Neonatal alloimmune thrombocytopenia due to HPA-3a antibodies: a case report

A healthy infant was born at term by elective cesarean section to a 32-year-old para 4, gravida 4, mother. Within 24 hours, the infant was noted to have fairly extensive bruising on the back and shoulders. A full blood count evaluation was remarkable for severe thrombocytopenia (platelet count of 29 x 10(9)/L). Other hematologic parameters were normal. Human leukocyte antigen (HLA) class-1 antibodies but not platelet-specific antibodies were detectable in the maternal serum using a commercial antigen-capture ELISA (GTI-PakPlus kit). Anti-HPA-3a antibodies, while weakly reactive in the monoclonal antibody immobilization of platelet antigens (MAIPA) assay in the immediate postpartum serum, were readily detectable using this assay in a sample taken 4 weeks later. Genotyping for human platelet antigens (HPA) 1-5 by the polymerase chain reaction technique with sequence-specific primers (PCR-SSP) revealed the infant's platelet genotype to be HPA-1a/1a, 3a/3b, while that of the mother was HPA-1a/1a, 3b/ 3b, consistent with a diagnosis of anti-HPA-3a neonatal alloimmune thrombocytopenia (NAIT). This case illustrates the increased sensitivity of the MAIPA technique for the detection of platelet-specific antibodies. We believe this to be the first serologically confirmed case of NAIT due to anti-HPA-3a to be reported in the republic of Ireland.

Recurrent transfusion-related acute lung injury

BACKGROUND

Transfusion-related acute lung injury (TRALI) is a rare condition that is commonly associated with the transfusion of donor plasma containing WBC antibodies. Biologically active lipids that accumulate during storage of RBCs and platelets may also cause TRALI. There has been only one previously reported case of recurrent TRALI.

CASE REPORT

A patient received a transfusion 2 days after undergoing hysterectomy; she developed TRALI after receiving the transfusion. The patient recovered after being on ventilation for 6 days but received an additional transfusion and had a second episode of TRALI, which required further ventilation.

RESULTS

Laboratory investigation of the first episode of TRALI suggested the presence of HLA-A2 (N = 1) and granulocyte-specific IgM antibodies (N = 2) in the sera from three of the donors. All three sera reacted in crossmatch studies with the patient's granulocytes and lymphocytes. Lymphocyte-specific IgG antibodies were detected in the patient's serum. There was no evidence to suggest the involvement of WBC antibodies in the second episode of TRALI. Antibody screening of the donors' samples and both forward and reverse crossmatch studies were negative.

CONCLUSION

The first episode of TRALI seems to be due to the action of HLA-A2 and granulocyte-specific IgM antibodies. The second episode may have been due to the action of lipid neutrophil-priming agents in the donors' units in association with the patient's underlying pulmonary condition (i.e., recovering from lung injury). TRALI can recur if a patient requires further transfusion support shortly after an initial episode of TRALI.

The effect of treatment with Campath-1H in patients with autoimmune cytopenias

We describe 21 patients with severe and life-threatening autoimmune cytopenias resistant to standard immunosuppression who were treated with the monoclonal antibody Campath-1H. Four patients had autoimmune neutropenia, four had autoimmune haemolytic anaemia, four had pure red cell aplasia, one had immune thrombocytopenia purpura (ITP), three had autoimmune haemolytic anaemia and ITP (Evan's syndrome), three had autoimmune pancytopenia (ITP, autoimmune neutropenia and autoimmune haemolytic anaemia), one had ITP (associated with acquired Glanzmann's disease) and autoimmune neutropenia, and one had ITP and red cell aplasia. Campath-1H was administered at a dose of 10 mg/d as an intravenous infusion for 10 d. Responses were seen in 15 patients, which were sustained in six. Relapse occurred in eight patients after Campath-1H treatment. Patients entering the study later, received cyclosporine after Campath-1H in an attempt to reduce the incidence of relapse. Three patients received a second course of Campath-1H; all responded but later relapsed. Fourteen patients are alive at a median of 12 months (range 4-61) after Campath-1H. Campath-1H represents an alternative therapeutic option for severe, refractory autoimmune cytopenias.

Neurochemical and electrophysiological evidence that 5-HT4 receptors exert a state-dependent facilitatory control in vivo on nigrostriatal, but not mesoaccumbal, dopaminergic function

In this study we investigated, using in vivo microdialysis and single unit recordings, the role of serotonin4 (5-HT4) receptors in the control of nigrostriatal and mesoaccumbal dopaminergic (DA) pathway activity. In freely moving rats, the 5-HT4 antagonist GR 125487 (1 mg/kg, i.p.), without effect on its own, significantly reduced the enhancement of striatal DA outflow induced by 0.01 (-35%) and 0.1 (-66%), but not 1 mg/kg, s.c. haloperidol (HAL). Intrastriatal infusion of GR 125487 (1 microM) had no influence on basal DA outflow, but attenuated (-49%) the effect of 0.01 mg/kg HAL. Systemic administration of GR 125487 modified neither basal nor 0.01 mg/kg HAL-stimulated accumbal DA outflow. In halothane-anaesthetized rats, 1 or 10 mg/kg GR 125487, without effect by itself, failed to modify the changes in accumbal and striatal DA outflow elicited by electrical stimulation (300 microA, 1 ms, 20 Hz, 15 min) of the dorsal raphe nucleus. Finally, GR 125487 (444 microg/kg, i.v.), whilst not affecting basal firing of DA neurons within either the substantia nigra or the ventral tegmental area, reduced HAL-stimulated (1--300 microg/kg, i.v.) impulse flow of nigrostriatal DA neurons only. These results indicate that 5-HT4 receptors exert a facilitatory control on both striatal DA release and nigral DA neuron impulse flow only when nigrostriatal DA transmission is under activated conditions. Furthermore, they indicate that the striatum constitutes a major site for the expression of the control exerted by 5-HT4 receptors on DA release. In contrast, 5-HT4 receptors have no influence on mesoaccumbal DA activity in either basal or activated conditions.

