Capnocytophaga canimorsus bacteremia: clinical features and outcomes from a Helsinki ICU cohort

BACKGROUND

Capnocytophaga canimorsus is a gram-negative rod capable of causing severe sepsis or septic shock. We studied the characteristics of patients with C. canimorsus bacteremia treated in intensive care unit (ICU).

METHODS

Patients with C. canimorsus bacteremia in the Helsinki University Hospital district from 2005 to 2014 were retrospectively reviewed using laboratory database and electronical patient records.

RESULTS

We identified 65 patients with C.canimorsus bacteremia. Of these, 16 (25%) were treated in an ICU. The most commonly affected organ systems were coagulation (94%) and kidney (69%). Mortality of ICU treated patients was 19%. Three survivors underwent lower limb amputations for gangrene. Only 25% of the patients were immune-compromised, but alcohol abuse was common (69%). All patients had a contact with dogs, but only 37% had a history of a dog-bite.

CONCLUSION

Capnocytophaga canimorsus infection may present with severe sepsis or septic shock with organ dysfunction, most frequently coagulopathy and acute kidney injury. Previously recognized risk factors are not always present. A dog in a household may be a sufficient exposure for developing a severe form of the disease. The possibility of C. canimorsus infection should be considered in patients with any contact with dogs, even in immunocompetent patients.

Glucocorticoid receptor expression and binding capacity in patients with burn injury

BACKGROUND

Burn injuries are associated with strong inflammation and risk of secondary sepsis which both may affect the function of the glucocorticoid receptor (GR). The aim of this study was to determine GR expression and binding capacity in leucocytes from patients admitted to a tertiary burn center.

METHODS

Blood was sampled from 13 patients on admission and days 7, 14 and 21, and once from 16 healthy subjects. Patients were grouped according to the extent of burn and to any sepsis on day 7. Expression and binding capacity of GR were determined as arbitrary units using flow cytometry.

RESULTS

GR expression and binding capacity were increased compared to healthy subjects in most circulating leucocyte subsets on admission irrespective of burn size. Patients with sepsis on day 7 displayed increased GR expression in T lymphocytes (51.8%, P < 0.01) compared to admission. There was a negative correlation between GR binding capacity in neutrophils and burn size after 14 days (P < 0.05).

CONCLUSIONS

GR expression and binding capacity are increased in most types of circulating leucocytes of severely burned patients on their admission to specialized burn care. If sepsis is present after 1 week, it is associated with higher GR expression in T lymphocytes and NK cells.

A novel mutation in the sulfate transporter gene SLC26A2 (DTDST) specific to the Finnish population causes de la Chapelle dysplasia

BACKGROUND

Mutations in the sulfate transporter gene SLC26A2 (DTDST) cause a continuum of skeletal dysplasia phenotypes that includes achondrogenesis type 1B (ACG1B), atelosteogenesis type 2 (AO2), diastrophic dysplasia (DTD), and recessive multiple epiphyseal dysplasia (rMED). In 1972, de la Chapelle et al reported two siblings with a lethal skeletal dysplasia, which was denoted "neonatal osseous dysplasia" and "de la Chapelle dysplasia" (DLCD). It was suggested that DLCD might be part of the SLC26A2 spectrum of phenotypes, both because of the Finnish origin of the original family and of radiographic similarities to ACG1B and AO2.

OBJECTIVE

To test the hypothesis whether SLC26A2 mutations are responsible for DLCD.

METHODS

We studied the DNA from the original DLCD family and from seven Finnish DTD patients in whom we had identified only one copy of IVS1+2T>C, the common Finnish mutation. A novel SLC26A2 mutation was found in all subjects, inserted by site-directed mutagenesis in a vector harbouring the SLC26A2 cDNA, and expressed in sulfate transport deficient Chinese hamster ovary (CHO) cells to measure sulfate uptake activity.

