Vergleich zwischen Shave-Therapie und kruraler Fasziektomie bei der Behandlung »therapieresistenter« venöser Ulzera

Ziel und Methoden: Von Januar bis Dezember 1997 wurden im Rahmen einer Vergleichsstudie 13 Patienten mit insgesamt 18 nichtheilenden (sogenannten therapieresistenten) venösen Ulzera in der Klinik für Dermatologie und Venerologie der Medizinischen Universität zu Lübeck mittels Shave-Therapie behandelt; im selben Zeitraum wurden 10 Patienten einer vergleichbaren Altersgruppe mit 14 Ulzera gleichen Schweregrades mittels kruraler Fasziektomie in der Klinik für Gefäßkrankheiten der William-Harvey-Klinik, Bad Nauheim, behandelt. Alle Ulzera waren Folge einer primären bzw. sekundären Leitveneninsuffizienz oder eines postthrombotischen Syndroms; zusätzlich bestand ein arthrogenes Stauungssyndrom. Ergebnis: 3 und 12 Monate postoperativ bestanden bezüglich der Zahl der persistierten bzw. rezidivierten Ulzera bei beiden Kollektiven keine signifikanten Unterschiede; nach einem Jahr fand sich eine komplette Abheilung bei 11 von 18 Ulzera (61,1%) der Shave-Gruppe und bei 9 von 14 Ulzera (64,3%) der Fasziektomie-Gruppe. Die durchschnittliche Abnahme der Ulkusfläche nach 12 Monaten war bei den Fasziektomie-Patienten größer; die stationäre Behandlungszeit (49,8 Tage) war doppelt so lang wie bei den Shave-Patienten (24,1 Tage). Schlußfolgerung: Die Untersuchung zeigt, daß bezüglich der klinischen Ergebnisse im ersten Jahr postoperativ beide Verfahren bei venösen »Problemulzera« gleichwertig sind. Eine Entfernung der Unterschenkelfaszie mit Eröffnung der dorsalen Kompartimente bietet während dieses Zeitraums keinen eindeutigen Vorteil.

Secondary prophylaxis of invasive fungal infections with combination antifungal therapy and G-CSF-mobilized granulocyte transfusions in three children with hematological malignancies

Fungal infections represent a life-threatening complication for patients receiving chemotherapy or undergoing hematopoietic stem cell transplantation. Historically, antifungal monotherapy is associated with a poor outcome. We treated three children with hematological malignancies and proven fungal infections (one cerebral mold infection, one disseminated Candida infection, one naso-pharyngeal mucor infection) with combination antifungal therapy plus granulocyte-colony-stimulation-factor-mobilized granulocyte transfusions as secondary prophylaxis during subsequent neutropenic episodes. With this approach, the fungal infection was effectively treated, and the anticancer therapy was completed without major delay. All children survived the fungal infection and the underlying malignancy. These experiences illustrate the feasibility of this approach using more than one antifungal agent together with immune-therapy in high-risk patients.

[Hip endoprosthesis]

The replacement of a hip joint after osteoarthritis or fracture is today a standard surgical procedure and performed worldwide in about 750,000 cases. Since it is possible to achieve durable anchorage of implants in bone and to effectively treat loss of function and pain of the hip joint, this operation belongs to the most successful in our times.Therefore, a differentiated technology has developed that encompasses modern implant materials, biomechanical knowledge, and surgical techniques. Current standards in this procedure are demonstrated.

CPM?Continuous Passive Motion: Behandlung verletzter und operierter Kniegelenke mit Mitteln der passiven Bewegung

There is still a controversial discussion in literature about the use of motor driven splints in knee surgery--as the principle of continuous passive motion, CPM. For this reason it seemed useful for an evaluation to look through the papers which were published since 1990. It was obvious, that negative results were published often before this year, but this papers are still quoted standard works. In medical data bases subito-doc.de, medscape.com, medica.de and zbmed.de 230 papers were found by search CPM, continuous passive motion and arthromot. Coincidentally there was a search for authors who were already quoted in other papers. 36 papers concerning CPM after knee surgery were utilized. The role of CPM regarding the range of motion, swelling, duration of hospital stay, use of analgesics, costs, postoperative manipulations, wound healing and thrombo embolic complications was evaluated. Although the results of this partial retrospective, partial prospective, sometimes randomized or double blinded studies are in contradiction, there can only be found a trend to better results. New clinical studies for evidence based guidelines in the handling of continuous passive motion after knee surgery are necessary.