Transfusion-related acute lung injury associated with interdonor incompatibility for the neutrophil-specific antigen HNA-1a

BACKGROUND AND OBJECTIVES

A patient transfused with two pooled platelet concentrates became breathless. Bilateral infiltrates were seen on chest X-ray. A diagnosis of transfusion-related acute lung injury (TRALI) was made. The patient received 100% oxygen and recovered after 5 days.

MATERIALS AND METHODS

Antibody screening, cross-matching for granulocyte and lymphocyte antibodies and typing for granulocyte antigens was undertaken.

RESULTS

The patient typed as HNA-1b/HNA-1b. Granulocyte and lymphocyte antibodies were not detected in the patient's serum or in any of the donor sera by cross-match. In antibody screening against typed panel granulocytes, complement-fixing anti-HNA-1a IgM antibodies were detected in the serum of one female donor. Two of the other donors who contributed to the pooled platelet concentrate containing the HNA-1a IgM antibodies typed as HNA-1a/HNA-1b.

CONCLUSION

Anti-HNA-1a IgM antibodies may have formed immune complexes with white cell fragments or soluble FcgammaRIII from HNA-1a+ donors in the pooled platelet concentrate and initiated TRALI.

Reduced antinociception and plasma extravasation in mice lacking a neuropeptide Y receptor

Neuropeptide Y (NPY) is believed to exert antinociceptive actions by inhibiting the release of substance P and other 'pain neurotransmitters' in the spinal cord dorsal horn. However, the physiological significance and potential therapeutic value of NPY remain obscure. It is also unclear which receptor subtype(s) are involved. To identify a possible physiological role for the NPY Y1 receptor in pain transmission, we generated NPY Y1 receptor null mutant (Y1-/-) mice by homologous recombination techniques. Here we show that Y1-/- mice develop hyperalgesia to acute thermal, cutaneous and visceral chemical pain, and exhibit mechanical hypersensitivity. Neuropathic pain is increased, and the mice show a complete absence of the pharmacological analgesic effects of NPY. In the periphery, Y1 receptor activation is sufficient and required for substance P release and the subsequent development of neurogenic inflammation and plasma leakage. We conclude that the Y1 receptor is required for central physiological and pharmacological NPY-induced analgesia and that its activation is both sufficient and required for the release of substance P and initiation of neurogenic inflammation.

Role of cholinergic and GABAergic systems in the feedback inhibition of dorsal raphe 5-HT neurons

Several observations indicate that 5-HT1A receptors found on a long neuronal feedback loop, originating from the medial prefrontal cortex, regulate 5-HT neuronal firing. In the present study, the muscarinic (M) receptor antagonists atropine and scopolamine as well as the M2 receptor antagonist AF-DX 116, but not the preferential M1 receptor antagonist pirenzepine, reduced the suppressant effect of the 5-HT1A receptor agonist 8-OH-DPAT on the spontaneous firing activity of rat dorsal raphe 5-HT neurons. Moreover, AF-64A-induced lesions of cholinergic neurons directly in the medial prefrontal cortex and after its i.c.v. injection attenuated the effect of 8-OH-DPAT. Finally, the NMDA receptor antagonist (+)MK-801 and the GABA(B) receptor antagonist SCH-50911, but not the GABA(A) receptor antagonist (-)bicuculline, dampened the latter response. The present study unveiled a key role for the cholinergic and GABAergic systems in the feedback inhibition of dorsal raphe 5-HT neurons.

[Epidemiology and etiology of acquired heart valve diseases in adults]

Acquired valvular heart disease remains common. Their causes have changed during the past 30 years with the increase in life expectancy and with the decrease in the incidence of rheumatic fever. Calcific aortic stenosis is currently the predominant cause, followed by left heart valvular regurgitations due to degenerative disease and infective endocarditis. Post-radiation valvular disease might become more frequent in the future. More recently, left heart valvular diseases were observed in the United States in patients treated by anorexigen treatment.

Endogenous serotonin enhances the release of dopamine in the striatum only when nigro-striatal dopaminergic transmission is activated

In this study, we use in vivo microdialysis to investigate the influence of endogenous serotonin (5-HT) on striatal dopamine (DA) and 5-hydroxyidoleacetic acid (5-HIAA) efflux in both basal and activated conditions. The selective serotonin reuptake inhibitors citalopram and fluoxetine were used to mobilize endogenous 5-HT. In halothane-anaesthetized rats, citalopram (5 mg/kg, i.p.), administered either alone or in combination with the 5-HT(1A) receptor antagonist WAY 100635 (0.1 mg/kg, s.c.), while reducing striatal 5-HIAA outflow (-25 and -15%, respectively), had no effect on basal DA output. When locally applied into the striatum, citalopram had no effect at 1 microM concentration, but enhanced DA release after its perfusion at 25 and 100 mircroM concentrations (+27% and +67%, respectively). However, the injection of the neurotoxin 5,7-dihydroxytryptamine into the dorsal raphe nucleus, which markedly depleted 5-HT in the striatum, failed to modify the effect of 25 microM citalopram. In freely-moving rats, the intrastriatal infusion of citalopram or fluoxetine (1 microM each), had no effect on its own, but significantly enhanced the increase in DA outflow induced by the subcutaneous administration of 0.01 mg/kg haloperidol (+31% and +30% for citalopram and fluoxetine, respectively). These findings indicate that, in the striatum, endogenous 5-HT has no influence on DA release under basal conditions, but positively modulates DA outflow when nigro-striatal DA transmission is activated.

