Yeast Surface Display Methodology for the Characterization of Food Allergens In Situ

High throughput allergen characterization is often based on phage display technique which is limited by the constraints of a prokaryotic expression system such as potential loss of conformational epitopes and lack of post-translational modifications. Replacing the phage display platform with a yeast surface display system could accelerate the immunological characterization of complex structured allergens. Yeast surface display is a powerful technique that allows faster immunochemical characterization of allergens in situ without the need for protein purification. Yeast surface display offers an alternative that could lead to the improvement of standard immunodiagnostic and immunotherapeutic approaches. In this chapter, we describe a protocol on yeast surface display for the characterization of plant-derived food allergens using actinidin (Act d 1), a major kiwifruit allergen, as a model system.

Outcomes in COVID-19 Patients with Pneumonia Treated with High-Flow Oxygen Therapy and Baricitinib—Retrospective Single-Center Study

Background. The aim of the study was to assess the effect of baricitinib on 28-day all-cause mortality and the progression of respiratory failure in patients needing transfer to the intensive care unit (ICU) with COVID-19 pneumonia treated with high-flow oxygen therapy. Methods. This retrospective study included hospitalized patients with COVID-19 pneumonia treated with high-flow oxygen non-invasive ventilation receiving standard of care (SOC) or SOC in addition to baricitinib. Data on patients’ characteristics, pro-inflammatory markers, D dimer, and National Early Warning Score 2 (NEWS2) values were collected and compared between groups. The primary endpoint was 28-day all-cause in-hospital mortality and the secondary outcome was transfer to the ICU. Results. The study included 125 patients. The primary outcome was observed in 44.8% of them: 27% in the baricitinib group vs. 62% in the SOC group, p < 0.001. Transfer to the ICU ward was significantly lower in the baricitinib group: 29% vs. 81%, p < 0.001. A significant improvement was observed when the baricitinib group was compared to SOC in procalcitonin, CRP, D-dimer, neutrophil-to-lymphocyte ratio values, and NEWS2. Conclusion. Treatment with baricitinib in addition to SOC was associated with reduced mortality and a lower prevalence of transfer to the ICU in hospitalized patients with COVID-19 pneumonia treated with high-flow oxygen non-invasive therapy.

MiR-375 and miR-21 as Potential Biomarkers of Prostate Cancer: Comparison of Matching Samples of Plasma and Exosomes

MiR-21 and miR-375 have been reported as dysregulated in prostate cancer (PCa) in multiple previous studies. Still, variable or even opposing data for the expression of these microRNAs in PCa were found, and their potential biomarker properties remain elusive. In an attempt to clarify their significance as PCa biomarkers, as well as to compare different types of specimens as a source of relevant microRNAs, we used plasma and matching plasma-derived exosomes from patients with PCa and patients with benign prostatic hyperplasia (BPH). Plasma and exosomes were obtained from 34 patients with PCa and 34 patients with BPH, and their levels of expression of miR-21 and miR-375 were determined by RT-qPCR. We found no significant difference in the level of expression of these microRNAs in plasma and exosomes between patients with PCa and BPH. The level of exosomal miR-21 was elevated in PCa patients with high serum PSA values, as well as in patients with aggressive PCa, while for plasma samples, the results remained insignificant. For miR-375, we did not find an association with the values of standard prognostic parameters of PCa, nor with cancer aggressiveness. Therefore, our results support the potential prognostic role of exosomal miR-21 expression levels in PCa.

Clostridioides Difficile Infection before and during Coronavirus Disease 2019 Pandemic-Similarities and Differences

The aim of this study was to investigate the differences of Clostridioides difficile infection (CDI) during the COVID-19 pandemic compared to the pre-COVID-19 era. CDI patients treated at the Clinic for Infectious Diseases, Clinical Center of Vojvodina, Serbia during 2017-2019 (n = 304) were compared with COVID-19/CDI patients treated in period September 2021-September 2022 (n = 387). Groups were compared by age, gender, comorbidities, previous medications, laboratory findings, and outcome within 30 days. In the CDI/COVID-19 group, we found: greater percentage of males 59.8% vs. 42.6% (p ≤ 0.001), older age 72.8 ± 9.4 vs. 65.6 ± 11.7 (p ≤ 0.001), higher Charlson comorbidity score (CCS) (3.06 ± 1.54 vs. 2.33 ± 1.34 (p ≤ 0.001), greater percentage of chronic renal failure (33.9% vs. 23.4% (p = 0.003), malignances (24.3% vs. 13.5% (p ≤ 0.001), chronic obstructive pulmonary disease (22.7% vs. 15.5% (p = 0.017), higher usage of macrolide (38.5% vs. 8.6% (p ≤ 0.001), greater percentage of patients with hypoalbuminemia ≤25 g/L (19.6% vs. 12.2% (p ≤ 0.001), lower percentage of patients with elevated creatinine (≥200 mmol/L) (31.5% vs. 43.8%) (p = 0.002), and greater percentage of lethal outcome 29.5% vs. 6.6% (p ≤ 0.001). In the prediction of lethal outcome multivariate regression analysis extracted as an independent predictor, only higher CRP values in the non-COVID-19 group and in the COVID-19 group: older age (p ≤ 0.001), CCS (p = 0.019) and CRP (p = 0.015). COVID-19 changes the disease course of CDI and should be taken into consideration when managing those patients.

Clinical Presentations, Predictive Factors, and Outcomes of Clostridioides difficile Infection among COVID-19 Hospitalized Patients—A Single Center Experience from the COVID Hospital of the University Clinical Center of Vojvodina, Serbia

Background: This study aimed to investigate the clinical form, risk factors, and outcomes of patients with COVID-19 and Clostridioides difficile co-infections. Methods: This retrospective study (2 September 2021-1 April 2022) included all patients with Clostridioides difficile infection (CDI) and COVID-19 infection who were admitted to the Covid Hospital of the University Clinical Center of Vojvodina. Results: A total of 5124 COVID-19 patients were admitted to the Covid Hospital, and 326 of them (6.36%) developed hospital-onset CDI. Of those, 326 of the CDI patients (88.65%) were older than 65 years. The median time of CDI onset was 12.88 days. Previous hospitalizations showed 69.93% of CDI patients compared to 38.81% in the non-CDI group (p = 0.029). The concomitant antibiotics exposure was higher among the CDI group versus the non-CDI group (88.65% vs. 68.42%, p = 0.037). Albumin levels were ≤ 25 g/L among 39.57% of the CDI patients and 21.71% in the non-CDI patients (p = 0.021). The clinical manifestations of CDI ranged from mild diarrhea (26.9%) to severe diarrhea (63.49%) and a complicated form of colitis (9.81%). Regarding outcomes, 79.14% of the CDI patients recovered and 20.86% had fatal outcomes in-hospital. Although a minority of the patients were in the non-CDI group, the difference in mortality rate between the CDI and non-CDI group was not statistically significant (20.86% vs. 15.13%, p = 0.097). Conclusions: Elderly patients on concomitant antibiotic treatments with hypoalbuminemia and with previous healthcare exposures were the most affected by COVID-19 and CD co-infections.