Invasive fungal infections are responsible for one-fifth of the infectious deaths in children with ALL

The following report will discuss in detail all lethal invasive fungal infections (IFI) that occurred in a group of 2021 children with acute lymphoblasic leukaemia (ALL). The German ALL-Berlin-Frankfurt-Muenster (BFM) study group is one of the largest cooperation for the treatment of childhood ALL. Between 1995 and 2000, 2021 children with ALL received chemotherapy according to the German BFM 95 protocols (ALL-BFM 95). This population was retrospectively screened, whether a lethal fungal infection occurred: totally, in this group, 43 of 2021 (2.1%) children died because of infections. Nine of 43 (21%) patients died in the context of an IFI: six fatal Aspergillus infections and three fatal yeast infections were reported. The following report will focus on the nine children with ALL who died from IFI. The underlying risk factors (RF) included neutropenia (seven of nine patients) and steroid medication (nine of nine patients). Seven of nine children had additional medical complications (e.g. liver failure, haemolytic uraemic syndrome and acute renal failure). In six of nine children the fungal infection was progressive despite intravenous antimycotic therapy, three patients received no antifungal therapy, as IFI was not considered. The progression of IFI despite antimycotic therapy illustrates the inherent problems of diagnosis and the need for innovative therapeutic modalities. The high percentage (21%) of death from IFI among lethal infections in paediatric ALL patients illustrates the relevance of fungi in this group of patients. On the contrary, the total number of IFI in paediatric ALL patients remains to be determined, as only lethal infections were included in this report.

[Preoperative planning and surgical technic in achieving stability and leg length equality in total hip joint arthroplasty]

One of the prerequisites for a good outcome of total hip arthroplasty is preoperative planning. Using a roentgenogram, the size of an implant, incision level on the femoral neck, depth required for fitting the cup, restoration of the center of hip rotation and, if necessary, correction of length descrepancy between the legs are determined. The preoperative planning based on an X-ray image was introduced by M. E. Müller and, in 1976, was modified by R. Schneider who used a transparent sheet for a template on which all relevant points guiding the surgical procedure are marked, i.e., the right position for implantation of the cup and stem, and incision lines. In uncomplicated cases, however, this approach is not necessary and the "planning principle of parallel lines" developed by L. Spotorno in 1988 can be used instead. The determination of length discrepancy between the legs is derived from a drawing of three reference lines on the roentgenogram. The lines parallel to each other indicace the same length for both legs. If the legs differ in length, the lines will diverge from each other in a way typical for this condition.

Vertebral osteomyelitis and endocarditis of a pacemaker lead due to Granulicatella (Abiotrophia) adiacens

Systemic infection due to Granulicatella (formerly Abiotrophia), a species of nutrition-deficient gram-positive cocci, is rare. We present the case of a 68-year-old diabetic male who presented with back pain and a history of fever and chills. Imaging studies revealed vertebral osteomyelitis of the Th 10/11 region. Transesophageal echocardiography disclosed a vegetation adjacent to the pacemaker lead and blood cultures grew Granulicatella adiacens. A diagnosis of vertebral osteomyelitis and endocarditis due to G. adiacens was made and the patient improved with bed rest and medical treatment alone. Granulicatella ssp. should always be part of the differential diagnosis of fastidious bacteria in vertebral osteomyelitis and endocarditis.

[Results of cement-free St. Nabor hip prosthesis implantation and clinical and radiological results after 8 to 10 years]

PURPOSE OF THE STUDY

The aim of the retrospective study was to analyse the medium-term results of the cementless hip prosthesis St. Nabor.

METHOD

46 patients with complete postoperative and radiographic documentation were available for clinical review. The average follow-up was eight years and five months (range from eight years, one month to ten years). The average age at the last follow-up was 60 years. Ten patients showed severe coxarthritis and 32 patients a dysplasia of the acetabulum before surgery. Two patients suffered from a severe osteonecrosis of the femoral head and two patients had fractures of the acetabulum or femoral neck, respectively.

RESULTS

The medium-term follow-up for the acetabular component showed a survival rate of 97.8%. The radiographic data visualized one loosening as a result of a low grade infection, 18 months after surgery. There was no migration of the acetabular component according to Sutherland et al. and no protrusion was found. None of the acetabular components showed radiolucent lines or was loose according to radiographic criteria. In comparison to the first post-operative radiograph, 26 of the hips were found with a significant reduction of lacunae, twelve of them showed a complete absence at last follow-up. The overall Harris hip score averaged 92 points (range 58 to 100 points) for the entire group. 41 (92%) of all hips were rated as excellent or good. Two hips (4%) of all hips were rated as fair and two hips (4%) were rated as poor.

CONCLUSION

The high rate of good and satisfying results in medium-term follow-up proves this St. Nabor acetabular component system to be an excellent implant in total hip arthroplasty for younger patients with or without dysplasia.

Recovery of mycobacteria from patients with cystic fibrosis

Despite decontamination, overgrowth by pseudomonads renders cultural isolation of mycobacteria from respiratory specimens of patients with cystic fibrosis (CF) difficult or impossible. We performed a prospective study by comparing levels of reduction of overgrowth and recovery of mycobacteria using either pretreatment with N-acetyl-L-cysteine (NALC)-NaOH alone or pretreatment with NALC-NaOH and then with oxalic acid. From 406 specimens of 148 CF patients, 11 specimens were positive for mycobacteria, 5 of which grew mycobacteria after decontamination by either procedure. Three specimens grew mycobacteria only after decontamination with NALC-NaOH, whereas three specimens grew mycobacteria only after treatment with NALC-NaOH followed by oxalic acid but were overgrown after decontamination with NALC-NaOH. Thus, inactivation of mycobacteria by the more aggressive oxalic acid treatment offsets its beneficial effect of reducing the proportion of cultures overgrown with microorganisms other than mycobacteria.

