Intensive care admission for Coronavirus OC43 respiratory tract infections

Background

Coronavirus OC43 infection causes severe pneumonia in patients presenting with comorbidities, but clinical signs alone do not allow for viral identification.

Objectives

To analyze acute manifestations of Coronavirus OC43 infections and outcomes of patients admitted to an intensive care unit (ICU).

Patients and methods

Retrospective and monocentric study performed during a Coronavirus OC43 outbreak. We used multiplex PCR to detect an OC43 outbreak in Reunion Island during the 2016 Southern Hemisphere's winter: seven admissions to the ICU.

Results

Mean age of patients was 71 [67;76] years, SAPS II was 42 [28;53], pneumonia severity index 159 [139;182] vs 73 [40.5;107] for patients in medical wards, and 43% required mechanical ventilation. Comorbidities were diabetes mellitus (87%), chronic respiratory failure (57%), and chronic renal failure (29%). One patient died from Haemophilus influenzae co-infection.

Conclusion

As for MERS Co-V infections, underlying comorbidities impacted the clinical outcomes of OC43 infections.

Cutaneous infection and bactaeremia caused by Erwinia billingiae: a case report

Cellulitis and erysipelas are common skin infections usually caused by Staphylococcus aureus and streptococci. Gram-negative rods are rarely implicated. We report here a case of dermohypodermitis and bactaeremia caused by Erwinia billingiae, a Gram-negative bacteria usually pathogenic and epiphytic to pome fruit tree.

Pattern and consequences of cardiologic medications management for patients with elevated troponin I upon admission into an intensive care unit not linked to type 1 acute myocardial infarction: A prospective observational cohort study

OBJECTIVES

No recommendations are currently available to help the clinician with the pharmacological management of intensive care unit (ICU) patients with elevated cardiac troponin (cTn) not linked to type 1 AMI. The aim of this study was to evaluate the pattern of cardiologic medications for patients with elevated cTnI in ICU not link to type 1 AMI and their effects on in-hospital mortality.

MATERIAL AND METHODS

A prospective observational cohort study conducted in two ICU units. Patients with increased plasma concentration of cTnI at admission not linked to type 1 AMI were consecutively included.

RESULTS

One hundred and ninety of the 835 patients admitted (23%) had an increased plasma concentration of cTnI not related to type 1 AMI. Antiplatelet therapy (AT) and statin were prescribed in 56 (29.5%) and 50 (26.3%) of patients, respectively. Others cardiologic medications were prescribed in less than 5% of all cases and were considered as contraindicated in more than 50% of cases. Antiplatelet therapy was the only cardiologic treatment associated with reduction of in-hospital mortality following uni- and multivariate analysis. The death rate was 23% and 40% in these patients treated with and without AT, respectively (aOR=0.39 [95% CI: 0.15-0.97]).

CONCLUSIONS

Statin and AT were frequently prescribed to patients with a cTnI elevation not linked to type 1 AMI. This study suggests that AT in patients with an increased plasma concentration of cTnI, not related to type 1 AMI in ICU, could reduce in-hospital mortality.

[The wounds of people receiving end-of-life palliative care]

When it includes the care of wounds, the management of patients at the end of life mobilises caregivers around a care project which brings together therapeutic, technical and relational challenges. In partnership with the patient and their families, the care must be adjusted and respectful of the patient's progression.

[Disseminated histoplasmosis caused by Histoplasma capsulatum in a renal transplant patient: first case report in the Reunion Island]

The purpose of this report is to describe the first case of indigenous disseminated histoplasmosis caused by Histoplasma capsulatum in a patient on immunosuppression 22 months after renal transplantation in the Reunion Island. Involvement was predominantly pulmonary and outcome was rapidly fatal. Diagnosis based on isolation of characteristic intramacrophagic Histoplasma capsulatum yeast cells from bronchoalveolar fluid was delayed since indigenous cases of this opportunistic infection were unprecedented. In addition to demonstrating the difficulty of achieving diagnosis in places located outside endemic areas without modern facilities, this case underlines the potentially the poor prognosis of disseminated histoplasmosis. This disease should be included in differential diagnosis in the Reunion Island where many patients undergo immunosuppresion and receive organs shipped in from outside locations.

Laparoscopic approach for idiopathic segmental infarction of the greater omentum

Idiopathic segmental infarction of the greater omentum is an uncommon condition that should be considered in the differential diagnosis of right-side abdominal pain. The case presented concerns a 40-year old woman admitted with right flank pain. Computed tomography scan of the abdomen showed the characteristic features of greater omentum infarction. Given worsening symptoms under conservative treatment, the patient underwent a laparoscopy with resection of the necrotic portion of the greater omentum. Segmental infarction of the greater omentum is usually treated conservatively. Nevertheless, surgical intervention may be necessary in order to establish definitive diagnosis and treatment. In this respect, laparoscopic approach offers substantial advantages for the patients while permitting definitive diagnosis and treatment.