The effect of serotonergic agents on haloperidol-induced striatal dopamine release in vivo: opposite role of 5-HT(2A) and 5-HT(2C) receptor subtypes and significance of the haloperidol dose used

This study investigated, using microdialysis in freely-moving rats, the role of serotonin (5-HT) and 5-HT(2) receptor subtypes in the enhancement of striatal dopamine (DA) release induced by various doses of haloperidol. The subcutaneous injection of 0.01, 0.1 or 1 mg/kg haloperidol dose-dependently increased DA outflow (160, 219 and 230% of baseline, respectively). The effect of 0.01 mg/kg haloperidol was, respectively, potentiated by the 5-HT uptake inhibitor citalopram (1 mg/kg, s.c.; +35%) and reduced by the 5-HT(1A) receptor agonist 8-OH-DPAT (0.025 mg/kg, s.c.; -32%). Also, it was reduced by the 5-HT(2A) antagonist SR 46349B (0.5 mg/kg, s.c. ; -40%) or by the 5-HT(2A/2B/2C) antagonist ritanserin (1.25 mg/kg, i.p.; -34%), and potentiated by the 5-HT(2B/2C) antagonist SB 206553 (5 mg/kg, i.p; +78%). Further, only this latter compound significantly modified basal dopamine release by itself (+26%). Dopamine released by 0.1 mg/kg haloperidol was enhanced (+100%) by citalopram, decreased (-61%) by SR 4634B, but unaltered by SB 206553. Finally, none of the compounds used were able to modify the enhancement of dopamine release induced by 1 mg/kg haloperidol. These results show that central 5-HT(2A) and 5-HT(2C) receptors exert an opposite (respectively excitatory and inhibitory) influence on DA release. Moreover, they suggest that the 5-HT(2A)-dependent modulation depends on the degree of central DA receptor blockade.

IgA myeloma of donor origin arising 7 years after allogeneic renal transplant

We report the case of a 38-year-old man who developed IgA myeloma of donor origin 7 years after allogeneic renal transplant. The diagnosis of multiple myeloma was unequivocal and based on positive results from serum electrophoresis, skeletal survey and bone marrow investigations. The donor origin of the myeloma cells was confirmed by DNA fingerprinting. We believe this is the first reported case of disseminated multiple myeloma of donor origin developing after allogeneic renal transplant and, as such, gives some insight into the natural history and biology of the disease.

Role of striatal serotonin2A and serotonin2C receptor subtypes in the control of in vivo dopamine outflow in the rat striatum

This study investigated, using in vivo microdialysis in the striatum of freely moving rats, the role of striatal serotonin2A (5-HT2A) and 5-HT2C receptor subtypes in the modulation of dopamine (DA) and 3, 4-dihydroxyphenylacetic acid (DOPAC) outflow, both in basal conditions and under activation induced by subcutaneous administration of 0.01 mg/kg haloperidol. The different 5-HT2 agents used were applied intrastriatally at a 1 microM concentration through the microdialysis probe. Basal DA efflux was enhanced (27%) by the 5-HT2A/2B/2C agonist 1-(4-iodo-2,5-dimethoxyphenyl)-2-aminopropane (DOI) and reduced (-30%) by the 5-HT2B/2C antagonist SB 206553. It was unaffected by infusion of the 5-HT2A antagonist SR 46349B. The effect of DOI was abolished by SB 206553 but not modified by SR 46349B. Haloperidol-stimulated DA efflux (65-70%) was reduced by both SR 46349B (-32%) and the 5-HT2A/2B/2C antagonist ritanserin (-30%) but not affected by SB 206553. Conversely, the effect of haloperidol was potentiated (22%) when DOI was coperfused with SB 206553. Also, haloperidol-stimulated DOPAC outflow (40-45%) was reduced (-20%) by SR 46349B and potentiated (25%) by the combination of SB 206553 with DOI. These results indicate that striatal 5-HT2A receptors, probably through activation of DA synthesis, positively modulate DA outflow only under activated conditions. In contrast, striatal 5-HT2C receptors exert a facilitatory control on basal DA efflux, which appears to be both tonic and phasic.

Expression of the imprinted tumour-suppressor gene H19 is tightly regulated during normal haematopoiesis and is reduced in haematopoietic precursors of patients with the myeloproliferative disease polycythaemia vera

cDNA subtraction was employed to uncover differences in gene expression between myeloproliferative polycythaemia vera (PV) and normal haematopoietic precursors. Following cDNA subtraction using mRNAs isolated from PV and normal CD34+/CD33- bone-marrow cells, expression of the tumour suppressor H19 was found to be low or absent in the PV sample. Low levels of H19 expression in PV patients were confirmed by in situ hybridization. Using semi-quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) to examine expression in the pluripotent haematopoietic cell line FDCP-mix and single bone-marrow precursors, unambiguous IGF2 and H19 expression was demonstrated in normal haematopoietic precursors. Examination of individual bone-marrow precursors revealed that all IGF2-expressing haematopoietic precursors also co-expressed H19, indicating that H19 and IGF2 may be co-ordinately regulated during haematopoiesis. Analysis of FDCP-mix undergoing differentiation and single pluripotent and committed bone-marrow precursors revealed that the pattern of H19 expression coincided with the commitment to a single lineage. Taken together, these observations demonstrate that H19 and IGF2 are specifically expressed during haematopoiesis and that low levels of H19 expression are associated with PV and may contribute to the pathology of the disease.