A new agent of mycobacterial lymphadenitis in children: Mycobacterium heidelbergense sp. nov

Nontuberculous mycobacterial lymphadenitis presents an increasing clinical problem in immunocompetent young children. A slowly growing, nonphotochromogenic mycobacterium was recovered twice (isolates 2553/91 and 2554/91) from the lymphatic tissue of a child with recurrent cervical lymphadenitis. It could be differentiated biochemically from described Mycobacterium species, although it most closely resembled Mycobacterium malmoense by thin-layer chromatography and high-performance liquid chromatography of mycolic acids. A striking characteristic of the isolate was its high degree of susceptibility to antituberculous drugs in vitro, including isoniazid. Direct determination of the 16S rRNA gene sequence revealed a unique sequence and positioned the strain phylogenetically on a branch separate from M. malmoense within a group of slowly growing mycobacteria that show a high degree of similarity to M. simiae at the 16S rRNA gene level. Despite 99.6% sequence identity with M. simiae at the 16S rRNA gene level, DNA-DNA hybridization studies (hydroxyapatite method) demonstrated DNA relatedness of less than 40%. We conclude that this organism is a new species for which we propose the name M. heidelbergense. A culture of the type strain, strain 2554/91, has been deposited in the American Type Culture Collection as strain ATCC 51253.

Cervical lymphadenitis due to an unusual mycobacterium

A scotochromogenic acid-fast bacillus was isolated from a lymph node of a 2-year-old female. On the basis of conventional testing, the mycobacterium appeared to be Mycobacterium scrofulaceum. Its mycolic acid profile, however, was not identical to that of Mycobacterium scrofulaceum but was similar to that of Mycobacterium interjectum. Direct sequencing of the 16S rRNA gene revealed a unique nucleic acid sequence, suggesting that the isolate represents a previously undescribed pathogenic species.

Characterization of mycobacterial isolates phylogenetically related to, but different from Mycobacterium simiae

The use of high-performance liquid chromatography (HPLC) revealed four previously unreported profiles within a group of mycobacteria consisting of 14 clinical isolates. These mycobacteria, whose identification by conventional tests appeared problematic, mostly resembled Mycobacterium avium complex or Mycobacterium simiae. Genetic analysis revealed, within this group, six different nucleic acid sequences in a hypervariable 16S rRNA segment, but all the isolates appeared to be phylogenetically related to M. simiae. Six isolates representing the largest of groups defined by means of genetic sequencing turned out to belong to the newly described species Mycobacterium lentiflavum. Furthermore, three such clusters precisely coincided with three of those defined by HPLC, while the three remaining clusters shared almost identical HPLC profiles. All but one strain (which, although clearly not belonging to the M. avium complex, hybridized with specific commercial DNA probes) showed high-grade resistance to the majority of antimycobacterial drugs. Three of the isolates were clinically significant according to stringent criteria. Sophisticated techniques, like genetic sequencing or HPLC, by now seem indispensable for differentiating unusual and new mycobacteria from well-established ones.

Isolation of an unusual mycobacterium from an AIDS patient

A mycobacterium isolated from a clinical sample of an AIDS patient was identified as Mycobacterium interjectum by direct 16S rRNA sequence determination. High-performance liquid chromatography, however, revealed a mycolic acid pattern which was different from the one shared by the previously analyzed strains of this species.

Non-invasive neurochemical analysis of focal excitotoxic lesions in models of neurodegenerative illness using spectroscopic imaging

Water-suppressed chemical shift magnetic resonance imaging was used to detect neurochemical alterations in vivo in neurotoxin-induced rat models of Huntington's and Parkinson's disease. The toxins were: N-methyl-4-phenylpyridinium (MPP+), aminooxyacetic acid (AOAA), 3-nitropropionic acid (3-NP), malonate, and azide. Local or systemic injection of these compounds caused secondary excitotoxic lesions by selective inhibition of mitochondrial respiration that gave rise to elevated lactate concentrations in the striatum. In addition, decreased N-acetylaspartate (NAA) concentrations were noted at the lesion site over time. Measurements of lactate washout kinetics demonstrated that t1/2 followed the order: 3-NP approximately MPP+ >> AOAA approximately malonate, which parallels the expected lifetimes of the neurotoxins based on their mechanisms of action. Further increases in lactate were also caused by intravenous infusion of glucose. At least part of the excitotoxicity is mediated through indirect glutamate pathways because lactate production and lesion size were diminished using unilateral decortectomies (blockade of glutamatergic input) or glutamate antagonists (MK-801). Lesion size and lactate were also diminished by energy repletion with ubiquinone and nicotinamide. Lactate measurements determined by magnetic resonance agreed with biochemical measurements made using freeze clamp techniques. Lesion size as measured with MR, although larger by 30%, agreed well with lesion size determined histologically. These experiments provide evidence for impairment of intracellular energy metabolism leading to indirect excitotoxicity for all the compounds mentioned before and demonstrate the feasibility of small-volume metabolite imaging for in vivo neurochemical analysis.