Does miliary sarcoidosis really exist? A case report and review of the literature

BACKGROUND

Miliary sarcoidosis is a rare form of sarcoidosis characterized by numerous miliary-like micronodules dispersed throughout the lungs. It has been documented in less than 1% of all sarcoidosis cases. We first described a rare case of miliary sarcoidosis and then conducted a literature review on the subject.

CASE PRESENTATION

A 51-year-old male complained about a progressive loss of appetite, significant weight loss, occasional night sweats, and fatigue. After a thorough clinical exploration, a differential diagnosis of miliary lung disease was suspected - miliary tuberculosis, fungal infection, metastatic pulmonary carcinoma, or sarcoidosis. High-resolution chest computed tomography revealed bilateral diffuse micronodules with mediastinal lymphadenopathy. Histopathological analysis of transbronchial bioptic tissue identified non-caseating epithelioid granulomas, while no malignant cells were found. Lung tuberculosis and fungal infections were excluded. The levels of angiotensin-converting enzyme in the blood, as well as serum's and 24-hour urine calcium levels, were elevated. After a multidisciplinary discussion, the diagnosis of miliary pulmonary sarcoidosis was established. The patient was treated with prednisone for a total of 9 months, with full clinical and radiological recovery. Using PubMed, we also conducted a review of the literature on this topic and discovered only a few case reports of patients with miliary sarcoidosis, with just one systematic review accessible. The key findings of studies investigating patients diagnosed with miliary sarcoidosis are tabularly displayed.

CONCLUSIONS

Miliary sarcoidosis is an uncommon type of pulmonary sarcoidosis that can mimic several entities that manifest as miliary nodules. Most patients require treatment since it can have a significant impact on lung function.

Optical properties of copper helical nanostructures: the effect of thickness on the SPR peak position

In this study, we have investigated the effect of thickness on the structural and optical properties of copper (Cu) helical nanostructures. Thin films with thicknesses of 160 nm, 280 nm, 450 nm, and 780 nm were obtained by e-beam glancing angle deposition. The morphology and the microstructure were studied by field emission scanning electron microscopy, x-ray diffraction and transmission electron microscopy, while for the optical analysis measurements spectroscopic ellipsometry was used. The results show that the deposited structures are porous with nanometer-sized crystallites preferentially oriented along (111) planes, as well as that the diameter of the helices increases with thickness. Detailed analyses of optical properties have demonstrated that the dielectric function of Cu structures is greatly influenced by the films thicknesses. With increasing thickness from 160 nm to 780 nm, the surface plasmon resonance peak was shifted from 1.31 eV to 1.05 eV, which was correlated with the growth mechanism and the size of deposited nanostructures.

Affinity-based isolation of extracellular vesicles by means of single-domain antibodies bound to macroporous methacrylate-based copolymer

Correct elucidation of physiological and pathological processes mediated by extracellular vesicles (EV) is highly dependent on the reliability of the method used for their purification. Currently available chemical/physical protocols for sample fractionation are time-consuming, often scarcely reproducible and their yields are low. Immuno-capture based approaches could represent an effective purification alternative to obtain homogeneous EV samples. An easy-to-operate chromatography system was set-up for the purification of intact EVs based on a single domain (VHH) antibodies-copolymer matrix suitable for biological samples as different as conditioned cell culture medium and human plasma. Methacrylate-based copolymer is a porous solid support, the chemical versatility of which enables its efficient functionalization with VHHs. The combined analyses of morphological features and biomarker (CD9, CD63 and CD81) presence indicated that the recovered EVs were exosomes. The lipoprotein markers APO-A1 and APO-B were both negative in tested samples. This is the first report demonstrating the successful application of spherical porous methacrylate-based copolymer coupled with VHHs for the exosome isolation from biological fluids. This inexpensive immunoaffinity method has the potential to be applied for the isolation of EVs belonging to different morphological and physiological classes.

Heterogeneous Skin Phantoms for Experimental Validation of Microwave-Based Diagnostic Tools

Considerable exploration has been done in recent years to exploit the reported inherent dielectric contrast between healthy and malignant tissues for a range of medical applications. In particular, microwave technologies have been investigated towards new diagnostic medical tools. To assess the performance and detection capabilities of such systems, tissue-mimicking phantoms are designed for controlled laboratory experiments. We here report phantoms developed to dielectrically represent malign skin lesions such as liposarcoma and nonsyndromic multiple basal cell carcinoma. Further, in order to provide a range of anatomically realistic scenarios, and provide meaningful comparison between different phantoms, cancer-mimicking lesions are inserted into two different types of skin phantoms with varying tumor–skin geometries. These configurations were measured with a microwave dielectric probe (0.5–26.5 GHz), yielding insight into factors that could affect the performance of diagnostic and detection tools.

Effects of elevation gradient and aspect on butterfly diversity on Galičica Mountain in the Republic of Macedonia (south–eastern Europe)

The patterns of butterfly diversity and community changes in relation to elevation are an interesting and well–covered topic in ecology, but the effects of aspect have rarely been evaluated. Here we studied the changes in butterfly species richness and communities along the elevation gradient and aspect of Galičica Mountain. As expected, species richness changed with altitude, showing a bimodal pattern with two peaks and a declining trend towards higher altitude. Changes were well–correlated with the area in each altitudinal zone, while the effects of productivity were less clear. Butterfly communities at higher altitudes were the most distinct when grouped according to β diversity estimates, followed by mid– and low–altitude communities. Indicator species were found in mid–altitudes and for the combination of low–mid and mid–high altitudes, but not among aspects. Overall, aspect produced a less conclusive effect on species richness and community composition. South and north accounted for most of these differences despite dominant western and eastern and exposition of the mountain slopes. The community temperature index declined with altitude and on the northern aspect, showing these areas hosted more cold–adapted species. Notes on butterfly conservation are provided as 23 species known from historical surveys have not been recorded recently. Data published through GBIF (Doi: 10.15470/jacl7y).

