter-MSO mixture. These 2 were not significantly different from each other. Bonide (LD50 = 6.2 microl per 54 cm2) and the Pluronic L121-MSO mixture (LD50 = 11.3 microl per 54 cm2) were less toxic than Golden Bear Oil and the MSO-Pryroter mixture and they were significantly different from each other. Bioassays with 4th-stage larvae of Anopheles stephensi Liston showed that toxicity of the Pyroter-MSO formulations increased about 2-fold from 18 degrees C to 24 degrees C (LD50 = 20.5 microl per 54 cm2 and 11.8 microl per 54 cm2, respectively). The laboratory bioassays suggest that MSO mixed with surfactants are potential mosquito larvicides. We also evaluated the influence of the 2 surfactants on the toxicity of 3 monoterpenes. The larvicidal activity of citral and limonene increased with the addition of surfactants, but neither surfactant enhanced the toxicity of cineole. All 3 monoterpenes, with and without surfactants, were considered poor candidates as surface larvicides because of their high volatilities.

Extracellular targeting of choline-binding proteins in Streptococcus pneumoniae by a zinc metalloprotease

A genetic-based search for surface proteins of Streptococcus pneumoniae involved in adhesion identified a putative zinc metalloprotease (ZmpB). ZmpB shared high amino acid sequence similarities with IgA1 proteases of Gram-positive bacteria, but ZmpB had neither IgA1 nor IgA2 protease activity. Analysis of a family of surface-expressed proteins, the choline-binding proteins (Cbp's), in a zmpB-deficient mutant demonstrated a global loss of surface expression of CbpA, CbpE, CbpF and CbpJ. CbpA was detected within the cytoplasm. The zmpB-deficient mutant also failed to lyse with penicillin, a sign of lack of function of the Cbp LytA. Immunodetection studies revealed that the autolysin (LytA), normally located on the cell wall, was trapped in the cytoplasm colocalized with DNA and the transformation protein CinA. Trafficking of CinA and RecA to the cell membrane during genetic competence was also not observed in the zmpB-deficient mutant. These results suggest a protease dependent regulatory mechanism governing the translocation of CinA and the Cbp's LytA and CbpA of S. pneumoniae.

Uncontrolled oxygen administration and respiratory failure in acute asthma

STUDY OBJECTIVES

To determine if 100% oxygen administration adversely influences gas exchange in acutely ill asthmatic subjects.

DESIGN

Prospective preinterventional and postinterventional comparison.

SETTING

University hospital emergency department.

PATIENTS

Thirty-seven asthmatic subjects seeking care for symptomatic exacerbations.

INTERVENTIONS

Twenty minutes of 100% oxygen administration by face mask.

MEASUREMENTS AND RESULTS

Arterial blood gases and FEV(1) were measured before and during the last minute of oxygen administration. On presentation, the subjects had moderately severe airway obstruction (FEV(1), 49.1 +/- 3.6% of predicted); hypocarbia (PaCO(2), 36.8 +/- 1.1 mm Hg); hypoxemia (PaO(2), 70.2 +/- 2.5 mm Hg); and respiratory alkalosis (pH, 7.43 +/- 0.01). During oxygen breathing, 25 patients (67.6%) experienced elevations in PaCO(2) ranging from 1 to 10 mm Hg (mean, 4.1 +/- 0.6 mm Hg; p = 0.0003). The increase was considered to be a physiologic manifestation of the Haldane effect (ie, < or = 2 mm Hg) in 10 subjects, but in the remaining 15 subjects (40.5% of the total studied), the elevation represented worsening gas exchange. In seven of these patients (46.7%), hypercapnic respiratory failure developed (PaCO(2) before oxygen, 39.6 +/- 0.6; during oxygen, 44.7 +/- 0.7 mm Hg; p = 0.005), and in six patients (40%), it worsened (PaCO(2) before oxygen, 46.8 +/- 1.9; during oxygen, 52.0 +/- 3.1 mm Hg; p = 0.03). In general, the tendency toward hypercarbia was the greatest in the participants with the most severe airway obstructions.

CONCLUSIONS

Our data demonstrate that the administration of 100% oxygen to acutely ill asthmatics may adversely influence carbon dioxide elimination.

