Sticholysin II shows similar immunostimulatory properties to LLO stimulating dendritic cells and MHC-I restricted T cell responses of heterologous antigen.

Induction of CD8+ T cell responses against tumor cells and intracellular pathogens is an important goal of modern vaccinology. One approach of translational interest is the use of liposomes encapsulating pore-forming proteins (PFPs), such as Listeriolysin O (LLO), which has shown efficacy at priming strong and sustained CD8+ T cell responses. Recently, we have demonstrated that Sticholysin II (StII), a PFP from the sea anemone Stichodactyla helianthus, co-encapsulated into liposomes with ovalbumin (OVA) was able to stimulate, antigen presenting cells, antigen-specific CD8+ T cells and anti-tumor activity in mice. In the present study, we aimed to compare StII and LLO in terms of their abilities to stimulate dendritic cells and to induce major histocompatibility complex (MHC) class I restricted T cell responses against OVA. Interestingly, StII exhibited similar abilities to LLO in vitro of inducing dendritic cells maturation, as measured by increased expression of CD40, CD80, CD86 and MHC-class II molecules, and of stimulating OVA cross-presentation to a CD8+ T cell line. Remarkably, using an ex vivo Enzyme-Linked ImmunoSpot Assay (ELISPOT) to monitor gamma interferon (INF-γ) producing effector memory CD8+ T cells, liposomal formulations containing either StII or LLO induced comparable frequencies of OVA-specific INF-γ producing CD8+ T cells in mice that were sustained in time. However, StII-containing liposomes stimulated antigen-specific memory CD8+ T cells with a higher potential to secrete IFN-γ than liposomes encapsulating LLO. This StII immunostimulatory property further supports its use for the rational design of T cell vaccines against cancers and intracellular pathogens. In summary, this study indicates that StII has immunostimulatory properties similar to LLO, despite being evolutionarily distant PFPs.

Factores de riesgo asociados a evolución desfavorable en el tratamiento de las infecciones de partes blandas

Introducción: Las infecciones de piel y partes blandas (IPPB) son una consulta frecuente y los casos graves conllevan morbimortalidad, por lo que su identificación y manejo precoz es fundamental para mejorar el pronóstico. Objetivo: Identificar los factores de riesgo asociados a una evolución desfavorable y mortalidad en pacientes tratados por IPPB en nuestro centro. Materiales y Método: Se realizó un estudio de casos y controles de una serie consecutiva de 172 pacientes con diagnóstico de IPPB entre enero de 2018 y enero de 2019, se recolectaron variables clínicas, de laboratorio e imagenológicas. Se definió como casos aquellos que requirieron cirugía, ingresaron a una unidad de paciente crítico o fallecieron, y como controles a los pacientes con buena respuesta al tratamiento médico. Resultados: Al realizar el análisis estadístico: la leucocitosis > 12.000 cel/mm3 (OR 6,56; IC 95%; 3,21-13,42), y la PCR > 150 mg/dl (OR 7,79; IC 95%; 3,59-16,91), resultaron ser factores de riesgo para evolución desfavorable. El puntaje LRINEC elevado (25,5% vs. 15,1%, p = 0,1034) y la cirugía tardía al ingreso (31,3% vs. 16,2%, p = 0.2632) fueron más frecuente en los casos de evolución desfavorable, pero sin diferencia significativa. Discusión: El uso de parámetros clínicos, de laboratorio e imágenes es fundamental para un diagnóstico precoz y tratamiento oportuno. Conclusiones: La leucocitosis, la elevación de la PCR y la cirugía tardía son factores de mal pronóstico en IPPB. El puntaje LRINEC aún es controversial por su baja sensibilidad.

Introduction: Skin and soft tissue infections (SSTI) are a frequent consultation and severe cases carry morbidity and mortality, so their early identification and management is essential to improve prognosis. Aim: To identify the risk factors associated with an unfavorable evolution and mortality in patients treated for SSTI in our center. Materials and Method: A case-control study of a consecutive series of 172 patients diagnosed with SSTI between January 2018 and January 2019 was carried out, clinical, laboratory and imaging variables were collected. Cases were defined as those that required surgery, were admitted to a critical patient unit or died, and as controls were patients with a good response to medical treatment. Results: When performing the statistical analysis: leukocytosis > 12,000 cel/mm3 (OR 6.56; 95% CI; 3.21-13.42), and CRP > 150 mg/dl (OR 7.79; 95% CI; 3.59-16.91), turned out to be risk factors for unfavorable evolution. The high LRINEC score (25.5% vs. 15.1%, p = 0.1034) and late surgery on admission (31.3% vs. 16.2%, p = 0.2632) were more frequent in cases of evolution unfavorable but without significant difference. Discussion: The use of clinical, laboratory and imaging parameters is essential for an early diagnosis and timely treatment. Conclusions: Leukocytosis, elevated CRP, and late surgery are poor prognostic factors in SSTI. The LRINEC score is still controversial due to its low sensitivity.