Isolation and characterization of a unique group of slowly growing mycobacteria: description of Mycobacterium lentiflavum sp. nov

A distinct group of slowly growing mycobacteria was identified on the basis of growth characteristics, biochemical and lipid profiles, and nucleic acid analyses. The isolates showed growth at 22 to 37 degrees C, yellow pigmentation, and negative tests for Tween 80 hydrolysis, nicotinic acid, nitrate reductase, and urease; tests for arylsulfatase, pyrazinamidase, and heat-stable catalase were variable. Analysis of cellular fatty acids by gas-liquid chromatography and mycolic acids by thin-layer chromatography and high-performance liquid chromatography indicated a distinctive pattern which was unlike those of other species. Determination of the 16S rRNA gene sequence showed a unique sequence closely related to Mycobacterium simiae and M. genavense. On the basis of DNA homology studies, we suggest that these organisms are representatives of a novel species, for which the name M. lentiflavum sp. nov. is proposed.

Diagnosis of mycobacterial infections by nucleic acid amplification: 18-month prospective study

We have investigated the use of DNA amplification by PCR for the detection of mycobacteria in clinical specimens, with the gene encoding the 16S rRNA as a target. Following generic amplification of mycobacterial nucleic acids, screening was done with genus-specific probe; this was followed by species differentiation by use of highly discriminating probes or nucleic acid sequencing. In a prospective 18-month evaluation, criteria to select specimens for PCR analysis were defined. Of a total of 8,272 specimens received, 729 samples satisfied the criteria and were subjected to DNA amplification. Clinical specimens included material from the respiratory tract (sputa and bronchial washings), aspirates, biopsies, and various body fluids (cerebrospinal, pleural, peritoneal, and gastric fluids). After resolution of discrepant results, the sensitivity of the PCR assay was 84.5%, the specificity was 99.5%, the positive predictive value was 97.6%, and the negative predictive value was 96.4%. The sensitivity and negative predictive value of culture (with a combination of broth and solid media) were 77.5 and 94.8%, respectively. In conclusion, this PCR assay provides an efficient strategy to detect and identify multiple mycobacterial species and performs well in comparison with culture.

Semantide- and chemotaxonomy-based analyses of some problematic phenotypic clusters of slowly growing mycobacteria, a cooperative study of the International Working Group on Mycobacterial Taxonomy

During previous cooperative numerical taxonomic studies of slowly growing mycobacteria, the International Working Group on Mycobacterial Taxonomy described a number of strains whose taxonomic status was ambiguous. A new study of DNA, RNA, and proteins from 66 of these organisms was performed to correlate their properties with phenotypic clustering behavior; the results of this study permitted 51 of the strains studied to be assigned to known species. The methods used to characterize the semantides included nucleotide sequencing and assessment of levels of semantide relatedness by affinity binding techniques, including whole DNA-DNA hybridization, probe hybridization, and antibody binding. There was good overall agreement between the phenotypic and chemotaxonomic clusters and the groups of organisms identified by semantide analyses. Our results supported the conclusion that we should continue to rely on polyphasic taxonomy to provide satisfactory systematic resolution of members of the genus Mycobacterium. We identified no single 16S rRNA interstrain nucleotide sequence difference value that unequivocally defined species boundaries. DNA-DNA hybridization remains the gold standard, but common resources are needed to permit DNA-DNA hybridization analyses to be made available to laboratories that are not prepared to use this technology. One of the large novel clusters which we studied corresponds to the recently described species Mycobacterium interjectum, a pathogen that resembles the nonpathogen Mycobacterium gordonae phenotypically. We also identified strains that appear to represent ribovars of Mycobacterium intracellulare which do not react with the commercial diagnostic probes that are currently used for identification of this species. Other branches or clusters consisted of too few strains to permit a decision about their taxonomic status to be made.

Mycobacteria of Runyon groups I, II and IV do not play an aetiological role in Crohn's disease

OBJECTIVE

In addition to Mycobacterium paratuberculosis, other slow-growing as well as rapid-growing mycobacteria were isolated from mucosa or full thickness samples of intestine from patients with Crohn's disease. The meaning of these data remained unclear. To investigate the possible aetiological role of these rapid- and slow-growing mycobacteria, serosa and mesenteric lymph nodes were also cultivated in the present study.

DESIGN AND METHODS

Mucosa, lymph nodes and serosa of 23 patients with Crohn's disease and 23 patients with other intestinal afflictions were incubated at 37 degrees C on Löwenstein-Jensen medium and Herrold egg yolk medium. These methods allow the cultivation of most atypical mycobacteria, including Mycobacterium paratuberculosis. In addition, full thickness samples of some of these patients were analysed for mycobacterial DNA using polymerase chain reaction.

