Persistent activation of NF-kappa B by the tax transforming protein involves chronic phosphorylation of IkappaB kinase subunits IKKbeta and IKKgamma.

The Tax transforming protein encoded by human T-cell leukemia virus type 1 (HTLV1) persistently activates transcription factor NF-kappaB and deregulates the expression of downstream genes that mediate cell cycle entry. We recently found that Tax binds to and chronically stimulates the catalytic function of IkappaB kinase (IKK), a cellular enzyme complex that phosphorylates and inactivates the IkappaB inhibitory subunit of NF-kappaB. We now demonstrate that the IKKbeta catalytic subunit and IKKgamma regulatory subunit of IKK are chronically phosphorylated in HTLV1-infected and Tax-transfected cells. Alanine substitutions at Ser-177 and Ser-181 in the T loop of IKKbeta protect both of these IKK subunits from Tax-directed phosphorylation and prevent the induction of IkappaB kinase activity. Each of these inhibitory effects is recapitulated in Tax transfectants expressing the bacterial protein YopJ, a potent in vivo agonist of T loop phosphorylation. Moreover, ectopically expressed forms of IKKbeta that contain glutamic acid substitutions at Ser-177 and Ser-181 have the capacity to phosphorylate a recombinant IKKgamma substrate in vitro. We conclude that Tax-induced phosphorylation of IKKbeta is required for IKKbeta activation, phosphoryl group transfer to IKKgamma, and acquisition of the deregulated IKK phenotype.

Evaluation of the Triage Micro Parasite Panel for detection of Giardia lamblia, Entamoeba histolytica/Entamoeba dispar, and Cryptosporidium parvum in patient stool specimens.

A study comparing the Triage Micro Parasite Panel (Biosite Diagnostics, Inc., San Diego, Calif.) to conventional O&P examination (O&P) was performed using patient fecal specimens. Five hundred twenty-three stool samples were compared. Nineteen specimens were found to be positive by Triage, and 29 were found to be positive by O&P. Seven specimens were positive for Giardia lamblia, four were positive for Entamoeba histolytica/E. dispar, and three were positive for Cryptosporidium parvum as determined by both methods. There was one false positive by Triage (C. parvum) and four false negatives by O&P (two G. lamblia, one E. histolytica/E. dispar, and one C. parvum). The Triage test accurately detected all 18 specimens that contained one of the three organisms that it was designed to detect. The Triage test is a rapid, easy-to-use enzyme immunoassay for the detection of G. lamblia, E. histolytica/E. dispar, and C. parvum in fresh or fresh-frozen fecal specimens. These data suggest that the Triage test can be used as a screen for the immediate testing of stool specimens for these three pathogenic parasites. If Triage test results are negative, O&P can be performed if parasitic infections other than G. lamblia, E. histolytica/E. dispar, or C. parvum are suspected.

Evaluation of the mycobacteria growth indicator tube compared to Septi-Chek AFB for the detection of mycobacteria.

The Mycobacteria Growth Indicator Tube (MGIT) and the AFB Septi-Check (SC) systems were compared for the ability to detect myobacterial isolates, time to detection, and rate of bacterial contamination. Fifty-eight mycobacterial culture positive specimens were studied. MGIT and SC were both positive in 30 of the 58 specimens (52%); SC alone was positive in 22 (38%), and MGIT alone was positive in 6 (10%) of the 58 specimens. Among the 30 isolates identified in both systems, there were 7 Mycobacterium tuberculosis, 14 M. avium, 6 M. fortuitum-chelonae complex, and 3 other mycobacterial species. MGIT detected Mycobacterium tuberculosis faster; SC detected M. avium complex faster and more often; and M. fortuitum-chelonae isolates were detected at the same rate. MGIT showed more contamination (12.6%) than did the SC (7.8%). MGIT is comparable to SC for the detection of MTB, but MAC isolates were detected more often and faster in the SC system.

Toothpick perforation of the intestine diagnosed by a small bowel series.

We report the case of a 50-yr-old man who unknowingly swallowed a double-pointed toothpick that ultimately perforated the distal small bowel over a period of several weeks. Appendicitis and ileitis were sequentially considered as diagnosis. A foreign body was diagnosed on a second small bowel series and removed. It has been noted that, because toothpicks are not radiopaque, radiographic studies are not useful in the diagnostic workup. In the case reported, the toothpick was seen on the contrast radiograph of the small bowel and the correct diagnosis ultimately made.

Limited incision cholecystectomy.