RESULTS

We identified a hitherto undescribed SLC26A2 mutation, T512K, homozygous in the affected subjects and heterozygous in both parents and in the unaffected sister. T512K was then identified as second pathogenic allele in the seven Finnish DTD subjects. Expression studies confirmed pathogenicity.

CONCLUSIONS

DLCD is indeed allelic to the other SLC26A2 disorders. T512K is a second rare "Finnish" mutation that results in DLCD at homozygosity and in DTD when compounded with the milder, common Finnish mutation.

Prevalence and predictive value of ionized hypocalcemia among critically ill patients

BACKGROUND

Ionized hypocalcemia is common among critically ill patients, and it has been shown to correlate with increased mortality. The purpose of this study was to examine the performance and independence of ionized calcium (Ca2+) in prediction of all-cause day-30 mortality among critically ill adult patients.

METHODS

Of 993 critically ill patients treated in the Helsinki University Hospital during a 24-month period, the study comprised 941 patients without calcium supplementation. Patient and laboratory data were obtained retrospectively from an intensive care database. The discriminative powers of admission and lowest Ca2+ values regarding day-30 mortality were evaluated by producing receiver operating curves (ROC). Hazard ratios for death of severe and mild hypocalcemia were calculated by Cox regression model.

RESULTS

The prevalence of ionized hypocalcemia (Ca2+ <1.16 mmol l-1) was 85%. Of 941 patients, 45 (4.7%) had ionized calcium >1.3 mmol l-1 and were excluded from mortality analysis. Univariate Cox regression model revealed hazard ratios of 5.1 (95% confidence interval, CI 2.9-9.0) for severe (<0.90 mmol l-1) and 1.8 (95% CI 1.3-2.4) for mild ionized hypocalcemia (0.90-1.15 mmol l-1) on admission, but hypocalcemia was not shown to be independently associated with mortality by multivariate Cox regression model. In prediction of day-30 mortality admission and lowest Ca2+, levels had areas under curves of 0.636 and 0.671, respectively.

CONCLUSION

Ionized hypocalcemia is common among critically ill adults and it is associated with increased mortality. Although non-survivors and survivors differ significantly in admission Ca2+, hypocalcemia is not independently associated with day-30 mortality.

SLC26A2 (diastrophic dysplasia sulfate transporter) is expressed in developing and mature cartilage but also in other tissues and cell types

Mutated alleles of the SLC26A2 (diastrophic dysplasia sulfate transporter or DTDST) gene cause each of the four recessive chondrodysplasias, i.e., diastrophic dysplasia (DTD), multiple epiphyseal dysplasia (MED), atelosteogenesis Type II (AO2), and achondrogenesis Type IB (ACG1B). SLC26A2 acts as an Na(+)-independent sulfate/chloride antiporter and belongs to the SLC26 anion transporter gene family, currently consisting of six homologous human members. Although Northern analysis has indicated some expression in all tissues studied, the only tissue known to be affected by SLC26A2 mutations is cartilage. Abundant SLC26A2 expression has previously been detected in normal human colon by in situ hybridization. We have used in situ hybridization and immunohistochemistry to examine multiple normal tissues for the expression of human SLC26A2. As expected, a strong signal for SLC26A2 mRNA and protein immunostaining were detected in developing fetal hyaline cartilage, while bronchial cartilage showed mRNA expression in adult tissues. SLC26A2 expression could also be detected in eccrine sweat glands, in bronchial glands, and in placental villi. In addition, immunoreactivity for the SLC26A2 protein was observed in exocrine pancreas. Our results suggest a more limited expression pattern for SLC26A2 than that found by Northern analysis. However, SLC26A2 expression is also detected in tissues not affected in chondrodysplasias caused by SLC26A2 mutations.