RESULTS

Despite lack of decontamination of 60% of lymph nodes and serosa, no mycobacterial growth was observed over a long incubation period (an average of 718 days in Crohn's disease and 552 days in controls) on Löwenstein-Jensen medium. Polymerase chain reaction was based on the amplification of 16S ribosomal DNA sequences specific for mycobacteria of tissues derived from four patients with Crohn's disease and one control was negative.

CONCLUSIONS

These findings suggest that mycobacteria, such as M. fortuitum and M. chelonei, which are widespread in the environment, are not involved in the aetiology of Crohn's disease but, rather, should be considered as environmental opportunists.

[Wound drainage with a continuous high vacuum drainage system and a drainage system with variable vacuum]

A study of 120 total hip replacements showed the advantages of the variable vacuum drainage system over the continuous high vacuum drainage system. Better wound healing, less severe hematomas and less occlusion of drains confirmed the higher effectiveness of secretion draining. With regard to hygienic aspects, and especially to wound infection, the continuous closed drainage system is an improvement of the intermittent closed drainage system.

Phylogeny of the Mycobacterium chelonae-like organism based on partial sequencing of the 16S rRNA gene and proposal of Mycobacterium mucogenicum sp. nov

The Mycobacterium chelonae-like organism (MCLO) is a recently described member of the Mycobacterium fortuitum complex which causes posttraumatic skin infections and catheter sepsis. This taxon is a distinct group biochemically and has a unique mycolic acid profile as determined by high-performance liquid chromatography. Its phylogenetic relationships to other mycobacteria, however, have not been studied previously. We sequenced 1,062 bp of the 16S rRNA genes from three MCLO strains obtained from the American Type Culture Collection and compared our results with the sequences of previously described taxa of rapidly growing and slowly growing mycobacteria. Two biochemically typical strains (ATCC 49650T [T = type strain] and ATCC 49651) had identical sequences, while the sequence of a biochemically atypical strain (ATCC 49649) differed by 4 bp from the sequence of the two typical strains. The Hamming distances between these MCLO strains and related rapidly growing mycobacteria are comparable to the Hamming distances among taxa of rapidly growing mycobacteria established as species by DNA-DNA hybridization. We propose the name Mycobacterium mucogenicum sp. nov. for this new taxon because of the highly mucoid nature of most isolates on solid media.

[Gorham-Stout massive ostelysis. A case report]

One case of massive osteolysis Gorham-Stout is presented. Idiopathic osteolysis is a rare disease. The coincidental radiological diagnosis following minor trauma or a few months' history of mild pain involving joints is characteristic. The disease process has a sudden onset. Bones undergo partial or complete resorption, which may spread across joints to contiguous bones. The osteolytic process eventually ceases spontaneously, but generally not before severe deformation and destruction of bone has occurred. Usually radiotherapy is not successful and is followed by local resection of the osteolytic process. Based on our presented case, we suggest early operative treatment to prevent severe damage.

Bias of culture techniques for diagnosing mixed Mycobacterium genavense and Mycobacterium avium infection in AIDS

Disseminated Mycobacterium avium infection is a common complication in late-stage AIDS. We describe a patient seropositive for human immunodeficiency virus with a disseminated infection caused by mycobacteria. Acid-fast rods were visible by microscopy in stool and bone marrow and in specimens from skin, liver, spleen, lung, and lymph nodes. Using molecular biology techniques and standard culture techniques, we found evidence of a mixed mycobacterial infection with M. genavense and M. avium. We suggest that the prevalence of M. genavense infection in patients with AIDS is underestimated because of the bias toward M. avium when using standard techniques for the detection and identification of mycobacteria.

Genetic alterations in streptomycin-resistant Mycobacterium tuberculosis: mapping of mutations conferring resistance

We report on the identification of mutations associated with streptomycin resistance in Mycobacterium tuberculosis. Two isolates (3656 and 3976) showed a wild-type ribosomal protein, S12, but exhibited a single point mutation at 16S rRNA position 491 (C-->T) or 512 (C-->T), respectively. Sequence analysis of a third isolate (2438) revealed a single base change at 16S rRNA position 904 (A-->G). This position is equivalent to invariant position 913 of the Escherichia coli 16S rRNA gene, an A-->G transition of which has been shown previously to impair streptomycin binding and streptomycin-induced misreading in vivo. Surprisingly, strain 2438 harbors an additional mutation in the ribosomal protein S12 (Lys-88-->Gln).

Identification of mutations in 23S rRNA gene of clarithromycin-resistant Mycobacterium intracellulare

Clarithromycin is a potent macrolide that has been used for treating infections with nontuberculous mycobacteria. Pairs of susceptible and resistant Mycobacterium intracellulare strains were obtained from patients with chronic pulmonary M. intracellulare infections undergoing monotherapy with clarithromycin. Nucleotide sequence comparisons of the peptidyltransferase region in 23S rRNAs from parental and resistant strains revealed that in three of six resistant strains, for which the MIC was > 32 micrograms/ml, a single base was mutated (Escherichia coli equivalent, A-2058-->G, C, or U). As the modification of adenine 2058 by dimethylation is a frequent cause of macrolide resistance in a variety of different bacteria, we suggest that mutation of A-2058 confers acquired resistance to clarithromycin in M. intracellulare.