Endovascular isolated hepatic perfusion under pneumoperitoneum

AIMS

Isolated hepatic perfusion (IHP) allows loco-regional administration of high drug doses for cancer treatment. Minimally invasive endovascular occlusion techniques can be used for IHP, but control of leakage remains a major drawback. We hypothesized that the increased intraabdominal pressure generated by a CO(2)-pneumoperitoneum (PP) can reduce the leakage rate of hypoxic endovascular IHP by mechanical compression of the capillary beds connecting the liver to the systemic circulation.

METHODS

IHP was performed on adult pigs through laparotomy using a fenestrated double balloon-catheter placed into the retrohepatic vena cava to collect the hepatic outflow which was reinfused into the hepatic artery through an extracorporeal circulation system. Each pig underwent IHP during four consecutive phases: abdomen open (Phase I), abdomen closed under a 15 and 20 mmHg pneumoperitoneum (Phase II and III, respectively) and abdomen re-opened (Phase IV). The leakage rate from the liver to the systemic circulation was continuously monitored using a nuclear medicine technique. The systemic arterial pressure, the IHP inflow and outflow pressures and the flow rate were recorded.

RESULTS

Leakage from the hepatic extracorporeal circulation to the systemic circulation occurred in all animals during Phase I. Under PP (Phases II and III), two leakage profiles were observed: (1) a major increase of the leakage rate in two animals with a high differential pressure (>50 mmHg) between the IHP inflow and the systemic pressures; (2) no change or a decrease of the leakage rate in the other three animals who had a low or negative differential pressure (<30 mmHg). Leakage was undetectable in all animals after exsufflation of the PP (Phase IV).

CONCLUSIONS

IHP under PP is feasible. Leakage is not reduced during PP. A high gradient between the IHP inflow and the systemic pressure increases systemic leakage during PP. Upon release of the PP, the leakage is most likely redirected towards the volume depleted low resistance portal territory.

Intoxication par bois de gale (Agauria salicifolia)

INTRODUCTION

Several plants of the Ericaceae family produce grayanotoxins, which can poison humans. The best-known of these intoxications involves the eating of "mad honey" contaminated by rhododendron nectar grayanotoxins. The authors report a case of poisoning due to ingestion of Agauria salicifolia, an Ericaceae species endemic in the Mascarene Islands.

CASE

A 28-year-old woman mistakenly ingested a herbal tea made with leaves of this plant. Symptoms were characteristic of grayanotoxin intoxication, with vomiting, arterial hypotension and bradycardia. The patient was managed in an intensive care unit and recovered within a few hours after symptomatic treatment of the low blood pressure and the severe digestive disorders.

CONCLUSION

This case underlines that ingestion of some plants can be toxic.

Encapsulation of packaging cell line results in successful retroviral-mediated transfer of a suicide gene in vivo in an experimental model of glioblastoma

AIMS

Retroviral-mediated gene therapy has been proposed as a primary or adjuvant treatment for advanced cancer, because retroviruses selectively infect dividing cells. Efficacy of retroviral-mediated gene transfer, however, is limited in vivo. Although packaging cell lines can produce viral vectors continuously, such allo- or xenogeneic cells are normally rejected when used in vivo. Encapsulation using microporous membranes can protect the packaging cells from rejection. In this study, we used an encapsulated murine packaging cell line to test the effects of in situ delivery of a retrovirus bearing the herpes simplex virus thymidine kinase suicide gene in a rat model of orthotopic glioblastoma.

MATERIALS AND METHODS

To test gene transfer in vitro, encapsulated murine psi2-VIK packaging cells were co-cultured with baby hamster kidney (BHK) cells, and the percentage of transfected BHK cells was determined. For in vivo experiments, orthotopic C6 glioblastomas were established in Wistar rats. Capsules containing psi2-VIK cells were stereotaxically implanted into these tumours and the animals were treated with ganciclovir (GCV). Tumours were harvested 14 days after initiation of GCV therapy for morphometric analysis.

RESULTS

Encapsulation of psi2-VIK cells increased transfection rates of BHK target cells significantly in vitro compared to psi2-VIK conditioned medium (3 x 10(6) vs 2.3 x 10(4) cells; P<0.001). In vivo treatment with encapsulated packaging cells resulted in 3% to 5% of C6 tumour cells transduced and 45% of tumour volume replaced by necrosis after GCV (P<0.01 compared to controls).

CONCLUSION

In this experimental model of glioblastoma, encapsulation of a xenogeneic packaging cell line increased half-life and transduction efficacy of retrovirus-mediated gene transfer and caused significant tumour necrosis.