Laparoscopic repair of bilateral and recurrent hernias

The optimal inguinal hernia repair has been controversial for decades. Since the advent of minimally invasive surgery, laparoscopic techniques have added to the controversy. Laparoscopic hernia repair has been advocated by many experts for the repair of bilateral and recurrent inguinal hernias. This study reviews the experience of a single community-based teaching hospital using the total extraperitoneal (TEP)-approach laparoscopic hernia repair for treating patients with bilateral and/or recurrent inguinal hernias. Since the TEP approach was adopted in June 1993, a total of 457 patients were treated for bilateral (322 patients) and/or recurrent (175) inguinal hernias (40 patients had recurrent and bilateral hernias). A total of 779 hernias were repaired with this technique. The average age of this patient group was 47 years, and there were 413 males and 44 females. Operative time averaged 68.3 minutes per patient, and there were 26 (5.7%) minor complications. There were 2 (0.4%) major complications, an enterotomy and a cystotomy, both early in the series and both in patients with previous lower abdominal surgery. There have been no deaths. With an average follow-up of 30 months (range, 1-60 months), there have been three (0.2%) recurrences. These recurrences were due to technical problems (inadequate mesh coverage), and each was repaired with a laparoscopic transabdominal approach or an anterior open approach. The use of the TEP-approach laparoscopic hernia repair is safe and effective in patients with recurrent and/or bilateral inguinal hernias.

Laparoscopy for diagnosis and staging of malignancy

The use of minimally invasive surgery for abdominal pathology, including malignancy, has increased significantly within the past decade. Despite the advances in radiographic imaging, the use of laparoscopy for diagnosing and staging abdominal malignancy has become an important tool in the overall care of these patients. A review of published series for a variety of abdominal malignancies is presented. With the growing experience in this technique, some preliminary conclusions and ongoing issues are discussed.

Macrophage-inflammatory protein-1alpha receptor expression on normal and chronic myeloid leukemia CD34+ cells

We have assessed expression of MIP-1alpha binding sites on the surface of CD34+ cells from normal bone marrow (NBM) and chronic myeloid leukemia (CML) peripheral blood. This study has highlighted a small subpopulation of CD34+ (15.7 +/- 6.2% in NBM and 9 +/- 4% in CML), which has specific macrophage-inflammatory protein-1alpha (MIP-1alpha) cell surface binding sites. Further phenotypic characterization of the receptor-bearing cells has shown that they do not express the Thy-1 Ag, suggesting that they are committed progenitor cells rather than CD34+ Thy+ stem cells. However, more than 80% of methanol-fixed CD34+ cells do bind MIP-1alpha, suggesting that these cells may possess a pool of internal receptors, although we were unable to induce cell surface expression by cytokine stimulation. The percentage of these CD34+, MIP-1alpha-R+ cells present in the CD34 compartment of NBM is significantly higher than in CML, implicating lack of binding sites as part of the mechanism for the loss of response to this chemokine seen in CML. Specific Ab to the MIP-1alpha receptor implicated in HIV infection, CCR5, revealed that very few CD34+ cells expressed these receptors and that expression was confined to the CD34+ Thy- progenitor population. Data presented in this work suggest that active binding sites for the stem cell growth inhibitor MIP-1alpha are not constitutively expressed on the surface of most resting primitive multipotent cells, and that these cells are not potential targets for HIV-1 infection through CCR5.

Transfusion-related acute lung injury (TRALI) following autologous stem cell transplant for relapsed acute myeloid leukaemia: a case report and review of the literature

A fatal case of transfusion-related acute lung injury (TRALI) in a child post-autologous stem cell transplant for relapsed acute myeloid leukaemia is described. The implicated product was a single unit platelet concentrate containing anti-HLA A2 and granulocyte-specific anti-NA1 antibodies. The recipient typed as HLA A2/A2, NA1/NA1. This is the first reported case of TRALI following a transplant procedure for a haematological condition. It is also unusual in that the patient failed to make a full recovery and that two relevant leucocyte antibodies of clear specificity were identified in the donor plasma. The literature relating to the pathophysiology, clinical sequelae and management of TRALI is reviewed.

The hazard of spatial disorientation during helicopter flight using night vision devices

INTRODUCTION

Night Vision Devices (NVDs) provide an enormous advantage to the operational effectiveness of military helicopter flying by permitting flight throughout the night. However, compared with daytime flight, many of the depth perception and orientational cues are severely degraded. These degraded cues predispose aviators to spatial disorientation (SD), which is a serious drawback of these devices.

METHODS

As part of an overall analysis of Army helicopter accidents to assess the impact of SD on military flying, we scrutinized the class A-C mishap reports involving night-aided flight from 1987 to 1995. The accidents were classified according to the role of SD by three independent assessors, with the SD group further analyzed to determine associated factors and possible countermeasures.

RESULTS

Almost 43% of all SD-related accidents in this series occurred during flight using NVDs, whereas only 13% of non-SD accidents involved NVDs. An examination of the SD accident rates per 100,000 flying hours revealed a significant difference between the rate for day flying and the rate for flight using NVDs (mean rate for daytime flight = 1.66, mean rate for NVD flight = 9.00, p < 0.001). The most important factors associated with these accidents were related to equipment limitations, distraction from the task, and training or procedural inadequacies.

CONCLUSIONS

SD remains an important source of attrition of Army aircraft. The more than fivefold increase in risk associated with NVD flight is of serious concern. The associated factors and suggested countermeasures should be urgently addressed.