The congenital chloride diarrhea gene is expressed in seminal vesicle, sweat gland, inflammatory colon epithelium, and in some dysplastic colon cells

Congenital chloride diarrhea (CLD) is an autosomal recessive disorder of intestinal electrolyte transportation caused by mutations in the anion transporter protein encoded by the down-regulated in adenoma (DRA), or CLD, gene. In this study, in situ hybridization and immunohistochemistry were performed to investigate the expression of CLD in extraintestinal normal epithelia and in intestinal inflammatory and neoplastic epithelia. The expression of the closely related anion transporter diastrophic dysplasia sulfate transporter, DTDST, was also examined and compared with that of CLD in colon. The only extraintestinal tissues showing CLD expression were eccrine sweat glands and seminal vesicles. In inflammatory bowel disease and ischemic colitis, expression of CLD mRNA in colon epithelium was similar to histologically normal colon epithelium, but the protein was found deeper in crypts, including proliferative epithelial cells. In intestinal tumors, the expression pattern of CLD was dependent on the differentiation status of the tissue studied: epithelial polyps with no or minor dysplasia showed abundant expression, whereas adenocarcinomas were negative. The DTDST gene was abundantly expressed in the upper crypt epithelium of colonic mucosa.

Identification of the Finnish founder mutation for diastrophic dysplasia (DTD)

Diastrophic dysplasia (DTD) is especially prevalent in Finland and the existence of a founder mutation has been previously inferred from the fact that 95% of Finnish DTD chromosomes have a rare ancestral haplotype found in only 4% of Finnish control chromosomes. Here we report the identification of the Finnish founder mutation as a GT-> GC transition (c.-26 + 2T > C) in the splice donor site of a previously undescribed 5'-untranslated exon of the diastrophic dysplasia sulfate transporter gene (DTDST); the mutation acts by severely reducing mRNA levels. Among 84 DTD families in Finland, patients carried two copies of the mutation in 69 families, one copy in 14 families, and no copies in one family. Roughly 90% of Finnish DTD chromosomes thus carry the splice-site mutation, which we have designated DTDST(Fin). Unexpectedly, we found that nine of the DTD chromosomes having the apparently ancestral haplotype did not carry DTDST(Fin), but rather two other mutations. Eight such chromosomes had an R279W mutation and one had a V340del deletion. We consider the possible implications of presence of multiple DTD mutations on this rare haplotype.

Atelosteogenesis type II is caused by mutations in the diastrophic dysplasia sulfate-transporter gene (DTDST): evidence for a phenotypic series involving three chondrodysplasias

Atelosteogenesis type II (AO II) is a neonatally lethal chondrodysplasia whose clinical and histological characteristics resemble those of another chondrodysplasia, the much less severe diastrophic dysplasia (DTD). The similarity suggests a shared pathogenesis involving lesions in the same biochemical pathway and perhaps the same gene. DTD is caused by mutations in the recently identified diastrophic dysplasia sulfate-transporter gene (DTDST). Here, we report that AOII patients also have DTDST mutations, which lead to defective uptake of inorganic sulfate and insufficient sulfation of macromolecules by patient mesenchymal cells in vitro. Together with our recent observation that a third even more severe chondrodysplasia, achondrogenesis type IB, is also caused by mutations in DTDST, these results demonstrate a phenotypic series of three chondrodysplasias of increasing severity caused by lesions in a single sulfate-transporter gene. The severity of the phenotype appears to be correlated with the predicted effect of the mutations on the residual activity of the DTDST protein.

The diastrophic dysplasia gene encodes a novel sulfate transporter: positional cloning by fine-structure linkage disequilibrium mapping

Diastrophic dysplasia (DTD) is a well-characterized autosomal recessive osteochondrodysplasia with clinical features including dwarfism, spinal deformation, and specific joint abnormalities. The disease occurs in most populations, but is particularly prevalent in Finland owing to an apparent founder effect. DTD maps to distal chromosome 5q and, based on linkage disequilibrium studies in the Finnish population, we had previously predicted that the DTD gene should lie about 64 kb away from the CSF1R locus. Here, we report the positional cloning of the DTD gene by fine-structure linkage disequilibrium mapping. The gene lies in the predicted location, approximately 70 kb proximal to CSF1R, and encodes a novel sulfate transporter. Impaired function of its product is likely to lead to undersulfation of proteoglycans in cartilage matrix and thereby to cause the clinical phenotype of the disease. These results demonstrate the power of linkage disequilibrium mapping in isolated populations for positional cloning.

