Challenges of Francisella classification exemplified by an atypical clinical isolate.

The accumulation of sequenced Francisella strains has made it increasingly apparent that the 16S rRNA gene alone is not enough to stratify the Francisella genus into precise and clinically useful classifications. Continued whole-genome sequencing of isolates will provide a larger base of knowledge for targeted approaches with broad applicability. Additionally, examination of genomic information on a case-by-case basis will help resolve outstanding questions regarding strain stratification. We report the complete genome sequence of a clinical isolate, designated here as F. novicida-like strain TCH2015, acquired from the lymph node of a 6-year-old male. Two features were atypical for F. novicida: exhibition of functional oxidase activity and additional gene content, including proposed virulence determinants. These differences, which could potentially impact virulence and clinical diagnosis, emphasize the need for more comprehensive methods to profile Francisella isolates. This study highlights the value of whole-genome sequencing, which will lead to a more robust database of environmental and clinical genomes and inform strategies to improve detection and classification of Francisella strains.

The reduced nicotinamide adenine dinucleotide "oxidase" of Acholeplasma laidlawii membranes.

An NADH dehydrogenase possessing a specific activity 3-5 times that of membrane-bound enzyme was obtained by extraction of Acholeplasma laidlawii membranes with 9.0% ethanol at 43 degrees C. This dehydrogenase contained only trace amounts of iron (suggesting an uncoupled respiration), a flavin ratio of 1:2 FAD to FMN and 30-40% lipid. Its resistance to sedimentation is probably due to the high flotation density of the lipids. It efficiently utilized ferricyanide, menadione and dichlorophenol indophenol as electron acceptors, but not O2, ubiquinone Q10 or cytochrome c. Lineweaver-Burk plots of the dehydrogenase were altered to linear functions upon extraction with 9.0% ethanol. A secondary site of ferricyanide reduction could not be explained by the presence of cytochromes, which these membranes lack. In comparison to other respiratory chain-linked NADH dehydrogenases in cytochrome-containing respiratory chains, this dehydrogenase was characterized by similar Km's with ferricyanide, dichlorophenol indophenol, menadione as electron acceptors, but considerably smaller V's with ferricyanide, dichlorophenol indophenol, menadione as electron acceptors, and smaller specific activities. It was not stimulated or reactivated by the addition of FAD, FMN, Mg2+, cysteine or membrane lipids, and was less sensitive to respiratory inhibitors than unextracted enzyme. The ineffectiveness of ADP stimulation on O2 uptake, the insensitivity to oligomycin and the very low iron content of A. laidlawii membranes were considered in relation to conservation of energy by these cells. Some kinetic properties of the dehydrogenation, the uniquely high glycolipid content and apparently uncoupled respiration at Site I were noteworthy characteristics of this NADH dehydrogenase from the truncated respiratory chain of A. laidlawii.

Purification of the reduced nicotinamide adenine dinucleotide dehydrogenase from membranes of Acholeplasma laidlawii.

The ethanol-extracted respiratory chain-linked NADH dehydrogenase of Acholeplasma laidlawii has been purified 25-35-fold. This purification involved delipidation of the ethanol-extracted minute non-sedimentable membrane fragments by detergent treatment and gel filtration on Bio-Gel P-200. Sodium deoxycholate-sucrose density gradient centrifugation was followed by dialysis of the active NADH dehydrogenase fractions which caused flocculation of 60% of the membrane proteins while the NADH dehydrogenase remained suspended. Poylacrylamide gel electrophoresis of the purified NADH dehydrogenase gave one major and two minor bands after staining with Coomassie Blue. The purified enzyme gave straight line kinetics in Lineweaver-Burk plots and a Km = 0.510 mM and V = 0.236 mumol/min. Fatty acid supplementation of A. laidlawii membranes had negligible effect on the membrane-bound or ethanol-extracted dehydrogenase, but substantiated the values of the Km and V. Purification, however, altered the constants by 2-4-fold, suggesting that alteration of the microenvironment or fragmentation of the dehydrogenase was significant. The purified dehydrogenase was very susceptible to a rapid inhibition was much slower (90 min) and less complete. Consideration of published purification procedures of NADH dehydrogenase strongly suggested that the purified A. laidlawii respiratory chian-linked NADH dehydrogenase was over 90% pure and certainly one of the most purified respiratory chain-linked bacterial NADH dehydrogenases.