Genome-wide meta-analysis identifies novel loci associated with free triiodothyronine and thyroid-stimulating hormone

PURPOSE

Thyroid hormones are essential for the normal function of almost all human tissues, and have critical roles in metabolism, differentiation and growth. Free triiodothyronine (fT3), free thyroxine (fT4) and thyroid-stimulating hormone (TSH) levels are under strong genetic influence; however, most of the heritability is yet unexplained.

METHODS

In order to identify novel loci associated with fT3, fT4 and TSH serum levels we performed a genome-wide meta-analysis of 7 411 206 polymorphisms in up to 1731 euthyroid individuals from three Croatian cohorts from Dalmatia region: two genetically isolated island populations and one mainland population. Additionally, we also performed a bivariate analysis of fT3 and fT4 levels.

RESULTS

The EPHB2 gene variant rs67142165 reached genome-wide significance for association with fT3 plasma levels (P = 9.27 × 10^-9) and its significance was confirmed in bivariate analysis (P = 9.72 × 10^-9). We also found a genome-wide significant association for variant rs13037502 upstream of the PTPN1 gene and TSH plasma levels (P = 1.67 × 10^-8).

CONCLUSION

We identified a first genome-wide significant variant associated with fT3 plasma levels, as well as a novel locus associated with TSH plasma levels. These findings are biologically relevant and enrich our knowledge about the genetic basis of pituitary-thyroid axis function.

Familial tauopathy with P364S MAPT mutation: clinical course, neuropathology and ultrastructure of neuronal tau inclusions

AIMS

This report presents the clinical course, neuropathology and ultrastructure of neuronal tau inclusions of four Slovene relatives with P364S MAPT mutation.

METHODS

The clinical history of three out of four P364S MAPT mutation carriers was taken. After formalin fixation, thorough sampling of the central nervous system was followed by paraffin embedding, H&E, Gallyas, Bielschowsky and immunostaining with AT8, anti-3R, anti-4R tau, anti-amyloid-β, anti-TDP43 and anti-alpha-synuclein antibodies. The distribution and density of different types of neuronal tau inclusions were semiquantitatively assessed. In addition, the ultrastructure of neuronal tau inclusions was analysed.

RESULTS

Macroscopic examination of the brains was unremarkable. Microscopically, neuronal tau inclusions of almost all known types were widespread and distributed fairly uniformly in all cases. Pick bodies and swollen neurones were found in only one family member. Mutant tau was composed of 3R and 4R isoforms, with a slight predominance of 3R tau. Composite neuronal tau inclusion (CNTI), found in all four relatives, was a hallmark of the P364S MAPT mutation. CNTI showed compartmental differences in H&E and Gallyas staining, tau isoforms immunolabelling and ultrastructure, displaying fuzzy fibrils in the core and paired twisted tubules at the periphery.

CONCLUSIONS

P364S MAPT mutation is characterized clinically by a variable combination of frontotemporal dementia, parkinsonism and motor neurone disease of short duration, and neuropathologically by a widespread uniform distribution of all known neuronal tau inclusions in one family member. Two-compartment CNTI is a unique characteristic of the P364S MAPT mutation.

Parameter Search Algorithms for Microwave Radar-Based Breast Imaging: Focal Quality Metrics as Fitness Functions

Inaccurate estimation of average dielectric properties can have a tangible impact on microwave radar-based breast images. Despite this, recent patient imaging studies have used a fixed estimate although this is known to vary from patient to patient. Parameter search algorithms are a promising technique for estimating the average dielectric properties from the reconstructed microwave images themselves without additional hardware. In this work, qualities of accurately reconstructed images are identified from point spread functions. As the qualities of accurately reconstructed microwave images are similar to the qualities of focused microscopic and photographic images, this work proposes the use of focal quality metrics for average dielectric property estimation. The robustness of the parameter search is evaluated using experimental dielectrically heterogeneous phantoms on the three-dimensional volumetric image. Based on a very broad initial estimate of the average dielectric properties, this paper shows how these metrics can be used as suitable fitness functions in parameter search algorithms to reconstruct clear and focused microwave radar images.

Fourier transform infrared spectroscopy provides an evidence of papain denaturation and aggregation during cold storage

Papain is a cysteine protease with wide substrate specificity and many applications. Despite its widespread applications, cold stability of papain has never been studied. Here, we used differential spectroscopy to monitor thermal denaturation process. Papain was the most stabile from 45 °C to 60 °C with ΔG°321 of 13.9±0.3 kJ/mol and Tm value of 84±1 °C. After cold storage, papain lost parts of its native secondary structures elements which gave an increase of 40% of intermolecular β-sheet content (band maximum detected at frequency of 1621 cm(-1) in Fourier transform infrared (FT-IR) spectrum) indicating the presence of secondary structures necessary for aggregation. The presence of protein aggregates after cold storage was also proven by analytical size exclusion chromatography. After six freeze-thaw cycles around 75% of starting enzyme activity of papain was lost due to cold denaturation and aggregation of unfolded protein. Autoproteolysis of papain did not cause significant loss of the protein activity. Upon the cold storage, papain underwent structural rearrangements and aggregation that correspond to other cold denatured proteins, rather than autoproteolysis which could have the commercial importance for the growing polypeptide based industry.

An experience with colistin applied in treatment of imunocompromised patients with peritonitis on peritoneal dialysis

INTRODUCTION

Immunocompromised patients, such as those with multiple myeloma on peritoneal dialysis, are particularly susceptible to the occurrence of peritonitis.

CASE REPORT

We presented a 56-year-old female patient with a 10-year history of multiple myeloma. The patient was on peritoneal dialysis since 2010. During 2012 the patient had the first episode of peritonitis that was successfully managed, but in 2013 the second episode of peritonitis occured. Analysis of dialysate culture and exit site swab revealed the presence of multiresistant Acinetobacter spp., which was susceptible only to colistin. Prompt colistin therapy was administered at the doses of 100,000 units/day during six days, which resulted in complete recovery of the patient, as well as improvement of local abdominal findings. Gram-negative bacteria (genus Acinetobacter) are common causative agents in hospital-acquired infections. Studies confirmed susceptibility of Acinetobacter to colistin, which was also the case with the presented patient. Intravenous administration of colistin resulted in a complete remission of this severe, life-threatening peritonitis.

CONCLUSION

Patients with multiple myeloma and renal failure are highly prone to severe life-threatening infections.

Breast monitoring via time-domain microwave radar: early clinical trial study

This work describes early results from our firststage clinical trial involving the monitoring of healthy volunteers with our time-domain microwave breast screening system. The system is composed of a 16-sensor multistatic array that records the electromagnetic energy scattered off of the breast tissue. All measurements are performed in the timedomain. We present here the system setup, patient-interface considerations, volunteer criteria and initial results from breast monitoring.