Cartilage-hair hypoplasia gene assigned to chromosome 9 by linkage analysis

Cartilage-hair hypoplasia (CHH) is an autosomal recessive skeletal dysplasia of unknown pathogenesis leading to short-limbed stature. Associated features include hypoplasia of hair, abnormal cellular immunity, deficient erythrogenesis, increased risk of malignancies, Hirschsprung disease, and Diamond-Blackfan type hypoplastic anaemia. We mapped the CHH gene by linkage analysis with 5 markers to chromosome 9. Multipoint linkage analysis gives a lod score of 9.94 for a location between D9S43 and D9S50. Based on strong linkage disequilibrium the closest marker, D9S50, is likely to be less than 1 cM from the gene. No heterogeneity was observed in 14 Finnish families, nor was there evidence of reduced penetrance. These results provide a starting point for the eventual cloning and characterization of the CHH gene.

Prenatal diagnosis of diastrophic dysplasia with polymorphic DNA markers

Ultrasonography is a non-invasive method for prenatal detection of diastrophic dysplasia (DTD) in the second trimester of pregnancy. As there is a need for genetic counselling as early as possible we wished to develop a method based on molecular analysis. Five fetuses in families with a previous history of DTD were studied by typing them and their relevant family members for DNA markers closely linked to the DTD gene. The DNA analyses predicted that three of the fetuses were unaffected and two affected. These results were concordant with those obtained by ultrasonography, and the phenotype of the fetus was correctly predicted in all cases. DNA analysis provides a reliable means of prenatal diagnosis in the first trimester of pregnancy.

Molecular cloning of the human alpha 2(IX) collagen cDNA and assignment of the human COL9A2 gene to chromosome 1

Type IX collagen, a heterotrimer of alpha 1(IX), alpha 2(IX) and alpha 3(IX) chains, is a cartilage-specific fibril-associated collagen. In the process of characterizing genomic clones for the mouse alpha 2(IX) collagen gene four pairs of oligonucleotide primers designed for amplification of murine exon sequences were also utilized to construct cDNA clones for human alpha 2(IX) collagen spanning > 90% of the coding region. The amino acid and nucleotide sequence identities between human and chick are 78% and 71%, respectively. Localization of the COL9A2 gene to human chromosome 1 was subsequently performed using a panel of DNAs from human/rodent somatic cell hybrids.

Linkage disequilibrium mapping in isolated founder populations: diastrophic dysplasia in Finland

Linkage disequilibrium mapping in isolated populations provides a powerful tool for fine structure localization of disease genes. Here, Luria and Delbrück's classical methods for analysing bacterial cultures are adapted to the study of human isolated founder populations in order to estimate (i) the recombination fraction between a disease locus and a marker; (ii) the expected degree of allelic homogeneity in a population; and (iii) the mutation rate of marker loci. Using these methods, we report striking linkage disequilibrium for diastrophic dysplasia (DTD) in Finland indicating that the DTD gene should lie within 0.06 centimorgans (or about 60 kilobases) of the CSF1R gene. Predictions about allelic homogeneity in Finland and mutation rates in simple sequence repeats are confirmed by independent observations.

