Kernicterus with abnormal high-signal changes bilaterally in the globus pallidus: A case report.

Kernicterus is a relatively rare consequence of hyperbilirubinemia. There is an important role for MRI imaging for this entity in the appropriate clinical context as there are distinct signal changes in the globus pallidus. A case report and image findings are presented

Detection of the common acute lymphoblastic leukemia antigen in the serum of leukemia patients.

The common acute lymphoblastic leukemia antigen (CALLA) has been detected in biological fluids using a radioimmunoassay based on the inhibition of binding of 125I-labeled monoclonal anti-CALLA antibody to glutaraldehyde-fixed NALM-1 cells. With this assay, we showed first that CALLA was released in culture fluids from NALM-1 and Daudi cell lines but was absent from culture fluids from CALLA negative cell lines. Then, we found that the sera of 34 out of 42 patients (81%) with untreated common acute lymphoblastic leukemia (c-ALL) contained higher CALLA levels than any of the 42 serum samples from healthy controls. The specificity of these results was further demonstrated by testing in parallel the sera from 48 patients with CALLA negative leukemias, including 26 acute myeloid leukemia (AML), 12 T-cell acute lymphoblastic leukemia (T-ALL), and 10 acute undifferentiated leukemia (AUL). All of these sera gave negative results, except for one patient with AUL, who had a significantly elevated circulating CALLA level, and one patient with AML, who had a borderline CALLA level, 3 SD over the mean of the normal sera. Preliminary results suggest that circulating CALLA is associated with membrane fragments or vesicles, since the total CALLA antigenic activity was recovered in the pellet of the serum samples centrifuged at 100,000 g. In addition, the CALLA-positive pellets contained an enzyme considered as a membrane marker, 5'-nucleotidase. Evaluation of the clinical importance of repeated serum CALLA determinations for the monitoring of c-ALL patients deserves further investigation.

Prophylaxis against infection in cataract surgery: a survey of routine practice.

PURPOSE: To survey the routine practice of consultant ophthalmic surgeons in the United Kingdom in preventing postoperative endophthalmitis following cataract surgery. METHODS: This is a cross-sectional questionnaire-based study. A questionnaire was sent to consultant ophthalmic surgeons in university teaching hospital ophthalmology departments in the United Kingdom. RESULTS: Questionnaires were sent to 391 consultant ophthalmic surgeons in 36 ophthalmology departments. The response rate was 55.0% (215 responses). Eleven (5.1%) did not perform cataract surgery routinely. Of the remaining 204 respondents, all performed phacoemulsification as routine. A total of 28 (13.7%) reported a 0% rate of postoperative infective endophthalmitis. Preoperative topical antibiotics were routinely prescribed by 12 respondents (5.9%). The most common immediately preoperative measure was the usage of povidone iodine (203 respondents, 99.5%). A total of 19 (9.3%) used an antibiotic infusion during surgery. Postoperative subconjunctival antibiotics were given by 138 (67.6%), most commonly cefuroxime. A total of 33 (16.2%) administered postoperative intracameral antibiotics. A total of 141 (69.1%) prescribed topical antibiotics after surgery, most commonly neomycin. None gave systemic antibiotics routinely pre-or postoperatively. CONCLUSIONS: The results show a wide variation of prophylactic measures used in the United Kingdom. The routine practices adopted reflect personal preferences, and were not necessarily evidence-based. Further prospective studies are required to provide evidence for the efficacy of these prophylaxis techniques.

Inhibition by two diphosphonates of bone lysis in tumor-conditioned media.

In order to test the effect of diphosphonates in inhibiting bone lysis induced by human tumors, neonatal mouse calvaria are cultured in sterile conditions in different media. Osteolysis is estimated by the amount of 45Ca released from bone to medium, the mice being given injections of 45Ca on their day of birth. An increased bone lysis is observed when calvaria are incubated in the same medium conditioned from cultured tumor fragments. This effect is significantly decreased when the mice have been treated with either ethanehydroxydiphosphonate or dichloromethylenediphosphonate. These experiments represent a first step in estimating the potential effects of different drugs on malignant osteolysis.

Preferential clonogenic deficit of CD8-positive T-lymphocytes infiltrating human solid tumors.