[Application possibilities of MR arthrography in diseases of the shoulder joint]

In a prospective study possible indications for MR arthrography of the shoulder were evaluated. 37 patients were examined before and after intraarticular administration of a 2-mmolar solution of Gd-DTPA. MR arthrography was performed if there was no joint effusion and/or an uncertain finding concerning the rotator cuff or the capsulolabral complex on plain MR images. MR arthrography leads to a better demonstration of labrum pathology in 11/22 patients and to a superior delineation of the capsuloligamentous apparatus in 20/22 cases. In 9/15 patients with impingement lesions MR arthrography allowed a differentiation of severe tendinitis from partial and small full-thickness tears of the rotator cuff. MR arthrography of the shoulder joint enhances the accuracy of MR in case of an uncertain finding on plain MR images.

Mycobacterium genavense. Autopsy findings in three patients

The authors report on the pathologic findings in three cases of disseminated infection with Mycobacterium genavense, a recently described nontuberculous mycobacterium, in human immunodeficiency virus (HIV)-I-positive patients. The mycobacterium was identified by amplification of a 16S rDNA gene fragment and subsequent sequence determination. The organs mainly involved were the small intestine, spleen, liver, and lymph nodes. In contrast, lungs, myocardium, and kidneys were not involved, or only minimally involved, in this generalizing disease. Histopathologically, infection with Mycobacterium genavense in HIV-positive patients was mostly characterized by masses of foamy histiocytes and, depending on the immunologic reactivity of the host, by ill-formed granulomas, rarely with small foci of necrosis. The pathologic findings and clinical features were similar to those presented by patients who had generalized infection with Mycobacterium avium-intracellulare complex. To obtain more precise information about the specific course of infection with Mycobacterium genavense, scrupulous microbiologic investigations, including molecular biologic techniques, are necessary in cases with mycobacterial infections.

Mycobacterium interjectum, a new species isolated from a patient with chronic lymphadenitis

Mycobacterium-like organisms, isolates 2081/92 and 4185/92, were recovered from a lymph node of a child with chronic lymphadenitis. The growth characteristics, acid-fastness, and mycolic acids of the isolate were consistent with those for Mycobacterium species. The isolates were biochemically distinct from described Mycobacterium species, although they most closely resembled M. scrofulaceum. Comparative 16S rDNA sequencing showed that these isolates represent a new slow-growing Mycobacterium species which is named M. interjectum. Our results demonstrate the importance of 16S rDNA sequencing for recognizing the diversity of species within the genus Mycobacterium.

Genotypic identification of mycobacteria by nucleic acid sequence determination: report of a 2-year experience in a clinical laboratory

Clinical isolates of Mycobacterium spp. were identified by direct sequence determination of 16S rRNA gene fragments amplified by polymerase chain reaction. Identification was based on a hypervariable region within the 16S rRNA gene in which mycobacterial species are characterized by species-specific nucleotide sequences. A manually aligned data base including the signature sequences of 52 species of mycobacteria easily allowed rapid and correct identification. The results of this study demonstrate that polymerase chain reaction-mediated direct sequence determination can be used as a rapid and reliable method for the identification of mycobacteria in the clinical laboratory. In addition, the prompt recognition of previously undescribed species is now feasible.

Molecular basis of streptomycin resistance in Mycobacterium tuberculosis: alterations of the ribosomal protein S12 gene and point mutations within a functional 16S ribosomal RNA pseudoknot

Multidrug-resistant strains of Mycobacterium tuberculosis have resulted in several recent outbreaks. Recognition of drug resistance is important both for treatment and to prevent further transmission. Here we use molecular biology techniques to study the basis of streptomycin resistance in single and multidrug-resistant M. tuberculosis. We demonstrate that streptomycin resistance is associated with mutations implicated in ribosomal resistance. The mutations found either lead to amino acid changes in ribosomal protein S12 or alter the primary structure of the 16S rRNA. The 16S rRNA region mutated perturbs a pseudoknot structure in a region which has been linked to ribosomal S12 protein.

Transoesophageal echocardiography and the intraoperative diagnosis of left atrial invasion by carcinoid tumour

A 41-yr-old woman with pulmonary carcinoid tumour presented for thoracotomy and lung resection. However, intraoperative transoesophageal echocardiography (TEE) revealed that the tumour had invaded the left atrium, and the planned resection was aborted to allow resection under cardiopulmonary bypass at a later date. Although the incidence of cardiac involvement by lung cancer at the time of pulmonary resection is unknown, transoesophageal echocardiography can be useful in identifying the extension of hilar lung tumours. This should preferentially be done preoperatively, but can be done intraoperatively as described in this case report.