Time-Domain Microwave Breast Cancer Detection: Extensive System Testing with Phantoms

Early detection of breast cancer is known to be a key factor in the successful treatment of the disease. Here, we present a detection technique complementary to the currently used modalities (primarily mammography, ultrasound and magnetic resonance imaging). Our time-domain breast cancer detection system transmits microwave-range pulses into the breast and records the scattering off of the breast in order to detect malignancies. This method is made possible by an intrinsic contrast in the dielectric parameters, specifically the relative permittivity and conductivity, of the healthy and malignant breast tissues over the microwave frequency range. The long-term goal of our work is to develop a system that can be used periodically to monitor for unusual changes in breast tissues; for instance, healthy breasts would be scanned, and follow-up scans at regular intervals would detect any small changes in breast tissue composition that could indicate the presence of a malignant growth. At that point, the patient would be referred to see a doctor for further investigation of the abnormal results. Such a system would compare each new scan with previous ones to determine the level of tissue changes, and would be used by patients at home. We report feasibility and performance tests for our initial system, conducted with breast phantoms made up of tissue-mimicking materials (unique skin, fat, gland and tumor mixtures). We initiated the system testing with simple homogeneous phantoms, consisting solely of adipose tissue. Then, we extended our tests to cases of increasing complexity by adding a skin layer and varying percentages of glandular structures and tumor sizes. In order to optimize the experimental system, we performed tests with multiple antenna arrangements, tumor sizes and locations. This work shows that there are specific antenna arrangements that are advantageous for tumor detection and demonstrates the capabilities of our time-domain microwave breast tumor detection system.

[Influence of different bonding agents on marginal sealing quality of amalgam restorations]

INTRODUCTION

Although advanced adhesive systems are in use, marginal microleakage is one of the greatest problems of contemporary restorative dentistry.

OBJECTIVE

The aim of this in vitro study was to evaluate the influence of different bonding agents on the marginal sealing quality of class II amalgam restorations.

METHODS

Forty freshly extracted human premolar and molar teeth were divided into four groups with 10 teeth in each one. Class II preparations were prepared and different adhesives were applied as follows: group I--Amalgam Liner (Voco); group II--ONE-STEP PLUS (Bisco); group III--PQ 1 (Ultradent). Group IV was used as a control, without any bonding agent. Amalgam (Cavex Non Gamma 2, Cavex) was hand-condensed into each preparation. Specimens were thermocycled 200 times at the following temperatures: 5-7 degrees C, 37 degrees C and 57-59 degrees C, and were then immersed into 1% solution of gentian violet for 72 hours. The teeth were sectioned longitudinally and microleakage was graded in the area of the gingival and occlusal quantity rim using a binocular magnifying glass with 25 times magnification.

RESULTS

The highest microleakage was recorded in the Amalgam Liner group; 1526.0 microm at the gingival wall and 694.5 microm at the occlusal cavity wall. The lowest dye penetration was observed in the PQ1 group; 589.5 microm at the gingival wall, and 599.9 microm at the occlusal wall of the restoration. ANOVA test showed that there was a statistically significant difference of dye penetration values at the gingival wall among all examination groups (p < 0.01). No statistically significant differences were found comparing microleakage values at the occlusal wall.

CONCLUSION

Results of this study showed that the best marginal sealing was accomplished by using the PQ1 bonding agent.

Histomorphometric characteristics of immune cells in small intestine of pigs perorally immunized with vaccine candidate F18ac nonenterotoxigenic E. coli strain

Colidiarrhea and colienterotoxemia caused by F4⁺ and/or F18⁺ enterotoxigenic E. coli (ETEC) strains are the most prevalent infections of suckling and weaned pigs. Here we tested the immunogenicity and protective effectiveness of attenuated F18ac⁺ non-ETEC vaccine candidate strain against challenge infection with F4ac⁺ ETEC strain by quantitative phenotypic analysis of small intestinal leukocyte subsets in weaned pigs.We also evaluated levamisole as an immune response modifier (IRM) and its adjuvanticity when given in the combination with the experimental vaccine. The pigs were parenterally immunized with either levamisole (at days -2, -1 and 0) or with levamisole and perorally given F18ac⁺ non-ETEC strain (at day 0), and challenged with F4ac⁺ ETEC strain 7 days later.At day 13 the pigs were euthanatized and sampled for immunohistological/histomorphometrical analyses. Lymphoid CD3⁺, CD45RA⁺, CD45RC⁺, CD21⁺, IgA⁺ and myeloid SWC3⁺ cell subsets were identified in jejunal and ileal epithelium, lamina propria and Peyer’s patches using the avidin-biotin complex method, and their numbers were determined by computer-assisted histomorphometry. Quantitative immunophenotypic analyses showed that levamisole treated pigs had highly increased numbers of jejunal CD3⁺, CD45RC⁺ and SWC3⁺ cells (p<0.05) as compared to those recorded in nontreated control pigs.In the ileum of these pigs we have recorded that only CD21⁺ cells were significantly increased (p<0.01). The pigs that were treated with levamisole adjuvanted experimental vaccine had significantly increased numbers of all tested cell subsets in both segments of the small intestine. It was concluded that levamisole adjuvanted F18ac⁺ non-ETEC vaccine was a requirement for the elicitation of protective gut immunity in this model; nonspecific immunization with levamisole was less effective, but confirmed its potential as an IRM.

Increased number of intestinal villous M cells in levamisole -pretreated weaned pigs experimentally infected with F4ac⁺ enterotoxigenic Escherichia coli strain

Immunoprophylaxis of porcine postweaning colibacillosis (PWC) caused by enterotoxigenic Escherichia coli (ETEC) expressing F4 fimbriae is an unsolved problem. Just as ETEC strains can exploit intestinal microfold (M) cells as the entry portal for infection, their high transcytotic ability make them an attractive target for mucosally delivered vaccines, adjuvants and therapeutics. We have developed a model of parenteral/oral immunization of 4-weeks-old pigs with either levamisole or vaccine candidate F4ac⁺ non-ETEC strain to study their effects on de novo differentiation of antigen-sampling M cells. Identification, localization and morphometric quantification of cytokeratin 18 positive M cells in the ileal mucosa of 6-weeks-old pigs revealed that they were: 1) exclusively located within villous epithelial layer, 2) significantly numerous (P< 0.01) in levamisole pretreated/challenged pigs, and 3) only slightly, but not significantly numerous in vaccinated/challenged pigs compared with non-pretreated/challenged control pigs. The fact that levamisole may affect the M cells frequency by increasing their numbers, makes it an interesting adjuvant to study development of an effective M cell-targeted vaccine against porcine PWC.