Postoperative pulmonary dysfunction after bilateral inguinal hernia repair: a prospective randomized study comparing the Stoppa procedure with laparoscopic total extraperitoneal repair (TEPP)

The infraumbilical incision required for open repair of bilateral inguinal hernia with a giant prosthesis is associated with postoperative pain and respiratory impairment. The aim of this study was to evaluate the postoperative respiratory dysfunction after bilateral hernia surgery. Thirty-nine patients were randomized into two groups: open repair according to the Stoppa technique and laparoscopic extraperitoneal repair (TEPP). Respiratory function tests were performed before and 24 hours after surgery. The two groups were well matched for age, American Society of Anesthesiologists (ASA) risk score, type of hernia, and preoperative lung function. The postoperative forced vital capacity (FVC), peak expiratory flow (PEF), and forced expiratory volume in 1 second (FEV 1.0) were significantly altered in both groups. The PEF dropped 15% in both groups. The FVC dropped 22% after Stoppa versus 25% after laparoscopy (P = 0.7). The FEV 1.0 dropped 21% after Stoppa versus 9% after laparoscopy (P = 0.12). We conclude that laparoscopic preperitoneal and open bilateral hernia repair are followed by similar ventilatory dysfunction, although a trend toward better postoperative FEV 1.0 was noted after laparoscopy. This might play a role in selected patients with severe pulmonary limitations. Overall, the limited drop in pulmonary function following bilateral hernia repair under general anesthesia may serve to explain the low pulmonary morbidity that follows these procedures.

Isolated liver perfusion for non-resectable liver tumours: a review

Many treatments have been proposed for non-resectable primary or secondary hepatic cancer but the results have generally been disappointing. Isolated Hepatic Perfusion (IHP) was first attempted four decades ago but it gained acceptance only recently, after spectacular tumour responses were obtained by isolated limb perfusion with melphalan and tumour necrosis factor (TNF) for melanomas and sarcomas. Surgical isolation of the liver is a technically demanding operation that allows the safe administration of high doses of chemotherapeutics and TNF. Percutaneous techniques using balloon occlusion catheters are simpler but result in higher leakage rates from the perfusion circuit into the systemic circulation. Several phase I-II trials indicate that IHP can yield high tumour response rates, even when there is resistance to systemic chemotherapy. However, no significant advantage in overall survival has been demonstrated so far. IHP offers unique pharmacokinetic advantages for locoregional chemotherapy and biotherapy. It might also allow gene therapy with limited systemic exposure and toxicity. At present, IHP nevertheless remains an experimental treatment modality which should therefore be used in controlled trials only.

Reduced acute phase response after laparoscopic total extraperitoneal bilateral hernia repair compared to open repair with the Stoppa procedure

BACKGROUND

Although laparoscopic hernia repair has been shown to be associated with less postoperative pain and an earlier recovery, there is still controversy about its role in hernia surgery. In general, laparoscopy produces less trauma to tissues than open surgery. This has been reflected by the reduced acute phase inflammatory response observed after laparoscopic surgery compared to open surgery in various settings, such as cholecystectomy or hysterectomy. The aim of this study was to evaluate the acute phase response after bilateral hernia repair by comparing the open Stoppa procedure with the laparoscopic totally extraperitoneal prosthetic repair (TEPP).

METHODS

Patients were randomly allocated to either technique after written informed consent was obtained. Measurements were made of complete blood count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-1b (IL-1b), IL-6, and tumor necrosis factor-a (TNF-a) preoperatively and 4, 24, and 48 h postoperatively. VAS pain scores, consumption of analgesics, and delay before resumption of normal activities were also recorded. All the procedures were performed under general anesthesia by or in the presence of the same surgeon.

RESULTS

Thirty-nine patients were included: 19 underwent the Stoppa procedure and 20 had a laparoscopic repair. The two groups were well matched for age, sex, ASA score, and preoperative values. The operation took longer (p <0.001) in the group undergoing TEPP. Patients resumed their normal activities earlier (p <0.05) after laparoscopy. In the open group, there was a larger decrease of the lymphocyte count after 4 (p <0.01) and 24 h (p = 0.04); an increased elevation of ESR after 48 h (p = 0.02); a larger increase of IL-6 after 4 (p = 0.05), 24 (p = 0.003), and 48 h (p <0.001); and a larger increase in CRP after 24 (p = 0.05) and 48 h (p = 0.01). There was no morbidity. There was no difference in postoperative IL-1b, TNF-a, total white blood cell count, polymorphonuclear count, VAS for pain, or need for analgesics between the two groups, except on the operative day.

CONCLUSIONS

The acute phase inflammatory response in clearly more active after the open Stoppa procedure than after TEPP, indicating that the former is associated with increased tissue trauma. This may play a role in the earlier recovery seen after the TEPP procedure.

T cell activation with systemic agonistic antibody versus local 4-1BB ligand gene delivery combined with interleukin-12 eradicate liver metastases of breast cancer

We have shown that interleukin-12 (IL-12) generated a strong, albeit transient, anti-tumor response, mostly mediated by natural killer (NK) cell. T cell participation, in addition to NK cells, was essential for persistence of the anti-tumor response. Ligation of 4-1BB, a co-stimulatory receptor expressed on activated T cells, is known to amplify T cell-mediated immunity. In this study, we compared the effect of a systemically delivered agonistic anti-4-1BB monoclonal antibody (anti-4-1BB mAb) with intra-tumoral adenoviral-mediated gene transfer of the 4-1BB ligand (ADV/4-1BBL) to liver metastases in a syngeneic animal model of breast cancer. Both treatments induced a dramatic regression of pre-established tumor. When combined with intra-tumoral delivery of the IL-12 gene, both anti-4-1BB mAb and ADV/4-1BBL were synergistic and led to survival rates of 87% and 78%, respectively. The anti-tumor immunity is mainly mediated by CD4+ T cells in IL-12 plus 4-1BB ligand-treated animals, and CD8+ T cells in IL-12 plus anti-4-1BB mAb-treated animals. However, only long-term survivors after treatment with IL-12 and 4-1BBL genes have showed significantly potent, systemic, and tumor-specific T cell-mediated immunity.

