Cryptococcal polysaccharides induce L-selectin shedding and tumor necrosis factor receptor loss from the surface of human neutrophils.

High titers of cryptococcal polysaccharides in the serum and spinal fluid and the lack of cellular infiltrates in the infected tissues are hallmarks of disseminated cryptococcosis. Cryptococcal polysaccharides given intravenously to mice inhibit the influx of leukocytes into sites injected with inflammatory mediators. The purpose of this investigation was to determine if cryptococcal polysaccharides, i.e., glucuronoxylomannan (GXM), galactoxylomannan, and mannoprotein, affect expression of molecules on the surface of neutrophils that are important in extravasation. GXM in the absence of serum was shown to induce human neurophils to shed L-selectin, a molecule needed in the first step of neutrophil movement into tissues. In the presence of serum, GXM caused a further shedding of L-selectin. Shedding of L-selectin was evident by reduced amounts of L-selectin on the neutrophils treated with GXM and by increased levels of soluble L-selectin in the GXM-treated neutrophil supernatants. GXM also stimulated neutrophils to have reduced expression of TNF receptor. In contrast, GXM-treated neutrophils showed increased levels of CD15 and CD11b, and unchanged CD16 expression. In the absence of serum, galactoxylomannan and mannoprotein did not affect L-selectin, TNF receptor, CD15, CD11b, or CD16 on neutrophils but did induce loss of L-selectin in the presence of serum. Our results indicate that cryptococcal polysaccharides, especially GXM, can cause shedding of L-selectin from the surface of neutrophils, and this may prevent neutrophils from attaching to the endothelial cell surfaces. Blockage of this early step in cell migration from the vessels into tissues may be responsible in part for reduced cellular infiltration into infected tissues of individuals with disseminated cryptococcosis.

Direct interactions of human lymphocytes with the yeast-like organism, Cryptococcus neoformans.

Lymphocytes, especially CD4+ T cells, are essential for clearance of the yeast-like organism Cryptococcus neoformans from the infected host. The mechanism(s) by which the lymphocytes facilitate elimination of cryptococci has not been elucidated. It is generally thought, however, that lymphocytes reactive with C. neoformans indirectly function by production of lymphokines to enhance clearance of the organism by natural effector cells such as macrophages. In the present study, we assessed the ability of freshly isolated human lymphocytes to interact directly with C. neoformans and to limit the growth of the organism in vitro. We found that large granular lymphocytes (LGL) as well as T cells bound to cryptococcal cells when the lymphocytes were mixed with the cryptococcal cells at a 2:1 ratio. The physical binding interactions of the two lymphocyte populations were different. LGL attached to the cryptococcal cells by many microvilli; T lymphocytes associated with the yeast through broad areas of membrane attached to the cryptococcal cell surface. The two types of lymphocyte interactions did not result in phagocytosis but resulted in direct inhibition of cryptococcal growth, making these lymphocyte interactions with cryptococci distinctly different from interactions of monocytes with cryptococci. With the human natural killer (NK) cell line, NK 3.3, we confirmed that NK cells that were present in the LGL population were capable of limiting the growth of C. neoformans. Through immunoelectron microscopy, human CD3+ lymphocytes were seen attached to cryptococcal cells and by mass cytolysis, human CD3+ lymphocytes were shown to be responsible for inhibition of C. neoformans growth. The direct inhibitory interactions of NK cells and T lymphocytes with cryptococcal cells may be important means of host defense against this ubiquitous organism that frequently causes life-threatening disease in AIDS patients.

Sigmoid colonic fistula secondary to Perfix-plug, left inguinal hernia repair.

The "plug and patch" mesh herniorrhaphy has become a popular option for inguinal hernia repair. Previous reports have documented several complications with some regularity. This case presents an additional complication and offers suggestions as to why this complication and others might occur.

Design and implementation of the Americas Hernia Society Quality Collaborative (AHSQC): improving value in hernia care.

