Trichilemmal carcinoma of the scalp.

This report describes the case of an 86-year-old male who presented with a large scalp tumour. Imaging revealed a large vertex mass, without intracranial extension, and multiple nodular subcapsular hepatic lesions suspected to be secondary in nature. Surgical resection was performed. Pathological examination revealed an adnexal carcinoma of follicular origin, thus a trichilemmal carcinoma. Controlled wound healing (budding of the diploë) was completely successful within 12 months. The patient refused the assessment and treatment of his metastases.

[Management of acute pancreatitis. A literature review]. / Prise en charge de la pancréatite aiguë. Revue de la littérature.

The management of acute pancreatitis is now fairly codified, with specific recommendations developed by expert groups. These recommendations deal in particular with the minimum initial assessment, recognized severity scores, initial medical management with hyperhydration, preventive anticoagulation, early refeeding, delays in imaging and management of complications. In this work, we have tried to bring together the various recommendations, articles and studies dealing with this subject, based more particularly on European recommendations, in order to guide the management of acute pancreatitis in current practice.

[A case of acute and necrotizing cutaneous Mycobacterium marinum infection in a patient treated with infliximab for Crohn's disease]. / Infection cutanée aiguë et nécrosante a Mycobacterium marinum chez un patient traité par infliximab pour une maladie de Crohn.

BACKGROUND: The increasing use of anti-TNFalpha exposes patients to emerging risks, particularly that of infection. We report a case of severe cutaneous Mycobacterium marinum infection in a patient treated with infliximab and we discuss therapeutic options. PATIENTS AND METHODS: A man treated with infliximab for Crohn's disease developed a severe cutaneous infection with M. marinum. Despite withdrawal of infliximab and the introduction of triple antibiotic therapy, the patient's lesions worsened and surgical treatment was required. DISCUSSION: The worsening experienced by our patient 1 week after the beginning of the treatment is comparable with the immune reconstitution syndrome occasionally observed in tuberculosis in immunocompromised hosts, thus raising the question of the potential value of continuing infliximab treatment. Recommendations are needed concerning the prevention and treatment of M. marinum infections in patients on anti-TNFalpha biotherapies.

Characterization of Na/Ca exchange in plasmalemmal vesicles from zona fasciculata cells of the bovine adrenal gland.

The presence of an Na/Ca exchange system in fasciculata cells of the bovine adrenal gland was tested using isolated plasmalemmal vesicles. In the presence of an outwardly Na(+) gradient, Ca(2+) uptake was about 2-fold higher than in K(+) condition. Li(+) did not substitute for Na(+) and 5 mM Ni(2+) inhibited Ca(2+) uptake. Ca(2+) efflux from Ca(2+)-loaded vesicles was Na(+)-stimulated and Ni(2+)-inhibited. The saturable part of Na(+)-dependent Ca(2+) uptake displayed Michaelis-Menten kinetics. The relationship of Na(+)-dependent Ca(2+) uptake versus intravesicular Na(+) concentration was sigmoid (apparent K(0.5) approximately 24 mM; Hill number approximately 3) and Na(+) acted on V(max) without significant effect on K(m). Na(+)-stimulated Ca(2+) uptake was temperature-dependent (apparent Q(10) approximately 2.2). The inhibition properties of several divalent cations (Cd(2+), Sr(2+), Ni(2+), Ba(2+), Mn(2+), Mg(2+)) were tested and were similar to those observed in kidney basolateral membrane. The above results indicate the presence of an Na/Ca exchanger located on plasma membrane of zona fasciculata cells of bovine adrenal gland. This exchanger displays similarities with that of renal basolateral cell membrane.

Analysis of norovirus outbreaks reveals the need for timely and extended microbiological testing.