Signal transduction by a death signal peptide: uncovering the mechanism of bacterial killing by penicillin

The binding of bactericidal antibiotics like penicillins, cephalosporins, and glycopeptides to their bacterial targets stops bacterial growth but does not directly cause cell death. A second process arising from the bacteria itself is necessary to trigger endogenous suicidal enzymes that dissolve the cell wall during autolysis. The signal and the trigger pathway for this event are completely unknown. Using S. pneumoniae as a model, we demonstrate that signal transduction via the two-component system VncR/S triggers multiple death pathways. We show that the signal sensed by VncR/S is a secreted peptide, Pep27, that initiates the cell death program. These data depict a novel model for the control of bacterial cell death.

Isolation and characterization of vancomycin-tolerant Streptococcus pneumoniae from the cerebrospinal fluid of a patient who developed recrudescent meningitis

The emergence of tolerance to vancomycin has recently been reported in Streptococcus pneumoniae, the most common cause of bacterial meningitis. A vancomycin- and cephalosporin-tolerant strain of S. pneumoniae, the Tupelo strain, was isolated from the cerebrospinal fluid of a patient who then developed recrudescence of meningitis despite treatment with vancomycin and a third-generation cephalosporin. The Tupelo strain evidenced no lysis in the exponential or stationary phase of growth when exposed to vancomycin and only minimal loss of viability. Further characterization revealed normal autolysin expression, localization, and triggering by detergents, indicating that the defect leading to tolerance in the Tupelo strain is in the control pathway for triggering of autolysis. Because tolerance is a precursor phenotype to resistance and may lead to clinical failure of antibiotic therapy, these observations may have important implications for vancomycin use in infections caused by S. pneumoniae.

Modification of the Kock's pouch for bladder replacement

AIM

To describe a modification of the Kock's pouch and present our clinical experience in its application.

METHOD

After isolating an adequate ileal segment, the bowel is split by a longitudinal incision, with both ends remaining unopened for about 3-4 cm in length. Previously anastomozed ureters are inserted into the proximal end so that a nipple valve is created. The distal unsplit end serves for a direct anastomosis with the urethra. During the past 9 years, this surgery was performed in 41 patients who underwent radical cystectomy due to invasive carcinoma. Seventeen patients died for unknown reasons or were lost to follow-up. The remaining 24 were included in the follow-up for a period of 7 months to 6 years post surgery.

RESULTS

Half of the patients included in the follow-up urinated spontaneously, with post void residuals less than 120 mL and no need for catheterization. Four patients did not urinate spontaneously and needed continuos catheterization, whereas 8 patients had post void residuals of 150-200 mL and needed catheterization once a day or once a week. None of the patients had a stricture at the site of ureteroileal anastomosis.

CONCLUSION

We believe that our modification of the Kock's pouch makes the uretero-intestinal anastomosis much easier to perform; both ureters are inserted into the unsplit bowel end, thus preventing reflux; anastomosis with the urethra is performed under visual control; and direct anastomosis of widely opened distal end of the bowel reduces the possibility of scar stenosis.

Pathogenesis of pneumococcal pneumonia

Pneumococcal pneumonia is the most severe of the common community-acquired pulmonary infections. The recent release of the complete DNA sequence reveals the entire capability of the bacteria and the current challenge is to map gene products to the mechanics of disease. This process will reveal antibiotic targets and protein vaccine candidates crossing serotype boundaries. Choline is a major constituent of surfactant and it is also a required nutrient for the pneumococcus. It appears that choline incorporated into the cell wall can bind the bacteria to the receptor for platelet activating factor, the gateway to invasion. The choline also serves as an antenna to which multifunctional proteins dock, thereby decorating the bacterial surface. This set of 12 choline binding proteins is subject to phase variation of expression resulting in display of different combinations of proteins that adapt the bacteria to survival on the mucosa versus the blood stream. These changes affect protective antigens, adhesions, and lytic proteins tying together the major elements of pneumococcal physiology: natural DNA transformation, adherence and invasion of host cells, and autolysis. Taking these components and building an understanding of disease is challenging. Clearly, the toxin pneumolysin is a major mediator of cell damage in the lung. Inflammation is also incited by cell wall components. The signal transduction pathways that explain pneumococcal inflammation are more complex than those for gram-negative endotoxin.