PURPOSE: Wide variation in care and costs exists regarding the management of abdominal wall hernias, with unproven benefit for many therapies. This work establishes a specialty society-based solution to improve the quality and value of care delivered to hernia patients during routine clinical management on a national scale. METHODS: The Americas Hernia Society Quality Task Force was charged by the Americas Hernia Society leadership to develop an initiative that utilizes the concepts of continuous quality improvement (CQI). A disease-based registry was created to collect information for CQI incorporating real-time outcome reporting, patient reported outcomes, stakeholder engagement, and collaborative learning methods to form a comprehensive quality improvement effort. RESULTS: The Americas Hernia Society Quality Collaborative (AHSQC) was formed with the mission to provide health care professionals real-time information for maximizing value in hernia care. The initial disease areas selected for CQI were incisional and parastomal hernias with ten priorities encompassing the spectrum of care. A prospective registry was created with real-time analytic feedback to surgeons. A data assurance process was implemented to ensure maximal data quality and completeness. Four collaborative meetings per year were established to meet the goals of the AHSQC. As of the fourth quarter 2014, the AHSQC includes nearly 2377 patients at 38 institutions with 82 participating surgeons. CONCLUSIONS: The AHSQC has been established as a quality improvement initiative utilizing concepts of CQI. This ongoing effort will continually refine its scope and goals based on stakeholder input to improve care delivered to hernia patients.

MIP-1 alpha contributes to the anticryptococcal delayed-type hypersensitivity reaction and protection against Cryptococcus neoformans.

Leukocyte infiltration into infected tissues is essential for the clearance of microorganisms. In animals with a cell-mediated immune (CMI) response to the infectious agent, as opposed to naive animals, leukocyte migration is greatly enhanced into sites of the organism or antigen. The role of the,chemotactic cytokine or chemokine, macrophage inflammatory protein-1 alpha (MIP-1 alpha), in the expression phase of the CMI response and in protection against Cryptococcus neoformans was assessed. With the use of a gelatin sponge model in mice as a means of detecting an anti-cryptococcal delayed-type hypersensitivity (DTH) reaction, we found that MIP-1 alpha levels in fluids from cryptococcal antigen (CneF)-injected sponges in immunized mice (DTH-reactive sponges) were significantly increased over levels of MIP-1 alpha in fluids from saline-injected control sponges at 12 and 24-30 h after injection. MIP-1 alpha levels peaked before increases in neutrophils and lymphocytes in the DTH-reactive sponges, suggesting that MIP-1 alpha was responsible, at least in part, for attracting these leukocyte types. Immunized mice treated with neutralizing antibody to MIP-1 alpha before sponge injection with CneF had reduced numbers of neutrophils and lymphocytes in the DTH-reactive sponges and showed reduced clearance of C. neoformans from the lungs, spleens, livers, and brains when compared with controls. Furthermore, injection of rmMIP-1 alpha into sponges in naive mice resulted in an increase in the influx of neutrophils and lymphocytes into the sponges compared with saline-injected sponges. Together our findings provide solid evidence that MIP-1 alpha is a component of the anticryptococcal DTH reaction. In addition, MIP-1 alpha influences neutrophil influx and attracts lymphocytes into the DTH reaction site. Finally, we showed that MIP-1 alpha plays a role in protection against C. neoformans.

Cytoplasmic components of natural killer cells limit the growth of Cryptococcus neoformans.

Murine natural killer (NK) cell-mediated inhibition of growth of a yeast-like target cell, Cryptococcus neoformans, was completely abrogated by blocking the effector cell secretory process with monensin. Therefore, further studies were performed to determine the ability of various cytoplasmic fractions of NK cells to mediate inhibition of cryptococcal growth. Percoll-fractionated homogenates of rat LGL tumor cells demonstrated that the granule-containing fractions plus three additional sets of less dense cytoplasmic fractions displayed anti-cryptococcal activity; whereas only the cytoplasmic granule-containing fractions had cytotoxic activity against YAC-1 tumor cell and sheep erythrocyte targets. Maximal cryptococcal growth inhibition induced by LGL granules occurred after a 1 h incubation, required the presence of Ca2+ (1.0 mM) or Mg2+ (0.5 mM or 5.0 mM), and was completely abrogated in the presence of rabbit anti-LGL granule IgG. Cytolysin, the granule component which mediates tumor cell and sheep erythrocyte lysis, effectively limited the growth of cryptococci. Since Percoll gradient fractionation of the LGL homogenates demonstrated three separate peaks of anti-cryptococcal activity other than the granule peak, it is possible that the cytolysin-containing granules are not the only subcellular component of NK cells playing a role in inhibition of C. neoformans growth.