Histomorphometric evaluation of intestinal cellular immune responses in pigs immunized with live oral F4ac+ non-enterotoxigenic E. coli vaccine against postweaning colibacillosis

Enterotoxigenic Escherichia coli (ETEC) infection is the most common type of porcine postweaning colibacillosis (PWC). Among fimbriae of porcine ETEC strains the best studied family of fimbriae are the members of F4 adhesins, existing in at least three variants: ab, ac, ad. Active immunization against porcine PWC is difficult due to: i) ETEC strains are only one of the essential predisposing factors, ii) the success of vaccinal antigen uptake depends on the presence of enterocyte receptors for F4 adhesins, iii) the intestinal immune system may react with tolerance or hypersensitivity to the same antigens depending on the dose and form of the vaccinal immunogen, and iv) kinetics of the specific immune responses may be different in the case of F4 (earlier) and the other ETEC adhesins, particularly F18 (later). The aim of this study was to test the effectiveness of a live attenuated F4ac+ non-ETEC vaccine against porcine PWC by analyzing quantitative differences in the small intestinal lymphoid and myeloid cell subsets of immunized (with or without levamisole given as an adjuvant) vs control non-immunized pigs. Four week-old pigs were intragastrically immunized with a vaccine candidate F4ac+ non-ETEC strain 2407 at day 0, challenged 7 days later with a virulent F4ac+ strain ETEC 11-800/1/94, euthanatized at day 13 and sampled for immunohistology. Non-immunized pigs received saline at day 0 and were processed as the principals. Immuno-phenotypes of lymphoid and myeloid cell subsets were demonstrated within jejunal and ileal mucosa by immunohistochemical avidin-biotin complex method and corresponding morphometric data were analyzed using software program Lucia G for digital image analyses. Monoclonal antibodies reactive with surface molecules on porcine immune cells such as CD3, CD45RA, CD45RC, CD21 and SWC3 enabled clear insight into distribution patterns and amount of these cells within the gut-associated lymphoid tissues (GALT) examined. The numbers of jejunal and ileal cell subsets tested were significantly increased (at P<0.5 or lower) in both principal groups (vaccinated or levamisole primed-vaccinated) of pigs, compared to those recorded in the control non-vaccinated pigs. Based on the histomorphometric quantification of porcine intestinal immune cells from the GALT compartments tested, it is possible to differentiate the responses of pigs immunized by an experimental mucosal vaccine from those of non-immunized pigs.

Photothermal microscopy: a step from thermal wave visualization to spatially localized thermal analysis

The calculation of photothermal response detected by a photothermal microscope is presented. By using a technique based on Green's functions and integral transforms, a model for laser-induced temperature distribution functions has been derived. The mathematical method for solution of inverse problem is proposed. It suggests that photothermal microscopy, besides imaging subsurface of solids, has the potential for quantitative thermal analysis of various samples.

[Correlation between sera levels of sICAM-1 and sVCAM-1 and severity of kidney lesions in patients with lupus nephritis]

INTRODUCTION

Adhesion molecules are essential for cellular interactions and are important in the activation and adhesion of cells. Studies have shown that elevated levels of solubile ICAM and VCAM are related to disease activity in patients with various acute and chronic inflammatory diseases. Our aim was to investigate the correlation between the levels of sICAM-1 anti sVCAM-1 and the degree of disease activity and severity of lupus nephritis.

MATERIAL AND METHODS

Using the ELISA procedure, we determined the sera levels of sVCAM-1 and sICAM-1 in 80 patients with SLE and in group of 27 healthy volunteers.

RESULTS

Patients with SLE had significantly higher sera levels of adhesion molecules comparing to the controls (p<0.001). There was a high positive correlation between the sera levels of sVCAM-1 and concentration of anti-ds DNA antibodies in patients with SLE (p<0.001), and there was also a negative correlation between the sera levels of sVCAM-1 and concentration of C3 and C4 component of complement (r=-0.64, r=-0.58). In the group of patients with lupus nephritis, significantly higher sera concentrations of sVCAM-1 were detected compared patients without nephritis. Patients with class III and IV kidney changes had significantly higher levels of sVCAM-1 compared to the patients with class II kidney changes. In the group of patients with activity index of kidney changes (AI) over 4 sVCAM-1 the sera levels were significantly higher compared to the group with AI <4.

CONCLUSION

The sera level of sVCAM-1 is a reliable parameter to evaluate the autoreactivity degree in SLE. In the same time, sVCAM-1 sera level can be used as a reliable marker to evaluate the renal lesion extensivity in SLE.

Littoral-cell angioma as a rare cause of splenomegaly

We report the case of a littoral-cell angioma of the spleen, a recently described benign vascular tumour, whose imaging and pathological characteristics have been discussed only by a few authors. The diagnosis was made after elective splenectomy. The CT images, scintigraphy and histological specimens are presented, and differential diagnoses discussed.

[Gastrointestinal stromal tumor of small intestine--case report]

Gastrointestinal stromal tumor is a form of mesenchimal neoplasm that may be present in all parts of gastrointestinal system. We are reviewing diagnostic and therapeutic algorithms for patient with diagnosed gastrointestinal neoplasm of small intestine, experiencing repeated episodes of painful bleeding from gastrointestinal trackt.

Histopathology of residual rectal carcinoma following preoperative radiochemotherapy