BACKGROUND: Norovirus outbreaks in hospitals remain a substantial threat despite many recommendations for prevention published recently. AIM: To analyse the factors contributing to onset of a norovirus outbreak in hospitals in order to identify new prevention options. METHODS: Data from 71 norovirus outbreaks occurring in five German hospitals between 2002 and 2012 were analysed focusing on the start conditions: the weekday of outbreak, the time span between the first symptomatic cases and the outbreak onset date, the timing of a positive norovirus test result in an outbreak, and presence of concomitant Clostridium difficile infections. FINDINGS: In 68 (96%) outbreaks index cases were identifiable. In 30 of 44 (68%) outbreaks the index case patient acquired norovirus infection in hospital. In 20% of all outbreaks, the index case was a staff member. Nine outbreaks were caused by not isolating contact patients during the incubation time after their exposure to a symptomatic case. Case numbers in norovirus outbreaks were lower when the norovirus test results were available before the outbreak onset (P = 0.028). In 30 of 46 (64%) norovirus outbreaks, C. difficile toxin tests were positive in up to ten patients. Co-infection or subsequent infection with norovirus and C. difficile in single patients occurred in nine (20%) outbreaks. CONCLUSION: Future prevention strategies should focus not only on patients but also on staff. Constant surveillance for new cases of diarrhoea and vomiting and timely adherence to contact precautions for all exposed persons is crucial in outbreak control, as is the need for extended microbiological testing.

Use of leucocyte esterase reagent strips in the diagnosis or exclusion of prosthetic joint infection.

Infection is a leading indication for revision arthroplasty. Established criteria used to diagnose prosthetic joint infection (PJI) include a range of laboratory tests. Leucocyte esterase (LE) is widely used on a colorimetric reagent strip for the diagnosis of urinary tract infections. This inexpensive test may be used for the diagnosis or exclusion of PJI. Aspirates from 30 total hip arthroplasties (THAs) and 79 knee arthroplasties (KA) were analysed for LE activity. Semi-quantitative reagent strip readings of 15, 70, 125 and 500 white blood cells (WBC) were validated against a manual synovial white cell count (WCC). A receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off point for the semi-quantitative results. Based on established criteria, six THAs and 15 KAs were classified as infected. The optimal cut-off point for the diagnosis of PJI was 97 WBC. The closest semi-quantitative reading for a positive result was 125 WBC, achieving a sensitivity of 81% and a specificity of 93%. The positive and negative predictive values of the LE test strip were 74% and 95% respectively. The LE reagent strip had a high specificity and negative predictive value. A negative result may exclude PJI and negate the need for further diagnostic tests.

Molecular epidemiology of multi-resistant Escherichia coli.

In this case-control study multi-resistant Escherichia coli isolates were characterized on a molecular level and risk factors for their development were identified. Thirty-two multi-resistant E. coli strains were isolated from the urine of 13 patients attending a renal clinic for chronic urinary tract infection (UTI) and from different sites of 11 terminally ill patients with nosocomial infections hospitalized on five different wards. All 32 isolates were resistant to ciprofloxacin, cotrimoxazole and produced beta-lactamase. All strains contained plasmids of 2-110 MDa of which a 50 MDa and a 100 MDa plasmid were present in 81% of the strains. Pulse-field gel electrophoresis (PFGE) analysis demonstrated 17 genotypes among 32 strains which indicates a polyclonal outbreak with some geographic clustering. Monitoring of patients over the study period showed that either the resident genotype remained the same and that these retained strains underwent changes in their plasmid contents, or that they were replaced by a different genotype after several months of therapy for chronic UTI. Univariate analysis indicated that multi-resistant E. coli develop in the presence of long-term selective ciprofloxacin pressure at a dosing regimen of 250 mg bid for more than 20 days and that treatment with a broad spectrum antimicrobial for more than three days favours the selection of multi-resistant E. coli in the flora of terminally ill patients with multiple disorders.

Antimicrobial resistance of Neisseria gonorrhoeae in Liberia.

The prevalence and molecular characteristics of penicillinase-producing Neisseria gonorrhoeae (PPNG) and tetracycline-resistant N. gonorrhoeae (TRNG) were determined in 10 clinics in Monrovia, Liberia, to assess the likely effectiveness of the current standard treatment with penicillin or tetracycline. One hundred gonococcal strains were isolated from 146 urethral swabs and 261 cervical swabs and screened for susceptibility to ceftriaxone, penicillin, spectinomycin and tetracycline by the disk diffusion method; 83% were resistant to penicillin and 63% to tetracycline. Twenty-one strains from 18 men and 3 women with uncomplicated gonorrhoea were subjected to more detailed characterization. These 21 strains belonged to 5 auxotype/serovar classes; 86% were PPNG/TRNG. Three PPNG harboured the 4.4 MDa penicillinase plasmid and 16 the 3.2 MDa plasmid. All TRNG harboured the 25.2 MDa plasmid and their MICs for tetracycline were > 32 mg/L. They gave a PCR product which, according to its restriction pattern, corresponded to the American type tetM gene. By the agar dilution method, all strains exhibited intermediate resistance to sulphamethoxazole-trimethoprim (19:1) (co-trimoxazole) with MICs of 8-32 mg/L. All strains were susceptible to spectinomycin and ciprofloxacin. The MICs for gentamicin were 4-8 mg/L. The use of effective and affordable antimicrobial chemotherapy with either 500 mg ciprofloxacin or a single dose of gentamicin is discussed, with consideration of molecular biological, pharmacological and public health aspects.