Intestinal secretion of digoxin in the rat. Augmentation by feeding activated charcoal.

Secretion of tritium-labeled digoxin was studied in rats using noneverted gut sacs, in ligated and perfused intestinal preparations in bile duct ligated rats, and by measuring 4 day fecal excretion of total radioactivity in bile duct ligated rats. Serosal to mucosal transfer was proportional to substrate concentration in vitro. In ligated intestinal loops radioactivity was concentrated in the lumen relative to serum. In perfused intestinal preparations the fraction of dose increased with time and was similar over a 100-fold range of doses. Bile duct ligated rats excreted 13.4 +/- 5.8 (S.D.) % of parenterally administered label in 4 day stool collections. Bile duct ligated rats treated with p.o. activated charcoal excreted significantly more radioactivity (33.4 +/- 7.9%). The results suggest that net nonbiliary intestinal secretion of digoxin and metabolites can be augmented by intraluminal binding. A role for this phenomenon in accounting for some effects of diseases and drug interactions is suggested.

Liposomes, a potential immunoadjuvant and carrier for a cryptococcal vaccine.

Mice immunized with a cryptococcal culture filtrate antigen (CneF) emulsified in complete Freund's adjuvant (CFA) develop an anticryptococcal cell-mediated immune response (CMI). CMI is detected by delayed-type hypersensitivity (DTH) reactions and by enhanced clearance of Cryptococcus neoformans from infected tissues. The objective of this research was to evaluate anticryptococcal DTH reactivity and clearance of cryptococci from groups of mice immunized with CneF encapsulated into liposomes (CneF-liposome) and compare the results to results from mice immunized with CneF-CFA. CBA/J mice were injected subcutaneously with vaccines or control formulations (saline-liposome or saline-CFA). Six days later the mice were footpad tested to assess their DTH response to CneF or the animals were challenged intravenously with 10(5) viable C. neoformans to determine clearance of infection. Clearance was evaluated 7 days later by enumeration of cryptococcal colony forming units (CFU) in lungs, spleens, livers, and brains of the infected mice. The CneF-liposome formulation induced a positive anticryptococcal DTH response and elicited increased clearance of C. neoformans from tissues as compared to mice treated with saline-liposome. Even though the CneF-liposome preparation did not induce as strong of a DTH response or as much protection as did CneF-CFA, our results indicate that liposomes are promising carriers for immunization with cryptococcal antigen and that such immunization can provide some protection to subsequent infection with C. neoformans.

Use of the prolene hernia system for inguinal hernia repair: retrospective, comparative time analysis versus other inguinal hernia repair systems.

No data are available for the duration of surgery for the various procedures currently used in hernia repair. This retrospective study was undertaken to determine the time required for the surgical repair of unilateral primary inguinal hernias using currently available procedures and to show specifically that the duration of surgery using the PROLENE Hernia System (PHS) was equal to or less than the duration of surgery using a plug-and-patch device. Data were collected from 1032 sequential hernia procedures performed by 16 surgeons at a community hospital between 1997 and 1999. To gain more accurate information to compare the PHS and plug-and-patch procedures data from four surgeons who had performed at least five of each procedure were used as the primary analysis database. The two most frequently used devices were the PHS (35.9%) and plug and patch (41.0%). The average times of surgery for these procedures were not significantly different (25.4 vs 27.2 minutes, respectively; P = 0.236). A significant variability was observed between surgeons in the duration of surgery and there was evidence for an inverse relationship between the duration of surgery and the number of procedures a surgeon had performed. Both procedures take approximately the same time to perform.

Directional coronary atherectomy in acute myocardial infarction.

To date, application of directional coronary atherectomy (DCA) in acute myocardial infarction (AMI) has had limited reports. In eleven patients with AMI, DCA was applied. In three of these patients, DCA was used as a stand-alone procedure without use of thrombolytic agents. In each case a guidewire was placed across the stenosis, and in eight patients balloon angioplasty was utilized as a predilating modality prior to DCA. The thrombolytic agent urokinase was utilized in five of these eight patients, either before, during, or after angioplasty and/or DCA. DCA success (defined as ability to cross the lesion, reduction of less than or equal to 20% in stenosis and thrombolysis--when a thrombus is present) was achieved in 10 of 11 patients. One patient had persistent abrupt reclosure of an LAD lesion, accompanied by hemodynamic compromise, necessitating intra-aortic balloon pump insertion and subsequent emergent coronary artery bypass graft surgery. Final angiograms revealed residual stenoses less than or equal to 20%, and adequate thrombolysis. Significant cardiac events were limited to one emergent CABG, Q wave MI in four patients, and non-Q wave MI in two patients. Clinically all eleven patients improved, survived the AMI/CABG, and were discharged. This clinical experience demonstrates the feasibility and safety of DCA application in selected patients who experience acute myocardial infarction.