Adenovirus-mediated gene transfer into selected liver segments using a vascular exclusion technique

Adenovirus-mediated gene therapy is hampered by severe virus-related toxicity, especially to the liver. The aim of the present study was to test the ability of a vascular exclusion technique to achieve transgene expression within selected liver segments, thus minimizing both viral and transgene product toxicity to the liver. An E1-E3-deleted replication-deficient adenovirus expressing a green fluorescent protein (GFP) reporter gene was injected into the portal vein of BDIX rats, with simultaneous clamping of the portal vein tributaries to liver segments II, III, IV, V, and VIII. GFP expression and inflammatory infiltrate were measured in the different segments of the liver and compared with those of the livers of animals receiving the viral vector in the portal vein without clamping. The GFP expression was significantly higher in the selectively perfused segments of the liver as compared with the non-perfused segments (p < 0.0001) and with the livers of animals that received the vector in the portal vein without clamping (p < 0.0001). Accordingly, the inflammatory infiltrate was more intense in the selectively perfused liver segments as compared with all other groups (p < 0.0001). Fluorescence was absent in lungs and kidneys and minimal in spleen. The clinical usefulness of adenovirus-mediated gene transfer to the liver largely depends on the reduction of its liver toxicity. Clamping of selected portal vein branches during injection allows for delivery of genes of interest to targeted liver segments. Transgene expression confined to selected liver segments may be useful in the treatment of focal liver diseases, including metastases.

Cytomegalovirus (CMV) prophylaxis by acyclovir in pre-transplant CMV-positive renal transplant recipients

Cytomegalovirus (CMV) infections, either primoinfection or reactivation, remain an important problem in organ transplantation. We therefore designed a prospective study in which pre-transplant CMV-positive renal transplant (RT) patients were randomized to receive for 3 months starting immediately after transplantation either acyclovir or nothing. Between April 1992 and January 1993, 53 cadaveric renal transplantations were performed in our institution. The immunosuppressive regimen included anti-thymoglobulins (ATG), azathioprine, steroids and cyclosporine A. Patients randomized in the acyclovir arm received the drug from day 1 to day 90 (D90) intravenously as long as the creatinine clearance was not above 10 ml/min and per os afterwards (3200 mg/day if the creatinine clearance was above 50 ml/min). CMV viraemia tests were systematically performed every 2 weeks until day 90 or when febrile episodes occurred. The patients were 53 adults who received a RT during the study period; 37 were included in the study of which 19 received acyclovir prophylaxis (group A) and 18, no prophylaxis (group B). The two groups did not significantly differ according to sex ratio, recipient's age, number of CMV-negative donors and number of days on ATG (10.76+/-6.16 vs. 8.28+/-4.21 days). There were significantly fewer viraemia episodes in group A (n = 6) than in group B (n = 13, P < 0.05); nevertheless, the percentage of symptomatic CMV viraemia was the same in both groups (35% vs. 38.5%). The onset of CMV viraemia occurred in the same period in both groups (39+/-13.8 days vs. 34.3+/-15 days; P = NS). The number of rejection episodes in the study period was the same in both groups (8 in each). We conclude from this prospective study that post-RT acyclovir prophylaxis reduces significantly the number of CMV viraemia episodes but does not delay their onset. Furthermore, it has no effect upon the percentage of symptomatic viraemias.

[Surgical treatment of hepatic metastases]

The liver is a common site for metastases from various forms of primary tumors. Colorectal cancer most commonly, but also neuroendocrine tumors, gastrointestinal sarcoma, ocular melanoma and others metastasize to the liver. A complete staging is important before considering treatment options. Surgical resection is the only form of curative treatment for colorectal cancer metastases. Systemic or intraarterial hepatic chemotherapy may be an alternative for patients with unresectable disease. Other promising treatment options such as cryotherapy and radiofrequency ablation are curRently under evaluation. The treatment of metastases from neuroendocrine tumors and other noncolorectal primary malignancies has to be individualized based on the patient's clinical status and the extent of the disease.