Preoperative radiotherapy with (CRT) or without chemotherapy (RT) in the management of patients with locally advanced rectal carcinoma is increasingly accepted as therapeutic modality to reduce local recurrence and improve survival, decrease tumor size and/or stage, has less toxicity compared to postoperative therapy, improves sphincter preservation and the ability to perform a curative resection. In a brief review of literature we discussed the possible prognostic role of most important pathologic parameters and their clinical implications. At present, predictive value of tumor response to neoadjuvant therapy remains uncertain, whether evaluated as five-point histological tumor regression grade (TRG) or recently proposed three-point rectal cancer regression grade (RCRG). However, most reports emphasize reduced local reccurence rates and disease-free survival advantage in patients with complete tumour regression or tumour down-staging, occuring in up to 20% and 60% of cases, respectively. Patients with advanced post-treatment tumour stage (ypT3/4), positive lymph nodes (ypN1/2), vascular invasion, positive circumferential resection margin, clearance < 2mm, or absence of tumor regression are shown to have poor clinical outcome. Among CRT-induced morphological features, only "fibrotic-type" stromal response with minimal inflammatory infiltrates and absence of surface ulceration are correlated to recurrence-free survival. Preliminary unpublished results of a pilot study from our multidisciplinary prospective trial relate to correlation of histopathologic parameters and morphologic changes to rectal cancer regression grade (RCRG). Therefore, we studied 22 consecutive patients, mean age 56 (range 23-69) years, with transmural cT3/4 stage and were subgrouped as follows: RCRG-1 (7 patients, 31.8%), RCRG-2 (9 patients, 40.,9%) and RCRG-3 (6 patients, 27,2%). In addition, 14 patients (63%) showed tumour downstaging and only 1 patient (4.5%) nodal down-staging after ypTNM restaging. There was the predominance of fibrotic-type stroma (16 patients, 72.8%) versus fibro-inflammatory response (6 patients, 27.2%), frequent tumoral necrosis (13 patients, 59%) but infrequent surface ulceration (5 patients, 22.7%) and peritumoural eosinophylic infiltration as well as endocrine cell differentiation (4 patients, 18%). The second aim of our study was to investigate determinants of radiosensitivity, i.e. the relationship between proliferative activity indices (Ki-67 and PCNA) as well as the induction of apoptosis (p53) and the tumour regression (RCRG) after neoadjuvant CRT. The interaction between Ki-67 and PCNA immunoexpression levels and the benefit of CRT was significant for Ki-67 (p = 0.03), but not for PCNA (p = 0.08) and p53 levels (p = 0.4). In a conclusion, high percentage of Ki-67-positive tumor cells in the preoperative biopsy predicts an decreased treatment response after preoperative CRT of rectal cancer. However, long-term follow-up and large studies are necessary to establish the value of regression grade and the need for its prediction by reliable biological markers.

Investigating the Role of 2-Phenylpropenal in Felbamate-Induced Idiosyncratic Drug Reactions

Felbamate (2-phenyl-1,3-propanediol dicarbamate, FBM) can cause aplastic anemia and hepatotoxicity. The mechanism of FBM-induced toxicities is unknown; however, it has been proposed that 2-phenylpropenal, a reactive metabolite of FBM, is responsible. The pathway leading to this metabolite involves hydrolysis of FBM to 2-phenyl-1,3-propandiol monocarbamate (MCF), oxidation to 3-carbamoyl-2-phenylpropionaldehyde (CBMA), and spontaneous loss of carbon dioxide and ammonia. We made a polyclonal antibody against 2-phenylpropenal bound to protein and confirmed its specificity using ELISA. We attempted to develop an animal model of FBM-induced aplastic anemia and/or hepatotoxicity, and we also used the antibody to try to detect covalent binding of 2-phenylpropenal using immunoblotting. However, none of the animals developed evidence of bone marrow or liver toxicity, and we were unable to detect covalent binding, possibly because significantly less 2-phenylpropenal is formed in rodents than in humans. As this type of idiosyncratic drug reaction is believed to be immune-mediated, we also studied the potential of FBM and its metabolites to stimulate an immune response using the reporter antigen popliteal lymph node assay in female Balb/c mice. We found that neither FBM nor MCF induced an immune response in popliteal lymph nodes (PLNs). However, CBMA treatment appeared immunogenic, causing footpad inflammation, hardening, scab formation, and an increase in thickness. The PLN cell count in CBMA-treated mice increased 8-fold as compared to control, FBM-, or MCF-treated mice. Immunohistochemical analysis of the CBMA-exposed PLNs revealed germinal center formation, indicating B cell proliferation, later confirmed by flow cytometry. Most of the cells expressing the activation surface marker CD54 were B cells. We also found that CBMA treatment caused an increase in the production of IgM and IgG1 antibodies as well as IL-4 and IFN-gamma cytokines. Our findings indicate that 2-phenylpropenal is a very potent immunogen, supporting its possible involvement in the FBM-induced hepatotoxicity and aplastic anemia.

[Colchicine in dermatology]

<zakljucak> Kolhicin je stari lek cija je primena, kao monoterapija ili u kombinaciji sa drugim lekovima, aktuelna i u savremenoj medicini. Najznacajnija mu je primena za lecenje i profilaksu perzistentne palmoplantarne pustuloze i oralnih aftoznih ulceracija, lecenje Svitovog sindroma, Beh?etove bolesti, sklerodermije i fibromatoze penisa.

A kinetic model of aqueous-phase alkali hydrolysis of 2,4,6-trinitrotoluene

Alkali hydrolysis of 2,4,6-trinitrotoluene (TNT) was studied using batch experiments with starting pH values 11 and 12 in glass conical flasks covered with aluminum foil. Isothermal (25 and 40 degrees C) as well as non-isothermal experiments were conducted. Experiments starting at pH 12 resulted in >95% reduction in the concentration of TNT; those starting at pH 11 had a maximum reduction of 20-25% in TNT concentration. In all the experiments, one major stable intermediate was produced but it could not be identified. The experimental data were used to determine the overall stoichiometry of TNT and hydroxyl ions. Approximately 100 M (standard deviation 11.4) of hydroxyl ions were consistently consumed per mole of TNT. However, control experiments showed that all but 13 M (standard deviation 2) of hydroxyl ions were consumed in reactions not related to TNT. A simple kinetic model involving formation of the intermediate was proposed to account for changes in concentrations of TNT and hydroxyl ions. The rate constants and activation energies of the reactions were identified using isothermal data and the kinetic model was then used to predict the experimental data in the non-isothermal experiments reasonably well.

Stimulation of growth factor synthesis in skin wounds using tissue extract (G-90) from the earthwormEissenia foetida

Growth factors are biologically-active mediators that bind to specific receptors on target cells and regulate genes involved in cell growth, wound healing and regeneration. In the case of wound healing, a proper wound dressing is needed to cover the wound area, protect the damaged tissue, and if possible to activate cell proliferation and stimulate the healing process. In this study we examined the efficacy of a glycolipoprotein tissue homogenate extract from Eisenia foetida (G-90) to activate signal transduction pathways, leading to wound healing. We measured the activation of EGF and FGF in healthy skin, in wounds with physiological healing and in wounds treated with G-90. The activation of EGF and FGF was measured during the first 24 h of wound healing under both physiological conditions and treatment with G-90. In both cases an increased concentration of EGF and FGF was observed 6 h after wounding. In comparison with healthy skin, the concentration of EGF increased 10-fold and FGF five-fold in wounds treated with G-90 (10 ng ml(-1)). Healing in physiological conditions resulted in a two-fold increase of EGF and 1.5-fold of FGF.