Excretion of urinary enzymes after extracorporeal shock wave lithotripsy: a critical reevaluation

The excretion of the urinary enzymes alanine aminopeptidase, alkaline phosphatase, gamma-glutamyl-transferase and N-acetyl-beta-D-glucosaminidase, and the 99mtechnetium-diethylenetriaminepentaacetic acid isotope clearance were studied in 35 patients treated with extracorporeal shock wave lithotripsy (ESWL*). Enzyme measurements were made before and consecutively on days 1, 2 and 5, and at 3 months after treatment. A control group investigated at the same intervals was included. Posttreatment enzyme values were not significantly different from those before treatment except for alkaline phosphatase on day 1 after ESWL. Some individuals had short-term increases of enzymuria that were greater than biological variations in the control group. The transient changes of enzymuria after ESWL had no predictive value for kidney function, since no decreased renal function was observed in individual patients with high enzyme excretions after ESWL.

Mycobacterium intermedium sp. nov

Strains of a new type of slowly growing mycobacterium were repeatedly isolated from sputum from a patient with pulmonary disease. This photochromogenic organism grew at 22, 31, 37, and 41 degrees C, possessed catalase, acid phosphatase, esterase, beta-galactosidase, and arylsulfatase activities, and hydrolyzed Tween. It did not produce nicotinic acid or have nitrate reductase, acetamidase, benzamidase, isonicotinamidase, nicotinamidase, pyrazinamidase, succinidamidase, and acid phosphatase activities. Urease activity was variable. The organism is susceptible to ethambutol and resistant to isoniazid and streptomycin. A mycolic acid analysis revealed the presence of alpha-mycolates, alpha'-mycolates, and keto-mycolates. The results of comparative 16S rRNA sequencing placed this organism at an intermediate position between the rapidly and slowly growing mycobacteria. On the basis of the pattern of enzymatic activities and metabolic properties, the results of fatty acid analyses, and the unique 16S rRNA sequence, we propose that this organism represents a new species, for which we propose the name Mycobacterium intermedium. The type strain is strain 1669/91; a culture of this strain has been deposited in the Deutsche Sammlung von Mikroorganismen und Zellkulturen as strain DSM 44049.

[Mycobacterium genavense infection in AIDS]

Fever, loss of weight, anaemia, hepatosplenomegaly and lymphadenopathy developed in two HIV-infected patients. At first malignant lymphoma with septicaemia was thought to be the cause. In both patients Salmonella enteritidis was isolated by blood culture and found to be sensitive against the antibiotics that were given (5 g azlocillin and 2 g cefotaxime, three times daily each; additionally in case 2, metronidazole, 500 mg three times daily). Because bone-marrow biopsy demonstrated acid-fast rods, antimycobacterial treatment was started (isoniazid 300 mg/d, rifampicin 600 mg/d, ethambutol 1,200 mg/d and pyrazinamide 2 g/d). Despite this the patients died of septic shock. Histological examination revealed massive amounts of acid-fast rods in spleen, liver, gut and bone marrow. Polymerase chain reaction and sequencing identified the structure as that of the recently discovered M. genavense.

Invasive infection with Mycobacterium genavense in three children with the acquired immunodeficiency syndrome

Three children with human immunodeficiency virus infection and invasive infection with Mycobacterium genavense are reported. Fever spikes, abdominal cramps and distension, diarrhea or ileus, and anemia were the predominant symptoms in the severely immunodeficient patients (CD4 lymphocytes < 0.04 x 10(9)/l). Numerous acid-fast bacilli were readily detectable by microscopy in stool samples and in lymph node biopsies, but cultures for mycobacteria remained negative. Mycobacterium genavense should be sought when invasive non-tuberculous mycobacteriosis is suspected and mycobacterial cultures from blood or other sites show limited growth. Multiple-drug regimens including amikacin, ethambutol, rifampin, and clarithromycin may be of benefit in controlling the infection, as observed in two patients.

Cervical lymphadenitis in a child caused by a previously unknown mycobacterium

Acid-fast bacilli were isolated from lymph nodes of an immunocompetent child presenting with unilateral cervical lymphadenitis. The slowly growing mycobacterium could not be identified by traditional methods. Direct sequencing of the enzymatically amplified 16S rRNA gene revealed a unique sequence belonging to a previously unrecognized mycobacterium. Direct 16S rDNA sequencing enables definitive identification of mycobacterial isolates. The method is useful for rapid recognition of previously unrecognized pathogens.