[Gene therapy and cancer]

Gene therapy by definition aims at modifying the genetic program of a cell towards a therapeutic or prophylactic goal. Several gene therapy strategies for cancer are currently under evaluation: 1) "suicide" gene therapy where an inactive prodrug is converted into a cytotoxic drug; 2) modification of the function of oncogenes and tumor suppressor genes; 3) modification of the host immune response towards the tumor; 4) disruption of the tumor neovascularisation; 5) lysis of tumor cells with replication-competent viruses. Recent results of phase I and II clinical studies have brought great hopes. However, the inefficiency of current gene vectors in infecting targeted cells and their inability to selectively access diseased cells distributed systemically are two major limitations that have to be overcome for further successful clinical applications.

Isolated granulomatous phlebitis: rare cause of ischemic necrosis of the colon: report of a case

Isolated phlebitis of the gastrointestinal tract is rare and potentially life threatening. We report on a patient who developed peritonitis, requiring emergency laparotomy, total colectomy, and ileostomy because of colon necrosis. The specimen displayed multiple ulcerations and erosions. Histology showed a predominantly lymphocytic infiltrate of small-sized and middle-sized veins in the submucosa and subserosa, associated with granulomas and foci of vein wall necrosis. Arteries were spared. No local recurrence or systemic vasculitis developed during a follow-up period of two years. Isolated granulomatous phlebitis seems to be self-limited, and its cause is unknown. Surgical resection of the diseased intestine is usually curative.

Value of laparoscopic staging for Hodgkin disease

Because of the potential for complications with laparotomy and splenectomy, and the widespread use of combination chemotherapy as first-line treatment, surgical staging is now performed in only 30% of patients with Hodgkin disease. Laparoscopic staging has rarely been reported. Three patients with the nodular sclerosis cell type of Hodgkin disease underwent laparoscopic staging. Mean operative time was 207 minutes. No conversion to laparotomy was necessary. There were no peri- or postoperative complications and no deaths. Mean blood loss was negligible. The pathologist deemed all liver and lymph nodes biopsies adequate for histologic analysis. Stage IA and IIA were confirmed in two patients: one patient with stage IIA was upstaged to IIIA after surgery. Performed by an experienced team, laparoscopy is the procedure of choice for abdominal staging of patients with Hodgkin disease.

The epidemiology of fractures of the distal femur

Between 1980 and 1989, reports on 2,165 fractures of the distal part of the femur (1,051 women and 1,114 men) were collected by AO Documentation and are analyzed in the present paper. The number of fractures showed a bimodal pattern with a marked variation in the number of fractures in relation to gender and age. A larger prevalence of fractures was observed either in young men (about 20 years old, traffic or sport) and in old women (about 70, fall at home, osteoporosis).

Effects of norepinephrine on the distribution of intestinal blood flow and tissue adenosine triphosphate content in endotoxic shock

OBJECTIVE

To investigate, during endotoxic shock, the effect of a treatment of norepinephrine (NE) administration on the distribution of blood flow and adenosine triphosphate (ATP) content in the intestinal wall.

DESIGN

Randomized controlled trial.

SETTING

Animal laboratory.

SUBJECTS

Domestic pigs.

INTERVENTION

A total of 18 pigs were anesthetized with ketamine and pentobarbital, mechanically ventilated, hemodynamically monitored, and then challenged with a continuous infusion of Escherichia coli endotoxin (ET) (15 microg/kg) for 2 hrs. Three groups of six animals were studied; one served as time control, one group received ET and fluid resuscitation, and a third group received ET, fluid resuscitation, and a perfusion of NE to maintain constant mean arterial pressure (MAP).

MEASUREMENTS AND MAIN RESULTS

Cardiac output, mesenteric arterial blood flow, MAP, pulmonary pressure, and portal pressure were measured. Intestinal mucosal intracellular pH (pHi) was determined with saline-filled balloon tonometers. Tissue blood flows to the intestinal mucosa and to the muscular layer were independently measured with fluorescent microspheres, using the arterial reference sample method. Measurements were performed before and 3 hrs after the start of the ET challenge. At the end of the experiments, muscularis and mucosal samples were quickly frozen for further enzymatic ATP measurements. ET administration with fluid resuscitation induced a distributive shock with increased mucosal blood flow and decreased muscularis blood flow, whereas pHi decreased and mucosal ATP content was significantly lower than in the control group. In the group receiving ET plus NE, MAP remained constant, mucosal blood flow did not increase, and mucosal ATP content was equal to the time control group. Meanwhile, mucosal acidosis was not prevented.

CONCLUSIONS

Normodynamic endotoxic shock may induce an alteration in mucosal oxygenation, despite an increased tissue blood flow. A treatment of NE combined with fluid resuscitation has complex effects on tissue blood flow, ATP content, and pHi.