A linkage map spanning the locus for diastrophic dysplasia (DTD)

Diastrophic dysplasia (DTD) is an autosomal recessive osteochondrodysplasia. Patients have short-limbed short stature and suffer from generalized joint dysplasia. We have recently mapped DTD to the distal long arm of chromosome 5. Here we report the localization of DTD in relation to 16 polymorphic markers on distal 5q. No recombinations occurred with two loci, D5S72 and D5S66. One presumptive candidate gene, osteonectin (SPARC), could be excluded on the basis of three recombinations with the DTD locus. Multipoint linkage analysis performed against a fixed order of markers placed DTD between glucocorticoid receptor (GRL) and SPARC favored by the odds of 33:1 over the next best location of DTD between D5S72 and D5S55. The sex-averaged distance between the definite flanking markers, GRL and D5S55, is 17.5 cM. From previously reported data on the physical localization of markers, we conclude that the DTD locus is in 5q31-q34.

RFLPs in the fibroblast growth factor receptor-4 locus (FGFR4) in 5q33-qter

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Localization of a gene for progressive myoclonus epilepsy to chromosome 21q22

Progressive myoclonus epilepsy of Univerricht-Lundborg type is a clinically defined entity among the progressive myoclonus epilepsies. It is an autosomal recessive disorder. The underlying biochemical defect is unknown. We used linkage analysis to localize the gene in 12 families with the aid of polymorphic DNA markers. Close linkage was detected with three markers on distal chromosome 21. The loci BCEI and D21S154 gave the highest positive logarithm-of-odds (lod) scores of 5.49 and 4.25, respectively, at zero recombination. The third locus, D21S112, gave a lod score of 6.91 at a recombination fraction of 0.034. There was no evidence of heterogeneity. Multipoint lod scores calculated against a fixed map of the three marker loci gave a maximum four-point lod score of 10.08 at a location of the disease gene at 6.0 centimorgans distal to locus BCEI and 0.8 centimorgan proximal to locus D21S154. As markers BCEI and D21S154 have previously been localized to 21q22.3 by physical methods, our findings place the EMP1 gene locus (for progressive myoclonus epilepsy of the Unverricht-Lundborg type) in chromosome 21 band q22.3. This finding provides an opportunity to test several other epilepsy phenotypes, particularly the so-called Ramsay Hunt syndrome, for linkage to the same locus. It also is a starting point toward isolating and characterizing the gene and its protein product.

The etiology of XX sex reversal

The primary testis-determining function is exerted by a gene in the sex-determining region of the human Y chromosome. This gene is termed the sex-determining factor or TDF. A zinc finger gene, ZFY, residing in this region has been cloned and characterized. It is a candidate for TDF. A challenge to future molecular research is to clarify the function of a zinc finger gene on the X chromosome, ZFX, that shows high structural similarity to ZFY. Furthermore, the existence of other genes involved in sex determination is likely but so far unproven. Sex reversal leading to testes in apparently XX individuals (XX males) is most often due to the presence of TDF on the paternally derived X chromosome. The abnormality arises during meiosis in the father when an abnormal exchange leads to the transfer onto the X of the entire pseudoautosomal region plus a portion of the Y chromosome-specific region including TDF from the Y. An XX male resulting from such an exchange is described. 10-20% of XX males do not have Y DNA. Two major mechanisms to explain such Y(-) XX males are discussed. First, several published pedigrees show clear-cut dominant autosomal or X chromosomal inheritance of XX maleness. These patients are always Y(-) and usually have sexual ambiguity. This indicates the existence of other genes, obviously 'downstream' from TDF, that when mutated can trigger testis determination. Nothing concrete is presently known about these putative genes, but their phenotypic effect is slightly different from that of TDF. Second, mosaicism with a prevalent XX lineage and a hidden or scarce lineage containing a Y chromosome can explain some apparently Y(-) XX males. Two XX/XXY mosaic patients are described in detail. In one, only a combination of DNA hybridization and cytogenetic studies led to the discovery of the XXY cell line. In conclusion, XX sex reversal in man is caused by at least 3 mechanisms, viz. abnormal Y-X interchange, genes other than TDF, and mosaicism.