Genetic complementation to identify DNA elements that influence complement resistance in Leishmania chagasi.

Past studies showed that Leishmania spp. promastigotes exhibit differential sensitivity to complement mediated lysis (CML) during development in vitro and in vivo. Leishmania chagasi promastigotes in cultures during logarithmic and stationary growth phases are CML-sensitive or CML-resistant when exposed to human serum, respectively, but only in cultures recently initiated with parasites from infected animals; serially passaged cultures become constitutively CML-sensitive regardless of growth phase. Building on these observations, a genetic screen was conducted to identify novel complement resistance factors of L. chagasi. A cosmid library containing genomic DNA was transfected into a promastigote line previously subjected to >50 serial passages. Selection with human serum for CML resistance yielded 12 transfectant clones. Cosmids isolated from 7 of these clones conferred CML resistance when transfected into an independent, high-passage promastigote culture; at 12% human serum, the mean survival of transfectants was 37% (+/- 11.6%), and that of control transfectants was about 1%. Inserts within the 7 cosmids were unique. Determination of the complete DNA sequence for 1 cosmid indicated that its 32-kilobase insert was 89% identical (overall) to a 31-kilobase region of Leishmania major chromosome 36, which is predicted to encode 6 genes, all of which encode hypothetical proteins.

Síndrome de hombre en barril secundario a trauma raquimedular. Reporte de caso / Man-in-the-barrel syndrome secondary to spinal cord trauma. Case report

Resumen Presentamos caso de un varón de 77 años con antecedentes de alcoholismo, limitación crónica al flujo aéreo, y trauma encéfalo craneano (TEC) antiguo, que ingresa por cuadro de insuficiencia respiratoria global con descompensación aparentemente infecciosa que evoluciona tórpidamente con asistencia de ventilación mecánica no invasiva (VMNI) persistente. Se objetiva diparesia de predominio braquial proximal lo que hace sospechar síndrome de hombre en barril (SHB). Se completa estudio con resonancia nuclear magnética (RNM) de columna cervical que muestra severa atrofia medular desde bulbo distal hasta C4. El paciente se mantiene con VMNI c/ BiPAP y apoyo kinésico, con lo que logra progresiva mejoría ventilatoria.

We present a patient 77-year-old male with a history of alcoholism, chronic airflow limitation, and old brain trauma injury, who is admitted due to a global respiratory insufficiency with apparently infectious decompensation that evolves rapidly dependent on non-invasive mechanical ventilation and with a, Man-in-the-barrel syndrome. A magnetic resonance of cervical spine showed severe spinal atrophy from the distal medulla oblongata to C4. The patient remains with kinesic motor support, thereby achieving progressive ventilatory improvement.

Intraocular reticulum cell sarcoma: diagnosis by choroidal biopsy.

A patient with uveitis and retinal pigment epithelial detachments underwent an extensive medical examination and pars plana vitrectomy in an attempt to confirm the clinical diagnosis of reticulum cell sarcoma. None of these examinations revealed the presence of malignancy. Transscleral biopsy of subretinal lesions confirmed the histopathological diagnosis of reticulum cell sarcoma. The patient was begun on systemic chemotherapy and external beam radiation to the eye and orbit, with resultant preservation of the eye, vision, and probable extension of life because of early detection of reticulum cell sarcoma by choroidal biopsy. This technique may be advantageous in the diagnosis cases of eyes with clinical evidence of reticulum cell sarcoma, no systemic signs of malignancy, and negative vitreous biopsies.

[Cranial metastasis of thyroid follicular carcinoma. Report of a case]. / Metástasis craneal de un carcinoma folicular del tiroides. Reporte de un caso.

Thyroid follicular carcinoma is able to produce metastatic lesions before the vanishing of the primary lesion. We present a case of a woman with a lytic, solitary, asymptomatic parietal bone lesion of 2 years of evolution. Autopsy revealed a thyroid gland with two small cystic areas and renal metastasis. Thyroid carcinoma should be included in the differential diagnosis in cases of lytic bone lesions with long evolution in patients 60 years of age or older.

Safety and efficacy of CYT387, a JAK1 and JAK2 inhibitor, in myelofibrosis.

