Idiotypic regulation of the immune system. Common idiotypic specificities between idiotypes and antibodies raised against anti-idiotypic antibodies in rabbits.

Anti-idiotypic antibodies (Ab2) were raised in allotype-matched rabbits against anti-carbohydrate or anti-tobacco mosaic virus antibodies (Ab1). Several Ab2 were purified and injected into a third series of rabbits III which synthesized antiantiidiotypic antibodies (Ab3). Antigen was then given for the first time in those rabbits who had synthesized Ab3. The specific antibody synthesized in rabbits III was called Ab1'. Anti-idiotypic antibodies were raised against purified Ab3 antibodies (Ab4). In most cases, Ab1' antibodies are sharing idiotypic specificities with Ab1. Ab3 did not react with antigen but shared idiotopes with Ab1 and Ab1' because Ab4 antibodies, which are anti-idiotypes to Ab3 do recognize specifically Ab1 and Ab1' antibodies belonging to the same chain of immunization. It seems therefore that Ab3 looks idiotypically like Ab1 and Ab4 displays the same behaviour as Ab2. A general view of the functioning of the immune system is presented.

Effect of lyophilized lactobacilli and 0.03 mg estriol (Gynoflor®) on vaginitis and vaginosis with disrupted vaginal microflora: a multicenter, randomized, single-blind, active-controlled pilot study.

OBJECTIVES: To evaluate the efficacy of lyophilized lactobacilli in combination with 0.03 mg estriol when compared to metronidazole in the treatment of bacterial vaginal infections. SETTING: Multicenter, randomized, single-blind, active-controlled pilot study in 3 independent gynecological practices in Belgium. METHODS: Forty-six, 18- to 50-year-old premenopausal women with a disrupted vaginal flora due to a bacterial vaginal infection (bacterial vaginosis, aerobic vaginitis) were included, provided that fresh phase-contrast microscopy of the vaginal fluid showed lactobacillary flora grade 2B or 3. Patients were given a blinded box with either 12 vaginal tablets of Gynoflor® (study medication) or 6 vaginal suppositories containing 500 mg metronidazole (control medication). Eight efficacy variables were studied to assess the status of the vaginal flora at entry, 3-7 days (control 1), 4-6 (control 2) weeks and 4 months after the end of therapy. RESULTS: At control 1, the combined variables equally improved in the lactobacilli group as in the metronidazole group. At control 2, the lactobacillus preparation showed slightly inferior results when compared to metronidazole. At 4 months, this analysis could not be performed due to low numbers, but analysis of recurrence rate and extra medication needed was not different between both groups. CONCLUSION: Lyophilized lactobacilli in combination with low-dose estriol are equivalent to metronidazole in the short-term treatment of bacterial vaginal infections, but have less effect after 1 month. Further studies are required to evaluate the long-term efficacy of lactobacilli when applied repeatedly.

Clinical usefulness and challenges of instrumented motion analysis in patients with intellectual disabilities.

BACKGROUND: Clinical laboratory testing of locomotor disorders is challenging in patients with intellectual disability (ID). Nevertheless, also in this population gait analysis has substantial value as motor problems are common. To promote its use, adequate protocols need to be developed and the impact on clinical decision making needs to be documented. RESEARCH QUESTION: What is the clinical usefulness of instrumented motion analysis in patients with ID? METHOD: This narrative review consists of three parts. A literature review was performed to describe the gait pattern of patients with ID. Next, benefits and challenges of standard gait analysis protocols are described. Finally, a case of a girl with ID due to genetic cause showing gait abnormalities is discussed. RESULTS: The literature review resulted in 20 studies on "gait" in patients with an "ID", published since August, 1st 2013. Gait deviations were observed in all studies investigating the ID population with an underlying genetic syndrome. Observed gait deviations in the ID population might be attributed to physical characteristics, cognitive components or both. The main goal of clinical gait assessment is the identification of gait deviations and the evaluation of their progress over time, in order to optimize the treatment plan. The choice of adequate method and measurement modalities depends on the clinical goal, the available resources and the abilities of the patient. In the case report we presented, we succeeded in performing an instrumented 3D gait analysis in a girl with severe ID at the ages of 4y4m, 6y0m, 7y2m and 8y2m. Progressive gait deviations were found suggesting a crouch gait pattern was developing. Results of the gait analysis led to the prescription of rigid ankle-foot orthoses. SIGNIFICANCE: Gait analysis has substantial value for patients with ID. Gait analysis allows clinicians to objectify the relationship between physical characteristics and gait features.

How appropriate is therapeutic drug monitoring for lithium? Data from the Belgian external quality assessment scheme.