Arthritis associated with a crystallizing cryoprecipitable IgG paraprotein.

A crystallizing IgG-lambda cryoprotein was found in the synovial fluid of a patient with peripheral erosive arthritis and tenosynovitis. The same crystallizing paraprotein could be demonstrated in serum incubated at 4 degrees C, but its formation could be inhibited by the in vitro addition of D-penicillamine. Crystals were present in synovial tissue and appeared to be initiating an inflammatory reaction via complement activation. Slit lamp examination showed crystals in Bowman's membrane. Plasmapheresis led to temporary improvement in the synovitis and tenosynovitis.

Tolerance of the liver to the effects of Yttrium-90 radiation.

There are no reliable data documenting the tolerance of the human liver to ionizing radiation from a continuous Yttrium-90 source. As Yttrium-90 incorporated into microspheres is being used to treat patients with liver cancer, it is imperative that the tolerance of the human liver to this form of radiation damage be determined. Four patients with metastatic liver cancer were treated with Yttrium-90 to deliver radiation doses above that considered tolerable when given by conventional external sources. Patients were monitored with serial estimations of liver function tests and between 7 and 9 months after treatment liver biopsies were performed. Histological examination of the liver biopsies confirmed only minimal changes in the normal liver parenchyma. These data indicate that the human liver may tolerate relatively large radiation doses when delivered by Yttrium-90 microspheres embedded in the liver parenchyma as a number of discrete point sources.

Esophageal malignancies: is preoperative radiotherapy the way to go?

During the period 1969 to 1988, 68 patients with esophageal malignancy were subjected to preoperative radiotherapy consisting of 30 Gy over 3 weeks followed by esophagectomy after a wait of 2 weeks. Sixty-two of 68 patients (91%) were followed up retrospectively (5-year survival rate, 17.2%; 10-year survival rate, 4.8%). Radiosensitivity of the tumor was graded by a radiation effect scoring method devised by us, and this was found to correlate with long-term prognosis (p = 0.05). Radiotherapy "sterilized" malignant involvement of adventitia and draining lymph nodes in 8 patients and thereby converted "palliative" into potentially "curative" resections with a mean survival of 57.2 months in this group of patients. Preoperative radiotherapy was found to increase the survival, decrease the incidence of residual tumor at the resected stump, reduce the incidence of local recurrence, and increase the resectability rate.

Ross River virus arthritis in Papua New Guinea.

In 1975 it was reported that antibodies to Ross River virus (RRV) were present in the sera of many population groups in Papua New Guinea. We describe here 3 cases of polyarthritis that occurred in Port Moresby, the capital of Papua New Guinea, during 1980-81 and in which the diagnosis of RRV infection was confirmed by serological tests, and 3 other cases in which serological tests suggested RRV infection but were not diagnostic. A possible case of fatal RRV encephalitis is also reported.

The origin of multinucleate giant cells in myeloma kidney from mononuclear phagocytes: an ultrastructural study.

Ultrastructural examination of a biopsy of a myeloma kidney has shown structural relationships between the multinucleate giant cells which characterize this condition and macrophage polykarya. On the other hand, no evidence was found of any resemblance to renal tubular cells. Moreover the electron microscopic observations indicate that these multinucleate giant cells, in common with the mononuclear phagocytes, attempt to ingest the cast material which in addition becomes fibrillar in the zones of endocytosis. No such phenomena were observed in the vicinity of tubular cells. In conclusion the ultrastructural evidence suggests that the multinucleate giant cells of myeloma kidney are derived from mononuclear phagocytes.

Collecting duct carcinoma of the kidney: a report of three cases and review of the literature.

Collecting duct carcinoma (CDC) of the kidney is a rare neoplasm arising from the medullary collecting ducts. The clinicopathological features of three cases are here presented to add to the 42 cases reported so far in the English language literature. Hematuria is the most common presenting symptom, although 10% of patients present with metastatic disease, often in neck lymph nodes. The tumor mass is typically centred on the medulla of the kidney and extends into the cortex. Radiological diagnosis may be difficult because the radiological features of CDC are poorly described. The histological appearances have been described as tubulo-papillary, tubular, solid and sarcomatoid. Intracytoplasmic mucin may be present. The typical immunohistochemical profile is positive staining with antibodies for low and high molecular weight keratin and epithelial membrane antigen (EMA) and positive staining with the lectin Ulex europaeus agglutinin. Literature reports of cytogenetic characterisation show loss of chromosomes resulting in monosomies. Prognosis is poor as more than half of the reported cases have developed metastases or died within two years of presentation.