Pneumolysin, a protein toxin of Streptococcus pneumoniae, induces nitric oxide production from macrophages

Nitric oxide (NO) production by inducible NO synthase (iNOS) during inflammation is an essential element of antimicrobial immunity but can also contribute to host-induced tissue damage. Under conditions of bacterial sepsis, large amounts of NO are produced, causing hypotension, a critical pathological feature of septic shock. In sepsis caused by gram-positive organisms, the bacterial factors contributing to host NO production are poorly characterized. We show that a soluble toxin of Streptococcus pneumoniae, pneumolysin (Pln), is a key component initiating NO production from macrophages. In contrast to wild-type bacteria, a mutant of S. pneumoniae lacking Pln failed to elicit NO production from murine macrophages. Purified recombinant Pln induced NO production at low concentrations and independently of exogenous gamma interferon (IFN-gamma) priming of RAW 264.7 macrophages. However, IFN-gamma was essential for Pln-induced NO production, since primary macrophages from mice lacking the IFN-gamma receptor or interferon regulatory factor 1, a transcription factor essential for iNOS expression, failed to produce NO when stimulated with Pln. In addition, Pln acts as an agonist of tumor necrosis factor alpha and interleukin 6 production in macrophages. The properties of Pln, previously identified as a pore-forming hemolysin, also include a role as a general inflammatory agonist.

Identification of two sources of carbon monoxide in comet Hale-Bopp

The composition of ices in comets may reflect that of the molecular cloud in which the Sun formed, or it may show evidence of chemical processing in the pre-planetary accretion disk around the proto-Sun. As carbon monoxide (CO) is ubiquitous in molecular clouds, its abundance with respect to water could help to determine the degree to which pre-cometary material was processed, although variations in CO abundance may also be influenced by the distance from the Sun at which comets formed. Observations have not hitherto provided an unambiguous measure of CO in the cometary ice (native CO). Evidence for an extended source of CO associated with comet Halley was provided by the Giotto spacecraft, but alternative interpretations exist. Here we report observations of comet Hale-Bopp which show that about half of the CO in the comet comes directly from ice stored in the nucleus. The abundance of this CO with respect to water (12 per cent) is smaller than in quiescent regions of molecular clouds, but is consistent with that measured in proto-stellar envelopes, suggesting that the ices underwent some processing before their inclusion into Hale-Bopp. The remaining CO arises in the coma, probably through thermal destruction of more complex molecules.

Emergence of vancomycin tolerance in Streptococcus pneumoniae

Streptococcus pneumoniae, the pneumococcus, is the most common cause of sepsis and meningitis. Multiple-antibiotic-resistant strains are widespread, and vancomycin is the antibiotic of last resort. Emergence of vancomycin resistance in this community-acquired bacterium would be catastrophic. Antibiotic tolerance, the ability of bacteria to survive but not grow in the presence of antibiotics, is a precursor phenotype to resistance. Here we show that loss of function of the VncS histidine kinase of a two-component sensor-regulator system in S. pneumoniae produced tolerance to vancomycin and other classes of antibiotic. Bacterial two-component systems monitor environmental parameters through a sensor histidine-kinase/phosphatase, which phosphorylates/dephosphorylates a response regulator that in turn mediates changes in gene expression. These results indicate that signal transduction is critical for the bactericidal activity of antibiotics. Experimental meningitis caused by the vncS mutant failed to respond to vancomycin. Clinical isolates tolerant to vancomycin were identified and DNA sequencing revealed nucleotide alterations in vncS. We conclude that broad antibiotic tolerance of S. pneumoniae has emerged in the community by a molecular mechanism that eliminates sensitivity to the current cornerstone of therapy, vancomycin.

Neuroprotection by a caspase inhibitor in acute bacterial meningitis

Half of the survivors of bacterial meningitis experience motor deficits, seizures, hearing loss or cognitive impairment, despite adequate bacterial killing by antibiotics. We demonstrate that the broad-spectrum caspase inhibitor N-benzyloxycarbonyl-Val-Ala-Asp-fluoromethyl-ketone (z-VAD-fmk) prevented hippocampal neuronal cell death and white blood cell influx into the cerebrospinal fluid compartment in experimental pneumococcal meningitis. Hippocampal neuronal death was due to apoptosis derived from the inflammatory response in the cerebrospinal fluid. Apoptosis was induced in vitro in human neurons by inflamed cerebrospinal fluid and was blocked by z-VAD-fmk. As apoptosis drives neuronal loss in pneumococcal meningitis, caspase inhibitors might provide a new therapeutic option directed specifically at reducing brain damage.