BACKGROUND: Lithium remains a mainstay in the management of mood disorders. As with many psychotropic drugs, lithium treatment requires continuous observation for adverse effects and strict monitoring of serum concentrations. The present study aimed to assess the appropriateness of lithium assays used by Belgian laboratories, and to evaluate acceptability of their clinical interpretations. METHODS: Nine in-house serum samples spiked with predetermined concentrations of lithium were distributed to 114 participants in the Belgian external quality assessment scheme. Laboratories were requested to report the assay technique, lithium measurements and interpretations with regard to measured concentrations. Inter/intramethod imprecision and bias were reported and acceptability of clinical interpretations was assessed. The intramethod variability was evaluated by selecting methods used by 6 laboratories or more. Flame photometry (IL 943) was considered as the reference method. RESULTS: Laboratories returned assay results using colorimetry (69.3%), ion selective electrode (15.8%), flame photometry (8.8%), atomic absorption spectroscopy (5.2%) or mass spectrometry (0.9%). Lithium concentrations were systematically higher when measured with the Vitros assay (median bias: 4.0%), and were associated with consecutive biased interpretations. In contrast, the Thermo Scientific Infinity assay showed a significant negative bias (median bias: 9.4%). 36.0% of laboratories reported numerical values below their manufacturer cut-off for the blank sample; 16.6% of these laboratories detected residual lithium concentrations. CONCLUSIONS: The present study revealed assay-related differences in lithium measurements and their interpretations. Overall, there appeared to be a need to continue EQA of therapeutic drug monitoring for lithium in Belgium.

Laparoscopy and primary diffuse malignant peritoneal mesothelioma: a diagnostic challenge.

Primary diffuse malignant peritoneal mesothelioma is a rare malignancy with an estimated incidence of 200 to 400 new cases annually in the USA. We describe a case of diffuse malignant peritoneal mesothelioma arising in a 65-year old man who presented ascites of unknown origin. The importance of laparoscopy with subsequent histology of biopsy specimens in the diagnosis of this disease is emphasized. Because of his poor general condition, the patient had no further treatment. Update of treatment is briefly described with particular attention to multimodality approach.

The laparoscopic resection of a benign stromal tumour of the duodenum.

A 72-year-old-female presented intermittent retrosternal pain, heartburn and dysphagia. Computerized CT-Scan showed a large mass with a cross-sectional diameter of 5 cm at the lateral side of part II of the duodenum. The preoperative histology was unclear. The tumour was successfully removed by laparoscopic approach.

The laparoscopic approach of a torsion of a benign mature ovarian teratoma: a case report and review of the literature.

Benign mature teratomas account for approximately 10-15% of all ovarian neoplasms. Many patients with these dermoid cysts are asymptomatic. The most frequent complication is torsion of the teratoma (in 3,5% of the cases). In a 26-year female patient admitted for severe, acute abdominal pain, a computerized abdominal tomography in accordance with the clinical characteristics of the abdominal examination, was highly suggestive for a torsion of a teratoma. The diagnose was confirmed by a celioscopic operative approach and the teratoma with the left tubo-ovarian complex was successfully removed laparoscopically.

Hand-assisted staging laparoscopy for suspected malignancies of the pancreas.

Fewer than 20% of patients with pancreatic cancer have resectable tumours at the time of diagnosis. In two patients with a pancreas neoplasm a laparoscopic staging work-up was performed. Because of the described limitations of laparoscopy, we propose to switch to a hand-assisted procedure. In our opinion the benefits of hand-assisted laparoscopic surgery, such as safe blunt digital dissection, restoration of tactile feedback and restored proprioception, account for greater accuracy in TNM staging and in the assessment of resectability of pancreatic cancer.

The hypothenar hammer syndrome: update and literature review.

The hypothenar hammer syndrome is a rather rare vascular injury. It is seen in posttraumatic digital ischaemia caused by irregularity or occlusion of the distal ulnar artery at the level of the hamate bone. It characteristically occurs in the dominant hand of middle-aged men whose occupational or recreational activities require the use of the hand as a hammer. Three typical cases are presented along with literature review. The different aspects of this syndrome are described such as the cause and pathogenesis, the most important clinical characteristics and differential diagnosis, the role of angiography and Doppler mapping in establishing the diagnosis and the various therapeutic options, ranging from conservative treatment to resection of the thrombosed artery segment with vein graft interposition.

Belgian recommendations on ANA, anti-dsDNA and anti-ENA antibody testing.

Autoantibodies to nuclear antigens, i.e. antinuclear antibodies (ANA), antibodies to double-stranded DNA (dsDNA) and extractable nuclear antigens (ENA), are useful as diagnostic markers for a variety of autoimmune diseases. In March 2010, the Belgian national External Quality Assessment Scheme sent a questionnaire on ANA, anti-dsDNA and anti-ENA antibody testing designed by the Dutch EASI (European Autoimmunity Standardization Initiative) team, to all clinical laboratories performing ANA testing. Virtually all laboratories completed the questionnaire (97·7%, 127/130). This paper discusses the results of this questionnaire and provides valuable information on the state-of-the-art of ANA, anti-dsDNA and anti-ENA antibody testing as practiced in the Belgian laboratories. In addition, this work presents practical recommendations developed by the members of the advisory board of the scheme as a result of the outcome of this study.