Asbestos related interstitial pneumonitis associated with glomerulonephritis and lymphomatoid granulomatosis.

We report a case of pulmonary asbestosis in a patient who also developed glomerulonephritis and lymphomatoid granulomatosis. The pulmonary reaction was unusual, characterized clinically by an acute onset of symptoms after a prolonged latent period and morphologically by an interstitial pneumonitis with prominent desquamative features and a paucity of fibrosis. The association of pulmonary asbestosis with glomerulonephritis and lymphomatoid granulomatosis has been hitherto unreported.

Collagenous colitis: a case report and review of the literature.

A case of collagenous colitis is reported and the literature reviewed. The disease presents with watery diarrhea and abdominal pain in middle-aged subjects. Women predominate in the small number of reported cases. Colonic and rectal biopsies show excessive collagenization of the so-called collagen table in the superficial lamina propria. There is an associated degeneration and desquamation of the interglandular epithelial lining cells. The cause is not known but the clinical course with symptomatic treatment can wax and wane with corresponding deterioration or improvement in the biopsy features.

Nodular lymphomas with intracellular immunoglobulin inclusions: report of three cases and a review.

Three cases of nodular lymphomas with cytoplasmic inclusions were studied histologically, histochemically and immunocytochemically, and ultrastructurally. One case had Russell body-like inclusions, another had needle-like inclusions not previously reported, while the last showed cells with cytoplasmic vacuoles. Two of the cases were followed to necropsy. New observations are described and the available literature is reviewed.

Fat necrosis in surveillance biopsies of heart transplants.

Fat necrosis was observed in surveillance biopsies of five patients following heart transplant. This reaction is poorly documented in the literature, but in personal communication, some pathologists working in the field have had experience with it. Four of the cases developed two to six days after transplantation, but in the fifth case, fat necrosis developed ten months after transplantation. Autopsy study of one case showed extensive severe fat necrosis involving both donor and recipient tissues. The cause is not known, and the changes are independent of rejection. However, the fat necrosis can be found within the interstitial tissues of the myocardium and subendocardium and may be mistaken for rejection if lymphocytes and polymorphs are part of the inflammatory response. The only clinical finding thought to be related to the fat necrosis was the development of transient complete heart block in a patient in whom the International Society for Heart and Lung Transplantation (ISHLT) standardised rejection grading was never greater than IA.

Melanoma in Western Australia in 1980-81: incidence and characteristics of histological types.

All cutaneous malignant melanomas diagnosed in Western Australia in 1980-81 were reviewed and classified according to histological type (i.e., superficial spreading melanoma, Hutchinson's melanotic freckle melanoma (lentigo maligna melanoma), nodular melanoma and melanoma of unclassifiable type). The most common invasive melanoma was superficial spreading melanoma with an incidence rate of 14.3 per 100,000 person-years in females and 9.0 in males. It most commonly affected the trunk in males and the lower limbs in females and showed a peak incidence in middle life. Invasive Hutchinson's melanotic freckle melanoma was much less common than invasive superficial spreading melanoma (1.8 per 100,000 person-years in both sexes), occurred most commonly on the head and neck and increased progressively in incidence with age. Nodular melanomas were more frequent in men (4.5 per 100,000 person-years) than women (2.0). They were thicker than other types of invasive melanomas, showed more mitotic activity and had less evidence of regression. Their site distribution was similar to that of superficial spreading melanoma. In women the pattern of incidence with age was also similar to that of superficial spreading melanoma. In men it was more like that of Hutchinson's melanotic freckle melanoma. Melanomas of unclassifiable type did not have distinctive epidemiological features common to both sexes, although the trunk was the site most commonly affected in both men and women. With some exceptions the patterns of occurrence of in-situ lesions were similar to those of the corresponding invasive lesions. Benign melanocytic naevi were found less often in association with Hutchinson's melanotic freckle (melanoma) (6%) and nodular melanoma (9%) than with superficial spreading melanoma (22%) or melanoma of unclassifiable type (34%).

The Rye classification of a population based series of Hodgkin's disease patients in Western Australia.