Identification of a Streptococcus pneumoniae gene locus encoding proteins of an ABC phosphate transporter and a two-component regulatory system

The Escherichia coli Pst system belongs to the family of ABC transporters. It is part of a phosphate (PHO) regulon which is regulated by extracellular phosphate. Under conditions of phosphate limitation, the response regulator PhoB is phosphorylated by the histidine kinase PhoR and binds to promoters that share a consensus PHO box. Under conditions of phosphate excess, PhoR, Pst, and PhoU downregulate the PHO regulon. Screening of a library of pneumococcal mutants with defects in exported proteins revealed a putative two-component regulatory system, PnpR-PnpS, and a downstream ABC transporter, similar to the Pst system in E. coli including a gene encoding a PhoU protein. Similar to E. coli, mutagenesis of the ATP-binding cassette gene, pstB, resulted in decreased uptake of phosphate. The effects of the loss of the pneumococcal Pst system extended to decreased transformation and lysis. Withdrawal of phosphate led to transformation deficiency in the parent strain R6x but not to penicillin tolerance, suggesting that reduced bacterial death was independent of phosphate. None of these phenotypes was observed in the pneumococcal loss-of-function mutant phoU. By using a lacZ reporter construct, it was demonstrated that expression of the two-component regulatory system PnpR-PnpS was not influenced by different concentrations of phosphate. These results suggest a more complex role of the Pst system in pneumococcal physiology than in that of E. coli.

Penicillin tolerance genes of Streptococcus pneumoniae: the ABC-type manganese permease complex Psa

Downregulation of the major autolysin in Streptococcus pneumoniae leads to penicillin tolerance, a feature that is characterized by the ability to survive but not grow in the presence of antibiotic. Screening a library of mutants in pneumococcal surface proteins for the ability to survive 10x minimum inhibitory concentration (MIC) of penicillin revealed over 10 candidate tolerance genes. One such mutant contained an insertion in the known gene psaA, which is part of the psa locus. This locus encodes an ABC-type Mn permease complex. Sequence analysis of adjacent DNA extended the known genetic organization of the locus to include two new open reading frames (ORFs), psaB, which encodes an ATP-binding protein, and psaC, which encodes a hydrophobic transmembrane protein. Mutagenesis of psaB, psaC, psaA and downstream psaD resulted in penicillin tolerance. Defective adhesion and reduced transformation efficiency, as reported previously for a psaA- mutant, were phenotypes shared by psaB-, psaC- and psaD- knockout mutants. Western blot analysis demonstrated that the set of mutants expressed RecA, but none of them showed translation of the autolysin gene, which is located downstream of recA. The addition of manganese (Mn) failed to correct the abnormal physiology. These results suggest that this ABC-type Mn permease complex has a pleiotropic effect on pneumococcal physiology including adherence and autolysis. These are the first genes suggested as being involved in triggering autolysin. The results raise the possibility that loss of function of PsaA, by vaccine-induced antibody for instance, may promote penicillin tolerance.

Effect of long-term salmeterol treatment on exercise-induced asthma

BACKGROUND

With long-term administration of salmeterol, the extent of protection afforded by the drug against experimental precipitants of asthma such as methacholine and adenosine may decrease. Whether this effect extends to a clinically relevant stimulus such as exercise is unknown.

METHODS

We performed a random-order, double-blind, crossover trial in 20 patients with exercise-induced asthma. Each patient received inhaled salmeterol or placebo twice daily for a month, with a one-week washout period between treatments. The patients performed cycle ergometry while breathing frigid air 30 minutes after the morning dose and 9 hours later on the 1st, 14th, and 29th study days. The primary end point was the extent of the decrease in forced expiratory volume in 1 second (FEV1) 10 minutes after exertion.

RESULTS

With placebo, significant airway narrowing developed at all times (mean [+/-SE] decrease from base line in FEV1, 19+/-2 percent in the morning and 18+/-2 percent in the evening). The morning dose of salmeterol attenuated the degree of bronchoconstriction at all times (decrease in FEV1 on day 1, 5+/-2 percent; on day 14, 10+/-3 percent; and on day 29, 9+/-3 percent; P=0.10). Its ability to act throughout the day, however, decreased with long-term administration (decrease in FEV1 from morning to evening on day 1, 6+/-2 percent; on day 14, 15+/-3 percent; and on day 29, 14+/-3 percent; P=0.003).

CONCLUSIONS

Protection against exercise-induced asthma is maintained with long-term administration of salmeterol, but the length of time that the drug remains active after a single dose decreases.