Eighty-one consecutive cholecystectomies were retrospectively reviewed; five were dropped because of incomplete data. The remaining 76 were divided into group A, patients who underwent a limited incision cholecystectomy (LIC) defined as less than 10 centimeters, and group B, those who underwent a standard subcostal incision (STD). An STD was used for 18 patients in 1984 and an LIC for subsequent patients unless anatomy dictated extension of the incision for safe surgical exposure. The groups were evaluated for possible benefits and disadvantages of the LIC approach. Multivariate analysis was done to contrast the approaches regarding operative time, operative and postoperative complications, postoperative pain, and hospital stay. The operative time was comparable between the two groups. The LIC approach was superior with less postoperative pain and shorter hospital stay. There were no intraoperative complications or mortality in either group. The postoperative complications were also comparable. No differences were noted in body size, weight, sex, or whether the patient was suffering from acute or chronic disease. The limited incision cholecystectomy can be utilized in the majority of patients with cholecystitis without added operative time or complications when compared to the traditional approach. The benefits of less postoperative pain, shorter hospital stay and better cosmetic results afford a higher degree of patient acceptance. This procedure should be considered when open cholecystectomy is required.

Percutaneous access to the common bile duct in laparoscopic cholecystectomy.

A simple, direct way to access the common bile duct percutaneously is described. Alternate methods of common bile duct exploration via operative laparoscopy are described and contrasted to the proposed method with respect to ease, advantages, and limitations.

Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage.

A balloon-expandable intraluminal graft was percutaneously deployed in the left subclavian artery of a 43-year-old woman. This graft was made of a stainless steel, 30-mm Palmaz balloon-expandable iliac stent completely covered with a thin coat of silicone. The procedure was successful in managing and preventing life-threatening hemorrhage as a large-bore catheter was removed from the subclavian artery via its subcutaneous tunnel. Surgical repair of the high brachial-axillary sheath insertion site was required after percutaneous deployment of the graft. However, the grafting procedure succeeded in obviating a thoracotomy. At follow-up of 6 months, despite diminution in brachial pulse volume recordings, the patient is asymptomatic at rest. She experiences mild fatigue with extremes of upper extremity exercise and declines angiographic follow-up and further intervention.

The role of nuclear scanning in the evaluation of arterial injuries.

Nuclear scanning appears to be a useful test to screen patients with penetrating injuries to the extremities who have proximity as the only finding suggestive of vascular injury. Patients with abnormal scans should be further studied with standard angiography. Interpretation of the scan is dependent on the reader's experience.

Selection of patients with abdominal stab wounds for laparotomy.

The roles of local wound exploration (LWE) and peritoneal lavage (PL) in the selective management of stab wounds to the lower chest and abdomen were evaluated prospectively in 53 patients. Twenty-four patients underwent immediate laparotomy for obvious clinical signs of intra-abdominal injuries. Twenty-nine patients with evidence of anterior abdominal fascia penetration or equivocal LWE had PL before laparotomy. Operative findings were correlated with the preoperative assessment of LWE and PL. Twenty patients in this group had intra-abdominal injuries. All patients with positive PL were found to have an intra-abdominal injury. Six patients with a negative PL and a positive LWE had visceral injuries. Three of these injuries were considered significant with an overall false negative PL of 15%. Laparotomy performed on the basis of LWE resulted in nine patients (31%) having an unnecessary laparatomy. Careful physical examination, the results of local wound exploration, and peritoneal lavage should be considered in selecting patients with abdominal stab wound for laparotomy.

The role of H.I.D.A./P.I.P.I.D.A. scanning in diagnosing cystic duct obstruction.

A newer approach to the early diagnosis of acute biliary tract disease is review. Ninety-two patients were evaluated with a new hepatobiliary agent (H.I.D.A/P.I.P.D.A.) for the presence of cystic duct obstruction. Seven patients with suspected acute gall bladder disease were dropped from the study for the lack of pathologic confirmation of the diagnosis. Forty-four of the remaining 85 patients were subsequently operated on and found to have acute cholecystitis. Forty-three of the 44 had cystic duct obstruction demonstrated on H.I.D.A. Scan (one false negative). An additional 23 patients underwent cholecystectomy for chronic disease. In this group, the gallbladder scan was only 43% (10/23) accurate in correctly identifying disease. Eighteen patients with nonbiliary disease had normal scans. The accuracy of ultrasonography and the scan are also compared in a smaller subgroup of 53 patients who had both studies.

Cocaine-codom ingestion. Surgical treatment.

We report one survivor and two deaths from cocaine toxicity. Cocaine, packaged in condoms, was deliberately ingested to avoid detection by customs agents. Because cocaine is a toxic drug, we recommend surgical removal of the ingested packages, as alternative methods of removal are unreliable and potentially dangerous.