Advances in reactive surfactants.

The study of reactive surfactants and their applications in the synthesis of latexes for waterborne coatings has been recently boosted by two successive European programmes, involving all together eight academic and five industrial laboratories. The most significant results were obtained using surfactants derived from maleic and related anhydrides, or both nonionic and anionic reactive polymeric surfactants. Such surfactants are able to improve the stability of styrenic and acrylic latexes vs. various constraints, such as electrolyte addition, freeze-thawing tests or extraction with alcohol or acetone. The properties of films used in waterborne coatings are also improved in case of water exposure (less water uptake, dimensional stability), as well as improved weatherability, and blocking properties. Formulations for woodstain varnishes, metal coating of printing inks, based on the use of simple polymerizable surfactants, are now in the market.

Beneficial effect of post -thawing osmoconditioning on the recovery of cryopreserved coffee (Coffea arabica L.) seeds.

Osmoconditioning-controlled rehydration of seeds in a solution with low osmotic potential -has been shown to reinvigorate aged seeds. The present work aimed at investigating the effect of osmoconditioning on the germination of cryopreserved seeds of Coffea arabica, whose viability and vigour are drastically affected by cryopreservation. For cryopreservation, seeds were desiccated to 0.21 g H2O/g dw, cooled at 1 degree C/min to -50 degree C, then immersed rapidly in liquid nitrogen. After rapid rewarming, seeds were osmoconditioned for 1 to 6 weeks using solutions with osmotic potentials between -1 and -4 MPa. The time to produce half of the final percentage of normal seedlings, T50, was about three fold lower with osmoconditioned seeds than with non-osmoconditioned seeds (12-14 d vs 36 d). Moreover, after a 6-week osmoconditioning treatment with solutions with osmotic potential of -1 and -1.25 MPa, the percentage of seedlings recovered from cryopreserved seeds was 64-74%, against 13-16% only for cryopreserved seeds which were not osmoconditioned.

Antibiotic resistance of Shigella in Monrovia.

Twenty Shigella strains were isolated from bloody stools, of which 10 had been collected from children. Eighty per cent of the Shigella isolates were serogrouped as S. flexneri. All 20 Shigella strains were susceptible to gentamicin, nalidixic acid and ciprofloxacin. More than 80% were resistant to ampicillin, cotrimoxazole and tetracycline and 65% were resistant to chloramphenicol. Ten of 20 Shigella isolates showed a quadruple resistance to all four antibiotics. The usefulness of nalidixic acid for the treatment of multiresistant Shigella infections is discussed.

Automated registration of optical coherence tomography and dermoscopy in the assessment of sub-clinical spread in basal cell carcinoma.

Optical coherence tomography (OCT) has been shown to be of clinical value in imaging basal cell carcinoma (BCC). A novel dual OCT-video imaging system, providing automated registration of OCT and dermoscopy, has been developed to assess the potential of OCT in measuring the degree of sub-clinical spread of BCC. Seventeen patients selected for Mohs micrographic surgery (MMS) for BCC were recruited to the study. The extent of BCC infiltration beyond a segment of the clinically assessed pre-surgical border was evaluated using OCT. Sufficiently accurate (<0.5 mm) registration of OCT and dermoscopy images was achieved in 9 patients. The location of the OCT-assessed BCC border was also compared with that of the final surgical defect. Infiltration of BCC across the clinical border ranged from 0 mm to >2.5 mm. In addition, the OCT border lay between 0.5 mm and 2.0 mm inside the final MMS defect in those cases where this could be assessed. In one case, where the final MMS defect was over 17 mm from the clinical border, OCT showed >2.5 mm infiltration across the clinical border at the FOV limit. These results provide evidence that OCT allows more accurate assessment of sub-clinical spread of BCC than clinical observation alone. Such a capability may have clinical value in reducing the number of surgical stages in MMS for BCC. There may also be a role for OCT in aiding the selection of patients most suitable for MMS.