In situ hybridization on blood smears for diagnosis of chicken anemia virus in broiler breeder flocks

Chicken anemia virus (CAV) infection was suspected in progeny from broiler breeder hens raised in a location that was geographically different from where most pullets were raised for one Georgia production company. These breeder pullets were raised in new or relatively new houses. Progeny from these pullets experienced a 10-fold increase in average daily mortality over progeny from flocks raised in established breeder houses. Lesions in the broilers included severe necrotizing dermatitis, pale bone marrow, and small thymus glands. Infection with CAV was confirmed in the breeders by enzyme-linked immunosorbent assay, indirect immunofluorescence, and in situ hybridization on peripheral blood smears. The in situ hybridization identified three broiler breeder flocks that were actively infected with CAV and were probably the source of infection in broiler flocks.

Seasonal abundance and distribution of mosquitoes at a rural waste tire site in Illinois

The species composition, abundance, and distribution of mosquito larvae in tires were determined on 3 dates at a relatively large rural tire dump (about 300,000 tires) in southeastern IL (Jasper County). Several observations at this site differed from those in previous reports about mosquitoes in tireyards, including 1) a relatively high percentage of tires positive for Aedes triseriatus larvae in an open-field area, 2) a greater abundance of Culex pipiens than Cx. restuans in late-season collections, 3) a seasonal change in the distribution of Aedes atropalpus larvae in tires from open field and edge of woods areas, and 4) the presence of Ae. albopictus as a major late-season species. Ae. albopictus adults were captured in sod-baited gravid traps along the edge of a wooded riparian area 200 m from the tire pile.

In situ hybridization for detection of chicken anaemia virus in peripheral blood smears

Blood smears, obtained from chickens known to be infected with or free from chicken anaemia virus (CAV), were tested to detect CAV DNA by in situ hybridization (ISH). A double-stranded, 1485 base-pair (bp) DNA probe was prepared employing polymerase chain reaction (PCR). The probe was labelled with digoxigenin or biotin by nick translation. In situ hybridization employing simple specimen preparation, using both digoxigenin- and biotin-labelled probes, provided a rapid and inexpensive method for diagnosis of CAV infection. Infection with CAV was detected by ISH prior to seroconversion by indirect immunofluorescence assay.

Trisomy 8 is a characteristic finding in pleuropulmonary blastoma

The cytogenetic findings in pleuropulmonary blastoma (PPB) have not been widely studied and reported and are of interest in view of the implications that PPB has for additional tumors in the patient and the patient's relatives. Using standard tumor cytogenetic methodology, we investigated three cases of PPB encountered in our institution over a 5-year period. Trisomy 8 was the only karyotypic abnormality in a localized type 2 PPB and was present with other abnormalities in another type 2 PPB and a massive type 3 PPB. Review of the literature yielded three additional karyotyped PPBs; all had trisomy 8 as part of the abnormalities detected. Trisomy 8 appears to be a characteristic of PPB and may be related to the development of PPB and related tumors.

[Classical and current aspects of purulent meningitis]

Even today acute purulent meningitis is a life-threatening disease requiring immediate diagnosis and therapy. Despite the availability of bactericidal antibiotics, the mortality has not changed within the last 20 years. A therapeutic approach interfering specifically with the pathogenesis of inflammation is necessary in order to prevent long-term neurological sequelae and death associated with bacterial meningitis. In this paper we discuss the present level of understanding of antibiotics and adjunctive therapy, especially with regard to the molecular pathophysiological events occurring during a CNS infection.

Antiretroviral monotherapy in early stage human immunodeficiency virus disease has no detectable effect on virus load in peripheral blood and lymph nodes

Initiation of antiretroviral monotherapy early in the course of infection with human immunodeficiency virus may result in a temporary slowing in the rate of disease progression; however, little is known about the virologic effects of early therapy. Virus load was measured in peripheral blood and lymph nodes from 16 antiretroviral-naive patients with a mean CD4 T lymphocyte count of 659 cells/microliter at baseline and after 8 weeks of either no treatment or zidovudine therapy. CD4 T lymphocyte counts and all virologic parameters examined remained unchanged regardless of zidovudine treatment status. Histopathology and virus distribution within lymph nodes remained constant between baseline and week 8 in each patient, indicating that the virologic and histologic parameters examined in a single lymph node are representative of a systemic process. Early antiretroviral monotherapy with zidovudine had no effect on virologic parameters in this group of patients with relatively high CD4 T lymphocyte counts and low measures of virus load at baseline.

An outcomes study of cochlear implants in deaf patients. Audiologic, economic, and quality-of-life changes

OBJECTIVES

To investigate and quantitate the changes in economic, emotional, and health-related quality of life after cochlear implantation.