JAK-STAT is a rational drug target in myelofibrosis (MF) given its association with JAK2/MPL mutations and aberrant inflammatory cytokine expression. We conducted a Phase 1/2 trial of CYT387, a potent JAK1/2 inhibitor, in patients with high- or intermediate-risk primary or post-polycythemia vera/essential thrombocythemia MF. Pre-planned safety and efficacy analysis has been completed for the initial 60 patients. In the dose-escalation phase (n=21), the maximum-tolerated dose was 300 mg/day based on reversible grade 3 headache and asymptomatic hyperlipasemia. Twenty-one and 18 additional patients were accrued at two biologically effective doses, 300 mg/day and 150 mg/day, respectively. Anemia and spleen responses, per International Working Group criteria, were 59% and 48%, respectively. Among 33 patients who were red cell-transfused in the month prior to study entry, 70% achieved a minimum 12-week period without transfusions (range 4.7->18.3 months). Most patients experienced constitutional symptoms improvement. Grade 3/4 adverse reactions included thrombocytopenia (32%), hyperlipasemia (5%), elevated liver transaminases (3%) and headache (3%). New-onset treatment-related peripheral neuropathy was observed in 22% of patients (sensory symptoms, grade 1). CYT387 is well tolerated and produces significant anemia, spleen and symptom responses in MF patients. Plasma cytokine and gene expression studies suggested a broad anticytokine drug effect.

CSF3R T618I is a highly prevalent and specific mutation in chronic neutrophilic leukemia.

Truncation mutations of the receptor cytoplasmic domain for colony-stimulating factor 3 (CSF3R) are frequently seen in severe congenital neutropenia, whereas activating missense mutations affecting the extracellular domain (exon 14) have been described in hereditary neutrophilia and chronic neutrophilic leukemia (CNL). In order to clarify mutational frequency, specificity and phenotypic associations, we sequenced CSF3R exons 14-17 in 54 clinically suspected cases of CNL (n=35) or atypical chronic myeloid leukemia (aCML; n=19). Central review of these cases confirmed WHO-defined CNL in 12 patients, monoclonal gammopathy (MG)-associated CNL in 5 and WHO-defined aCML in 9. A total of 14 CSF3R mutations were detected in 13 patients, including 10 with CSF3RT618I (exon 14 mutation, sometimes annotated as CSF3R T595I). CSF3RT618I occurred exclusively in WHO-defined CNL with a mutational frequency of 83% (10 of 12 cases). CSF3R mutations were not seen in aCML or MG-associated CNL. CSF3RT618I was also absent among 170 patients with primary myelofibrosis (PMF; n=76) or chronic myelomonocytic leukemia (CMML; n=94). SETBP1 mutational frequencies in WHO-defined CNL, aCML, CMML and PMF were 33, 0, 7 and 3%, respectively. Four CSF3RT618I-mutated cases co-expressed SETBP1 mutations. We conclude that CSF3RT618I is a highly sensitive and specific molecular marker for CNL and should be incorporated into current diagnostic criteria.

Mayo prognostic model for WHO-defined chronic myelomonocytic leukemia: ASXL1 and spliceosome component mutations and outcomes.

We evaluated the prognostic relevance of several clinical and laboratory parameters in 226 Mayo Clinic patients with chronic myelomonocytic leukemia (CMML): 152 (67%) males and median age 71 years. At a median follow-up of 15 months, 166 (73%) deaths and 33 (14.5%) leukemic transformations were documented. In univariate analysis, significant risk factors for survival included anemia, thrombocytopenia, increased levels of white blood cells, absolute neutrophils, absolute monocyte count (AMC), absolute lymphocytes, peripheral blood and bone marrow blasts, and presence of circulating immature myeloid cells (IMCs). Spliceosome component (P=0.4) and ASXL1 mutations (P=0.37) had no impact survival. On multivariable analysis, increased AMC (>10 × 10(9)/l, relative risk (RR) 2.5, 95% confidence interval (CI) 1.7-3.8), presence of circulating IMC (RR 2.0, 95% CI 1.4-2.7), decreased hemoglobin (<10 g/dl, RR 1.6, 99% CI 1.2-2.2) and decreased platelet count (<100 × 10(9)/l, RR 1.4, 99% CI 1.0-1.9) remained significant. Using these four risk factors, a new prognostic model for overall (high risk, RR 4.4, 95% CI 2.9-6.7; intermediate risk, RR 2.0, 95% CI 1.4-2.9) and leukemia-free survival (high risk, RR 4.9, 95% CI 1.9-12.8; intermediate risk, RR 2.6, 95% CI 1.1-5.9) performed better than other conventional risk models and was validated in an independent cohort of 268 CMML patients.

Mutations and prognosis in primary myelofibrosis.