The ability of the chemiluminescence test to predict clinical outcome and the necessity for amniocenteses in pregnancies at risk of haemolytic disease of the newborn

The chemiluminescence test measures the ability of anti-D to sensitise red cells for recognition by monocytes. It predicts clinical outcome in haemolytic disease of the newborn with greater precision than quantification of anti-D levels by AutoAnalyzer. However, whether or not the chemiluminescence test can, or should, affect clinical management is not clear. Of 56 alloimmunised women referred to a single fetal medicine unit, 30 underwent a total 63 amniocenteses to establish the extent of fetal haemolysis. Overall, chemiluminescence test results were a better predictor of amniocenteses with elevated bilirubin levels than the AutoAnalyzer (P < 0.01). Chemiluminescence results > 30% were always associated with elevated bilirubin levels. The chemiluminescence test might be used to prompt the direct evaluation of fetal haemolysis in patients with borderline levels of anti-D (5-15 IU/mL). However, the ability of the test to predict amniocenteses with normal bilirubin levels was less clear.

[Transesophageal echocardiography before electric cardioversion for supraventricular arrhythmia]

OBJECTIVES

The aim of this prospective study was to assess the risks of electrical shock cardio-version in the treatment of supraventricular rhythm disorders when administered under effective-dose but short duration anticoagulation in patients with no intracavitary thrombus detectable by transesophageal echocardiography.

PATIENTS AND METHODS

One hundred nineteen patients, mean age 66 years, with permanent arrhythmia due to atrial fibrillation (n = 102), atrial flutter (n = 16) or atrial tachycardia (n = 1) and taking no long-term anticoagulant therapy were treated by electrical shock cardioversion. The patients were given heparin at an effective dose 72 hours prior to cardioversion. A transthoracic and a transesophageal echocardiography were performed less than 24 hours prior to cardioversion.

RESULTS

Twenty-one thrombi were evidenced in 16 patients (14.6%) including 18 in the left auricle, 1 in the left atrium and 2 in the right atrium. A spontaneous contrast was visualized in 38 patients (32%). Cardioversion was performed in 103 patients without thrombus and later in 9 of the 16 patients with thrombus after absorption under anticoagulant therapy as evidenced on the control transesophageal echocardiography. A sinus rhythm was obtained in 82% of the cases. All patients were given anti-vitamin K anticoagulants for one month. There were no clinical manifestation of ischemic vascular events during cardioversion nor during the one-month follow-up.

CONCLUSION

Early use of electrical shock cardioversion in patients with supraventricular rhythm disorders can be proposed without long-term anticoagulation therapy if the absence of thrombi is demonstrated by transesophageal echocardiography and short-term heparin is given followed by oral anticoagulants for at least 4 weeks. A large-scale randomized prospective study comparing the conventional strategy with the protocol used in this study would be required to definitively validate this approach and determine its possible advantages.

Eosinophilic colitis presenting as a left-sided colocolonic intussusception with secondary large bowel obstruction: an uncommon entity with a rare presentation

Eosinophilic gastroenteritis is a quite uncommon clinical entity usually involving the stomach or small bowel. Occasionally, the colon is involved. We have encountered a case of eosinophilic colitis leading to a left-sided colocolonic intussusception and subsequent large bowel obstruction. This is a unique presentation that, to our knowledge, has not been previously reported. We present our case in detail as well as a review of the literature to better understand this rare clinical entity.

Penetration of trovafloxacin into cerebrospinal fluid in humans following intravenous infusion of alatrofloxacin

A single-dose study was conducted to determine concentrations of trovafloxacin (CP-99,219) achieved in the cerebrospinal fluid (CSF) relative to those in the serum of healthy subjects after intravenous infusion of alatrofloxacin (CP-116,517), the alanyl-alanyl prodrug of trovafloxacin. Twelve healthy subjects were administered single doses of alatrofloxacin at a trovafloxacin equivalent of 300 mg as an intravenous infusion over 1.0 h. CSF samples were taken by lumbar puncture at 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 24 h after the start of the infusion; each subject was sampled at only one time point. Serum samples were taken from each subject at the time of CSF collection. A mean concentration of 5.8 microg of trovafloxacin per ml was present in serum 1.0 h after the start of the infusion. CSF/serum ratios ranged from 0.14 to 0.33 in the postdistribution phase (5 to 24 h postinfusion), with a mean ratio of 0.25. The most common adverse events were dizziness, nausea, and rash and were mild or moderate in intensity. The potency of trovafloxacin against susceptible organisms, coupled with its rapid penetration of CSF following the intravenous administration of alatrofloxacin, suggests that it may be useful in the treatment of bacterial meningitis in humans.

8-OH-DPAT, a 5-HT1A agonist and ritanserin, a 5-HT2A/C antagonist, reverse haloperidol-induced catalepsy in rats independently of striatal dopamine release

In this study, both catalepsy and changes in extracellular levels of striatal dopamine (DA) and dihydroxyphenyl acetic acid (DOPAC) induced by the typical neuroleptic haloperidol (HAL) were simultaneously assessed, using intracerebral microdialysis in freely moving rats, in the presence of either the 5-HT1A agonist 8-OH-DPAT or the 5-HT2A/C antagonist ritanserin. HAL (1 mg/kg, SC) elicited a strong cataleptic state, reaching its maximal intensity (about 240 s) 2 h after the drug administration. This effect was paralleled by a long-lasting enhancement of striatal DA and DOPAC extracellular levels, reaching 230 and 350% of basal values, respectively. 8-OH-DPAT (0.1 mg/kg, SC) given 2.5 h after, and ritanserin (0.63 and 1.25 mg/kg, IP), given 15 min prior to HAL, significantly reduced the neuroleptic-induced catalepsy. However, both 5-HT agents failed to modify basal DA and DOPAC striatal outflow as well as the stimulatory effect of HAL on these parameters. It can thus be concluded that the anticataleptic effect of these compounds is not related to an alteration of DA release within the striatum.