Delayed presentation of blunt splenic injury

Eleven patients with delayed presentation of splenic injury after blunt abdominal trauma treated during a 10 year period have been described. They represented 24 percent of all patients treated for blunt splenic injury in our department in that time period. Ten patients required operative treatment and one was treated nonoperatively. There were no deaths. The value of computerized tomography and ultrasonography in the accurate preoperative assessment of splenic injury has been documented. In addition, the various diagnostic and therapeutic possibilities in blunt splenic trauma have been discussed.

Results of sphincteroplasty in patients with spastic sphincter of Oddi. Predictive value of operative biliary manometry and provocation tests

The predictive value of different preoperative provocation tests and operative biliary manometry was studied in a series of 22 patients undergoing sphincteroplasty for suspected spastic sphincter of Oddi (SPO). The result of the operation was good in 59%, 54%, and 71% of patients in groups with a positive codein test, a positive endoscopic retrograde cholangiopancreatography filling pain sign, and positive fentanyl test, respectively. Common bile duct pressure (CBDP) did not differ significantly between the SPO spasm group and control patients, but in the fentanyl test the CBDP elevation was significantly higher (p less than 0.01) than in controls (7.7 versus 3.3 mm Hg). It was concluded that the operative fentanyl test seems to be useful in predicting the response to surgery (sphincteroplasty) in patients with post-cholecystectomy biliary-type pain and suspected SPO spasm.

Cholesterol precursor sterols, plant sterols, and cholestanol in human bile and gallstones

Biliary and gallstone sterol compositions were analyzed in 20 consecutive cholecystectomized patients. The main intention was to identify and quantitate noncholesterol sterols and to compare the sterol patterns of the two sources. Cholesterol comprised approximately 97% of the stone and gallbladder bile sterols; the remainder were from plant sterols, cholestanol, and cholesterol precursors, mainly lathosterol and methylsterols (two methostenols, lanosterol, and two dimethylsterols). Desmosterol and delta 8-lathosterol were also identified in both the bile and the gallstones. The sterol patterns of the bile and gallstones differed markedly. Thus, the contents of the two lathosterols and the two methostenols were clearly higher in the gallstones, whereas lanosterol stayed almost totally, and other minor sterols were preferentially, in the bile. In fact, the gallstone methylsterols consisted mainly of the two methostenols, a pattern usually seen in esterified methylsterols in serum. The core and matrix of the stone, and large and small stones as well, had only a small variation in their sterol composition within each individual, suggesting that the pattern of the noncholesterol sterol precipitation remains the same during the growth of the stone. Centrifugation of the bile revealed sedimentation of methylsterols with the stonelike sterol pattern. It can be speculated that the soluble and poorly soluble bile sterols have different hepatic origins and that the similarity between (a) methylsterols in the stone and sediment and (b) esterified methylsterols in serum points to a common hepatic site of origin.

Splenectomy for myelofibrosis

In 30 consecutive splenectomies for myelofibrosis (MF) with cytopenia(s) and/or massive splenomegaly the operative mortality was 6.7% (2 patients). Postoperative complications were observed in 11 (37%) patients. When surgery was undertaken within one year of the diagnosis of MF the postoperative morbidity rate was 13% (2/16), but significantly (p less than 0.01) higher at 64% (9/14) in patients operated on later. A similar significant difference was observed in the amount of intraoperative blood loss. Of the patients undergoing splenectomy for anaemia and/or thrombocytopenia, 79% gained definite benefit from the operation for 2 to 70 months (median 10 months). It is concluded that, although splenectomy probably does not prolong the life of patients with MF, it gives considerable symptomatic relief in cases with massive splenomegaly, and can improve the patient's haematological status and reduce blood transfusion requirements. To avoid the increased risks of postoperative complications surgery is best undertaken as soon as cytopenia is present.