Choroid plexus tumors: a review of 28-year experience

The aims of the study were to review the patients with choroid plexus tumor (CPT) treated in Slovenia between 1972-1999, to calculate the incidence of CPTs, and to evaluate treatment results in respect to tumor histology and mode of therapy. Cancer Registry of Slovenia database was used for patientś identification. Histological specimens and medical records were reviewed. Twelve patients (7 females, 5 males), 0.8-43 years old (median 6.1 years; <15 years: 10/12,83%) with CPT, representing 0.36% of all intracranial tumors registered during the period under study, were identified. Considering children less than 15 years old only, the corresponding percentage was 3.69. There were eight papillomas (CPPs) and four carcinomas (CPCs) with no difference in age distribution between the groups. Of seven patients with gross tumor resection in CPP group, one patient died of postoperative meningitis and one had local recurrence 1.6 years after surgery; the latter is disease-free 17.9 years after re-operation. One patient with macroscopic residue after surgery is alive and asymptomatic after 16.5 years. In the CPC-group, only the patient who received adjuvant BEP chemotherapy and craniospinal irradiation following incomplete surgery is alive with no signs of disease after 6.5 years. Ten-year disease-specific survival for all CPTs and for CPP subgroup was 73% and 100%, respectively. In Slovenia, CPTs represent 0.36% of intracranial tumors. In children, the incidence is 3.69%. CPPs are twice as frequent as CPCs. In CPPs, the treatment of choice is surgery alone. After incomplete surgery, wait-and-see policy seems to be justified. For CPCs, adjuvant multiagent chemotherapy and craniospinal radiotherapy following surgery should be considered.

Amniotic fluid embolism with involvement of the brain, lungs, adrenal glands, and heart

The case of a healthy 31-year-old woman in the 40th week of second pregnancy is presented. During preparation for an emergency caesarean section, she developed an amniotic fluid embolism (AFE) with unusual and unique features. The acute onset of disease with cardiorespiratory failure with hypotension, tachycardia, cyanosis, respiratory disturbances and loss of consciousness, suggested at first a pulmonary thromboembolism, but the appearance of convulsions led to the diagnosis of AFE. The patient died after 5 days due to an untreatable brain edema. At autopsy, AFE with the usually associated disseminated intravascular coagulation was found in the lungs, brain, left adrenal gland, kidneys, liver and heart. Eosinophilic inflammatory infiltrates were found in the lungs, hepatic portal fields and especially in the heart, suggesting a specific hypersensitivity reaction to fetal antigens. Moreover, intravascular accumulation of macrophages in the lungs also favored a non-specific immune reaction to amniotic fluid constituents.

Local recurrence and five year survival after abdominoperineal resection of the rectum due to rectal carcinoma

In the period 01.01.1991-12.31.1996, 523 operations due to rectal carcinoma were performed on the First Surgical Clinic, the Third Department for Colorectal Surgery. Most common localization of tumor was in the distal third of the rectum 65.2%. In the middle third, there were 28.9% and in the upper, intraperitoneal third 5.9%. We performed 286 low anterior stapled resections, 93 anterior resections with hand-sewn anastomosis and 144 Abdominoperineal excisions of rectum (Miles procedure). Pathohistological examination revealed adenocarcinoma in all cases. In this study we analyzed local recurrence and five-year survival after long-term follow-up in the group where Miles procedure was carried out as a potentially curative procedure (except 4.9% cased with Dukes D stage). There were 74.3% males and 23.7% females median age 59.2 years. According to Dukes classification there were 4.9% in stage A, 47.2% in stage B, 43.1% stage C, and 4.9% stage D. There were 4(2.7%) postoperative deaths. Recurrence of the disease was registered in 44 (30.5%) patients. Local recurrence alone was found in 14 (9.7%) patients, while distant spread was registered in 30 (20.8%) patients. At present, the median follow-up is at 72.9 months. Analysis by the Kaplan-Meier's test shows cumulative survival of 61%, and disease free survival of 63.4% at 60 months of the follow-up. Dukes C is associated with a very poor prognosis; survival after 60 months of follow up shows cumulative Survival of 0.35 while Dukes B has far better prognosis (0.86). Analysis of disease free survival by Dukes stage shows that Dukes C has the worst prognosis (disease free survival 0.36 after 60 months), while stage B has much better prognosis (0.84). Local recurrence analysis by the Kaplan-Meier's test shows disease free survival of 84.9% at 60 months of follow-up. Analysis of local recurrence by Dukes stage shows 1.00% disease free survival for cases in stage A, 0.94 for Dukes B and 0.66 for Dukes C, while overall comparison between groups regarding local recurrence using the Wilcoxon (Gehan) statistic shows statistically significant difference (p-0.005). There is no statistical difference between Dukes A and Dukes B cases in distribution of local recurrence.

[The role of strictureplasty in the treatment of Crohn's disease]

Crohn's disease is pandigestive disease of unknown aethiology, with tendency to reccurrences. Until now it is impossible to heal this disease either by medical or surgical treatment. All unfavourable consequences of this disease are result of inadequate treatment of complications which are leading to systemic weakening, with further progression of morbid process. Therefore, the principle of timely and minimal invasive surgical procedure has been generally adopted. Introduced in eighties, strictureplasty is a procedure of such characteristics. During the period 1980-2001 this method was used in 1/3 of 126 patients with Crohn's disease. There were 79 strictureplaties performed, 9 long and 70 short. Out of these 42, 12(28.6%) were postoperative recurrences, and there was one case of duodenal strictureplatsty. Postoperative small bowel fistulae were not observed, and there was no mortality in this group. During the follow up period of at least 5 years, in only two cases (4.76%) some functional disturbances of digestive functions were observed, without indications for reoperation. In this article indications and details of operative technique are discussed.

[Late results of splenectomy in patients with chronic immune thrombocytopenic purpura]

Splenectomy is definitive treatment for idiopathic thrombocytopenic purpura (ITP) because it removes both the sites of autoantibody producing cells and also the major site of platelet destruction. The purpose of this study was to evaluate long term results of splenectomised patients with ITP and to determine predictor factors for good response. A 167 patients with chronic ITP (136 females, 31 males), median aged 35 years (17-74) was splenectomised after 2 to 160 months (Median 12) from diagnosis of ITP. Indications for splenectomy were: 6 weeks of steroid therapy with platelet count below 10 x 10(9)/l or 3 months with platelet count under 30 x 10(9)/l, or treatment with prednisone above 30 mg more of 6 months to increase platelet count over 30 x 10(9)/l, or repeated relapses. Postoperative complications developed in 16 patients (9.5%), 3 of them died (1.8%) due to thromboembolism and 17 patients discontinued later controls. During follow up to 172 months (Median 62) 111/147 splenectomised patients were in remission (75.5%), 99 in complete (above 100 x 10(9)/l), 12 in partial (50-100 x 10(9)/l) and 36 patients (24.5%) were relapsed (below 50 x 10(9)/l). Remission was achieved in 79/88 patients (89.8%) with good response to prednisone before splenectomy toward 32/62 patients (51.6%) with poor response to prednisone (p < 0.01). Remission was obtained in 9/11 patients (81.8%) who responded well to intravenous immune globulin (0.4 g/kg x 5 d) and only in 1/8 who did not (p < 0.05). Higher response rate was achieved in patients under 40 years of age (81.6%) than in older ones (63.4%) (p < 0.05). No difference was shown between sex and time intervals (3, 6, 12, 24, 36 or over 36 months) from diagnosis to splenectomy. Splenectomy is an effective treatment of refractory ITP with response rate of 75.5% after median follow up of 62 months. In our patients better results on splenectomy were associated with age less than 40 years, good responses to steroid, and intravenous immune globulin.