Pheochromocytoma, chronic renal insufficiency, and hemodialysis: a combination leading to a diagnostic and therapeutic dilemma

Pheochromocytomas are functioning paragangliomas often presenting with paroxysmal hypertension due to catecholamine secretion. The preferential diagnostic workup includes urine and serum catecholamine measurements. Therapeutic management consists of pharmacologic cardiovascular manipulation and volume expansion with subsequent surgical resection. We have encountered a symptomatic pheochromocytoma in a chronic renal insufficiency patient on hemodialysis. The diagnostic dilemma arose due to the patient's anuric status and the inherent increase in serum catecholamine levels noted in anuric patients. The therapeutic dilemma arose in the proper pharmacologic management and volume expansion in this patient on hemodialysis. The patient underwent successful resection of the pheochromocytoma and has done well. An analysis of our diagnostic and therapeutic processes as well as a review of the literature are presented to assist in the management of this difficult clinical situation.

Serotonin stimulation of 5-HT4 receptors indirectly enhances in vivo dopamine release in the rat striatum

Serotonin (5-HT) applied at 1, 3, and 10 microM into the striatum of halothane-anesthetized rats by in vivo microdialysis enhanced dopamine (DA) outflow up to 173, 283, and 584% of baseline values, respectively. The 5-HT effect was partially reduced by 1 or 10 microM GR 125,487, a 5-HT4 antagonist, and by 100 microM DAU 6285, a 5-HT3/4 antagonist, whereas the 5-HT1/2/6 antagonist methiothepin (50 microM) was ineffective. In the presence of tetrodotoxin the effect of 1 microM 5-HT was not affected by 5-HT4 antagonists. In addition, tetrodotoxin abolished the increase in DA release induced by the 5-HT4 agonist (S)- zacopride (100 microM). In striatal synaptosomes, 1 and 10 microM 5-HT increased the outflow of newly synthesized [3H]DA up to 163 and 635% of control values, respectively. The 5-HT4 agonists BIMU 8 and (S)-zacopride (1 and 10 microM) failed to modify [3H]DA outflow, whereas 5- methoxytryptamine (5-MeOT) at 10 microM increased it (62%). In prelabeled [3H]DA synaptosomes, 1 microM 5-HT, but not (S)-zacopride (1 and 10 microM), increased [3H]DA outflow. DAU 6285 (10 microM) failed to modify the enhancement of newly synthesized [3H]DA outflow induced by 5-MeOT or 5-HT (1 microM), whereas the effect of 5-HT was reduced to the same extent by the DA reuptake inhibitor nomifensine (1 microM) alone or in the presence of DAU 6285. These results show that striatal 5-HT4 receptors are involved in the 5-HT-induced enhancement of striatal DA release in vivo and that they are not located on striatal DA terminals.

Biomechanical and computer analysis of radial head prostheses

Radial head fractures can lead to significant upper extremity disability. A comminuted radial head fracture with a medial collateral ligament tear presents a clinical conundrum. The radiocapitellar (RC) joint should be maintained, yet the head frequently cannot be reduced and stabilized. The silicone rubber implant currently available is not biomechanically or clinically satisfactory, and thus there is a need for a more suitable prosthetic replacement for the radial head. We have attempted to design such a prosthesis and have examined prosthetic design with various materials that would best transmit force of the RC joint. Design configurations based on our cadaveric and radiographic measurements were tested with structural finite element method computer analyses. Materials examined included titanium alloy, cobalt-chrome alloy, alumina ceramic, and ultrahigh molecular weight polyethylene (UHMWPE). Metals and ceramic transmitted force at the distal bone and implant interface and strain shielded the proximal radial cortex while UHMWPE distributed load uniformly through the cortex and along the entire bone and implant interface. In addition, load transmission comparisons were made with the intact radial head, with a silicone prosthesis, and with 6 and 10 mm thick UHMWPE prostheses in cadaveric specimens. UHMWPE prostheses transmit more force to the RC joint than the silicone prosthesis and with leads closer to physiologic levels at all flexion angles. UHMWPE prostheses not only transmit much more force than silicone, but because of substantially less deformation under load, also provide more stability to the joint.

A comparison of the effect of bcr/abl breakpoint specific phosphothiorate oligodeoxynucleotides on colony formation by bcr/abl positive and negative, CD34 enriched mononuclear cell populations

In chronic myeloid leukaemia, the expression by clonal cells, of a leukaemia specific bcr/abl chimeric mRNA, makes the condition suitable for the application of "antisense" strategies. Furthermore, the origin of the condition in a pluripotential progenitor allows enrichment of leukaemic clonogenic cells by selection for CD34 expression, together with a useful reduction in contaminating accessory cells. In a methylcellulose clonogenic assay system we incubated bcr/abl expressing (n = 9) and bcr/abl negative (n = 8), CD34 enriched progenitors with phosphothiorate oligodeoxynucleotides (PS oligomers), antisense and sense to the b3a2 and b2a2 chimeric bcr/abl junctional sequences. All samples were cloned in the presence of both antisense, and sense PS oligomers to provide appropriate controls. For bcr/abl positive progenitors, the mean number of colonies formed was reduced by 21 (39%) (P < 0.05) in the presence of the specific antisense oligomer, 11 (20%) (P < 0.05) with the antisense oligomer directed to the alternative junctional breakpoint, and colony formation was not significantly altered by either sense PS oligomer. Colony formation by bcr/abl negative progenitors was not reproducibly reduced by any of the PS oligomers. These results confirm that PS oligomers can have a sequence dependent inhibitory effect on a CD34 enriched progenitor population from patients with chronic myeloid leukaemia.