Rejection of disseminated metastases of colon carcinoma by synergism of IL-12 gene therapy and 4-1BB costimulation

In an orthotopic model of metastatic colon carcinoma established in the liver of mice, we have previously shown that the natural killer (NK) cells were the major effectors after intratumoral delivery of a recombinant adenovirus expressing the murine IL-12 gene. However, tumor cure and long-term survival were achieved only in a minority of animals. In the present study, we generated an effective antitumoral CD8(+ ) T-cell response by the combination of IL-12 gene therapy and systemic delivery of an agonistic monoclonal antibody against 4-1BB, a costimulatory molecule expressed on activated T cells. In the IL-12 plus anti-4-1BB combination treatment, the effective dose of IL-12 could even be reduced even up to 18-fold and still achieved a better efficacy than the maximal dose of either treatment alone. We further demonstrate that the innate and the adaptive antitumoral immune responses were synergistic, as animals bearing hepatic as well as multiple pulmonary metastases were quantitatively cured of their diseases after IL-12 gene therapy + anti-4-1BB combination treatment. Both NK and CD8(+) T cells were necessary in maintaining the long-term antitumor immunity, as depletion of either cell type in the cured animals abolished their abilities to reject tumor cells implanted at distal sites. These results indicate that synergism between innate and adaptive immune responses may be effectively exploited to treat patients with metastatic diseases.

Immunomodulatory gene therapy with interleukin 12 and 4-1BB ligand: long- term remission of liver metastases in a mouse model

BACKGROUND

The success of immunomodulatory cancer therapy is frequently hampered by the transient nature of the antitumor immune response. We have shown previously in a mouse model that interleukin 12 (IL-12) generates a strong natural killer (NK) cell-mediated antitumor response and reduces liver metastases induced by a colon carcinoma cell line. However, only a small percentage of the treated animals developed the cytotoxic T-lymphocytic response required for a long-term systemic antitumor immunity. 4-1BB is a co-stimulatory molecule expressed on the surface of activated T cells. Interaction of 4-1BB with its natural ligand (4-1BBL) has been shown to amplify T-cell (especially CD8+)-mediated immunity. In this study, we investigated the effects of adenovirus-mediated gene therapy delivering both IL-12 and 4-1BBL genes on mice with hepatic metastases induced by colon cancer cells.

METHODS

Syngeneic BALB/c mice received intrahepatic injection of poorly immunogenic MCA26 colon cancer cells. Various combinations of replication-defective adenoviruses expressing IL-12 and 4-1BBL genes were injected into the established liver tumors. Changes in tumor size and animal survival were then monitored. All statistical tests were two-sided.

RESULTS

The long-term survival rate of mice treated with the combination of IL-12 and 4-1BBL was significantly improved over that of animals in the control group (P =.0001). In vivo depletion of NK cells or CD8+ T cells completely abolished the long-term survival advantage of the IL-12 plus 4-1BBL-treated animals (P<.002). Moreover, the systemic immunity induced by this combination treatment protected these animals against a subcutaneous challenge with parental MCA26 cells.

CONCLUSION

Adenovirus-mediated transfer of IL-12 and 4-1BBL genes directly into liver tumors resulted in tumor regression that required both NK and CD8+ T cells and generated a potent, long-lasting antitumor immunity.

Laparoscopic management of mechanical small bowel obstruction: are there predictors of success or failure?

BACKGROUND

Laparoscopy is used increasingly for the management of acute abdominal conditions. For many years, previous abdominal surgery and intestinal obstruction have been regarded as contraindications to laparoscopy because there is an increased risk of iatrogenic bowel perforation. The role of laparoscopy in acute small bowel obstruction remains unclear.

METHODS

Since 1995, data from patients undergoing laparoscopic surgery have been entered prospectively into a database. Patients who underwent surgery before 1995 were added retrospectively to the same database. The charts of all patients treated surgically for mechanical small bowel obstruction were reviewed. Univariate analysis was performed to identify factors associated with success or failure, especially intraoperative complications, conversion, and postoperative morbidity. Stepwise logistic regression was used to assess for independent variables.

RESULTS

This study included 83 patients (56 women and 27 men) with a mean age of 56 years (range, 17-91 years). Conversion was necessary in 36 cases (43%). Laparoscopy alone was successful in 47 patients (57%). Intraoperative complications were noted in 16% and postoperative complications in 31% of the patients. Eight reoperations (9%) were necessary. Mortality was 2.4%. Duration of surgery (p < 0.001) and a bowel diameter exceeding 4 cm (p = 0. 02) were predictors of conversion. No risk factor for intraoperative complication was identified. Accidental bowel perforation (p = 0. 008) and the need for conversion (p = 0.009) were the only independent factors associated with an increased risk of postoperative complications.

CONCLUSIONS

Laparoscopic management of small bowel obstruction is possible in roughly 60% of the patients selected for this approach. Morbidity is lower, resumption of a normal diet is faster, and hospital stay is shorter than with patients requiring conversion. No clear predictor of success or failure was identified, but intraoperative complications must be avoided. If the surgeon is widely experienced in advanced laparoscopic surgery and there is a liberal conversion policy, laparoscopy is a valuable alternative to conventional surgery in the management of acute small bowel obstruction.