Outbreak of Stenotrophomonas maltophilia on an intensive care unit.

BACKGROUND: Stenotrophomonas maltophilia causes opportunistic infections and remains a problem pathogen on intensive care unit (ICU) due to its multidrug resistance. AIM: An outbreak of S. maltophilia on ICU is described in order to highlight the risk from contaminated devices for supply of drinking water. METHODS: The outbreak was investigated by a combination of epidemiology, environmental sampling and molecular typing. FINDINGS: From 2009 to 2011 isolates of S. maltophilia from 23 patients were found to belong to only two genotypes by contrast with isolates from 52 other patients during this period, which represented distinct strains. The monthly incidence for all S. maltophilia strains ranged from 0 to 11% and for the two outbreak strains from 0 to 9%. Admission and weekly pharyngeal screening on ICU showed that the outbreak strains were acquired on ICU (range: 3-90 days). The majority of isolates (74%) were from the respiratory tract. Only two of 12 (17%) colonized intubated patients developed pneumonia. Environmental sampling found the two outbreak strains in two sinks and in the drinking water of the cooling unit in the ICU kitchen. S. maltophilia had formed a biofilm in the flexible tube from the carbon filter to the chiller and from the latter to the tap at the kitchen sink. This cooled water was used for providing drinking water and mouth care to ICU patients. The outbreak strains disappeared after removal of the water-cooler and the monthly incidence fell to <2% of ICU admissions. CONCLUSION: This outbreak report highlights the risk from biofilms in devices that supply drinking water for ICU patients.

Synovial fluid white cell and differential count in the diagnosis or exclusion of prosthetic joint infection.

Cut-off values with highest sensitivity and specificity for the synovial fluid white cell and differential count will facilitate the accurate diagnosis of infection in total knee (TKR) and total hip replacement (THR). All patients undergoing revision TKR or THR for suspected prosthetic joint infection between 2009 and 2011 at two hospitals were identified. A total of 75 patients were included with a mean age of 70.3 years (38 to 89). Synovial fluid was aspirated pre-operatively and peri-prosthetic tissue samples were taken intra-operatively for histological and microbiological examination. Receiver operating characteristic (ROC) plots were constructed for white cell and differential counts in aspirated fluid. The optimal cut-off for TKR and THR was 1590 white cells/µl and 65% neutrophilia. The white cell count cut-off value identified for THR was notably lower than previously quoted in the literature. A cut-off value for white cell count in synovial aspirate in suspected prosthetic joint infection of between 1100 and 1700 white cells/µl is likely to be applicable to both THR and TKR.

[Prenatal diagnosis of cleft lip with or without cleft palate: retrospective study and review]. / Diagnostic anténatal des fentes labiales avec ou sans fente palatine : étude rétrospective et revue de la littérature.

OBJECTIVES: To evaluate the management of prenatally diagnosed cleft lip with or without cleft palate and the immediate postnatal outcome. MATERIAL AND METHODS: Retrospective study of all cases of cleft lip with or without cleft palate referred to our fetal medicine unit, between January 2005 and January 2011. The anatomical type of cleft, associated malformations, and the postnatal outcome were reviewed. RESULTS: Forty-three cases of fetal cleft lip with or without cleft palate were reviewed. The mean gestational age at diagnosis was 24 weeks ± 4. The postnatal distribution of clefts was: 30 cleft lip and palate (70%) and 13 cleft lip (30%). The prenatal diagnosis of the cleft type was exact in 27 cases (62.8%). Nine cases had associated anomalies (21%), detected prenatally in three cases (37.5%). There was no karyotypical abnormality. Six pregnancies were terminated (14%). The immediate postnatal outcome was comparable with unselected newborns. CONCLUSION: The prenatal diagnosis of cleft lip with or without cleft palate is correct, with two thirds of exact diagnoses. Large clefts palate are the best detected. Associated malformations cannot always be diagnosed by prenatal ultrasound, but have to be searched for because they modify the fetal outcome.