The effect of buprenorphine and oxycodone on the intracholedochal passage pressure

The effect of i.v. buprenorphine (0.3 mg) and oxycodone (10mg) on intracholedochal passage pressure were studied in 20 patients who had undergone surgery of the common biliary tract, prior to the extraction of an indwelling T tube. Informed consent was obtained from all patients, each of who was given buprenorphine or oxycodone in random order. The intracholedochal passage pressure was measured from the T tube perfused with continuous saline infusion (55 ml/h). Both analgesics significantly (P less than 0.01) increased the intracholedochal passage pressure after 5 min, with an equal peak increase of about 1.5 kPa at about 7 min. The pressure decline was rapid and similar in both groups: 20 min after administration of the test drug only about 40% of the maximum elevation caused by either drug remained. Thereafter, a slower fall towards the baseline was recorded after both drugs during the remaining 45 min of the study period. The results indicate that buprenorphine can be used with the same indications and precautions as other narcotics for postoperative pain relief in patients who have undergone surgery of the biliary tract.

Early cholecystectomy for acute cholecystitis: a prospective randomized study

A randomized clinical trial was undertaken to compare early and delayed cholecystectomy for acute cholecystitis. Patients entering early (n = 83) or delayed (n = 82) surgery groups were comparable with regard to prerandomization data. One patient in the early group and five in the delayed group refused surgery (p < 0.1) and two misdiagnoses occurred in each group. (2.4%). There was no difference in the incidence of technical difficulty measured by operative complications and duration of operations between the two groups. The same number of patients with common duct stones and perforations of the gallbladder were in each group. There was one death in the delayed group and none in the early group. Postoperative morbidity was 13.8% in the early group and 17.3% in the delayed surgery group (p > 0.1). Wound complications were slightly more common in the early surgery group (p > 0.1). In the delayed surgery group 13% of the patients had to be operated on before the planned date of surgery because conservative management failed. In addition, 15% of the patients had clear recurrent symptoms. Early surgery reduced total hospital stay by a mean of 7.5 days and the period of the patient's incapacity for work by 14.4 days. The data suggest that in acute cholecystitis early surgery is preferable when performed by an experienced surgeon with adequate pre- and intraoperative aids. Besides lower costs it offers the advantage of avoiding recurrent attacks and emergency operations without increasing mortality or morbidity.

[Intravenous cholegraphy in acute cholecystitis (author's transl)]

In this prospective study iv-cholegraphy was performed before surgery on 152 patients by whom acute cholecystitis could not be excluded. The examination was diagnostic in 85% of the cases. Most of the patients (20/23) with nonvisualization of the biliary tract by iv-cholegraphy suffered from acute cholecystitis, the others (3/23) from acute pancreatitis. In three false negative examinations the opacification of the gallbladder was weak and in three false positive cases the cystic duct obstruction was caused by a chronic gallbladder disease. Because the preliminary clinical suspicion of acute cholecystitis even when using rigid criteria proved to be false in 30% of the cases, we consider a radiologic clarification to be indicated. Iv-cholegraphy is found to be an important examination in acute cholecystitis, practicable even at small radiologic departments with conventional equipment, and a reliable indicator of cystic duct obstruction.

Treatment of idiopathic thrombocytopenic purpura in adults. Long-term results in a series of 41 patients

The results of treatment of idiopathic thrombocytopenic purpura (ITP) were analysed in a series of 41 patients 2 to 10 years (median 4 years) after initial treatment. There was one spontaneous remission. A good or fair long-term result was obtained in 11 patients after prednisone treatment, in 20 of 24 patients after splenectomy, and in 3 of 4 patients after immunosuppressive treatment. Short duration of symptoms and rapid response to prednisone had some value in predicting a good long-term result of prednisone treatment. Young age, a good response to prednisone and splenic sequestration of platelets were associated with good results after splenectomy, as was rapid postoperative normalization of platelet counts. These factors were unable to disclose with certainty a refractoriness to splenectomy. Nevertheless splenectomy was regarded to be the treatment of choice in all patients not adequately controlled with corticosteroids.