Reliability of head and trunk kinematics during gait in children with spastic diplegia.

This study describes the reliability of a clinically oriented model for three-dimensional movement analysis of head and trunk movements in children with spastic diplegia. The model consists of five rigid segments (head, thorax, pelvis, shoulder line, spine) and includes a detailed analysis of spinal segmental movements. Within and between session reliability during gait was tested in 10 children with spastic diplegia (6-14yrs). Reliability of discrete parameters was assessed with the intraclass correlation coefficient (ICC) and similarity of thorax and pelvis waveforms with the coefficient of multiple correlation (CMC). Measurement errors were calculated for all parameters (SEM, σ). Results indicated acceptable within and between session reliability of discrete parameters for thorax, pelvis, shoulder line, angle of kyphosis and the majority of the spinal segmental angles, reflected by low SEMs (<4°) and most ICCs>0.60. Within and between session waveform errors were below 4°. CMCs ranged from poor to very good, with highest values for movements in the frontal and transversal planes. The angle of lordosis showed lower between session reliability for several discrete parameters, although waveform errors were still below 5°. Head parameters showed lower overall reliability. The results of this study support the reliability of the proposed model. Head kinematic parameters should be interpreted with caution, due to difficulties in standardization. Accurate palpation of the spinal markers, especially the lumbar spine, is critical and demands thorough training of the assessor.

Mechanical energy estimation during walking: validity and sensitivity in typical gait and in children with cerebral palsy.

Gait efficiency in children with cerebral palsy is usually quantified by metabolic energy expenditure. Mechanical energy estimations, however, can be a valuable supplement as they can be assessed during gait analysis and plotted over the gait cycle, thus revealing information on timing and sources of increases in energy expenditure. Unfortunately, little information on validity and sensitivity exists. Three mechanical estimation approaches: (1) centre of mass (CoM) approach, (2) sum of segmental energies (SSE) approach and (3) integrated joint power approach, were validated against oxygen consumption and each other. Sensitivity was assessed in typical gait and in children with diplegia. CoM approach underestimated total energy expenditure and showed poor sensitivity. SSE approach overestimated energy expenditure and showed acceptable sensitivity. Validity and sensitivity were best in the integrated joint power approach. This method is therefore preferred for mechanical energy estimation in children with diplegia. However, mechanical energy should supplement, not replace metabolic energy, as total energy expended is not captured in any mechanical approach.

Increased mechanical cost of walking in children with diplegia: the role of the passenger unit cannot be neglected.

Gait efficiency in children with cerebral palsy is decreased. To date, most research did not include the upper body as a separate functional unit when exploring these changes in gait efficiency. Since children with spastic diplegia often experience problems with trunk control, they could benefit from separate evaluation of the so-called 'passenger unit'. Therefore, the aim of the current study was to improve insights in the role of the passenger unit in decreased gait efficiency in children with diplegia. Mechanical cost of walking was investigated by calculating work by the integrated joint power approach in 18 children with diplegia and 25 age-related typical developing controls. The total mechanical work in children with diplegia was 1.5 times higher than in typical children. In children with diplegia work at the lower limbs was increased by 37% compared to typical children. Substantially higher increases, up to 222%, were noted at the passenger unit. Trunk and head were the main contributors to the increased work of the passenger unit, but the role of the arms cannot be neglected. Due to these disproportional increases in locomotor and passenger unit, the demands of the passenger unit in pathological gait can no longer be considered minor, as in typical gait. Therefore, the role of the passenger unit must be recognized in the decrease of gait efficiency in children with spastic diplegia and should be part of the evaluation of gait efficiency in clinical practice.

Age-related changes in mechanical and metabolic energy during typical gait.

The purpose of the study was to investigate and report age-related changes in walking energy expenditure using different methods of energy estimation. For 81 children and 16 adults (3-35 years) energy expenditure was investigated by using the following methods: analysis of energy changes of the centre of body mass (external and internal mechanical work), sum of segmental energies, sum of net joint work and gross and net metabolic cost, as well as net non-dimensional oxygen cost. Different methods of energy estimation not only show different outcome results but also different age-related changes. Significant changes were found for negative net joint work, external mechanical work and recovery as well as sum of segmental energies, until 9, 11 and 19 years respectively. Positive net joint work showed no differences between age groups and the differences for internal work did not suggest development. Metabolic energy showed significant changes until adult age. Gross cost decreases with increasing age in children and, although more gradually, still in adolescents. Net and net non-dimensional cost shows a more constant decrease with increasing age until adulthood. Therefore, the choice of estimation method and the use of age-related reference data when evaluating young patients should be carefully considered. For interpretation of oxygen consumption in children the use of net is superior to gross cost, but even after net non-dimensional normalization, age-related reference data should be used.