Adenovirus-mediated gene transfer of endostatin in vivo results in high level of transgene expression and inhibition of tumor growth and metastases

Inhibition of angiogenesis has been shown to be an effective strategy in cancer therapy in mice. However, its widespread application has been hampered by difficulties in the large-scale production of the antiangiogenic proteins. This limitation may be resolved by in vivo delivery and expression of the antiangiogenic genes. We have constructed a recombinant adenovirus that expresses murine endostatin that is biologically active both in vitro, as determined in endothelial cell proliferation assays, and in vivo, by suppression of angiogenesis induced by vascular endothelial growth factor 165. Persistent high serum levels of endostatin (605-1740 ng/ml; mean, 936 ng/ml) were achieved after systemic administration of the vector to nude mice, which resulted in significant reduction of the growth rates and the volumes of JC breast carcinoma and Lewis lung carcinoma (P < 0.001 and P < 0.05, respectively). In addition, the endostatin vector treatment completely prevented the formation of pulmonary micrometastases in Lewis lung carcinoma (P = 0.0001). Immunohistochemical staining of the tumors demonstrated a decreased number of blood vessels in the treatment group versus the controls. In conclusion, the present study clearly demonstrates the potential of vector-mediated antiangiogenic gene therapy as a component in cancer therapy.

Delayed hemoperitoneum following large-volume paracentesis in a patient with cirrhosis and ascites

The diagnosis of early or late hemoperitoneum after large-volume paracentesis can be reached easily by a repeat tap, but gastrointestinal bleeding and other common causes of hypotension in cirrhotics must be ruled out first. When the hemoperitoneum is confirmed, imaging studies are often inconclusive and laparotomy should be considered when hemodynamic instability persists despite adequate fluid resuscitation. However, in instances of delayed hemoperitoneum, it must be anticipated that operation may not identify the bleeding site and result in further decompensation of the liver. OLT may well be the best therapeutic option in this rare, high-risk situation.

Loading model for the human femur taking the tension band effect of the ilio-tibial tract into account

A loading model permitting the application of relevant loads to the diaphysis and constructed on the basis of current knowledge of the biomechanics of the femur will be presented. This model takes into account the force acting through the ilio-tibial tract in the frontal plane and the forces acting on the condyles in the sagittal plane. There is compression on the femoral head and on the condyles and tension on the greater trochanter. Experimental verification using human cadaveric femora instrumented with strain gauges has shown that the adequate loading condition is: a line of force tangential to the femoral head a line of force tangential to the dorsal aspect of the distal junction of the diaphysis and metaphysis. Under these conditions, the calculated forces will accord well with values assessed in vivo. The model described here represents a simple procedure for experimental load application, producing realistic strain values. The proximal part of the bone is placed under tension on the dorsal aspect; the medial aspect is under compression. The strain pattern develops such that the tensile forces affect the anterior aspect distally and compression the dorsal aspect.

The mechanics of internal fixation of fractures of the distal femur: a comparison of the condylar screw (DCS) with the condylar plate (CP)

Distal femoral fractures are rare and usually complex. Mostly, they are fixed with the Dynamic Condylar Screw (DCS) or the 95 degrees condylar plate (CP). The simplicity of applying the DCS compared with the CP led us to investigate whether any possible mechanical deficiencies of the CP would detract from its technical advantages, thus limiting the indications for its use in the treatment of fractures of the distal femur. An in vitro investigation was carried out to measure the stability of a Y-osteotomy (with and without medial metaphyseal bone defect) stabilized either with the CP or the DCS. 8 pairs of human cadaveric femora classified according to their bone density were used. CP and DCS were applied to 1 bone in each pair by means of three lag screws (anterior, posterior and through the plate). Physiological loading was simulated and measurements were taken at the level of the osteotomy in the frontal and sagittal planes in order to assess rotational instability and the amount of gap opening in the vertical branch of the osteotomy. There was no relevant difference in the mechanical properties of the two fixations for fractures without medial defect, even if the stability of the fixation was reduced by removing the distal screw. Furthermore, interfragmental movement was minimal. In the frontal plane, simulated closure resulted in closure of the medial branch of the osteotomy in every case without any opening of the vertical branch of the osteotomy. In the sagittal plane, the closure of all branches of the osteotomy was confirmed for 11 bones and a rotation of the condyle was observed in 5 bones (3 CP, 2 DCS). Removing the distal lag screw did not increase the instability. Even in osteoporotic bones, the DCS provided the same stability as the CP. For simple Y-osteotomies, the CP did not offer any technical or mechanical advantages. The stability in the frontal plane however was significantly reduced in osteotomies with medial defect. The amplitude of interfragmental movement on all bones fixed by the CP, except for 1 pair, was greater than those fixed by the DCS. The absence of the anterior lag screw did not reduce stability. However, the absence of the lag screw within the implant considerably weakend the fixation--more so for the CP than for the DCS. Instability reached a maximum without any lag screw at all, which again was more pronounced for the CP than for the DCS. The Dynamic Condylar Screw (DCS) must be regarded as the implant of choice both technically and mechanically even in osteoporotic bones, but the distal condylar block must be at least 4 cm in length.