A method for hyperthermic treatment of mouse skin.

The Sencar mouse skin system is a recognized model for tumour initiation, promotion and progression. The current interest in the effect of hyperthermia on this multi-stage tumorigenesis model prompted the need for a technique to accurately heat a section of dorsal skin of a large number of mice for 30 min per heat treatment. In the technique described, experimental groups of 25 female Sencar mice were treated at 7-8 weeks of age under general methoxyflurane anaesthesia. Treatment consisted of the application of initiating and/or promoting agents with or without hyperthermia. For hyperthermic skin treatments, each group of mice was placed onto a platform in a water bath so that the dorsal skin of the mice was in contact with 44 degrees C temperature controlled water.

Abdominal and pelvic imaging as part of liver-spleen scintigraphy for the detection of mesenteric bleeding in trauma. A case report.

Liver--spleen scintigraphy in patients who have incurred blunt abdominal trauma is accepted as a useful diagnostic tool. Abdominal and pelvic imaging to detect extrahepatic or extrasplenic sites of hemorrhage should be a routine part of liver--spleen imaging in the evaluation of blunt abdominal injury. A patient with mesenteric bleeding and a normal liver and spleen detected by liver--spleen scintigraphy is reported.

Therapeutic versus traditional foster care: theoretical and practical distinctions.

This article explores the conceptual and practical differences between traditional and therapeutic foster care. Most important is that therapeutic foster care is linked to an emerging philosophy referred to as postmodernism. If this philosophical basis is not understood, the thrust of therapeutic foster care may be seriously misconstrued, and a community-based style of treatment may be destroyed.

Factors associated with premature termination of psychotherapy by children.

This study reports findings on factors associated with children who terminate psychotherapy prematurely. The sample was composed of 45 children, with an average age of 13.5 years. It was found that children are more likely to remain in treatment if the therapist is perceived as professional and caring, and if the treatment plan is adequately explained.

Postmodernism and clinical practice: a critical analysis of the disease model.

The disease model attempts to explain a variety of phenomena ranging from mental illness to criminal behavior. This approach is grounded in the Western philosophical tradition of dualism. The limitations of the disease model are analyzed through a postmodern perspective. Socially sensitive strategies for clinical intervention are offered.

WAG-F8(m1Ycb) rats harboring a factor VIII gene mutation provide a new animal model for hemophilia A.

BACKGROUND: We recently described an inherited coagulopathy arising in an inbred colony of WAG/RijYcb rats. The bleeding phenotype, demonstrated by both male and female rats, included periarticular hemorrhage, spontaneous bruising, prolonged bleeding from minor wounds and maternal peripartum deaths. Coagulation testing of affected rats revealed normal prothrombin time but prolongation of activated partial thromboplastin time to twice that of controls. OBJECTIVE: To determine the specific coagulation factor and the underlying genetic defect responsible for the inherited coagulopathy in the WAG/RijYcb rats. RESULTS: Evaluation of individual clotting factor activities revealed that the affected animals had a specific deficiency of factor (F) VIII (FVIII). The FVIII gene (F8) has an autosomal location on chromosome 18 in rats, in contrast to its location on the X chromosome in mice and humans. Sequencing of F8 cDNA led to the identification of a point mutation resulting in a substitution, Leu176Pro, in the A1 domain, that is predicted to disrupt the tertiary structure of the FVIII molecule. Administration of human plasma or human recombinant FVIII corrects the coagulation abnormality in the affected animals. CONCLUSIONS: We have now identified the genetic basis of the hemostatic defect in the WAG/RijYcb rat colony. The larger size of rats relative to mice and the presence of this coagulation defect in both sexes provide a unique model, well-suited to the development of novel therapies for acquired and hereditary FVIII deficiencies.