[Surgical treatment of hematologic disorders of the spleen]

Splenectomy--the surgical removal of spleen is being performed in cases of: traumatic spleen rupture, as part of other surgical procedures, number of hematological, infectious and metabolic disorders. During the years 1988.-2001., there were 396 splenectomies performed at the First surgical clinic, for the cause of: autoimmune disorders 187 (47.34%), lymphoproliferative diseases 89 (22.59%). Hodgkin disease 35(8.94%), myeloproliferative disease 39 (9.95%), as part a of "staging" laparotomy 37(9.34%), other hematological disorders 7(2.20%). The spleen of [table: see text] 244 patients weighted 500-1500 g(61.62%), in 56 patients (14.14%) weighted less than 500 g, and in 96 patients (24.24%) spleen weighted more than 1500 g. Patients with thrombocytes less than 40,000/l 16 (4.04%) were perioperativly treated with fresh thrombocytes. Postoperative morbidity and mortality were registered in 54 (13.64%), i.e. 8 (2.02%) patients. Delayed results depended on primary disorder, comorbidities and supportive therapy. In this article, the particularities of the operative procedure were discussed, as well as importance of cooperation of surgeon and hematologist in perioperative treatment.

[Autotransplantation of the spleen]

Auto transplantation of the spleen can be performed in the patients with traumatic rupture of the spleen, in whom spleen could not be conserved in the other way. The right indication for this method is isolated rupture of the spleen (concvasation or complete devascularisation). This method is not recommended in the endangered patients, patients with previous disease of the spleen as well as in the patients with the perforation of the other abdominal organs at the same time. Auto transplantation was performed in 12 patients with isolated splenic rupture and hematoperitoneum, 11 men and one woman. The majority of patients are younger. In 8 patients, autotransplant was placed into big omentum, in three into lipomatous tissue surrounding left kidney, and in one into anterior abdominal wall. In all the patients from this group, following analysis were taken: MCV (middle volume of erythrocytes), HTC, Hb, Le, Glucose, urea, creatinin, sodium, potassium, alkali phosphatasis, target cells, Howell Jolly's bodies, Heinz's bodies, IgG, IgA, IgM, C3, C4, T3, T4, T8, B, segmentated, eosinophiles, lymphocytes, reticulocytes, thrombocytes, fibrinogen, PT, APTT, aggregation of thrombocytes and aggregation of thrombocytes on collagen. The same parameters were taken in 12 patients with surgery similar to splenectomy and in 12 after splenectomy. After splenectomy, there was decrease of the immunologic defending abilities of the organism because of the loss of the childrens function of the spleen, decreased level of the opsonines and tutsin, which leads to the impaired phagocytosis, decreased concentration of IgM and T and B lymphocytes, while in patients after auto transplantation the results were physiological. The most important thing in the assessment of the function of the autotransplanted spleen is scintigraphic investigation using 99mTc-denaturated red blood cells. In our study, auto transplant function was assessed in 10/12 patients by scintigraphy. Five years after surgery, no one patient was proved to have postsplenectomic sepsis.

[Recurrence of immunologic thrombocytopenic purpura due to hypertrophy of retained accessory spleens]

Idiopathic thrombocytopenic purpura is an autoimmune disease in which macrophages of reticuloendothelial system, mainly in the spleen, remove platelets covered by autoantibodies from circulation. By removing the spleen 60-80% of patients are cured. Partial remission is achieved in 10-20% cases. Very few patients do not react on splenectomy. Recurrency of idiopathic thrombocytopenic purpura in a splenectomized patient after already achieved complete remission, may be caused by hypertrophy of one or more of the retained accessory spleens. We present 3 patients, 41, 23 and 44 year old, in whom splenectomy for ITP had been performed 10, 3 and 11 years earlier. After full remission which lasted 10, 2.5 and 10.5 years a full recurrency of ITP took place with signs of severe thrombocytopenia and haemorrhagic syndrome. Using ultrasonography, computed tomography and scintigraphy accessory spleen/s, were discovered. By their removal, a full remission was achieved in all 3 patients, but full favorable effect appeared approximately three months after surgery during which period additional steroid therapy was necessary.

[Cesarean section combined with splenectomy in severely resistant immune thrombocytopenia]

Immune thrombocytopenic purpura (ITP) associated with pregnancy often involves considerable risk both for mother and child, and usually worsens in the third trimester of gestation. Pregnancy and delivery are especially difficult in patients with severe ITP (platelet count below 20 x 10(9)/L), who are resistant to prednisone and high dose intravenous immunoglobulin (IVIgG). In those cases we applied cesarean section (CS), to prevent intracranial haemorrhage due to fetal/neonatal ITP, and splenectomy at the same time as an effective therapeutic strategy for ITP. We present 5 patients (4 with chronic ITP and 1 with ITP associated with HIV infection), aged 21-35 years, with severe ITP (platelet count 2-10 x 109/L), resistant to prednisone (1-2 mg/kg), and 2/3 were resistant to IVIgG (0.4 g/kg x 5 d). Four patients with severe resistant ITP were supported with 1-2 doses of platelets from cell separator before CS and 1-3 dose during splenectomy. One patient increased platelet count to 55 x 109/L after treatment with IVIgG and splenectomy following CS were done without platelet transfusion. Splenectomy was performed immediately after CS in all patients, and two of them were hysterectomised (one with HIV infection). After splenectomy, platelet count was normalised in all patients, and they had no haemorrhage, wound haematoma formation or any adverse events. But ITP relapsed in 2/5 patients after 1-2 months. Two newborns had severe thrombocytopenia, which solved spontaneously after 3 days in one or after treatment with IVIgG in other. We propose that splenectomy following cesarean section should be considered as approach for delivery and treatment option for mothers with severe resistant ITP.