[Treatment of intimal hyperplasia by gene therapy: an update]

Injury to the vessel wall leads to smooth muscle cell (SMC) activation followed by intimal hyperplasia (IH). This process contributes to restenosis following balloon angioplasty--particularly with stenting--occlusion of vascular bypasses, and transplant arteriopathy. Genetic interventions affecting the cell cycle or early postinjury events have been successful in limiting SMC proliferation in vitro and in animal models. Gene therapy strategies have included the use of antisense oligonucleotides that block protein synthesis, transduced "suicide" genes that cause cytotoxicity, and cells engineered genetically to reduce the response to injury. The clinical application of gene therapy in vascular diseases should become a reality with the development of new delivery systems permitting efficient gene transfer to the injured vascular wall (J Mal Vasc 1999; 24: 349-355).

[Gene therapy and liver metastases]

Liver metastases occur in approximately 60% of patients with colorectal cancer. Liver resection is currently the only treatment that offers long-term survival. The 5-year survival rates range from 25 to 40%; however, less than 20% of patients are candidates for resection. The prognosis for the remaining patients is grim, since palliative chemotherapy and symptomatic care are the only available options. The ability to transfer therapeutic genes to target cells in vivo has opened up unprecedented possibilities for the management of metastatic liver cancer. A large number of genes with therapeutic potential have been cloned. Families of genes currently used can be classified as "suicide", cytokine, anti-angiogenic, tumour-suppressor, and oncogenes. Physico-chemical and, more commonly, viral vectors can be used to enhance gene transfer into tumours. The delivery systems for gene therapy continue to improve as minimally invasive techniques are combined with recent vector technology. Encouraging results, such as tumour destruction and long-term protective immunity against metastatic disease, have been obtained in different animal models. This article discusses several recent phase I and II clinical trials. The results of these combined laboratory and clinical studies are expected to define optimal means of incorporating gene therapy into the treatment of liver metastasis.

CMV prophylaxis in high-risk renal transplant patients (D+/R-) by acyclovir with or without hyperimmune (CMV) immunoglobulins: a prospective study

In this prospective randomized study including 28 patients, we show that, in cytomegalovirus (CMV)-seronegative renal transplant recipients (R-) receiving a CMV-seropositive graft (D+), high doses of acyclovir (ACV, i.e. 3,200 mg/day) during the first 3 months after transplantation were as efficient as hyperimmune CMV immunoglobulins (CMV Igs) plus high doses of ACV regarding the prophylaxis of CMV primoinfection. Fifty-four percent of the patients in the ACV arm and 50% in the other arm presented at least one episode of viremia (n.s.). The incidence of CMV disease was 31% in the ACV group and 20% in the ACV + CMV Ig group (n.s.). By comparison with historical controls (no prophylaxis), we found that ACV with or without CMV Ig significantly delayed and significantly decreased the rate of CMV disease, although the severity score was not statistically different. Moreover, high doses of ACV were far less expensive than their combination with hyperimmune CMV Igs. Thus, until oral ganciclovir is available for the prophylaxis of primary CMV infection in renal transplant patients, we recommend the use of high doses of ACV for the first 3 months after transplantation in high-risk renal transplant patients, i.e. D+/R-.

[Clinical aspects and diagnosis of arterial embolism of the upper extremity]

The upper limb embolus is rarely encountered (upper limb:lower limb emboli 1:4-5). Our problem was to determine in which way the paraclinical investigations influence the operation indication. In 1992, we have seen 10 consecutive patients with an upper limb embolus. The characteristics of our patient group are the advanced age and the cardiovascular morbidity. It was always possible to diagnose the emboli clinically. 7 duplex, 6 Dopplers and 2 angiographies were performed and have confirmed the clinical diagnosis and the clinically suspected localisation of the emboli. All the patients were operated in local anesthesy. An embolectomy with Fogarty catheter was done. After the operation, all our patients were asymptomatic. No amputation was done. We do think that when the clinic is clear enough to diagnose an embolus, no other investigations are necessary to the operation indication.

[The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures]

The DHS-implant system is a technically simple and widely used operative treatment modality for pertrochanteric fractures of the femur. In unstable 4-part fractures rotation of the head and neck fragment around the lag screw and significant impaction might lead to lateralisation of the greater trochanter and therefore to marked shortening. To prevent these effects we treated 17 patients with 4-part fractures with a prototype of a modular trochanteric DHS buttress plate. With this additional implant lateralisation of the greater trochanter could be prevented in all cases. This also leads to a limitation of telescoping, with less shortening even with immediate full weight bearing.

[The dynamic hip screw support plate for management of unstable proximal femoral fractures]

The DHS-Implant system is a technically simple and widely used operative treatment modality for pertrochanteric fractures of the femur. In unstable 4 part-fractures rotation of the head and neck fragment around the lag screw and a significant impaction might lead to a lateralisation of the greater trochanter and therefore to an important shortening. To prevent these effects we treated 17 patients with 4 part-fractures with a prototype of a modular trochanteric DHS buttress plate. With this additional implant the lateralisation of the greater trochanter could be prevented in all cases. This also leads to a limitation of the telescoping, with less shortening even with immediate full weight bearing.