Patient outcome in primary myelofibrosis (PMF) is significantly influenced by karyotype. We studied 879 PMF patients to determine the individual and combinatorial prognostic relevance of somatic mutations. Analysis was performed in 483 European patients and the seminal observations were validated in 396 Mayo Clinic patients. Samples from the European cohort, collected at time of diagnosis, were analyzed for mutations in ASXL1, SRSF2, EZH2, TET2, DNMT3A, CBL, IDH1, IDH2, MPL and JAK2. Of these, ASXL1, SRSF2 and EZH2 mutations inter-independently predicted shortened survival. However, only ASXL1 mutations (HR: 2.02; P<0.001) remained significant in the context of the International Prognostic Scoring System (IPSS). These observations were validated in the Mayo Clinic cohort where mutation and survival analyses were performed from time of referral. ASXL1, SRSF2 and EZH2 mutations were independently associated with poor survival, but only ASXL1 mutations held their prognostic relevance (HR: 1.4; P=0.04) independent of the Dynamic IPSS (DIPSS)-plus model, which incorporates cytogenetic risk. In the European cohort, leukemia-free survival was negatively affected by IDH1/2, SRSF2 and ASXL1 mutations and in the Mayo cohort by IDH1 and SRSF2 mutations. Mutational profiling for ASXL1, EZH2, SRSF2 and IDH identifies PMF patients who are at risk for premature death or leukemic transformation.

Retinal and choroidal vascular occlusion following intralesional corticosteroid injection of a chalazion.

Unilateral visual loss following periocular corticosteroid injection is a reported complication of injections of tonsillar, nasal, scalp, and retrobulbar sites. This is the first reported case, to our knowledge, of intralesional corticosteroid injection of a chalazion producing ipsilateral microembolization and infarction of retinal and choroidal vasculature. An eight-year-old boy underwent reexcision of an upper lid chalazion under general anesthesia. Intraoperatively, 0.5 ml of depot-steroid preparation was injected into the excision site. Postoperatively, vision was unilaterally reduced to light perception only. Examination revealed an afferent pupillary defect, retinal and choroidal emboli, retinal edema, and a macular "cherry red spot". Anterior chamber paracentesis, carbon dioxide rebreathing, carbonic anhydrase inhibitors and ocular massage failed to change the embolic pattern. No visual recovery resulted. Fundus photography and fluorescein angiography demonstrated occlusion of the retinal and choroidal vasculature. Extreme care should be exercised during and immediately following intralesional corticosteroid injection of chalazia.

Left bronchial intubation by a single-lumen tube in adults: effects of bevel and curvature.

This study was designed to determine whether left bronchial intubation could be accomplished by reversal of the direction of the bevel or by changing the direction of curvature of a normal tracheal tube. The 60 study patients were divided into three groups. In group 1, the patients were intubated in the usual manner, with bevel to the left and the tube concave anteriorly. In group 2, the normal tracheal tube was rotated 90 degrees counterclockwise during insertion. In group 3, the bevel of the tracheal tube was altered to face the right, with the tube still concave anteriorly. In group 1, all 20 tracheal tubes entered the right primary bronchus. In group 2, 14 tracheal tubes (70%) entered the left primary bronchus. In group 3, 18 tubes entered the right primary bronchus and 2 entered the left. The position of the bevel did not influence the positioning of the tracheal tube in the right or left bronchus. In summary, 90 degrees counterclockwise rotation from the usual position and altering the concavity of the tube to face the left significantly increased the likelihood of intubation of the left primary bronchus.

Delayed ischaemia of the hand necessitating amputation after radial artery cannulation.

We present a case of ischaemic hand injury in a patient, who had 95% occlusion of both the ulnar and radial arteries, after atraumatic placement of a left radial artery catheter. The presence of cigarette burns on the dorsum of the hand was highly suggestive of vascular compromise. There were no signs of vascular compromise after placement of the arterial line which was removed 24 hr later. Ten days after placement the patient complained of pain with ensuing ischaemic changes resulting in necrosis of the finger tips and eventual amputation of the hand. We recommend using other sites of arterial access such as axillary or superficial temporal artery in patients with severe peripheral vascular disease.

Pneumothorax during laparoscopic Nissen fundoplication.

We present a case of 100% pneumothorax in a 41-yr-old man with a history of gastritis and gastroesophageal reflux scheduled for Nissen fundoplication. The patient was anaesthetized, and insufflation of the abdominal cavity with carbon dioxide was performed uneventfully. There was an increase in the peak inspiratory pressure and wheezing was noted with a decrease in the arterial oxygen saturation to 91%. An obstructive pattern was noted on the end tidal carbon dioxide monitor. The patient also had decreased breath sounds in the left lung field. The endotracheal tube was withdrawn 1.5 cm with equal breath sounds noted in both lung fields, but the wheezing persisted. At the end of the case the trocars were removed and the abdomen was deflated. The arterial oxygen saturation increased to 94% while breathing F1O2 of 1.0. A chest roentgenogram showed a 100% left pneumothorax. A left chest tube was placed with immediate improvement of the arterial oxygen saturation to 100%. We recommend monitoring of arterial oxygen saturation, peak inspiratory pressures, and excursion of the chest for early diagnosis and prompt treatment of pneumothorax during laparoscopic procedures.