Data are presented on the incidence in Western Australia of subtypes of Hodgkin's disease which were obtained by review of all cases of the disease notified between 1960 and 1974. Observations were also made on within- and between-observer agreement on the use of the Rye classification by a group of 9 surgical pathologists, all in the day-to-day practice of pathology. Although many consensus diagnoses were made only after spirited discussion by the Group, the results suggested that general surgical pathologists can perform nearly as well as lymphoma experts. A comparison of the incidence of Hodgkin's disease and distribution of Rye subtypes in Western Australia with 4 other populations showed a similar overall incidence but appreciable variation in the relative frequency of the subtypes--mainly in the proportions of nodular sclerosing and mixed cellularity.

Herpes simplex virus interstitial nephritis in a renal allograft.

We report a 35-year-old woman who developed herpes simplex virus (HSV) type 1 interstitial nephritis following a cadaveric renal transplant. Transplant function was poor and a transplant nephrectomy was performed 23 days post-transplant. Histological changes characteristic of herpes virus infection were seen on the renal biopsy with positive immunoperoxidase staining for HSV. HSV 1 was cultured from the transplant nephrectomy specimen.

Abdominal aortic dissection due to idiopathic medial aortopathy in a 32-year-old Caucasian man.

A case of dissection of the abdominal aorta in a 32-year-old Caucasian man associated with a histological diagnosis of granulomatous aortitis and a clinical diagnosis of idiopathic medial aortopathy is described. The relationship between giant cell "temporal" arteritis, Takayasu's disease and idiopathic medial aortopathy is discussed.

Effective of acetylsalicylic acid, indomethacin, phenylbutazone, paracetamol, ibuprofen and naproxen on canine gastric mucosa: a histological and ultrastructural study.

The effect of various non-steroidal analgesic drugs on gastric mucosal cells was studied in 48 dogs with 2 other dogs as control. Each drug was instilled into the stomach of 8 anaesthetised dogs through a gastrostomy. Gastric biopsies, obtained at 0, 1, 2 and 3 hours after administration of the drug, were subjected to histological and electron microscopical examination. Histological analysis did not show any significant changes in gastric mucosal cells in any of the drug-related groups as compared to controls. Electron microscopy, however, showed significant changes in the gastric mucous cells and parietal cells of all test groups, as compared to controls. Ultrastructural abnormalities in mucous cells included dilation of cisternae of endoplasmic reticulum, loss of granules and microvilli, and thickening of the mucous layer and were most pronounced with acetylsalicylic acid, moderate with phenylbutazone, indomethacin and naproxen, but mild with paracetamol and ibuprofen. Parietal cell changes consisting of reduction in the concentration of tubulovesicles, which canaliculi, were found to be severe with indomethacin and phenylbutazone, moderate with paracetamol and naproxen, but only minimal with acetylsalicylic acid and ibuprofen.

Endoscopic, histological and ultrastructural correlations in the diagnosis of colitis.

The accuracy of the endoscopic diagnosis, found at fiberoptic distal-colonoscopy, was assessed by correlation with the histological findings of multiple colo-rectal biopsies. Of 25 subjects with normal colon at endoscopy, 18 (72%) had normal histology, while 7 (28%) had histological evidence of mild non-specific colitis (6 cases) or Crohn's colitis (one case). Of 15 cases with endoscopic appearance of mild colitis, histological sections showed mild non-specific colitis in 12 (80%), idiopathic ulcerative colitis in one and Crohn's colitis in another. In 12 patients with an endoscopic diagnosis of moderate-severe colitis, histology confirmed moderate to severe idiopathic ulcerative colitis in 9 (75%) and severe Crohn's colitis in 2. Pseudomembranous colitis was confirmed by histology in 2 out of 3 cases detected by endoscopy. Electron-microscopy, although amplifying the histological findings, did not provide any specific diagnostic information. It is concluded that histological studies of multiple colo-rectal biopsies can significantly improve the diagnostic accuracy of distal-colonoscopy. Biopsies should therefore be obtained routinely in colonoscopy even if the appearances look normal.

Patient outcomes measure home health care accomplishments.

Professional, governmental, and economic stakeholders are calling for more explicit accountability for consistent quality from home health-care agencies. A system oriented toward outcomes for the patient rather than toward service design and distribution is more likely to improve the quality of care and satisfy everyone involved.