SUBJECTS

Nine patients between the ages of 18 and 60 years who qualified for surgery.

METHODS

Patients underwent assessment using four socioeconomic indicator scales administered preoperatively, and at 6 months, 1 year, 2 years, 30 months, and 3 years postoperatively. All patients continued to use their cochlear implants during the 3-year follow-up period.

RESULTS

Uniform and systematic improvement in quality of life and psychologic well-being, and a steady increase in mean personal income for the group that underwent implantation, supporting the contention that cochlear implantation is a beneficial surgical procedure for profoundly deaf patients.

Urogenital wounds during the war in Croatia in 1991/1992

There were 142 war injuries to the urogenital organs in 115 of 4,425 wounded patients treated at our clinical hospital during 18 months of warfare in Osijek, Croatia. Kidney injury was the most common (64 cases) and urethral injury (4) the least common, with a relatively large number of ureteral injuries (11). Two-thirds of the injuries were associated with other trauma, most frequently abdominal injuries. The mortality rate was high (15.6%), explained by the proximity of the battlefield and resulting rapid patient transport (average 52.21 minutes), which excluded the possibility of separating out the moribund cases, as well as the exceptional destructive power of modern explosives and firearms, and associated wounds of the vital organs. Of the wounded 60% were members of the Croatian armed forces, 1 was a member of the United Nations Professional Force and 39.13% were civilians. Surgical intervention was characterized by a tendency toward conservation and the avoidance of organ sacrifice. Thus, nephrectomy was performed in only a quarter of the cases of renal injury. Nevertheless, orchiectomy was performed in two-thirds of the cases of testicular injury. In 5 of 8 cases of corpus spongiosum injury the tunica albuginea was primarily reconstructed with free transplantation of the fascia lata. For ureteral injury resection with primary suture yielded good results in contrast to stents without resection in cases of ureteral wall contusion, which resulted in ureteral stenosis in our patients.

Comparative localization of carboxylesterase in F344 rat, beagle dog, and human nasal tissue

BACKGROUND

Carboxylesterases (CE) exhibit high activity in the nasal mucosae and produce acid metabolites toxic to the olfactory epithelium following exposures to inhaled esters. The regional distribution and activity of CE have been studied in rodents, but no comparative studies have examined regional localization or activity in dog or human nasal tissues.

METHODS

We determined the immunohistochemical distributions of CE in the nasal respiratory and olfactory mucosae of Beagle dogs, and the nasal respiratory mucosa of the human nose and compared these distributions to those in the F344 rat.

RESULTS

In the dog respiratory mucosa, the greatest CE immunoreactivity was in the subepithelial glands and surface epithelial cells. In the olfactory mucosa, immunoreactivity was observed in the apical portion of the sustentacular cells, and in duct cells and acinar cells of Bowman's glands. This distribution is similar to that found in rat, except the subepithelial glands of the rat respiratory mucosa showed little to no immunoreactive CE. The human respiratory mucosa showed immunostaining in surface epithelial cells as well as glandular cells. Immunostaining in the human tissue samples was dramatically reduced in the presence of hyperplastic lesions and virtually eliminated in samples with squamous metaplasia.

CONCLUSIONS

The data indicate that the distribution of CE is very similar in healthy nasal mucosae across the three species studied. However, the loss of CE immunoreactivity correlated with nasal epithelial lesions in the human samples suggests enzymatic activity may be compromised by insults to nasal tissues. Further studies of CE activity in animals following nasal insult could improve the ability to predict human responses to inhaled esters.

Papillomavirus infection and its pathologic correlate in sexually active adolescents

We investigated the prevalence of human papillomavirus (HPV) and its pathologic correlation in an adolescent clinic population (13-20 years, mean 16 years) over a 2-year period. 413 cervical specimens were obtained and analyzed cytologically and by a Southern Blot (SB) method for HPV DNA. 277 specimens from 210 patients could be fully analyzed. 23 patients (10.9%) were positive for HPV DNA by SB. Cytologic findings in these 23 patients demonstrated changes compatible with low-grade squamous intraepithelial lesions (LGSIL) and HPV-associated changes in 4 cases (17%). Cervical biopsies obtained in 3 cases with abnormal cytology demonstrated LGSIL in all cases. 6 patients were retested for HPV 2 to 6 months after the initial positive, two showed persistence of the initial virus, one was positive for a different HPV type and three were negative for HPV DNA.