Defective plasmacytoid dendritic cell-NK cell cross-talk in HIV infection.

HIV viremia is associated with a wide range of immune dysfunctions that contribute to the immunocompromised state. HIV viremia has been shown to have a broad effect on several immune cell types and/or their interactions that are vital for mounting an effective immune response. In this study, we investigated the integrity of plasmacytoid dendritic cell (pDC)-NK cell interactions among HIV viremic, aviremic, and seronegative individuals. We describe a critical defect in the ability of pDCs from HIV-infected individuals to secrete IFN-alpha and TNF and subsequently activate NK cells. We also describe an inherent defect on NK cells from HIV-infected individuals to respond to pDC-secreted cytokines. Furthermore, we were able to demonstrate a direct effect of HIV trimeric gp120 on NK cells in vitro similar to that described ex vivo. Finally, we were able to establish that the HIV gp120-mediated suppressive effect on NK cells was a result of its binding to the integrin alpha(4)beta(7) expressed on NK cells. These findings suggest a novel mechanism by which HIV is capable of suppressing an innate immune function in infected individuals.

Neoadjuvant chemoradiotherapy for esophageal cancer: is it worthwhile?

BACKGROUND: With promising results from several institutions, many centers began treating patients with esophageal cancer with neoadjuvant chemoradiotherapy (NC) followed by esophagectomy. This approach is demanding for the patient and has not been proved to be better than esophagectomy alone. OBJECTIVE: To assess survival time and measures of quality of life associated with NC. DESIGN: A retrospective review during 1990 to 1996. SETTING: The 3 tertiary academic hospitals affiliated with the University of Massachusetts Medical School, Worcester. PARTICIPANTS: All patients (N=51) with cancer of the middle or lower esophagus who were treated with NC followed by esophagectomy during this period. MAIN OUTCOME MEASURES: Median and 1-, 2-, and 3-year survival times; median preoperative treatment time (first office visit for surgical consultation before beginning NC to the date of surgery), median hospital stay, and postoperative swallowing function. RESULTS: The median survival time of all patients was 16.3 months; 1-, 2-, and 3-year overall survival rates were 67%, 46%, and 39%, respectively. The median hospital stay was 12 days. The median postoperative treatment time was 3.3 months, which was 20% of the median survival time. Of the 51 patients, 19 were alive with a median follow-up time of 2.5 years. Twenty-nine percent of the patients had a complete pathological response with median and 1-, 2-, and 3-year survival rates of 17.5 months, 73%, 57%, and 57%, respectively. Palliation of dysphagia was excellent, with 44 (93%) of 47 operative survivors taking either a soft diet (18 [38%]) or a regular (26 [55%]) diet by the first postoperative visit. CONCLUSIONS: Median survival time with NC followed by esophagectomy for resectable cancer of the esophagus does not appear to be significantly better than that reported for esophagectomy alone. Further, treatment time with NC consumed 20% of survival time. Examining only these outcome variables suggests that NC is not worth-while. However, examining a longer-term outcome survival variable, such as 3-year survival time, suggests that NC followed by esophagectomy may result in greater long-term survival than that reported for esophagectomy alone. We conclude that further randomized, controlled studies are necessary before NC followed by esophagectomy is considered superior to esophagectomy alone for the treatment of resectable esophageal cancer.

Expandable metallic esophageal stents in benign disease: a cause for concern.

Over a 2-year period at our institution, 6 patients underwent metallic stent treatment, 5 for malignant conditions and 1 for a benign condition of the esophagus. The use of expandable metallic stents for benign strictures has paralleled malignant indications but is limited and less understood from a clinical standpoint. A review of current literature in the treatment of benign strictures is presented. Treatment of benign strictures is associated with high morbidity and mortality as demonstrated by the cumulative experience of 21 patients. Migration, hyperplastic tissue obstruction at the terminal ends, reflux, and complications of perforation occur at a prohibitive rate. We conclude that expandable metallic stents should be reserved for palliative treatment of esophageal malignant obstructions and tracheoesophageal fistulas. Pharmacological management, necessary dilatations and operative corrections (antireflux procedures, esophagectomy) are recommended treatments for benign strictures.

Hernia of the lung: case report and literature review.

Hernia of the lung is an uncommonly encountered clinical entity. The majority of reported hernias are acquired traumatic thoracic hernias. A case report of an acquired spontaneous lung hernia is presented. A literature review of the classification, diagnosis, treatment and current incidence is discussed.

Peripheral arterial trauma in children. A fifteen year review.

A 15 year retrospective evaluation of peripheral vascular trauma in infants and children was undertaken. Forty-eight affected limbs in 47 patients (mean age 5.1 years) were explored for peripheral arterial injury. There were 40 iatrogenic, five penetrating and three blunt injuries. Thrombectomy alone, thrombectomy with autogenous saphenous vein patch angioplasty, direct angioplasty, segmental resection with end-to-end anastomosis and interposition-bypass grafting were the most common reparative procedures used. Circulation was normal within 24 hours of surgery in 35 of the 45 limbs (77.8%) whose patency was restored. In patients less than three years or 12.5 kg with iatrogenic injuries, patency rate was significantly lower (p 0.05). Four children died of congenital heart disease. All six children with failed vascular reconstruction suffered late sequelae.

Management of transposition after the baffes procedure: a case report and review of our experience.

A case report details the operative technique used in the repair of complete transposition of the great arteries (TGA), ventricular septal defect (VSD), and pulmonary stenosis in a patient who had had Baffes procedure previously. Experience in managing 10 patients with complete TGA who had undergone a Baffes procedure is discussed. Four patients with a large VSD had pulmonary vascular disease. The condition of 1 of them was improved by a palliative Mustard operation. Four children with isolated TGA underwent a successful modified Mustard repair. The 2 remaining patients had a VSD and pulmonary stenosis; in 1 the condition was palliated by a Glenn shunt. The other is the subject of the case report. The mean interval between the Baffes procedure and the second operation was 11 years. There was 1 late death after secondary repair. Follow-up in the remaining 6 patients at a mean of 10.6 years indicates a favorable outcome.