Synergistic interaction of interferon-beta and interferon-gamma in coxsackievirus B3-infected carrier cultures of human myocardial fibroblasts

The antiviral effects of human interferon-beta (IFN-beta) and human recombinant interferon-gamma (rIFN-gamma) were studied in persistently coxsackievirus B3-infected carrier cultures of human myocardial fibroblasts over a period of 21 days. Synergism was observed with concentrations as low as 30 IU of IFN-beta plus 10 IU of rIFN-gamma/mL, reducing mean viral titers from 6.0 x 10(7) to 1.3 x 10(4) pfu/mL and number of infected cells from 14.4% to 0.1% as determined by quantitative in situ hybridization. Higher concentrations of IFNs (both > or = 30 IU/mL) were associated with transient antagonism followed by antiviral synergism. With 100 IU of IFN-beta plus 30 IU of rIFN-gamma/mL, elimination of infectious virus was consistently achieved and sustained for 6 weeks after cessation of IFN application, whereas at least threefold higher concentrations were required with single drugs. In summary, our data support a concept of low-dose IFN combination schedules that might become useful in the treatment of enteroviral heart disease.

Genetic heterogeneity within Mycobacterium fortuitum complex species: genotypic criteria for identification

A 1.5-kb segment of the DNA that encodes 16S rRNA was amplified by polymerase chain reaction, and 880 nucleotide positions were determined from each of the described biovariants of Mycobacterium fortuitum. Signature sequences which allow rapid identification of M. fortuitum strains at the biovariant level are described. Our data demonstrate a close phylogenetic relationship between Mycobacterium senegalense and M. fortuitum and indicate that the described biovariants of M. fortuitum represent genetically distinct taxa.

Disseminated "Mycobacterium genavense" infection in patients with AIDS

We describe 18 patients with advanced HIV infection, most of whom had a chronic illness characterised by fever, diarrhoea, and massive loss of weight. Biopsy and necropsy samples revealed abundant acid-fast microorganisms in intestines, liver, spleen, lymph nodes, and many other tissues, which did not grow on solid media, although limited growth was observed in liquid blood cultures. Using primers complementary to bacterial 16S rRNA we amplified DNA sequences from tissue and leucocyte extracts and from blood-culture bottles. The sequences obtained were unique and suggest that the microorganism is a new member of the genus Mycobacterium, for which we propose the name "Mycobacterium genavense". Disseminated infection with "M genavense" should be considered in the differential diagnosis of HIV-infected patients with extreme immunosuppression, wasting, and fever.

[MR tomography versus CT arthrography in glenohumeral instabilities]

In a prospective study the diagnostic value of MRI compared to CT arthrography (CT-A) was evaluated in 26 patients with 27 instable shoulder joints. Surgical and/or arthroscopic correlation was available in all cases. Both methods showed a high accuracy (96% CT-A, 94% MRI) in the evaluation of the glenoid labrum. CT-A was significantly superior to MRI in the detection of capsular lesions (sensitivity 96% vs. 44%, accuracy 96% vs. 72%, negative predictive value 96% vs. 67%). CT-A and MRI results regarding humeral head fractures were similar; fractures of the glenoid rim were better detected by CT-A, the difference, however, was statistically not significant. Overall, CT-A proved to be superior to MRI, as lesions of the joint capsule were shown with greater certainty.

Mycobacterium confluentis sp. nov

A new rapidly growing mycobacterium was isolated from human sputum. This organism grew at 22, 31, 37, and 41 degrees C and possessed catalase, acid phosphatase, acetamidase, urease, nicotinamidase, pyrazinamidase, and nitrate reductase activities. It did not produce nicotinic acid, hydrolyze Tween, or have benzamidase, isonicotinamidase, succinidamidase, and arylsulfatase activities. A mycolic acid analysis revealed a simple, unique pattern. The organism is susceptible to antituberculotic drugs. A comparative 16S rRNA sequence analysis placed this organism within the confines of the genus Mycobacterium, most closely related to the thermotolerant rapidly growing species. On the basis of the pattern of enzymatic activities and metabolic properties, as well as the unique 16S rRNA sequence, we propose that our single strain represents a new species, for which we propose the name Mycobacterium confluentis. The type strain is strain 1389/90; a culture of this strain has been deposited in the German Collection of Microorganisms and Cell Cultures as strain DSM 44017.

[CT arthrography of the shoulder after surgical repair for ventral instability]

25 patients who had undergone a modified Lange repair were examined postoperatively after about four years, both clinically and by CT arthrography. Ventral redislocation was no longer seen postoperatively. As regards residual ventral instability, there was agreement between CT arthrography and the clinical findings in 20/25 patients (90%). Newly developed or residual dorsal instability could be accurately demonstrated by the presence of pathological changes of the dorsal labrum and by the observation of a wide dorsal joint recess. CT arthrography did not provide reliable evidence concerning loss of function and mobility of the treated shoulder. However, the presence of marked capsular folding suggests a poor clinical result.

[ESWL with the Lithostar--experience with 3,000 treatments]

The experiences with 3,000 extracorporeal shock wave lithotripsies of kidney and ureteral calculi using the Lithostar are reported. Indications, contraindications and therapeutic approach are reviewed and the importance of out-patient follow-up is stressed. The success rate of 75% (including further spontaneous passage of residual desintegrated calculi) is good in the view of an unselected and unfavourable patient population. In the other patients a second ESWL treatment may be necessary. In the initial period in 6% of the patients percutaneous nephrolitholapaxy or open operation have been performed whereas in the last 100 patients it was not necessary.