Expression of either the TCL1 oncogene, or transcripts from its homologue MTCP1/c6.1B, in leukaemic and non-leukaemic T cells from ataxia telangiectasia patients

Patients with the recessively inherited disorder ataxia telangiectasia (A-T) have a high level of specific chromosome translocations which can be easily observed in peripheral T cells and show a greatly increased predisposition to leukaemia/lymphoma, mainly of T cell origin. Some translocation cells proliferate into a large clone and may develop into T cell prolymphocytic leukaemia (T-PLL). By the time of diagnosis of T-PLL, the clone contains many more genetic changes in the form of additional translocations. T-PLL is also seen in non-A-T individuals where expression of either TCL1 (at 14q32) or the c6.1B/MTCP1 A1 transcript (at-Xq28) has been demonstrated in just a few instances. We show here, that expression of TCL1 occurs in leukaemic T cells from A-T patients with chromosome 14 rearrangements. Expression of TCL1 also occurs in the preleukaemic clone cells of A-T patients containing the primary translocation alone. Some expression of TCL1 could also be detected in randomly selected A-T patients without large cytogenetic clones and without any evidence of leukaemic change. We also show that expression of the B1 transcript from a second gene, MTCP1, occurred at a relatively high level only in two T-PLL tumours from A-T patients with t(X;14) translocations whereas the MTCP1/A1 transcript is much more widely expressed in both tumour and non tumour cells of A-T and non-A-T individuals.

Major surgery in haemophilic patients with inhibitors using recombinant factor VIIa

In the haemophilic patient, development of antibodies that inhibit the function of the missing coagulation factor causes several delicate problems. Most importantly, antibodies will block the function of the specific coagulation factor, and often the antibody activity is so fierce that effective substitution therapy is outruled. In consequence, alternative measures must be adopted to control bleeding. Amongst those most commonly employed, like factor IX concentrates, activated prothrombin complex concentrates, and factor VIII of porcine origin, a new recombinant activated factor VII molecule has been evaluated clinically for some years with promising results. The aim of the present paper was to present a series of patients suffering from haemophilia A or B in whom inhibitors have complicated the clinical picture, and in whom a surgical procedure was indicated. As part of a compassionate use program devised by the producer of this genetically engineered factor VIIa, 12 patients underwent life-saving or essential surgery where the recombinant factor VIIa product was used to promote haemostasis in 13 surgical procedures. Due to a short in vivo half-life of activated factor VIIa, frequent administration was scheduled, injecting factor VIIa every 2-3 h for up to 2 days after which dosage intervals were prolonged. In one case, a global evaluation of the end treatment result was not reported, but in all of the other 12 cases the end result were considered excellent (n = 11) or efficient (n = 1). In none of the cases was other types of coagulation factor treatment modalities necessary. In conclusion, recombinant factor VIIa seems a tempting alternative to traditional treatment of the haemophilic patient with inhibitors, in whom surgery is called for. With other types of haemostatic agents, surgery in haemophilic inhibitor patients has only been studied rarely, and operations have generally been restricted to life-threatening situations.

Testicular neoplasm presenting as a major pulmonary embolism

OBJECTIVE

To report an unusual and life-threatening presentation of a nonseminomatous germ cell tumor of the testis.

METHODS

A 35-year-old male presented with pulmonary embolism secondary to a neoplastic thrombus from a nonseminomatous germ cell tumor. Prompt management involved surgical thrombectomy with cardiopulmonary bypass and deep hypothermic circulatory arrest, followed by orchiectomy and adjuvant chemotherapy.

RESULTS

Three years later, the patient remains disease free according to physical examination, radiographic workup and serum markers.

CONCLUSION

The excellent long-term outcome of this patient supports an aggressive multidisciplinary management of nonseminomatous germ cell tumors in young adults.

Serotonin enhances striatal dopamine outflow in vivo through dopamine uptake sites

Serotonin (5-HT) administered at 1, 3, and 10 microM into the striatum of halothane-anesthetized rats by in vivo microdialysis increased extracellular dopamine (DA) in a concentration-dependent manner (approximately 65, 190, and 440%, respectively). These effects were reduced by 50% in the presence of 1 microM tetrodotoxin (TTX) or in the absence of Ca2+ ions. The DA uptake blocker nomifensine (0.1 microM) significantly lowered (by 50%) the enhancement of DA outflow induced by 3 microM 5-HT. Nomifensine (1 microM) coperfused with 1 microM TTX abolished the 1 and 3 microM 5-HT-induced DA outflow, whereas the effect of 10 microM 5-HT was significantly reduced by 1 (-55%) and 10 micro M (-70%) nomifensine. These data demonstrate that, in vivo, striatal DA uptake sites are partially involved in the DA-releasing action of 5-HT.

Surgical options for familial adenomatous polyposis

Familial adenomatous polyposis (FAP) is a genetic disorder transmitted in an autosomal dominant pattern. One-half of members of an affected family will carry the gene, and all carriers will succumb to colon cancer or extracolonic manifestations if not detected and treated early. When the diagnosis is made, surgery is indicated. Surgical options include total proctocolectomy with ileostomy, continent ileostomy, total colectomy with ileorectal anastomosis, and total proctocolectomy with ileal pouch anal anastomosis. Many diverse factors, such as extent of rectal disease, the presence and extend of carcinoma, sphincter function, and extracolonic disease, influence which surgical procedure is most appropriate for the individual patient with FAP. This article reviews the surgical options for treating FAP, with emphasis on specific indications, contraindications, and anticipated outcomes.

Initial brachytherapy in the breast conservation approach to breast cancer

The outcome of 100 consecutive newly diagnosed breast cancer patients treated between 1975 and 1985 within a protocol of planned segmental mastectomy and radiation therapy that included an initial brachytherapy boost is reported. Margins were not routinely inked in this study and the tumor bed was determined with the operating surgeon at the time of brachytherapy. There were 30 T1 tumors, 61 T2, and 9 T3. Segmental mastectomy was followed 2 weeks later by an interstitial implant with iridium-192 sources given as initial boost dose to the tumor bed, at the time of axillary dissection. All patients received at least 20 Gy as boost dose followed by external beam radiation to a total dose of 45-50 Gy to the breast and regional nodes delivered over a period of 4-5 weeks. With a median follow-up of 7 years a total of 3 (3%) breast recurrences were detected (1/30 in T1 tumors, 2/61 in T2 tumors). Only one of the three recurrences was at the initial tumor bed. None of the nine T3 patients included in this series recurred locally. There were 4 severe complications (2 soft tissue necroses and 2 osteonecroses) occurring in 2/30 T1 and in 2/61 T2. Cosmetic results were good to excellent in 77% of the cases and fair to poor in 23%. The actuarial local control and survival probability rate were, respectively, 95% and 85% at 5 years and 93% and 73% at 10 years. Initial brachytherapy boost to a target volume accurately determined with the operating surgeon followed by subsequent external beam radiotherapy achieved excellent local control in the breast even for lesions larger than 2 cm (70% of the reported cases).

Laparoscopic diagnosis and treatment of Morgagni hernia

The application of new minimally invasive techniques in the diagnosis and treatment of surgically correctable diseases continues to produce impressive results. Herniae of the Foramen of Morgagni are unusual abdominal wall defects which have historically been difficult to diagnose. Interestingly, laparoscopy was utilized for the diagnosis and repair of three such herniae during a 5-month period. All of these repairs were performed by one primary author in conjunction with co-authors. In this report we will review this rare hernia and report our technique of repair. We believe that an aggressive approach to diagnostic laparoscopy may produce cost-effective solutions to old and new intraabdominal problems.

Laparoscopic surgery for colorectal neoplasms

Laparoscopy is being used to assist in an increasing number and variety of bowel procedures. However, when being used for neoplastic disease concerns of margins and adequacy of mesenteric dissection must be addressed. We've performed 110 laparoscopic-assisted bowel procedures, with 45 of these performed for neoplastic disease. Ninety-two bowel resections were performed including 24 subtotal, total, or proctocolectomies. In this chapter we review the results of our series, as well as other reported series, and discuss some of the controversies involved with laparoscopy for neoplastic disease.

Occupational risk factors in patients with alcoholic or non-alcoholic liver disease

The present study examines the presence of specific occupational risk factors in a group of patients suffering from alcoholic liver disease compared with a group of patients with non-alcoholic liver disease. The first group was more dependent on alcohol, with fewer social or psychological alcohol-related problems. The majority of them were employed, although more likely to be employed in traditional 'high risk' occupations. They showed lower job satisfaction, and the total sum of all previously reported occupational risk factors was highly significant. This was the first empirical evidence in support of the importance of the specific occupational risk factors previously postulated.

Auditing drug metabolism protocols, data, and reports

A critical component of the drug discovery process is to assess the safety and metabolic disposition of a drug. This can be accomplished by evaluating drug concentration levels as part of safety assessment studies (toxicokinetics) and identifying the drug's presence in and throughout the body by conducting ADME (adsorption, distribution, metabolism, and excretion) studies. From a regulatory perspective, the major difference between these two types of evaluations is that toxicokinetic studies are under the purview of the Good Laboratory Practice (GLP) regulations (21 CFR 58) and ADME studies are not. International debate continues to resolve around the need to consider the applicability of the GLPs to ADME studies. While it is recognized that the current regulatory intent between ADME and toxicokinetic studies differs, this inspecting/auditing approach treats them generally the same. It assures management and external reviewers that data integrity measures are in place for all drug metabolism studies conducted by the facility.

Panlobar nephroblastomatosis with cystic dysplasia: an unusual case with diffuse renal involvement studied by immunohistochemistry

A unilateral cystic renal process discovered prenatally was removed in a neonate. Dysplastic cysts were associated with diffuse (both intra- and perilobar) nephroblastomatosis. We describe a comprehensive immunohistological study confirming the transition observed on simple histology between the different structures: nephrogenic rests (CD9+, CD24+/-, CD56+/-), glomeruloid bodies (CD10++, CD35++), ducts lined by columnar epithelium (CD9+, CD24+, CD56++), cysts lined by cuboidal or thin epithelium (some cells CD10+, CD26+, others EMA+, CD24+). Although no typical S-shaped bodies are seen, small cysts and ducts with a columnar epithelium are considered similar. The dysplastic primitive ducts are KL1++, vimentin+/-, CD9+, CD24+. With a view to assessing dysplastic preneoplastic potential, the value of CD56 and Ki67 as activation antigens with possible prognostic significance is discussed.

Reduction of HIV transmission during laparoscopic procedures

Laparoscopic surgery has recently been encouraged as an alternative to open procedures in patients infected with the human immunodeficiency virus (HIV). The laparoscopic technique reduces exposure to blood products and sharp instruments; however, it exposes the surgical team to the HIV-infected patient in a manner not encountered during open procedures. The evacuation of the pneumoperitoneum during laparoscopic procedures releases aerosolized HIV-infected blood and peritoneal fluid into the operative suite. Evacuation of the penumoperitoneum into a closed system and appropriate precautions during instrument changes will diminish the exposure of the surgical team to aerosolized HIV-infected blood and peritoneal fluid.