The vast majority of tumor infiltrating lymphocytes (TIL) are either CD4+ or CD8+ T-lymphocytes. In order to examine directly the functional capabilities of the individual CD4+ and CD8+ TIL subsets we performed cell sorting of double immunofluorescence-labeled TIL recovered from 15 biopsies by enzyme digestion. These CD4+ and CD8+ TIL subsets were compared with similar subsets of T-lymphocytes from peripheral blood of normal subjects. Both CD4+ and CD8+ TIL showed a reduced clonogenicity as assessed quantitatively by limiting dilution analysis in a microculture system which allows every normal T-lymphocyte to undergo clonal expansion. The reduced clonogenic potential was unequally distributed among the CD4+ and CD8+ subsets with the CD8+ TIL showing a significant reduction of the frequency of proliferating T-lymphocyte precursors compared to the CD4+ TIL (with a median of 1/50 proliferating T-lymphocytes in CD8+ TIL versus a median of 1/11 in CD4+ TIL). The reduced response of CD8+ TIL was not caused by suppressor cells, lack of surface expression of CD2 and CD3 antigens nor of the alpha, beta T-cell receptor, nor by an accumulation of CD8+ cells of large granular lymphocyte morphology. Using low density cultures, the highly purified CD4+ and CD8+ TIL were stimulated either via the T-cell receptor or the CD2-mediated antigen-independent pathway of activation. Whereas CD8+ TIL did not respond to either stimulus the CD4+ TIL showed evidence of responder and nonresponder groups. In addition, we show that the deficient response obtained by triggering CD4+ TIL via the TCR can be restored by activation of the antigen-independent pathway. Finally, a total of 94 clones from four different TIL samples were obtained by limiting dilution and examined for their respective helper and cytolytic capabilities: 57% of the CD4+ TIL clones were able to produce interleukin 2 and 93% of the CD8+ TIL clones demonstrated cytolytic activity mediated by the T-cell receptor complex, indicating that the functional potential of proliferating TIL is intact.

Patterns of corneal graft rejection in the rabbit and reversal of rejection with monoclonal antibodies.

The purpose of this study was to determine whether the local administration of monoclonal antibodies could reverse rabbit corneal graft rejection. To provide a rational basis for the choice of monoclonal antibodies as potential immunosuppressive agents, the phenotypes of cells infiltrating rejecting rabbit corneal allografts were examined by immunohistochemistry. About half the leukocytes accumulating in these grafts bore an immunodominant T cell marker, over two-thirds carried MHC class II antigens, and about one-fifth carried myeloid cell markers. A kinetic study of the cell population appearing in rabbit aqueous during corneal graft rejection was performed by examination of repetitive anterior chamber taps taken over a ten-day period; again, the major components were T cells, MHC class II antigen-positive cells and myeloid cells. Monoclonal antibodies L11/135 (directed against a peripheral T cell determinant), 2C4 (directed against a monomorphic MHC class II antigen), and LION 2 (directed against a myeloid antigen) were chosen for intracameral injection into rabbits with rejecting corneal grafts. Each animal received a total of 50-100 micrograms of antibody in two injections at 3-4-day intervals. L11/135 and LION 2 reversed rejection in 5/9 and 8/12 animals, respectively, in the absence of any other immunosuppression; 2C4 was without effect. We suggest that monoclonal antibody therapy in corneal transplantation deserves further attention.

Evidence for HLA-linked susceptibility factors in childhood leukemia.

To test the hypothesis that susceptibility to leukemia can be governed by (a) recessive gene(s) associated with the major histocompatibility complex (MHC) in man, we performed an analysis of the inheritance of HLA antigens in 55 families in which one of the children developed ALL. We found among the parents of affected children a highly significant increased compatibility at the DR locus (p = 0.003). A similar increase was observed in sharing HLA antigens of the B locus (p = 0.02). The observed number of homozygotes among the patients was twice the expected value in families where the parents shared a B and a DR antigen. In segregation analysis, heterozygotes for the shared parental HLA antigen were significantly more prevalent among the healthy siblings. Our genetical analysis indicates that mating of certain shared alleles of the HLA system (especially of the DR locus) is associated with the risk for the offspring to develop ALL in childhood. This situation favors the expression of recessive genes associated with the MHC, and presumably those involved in the susceptibility to acute leukemia. Because familial leukemia is a rare event, the susceptibility to childhood ALL must also implicate genes outside the MHC and important environmental factors.

Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora.

BACKGROUND: Congenital nasolacrimal obstruction is usually the result of failure of canalisation of the distal end of the nasolacrimal duct. The most common outcome is spontaneous resolution, but some children do require surgical treatment by probing. Probing is a blind procedure with a recognised failure rate. METHODS: In 52 lacrimal systems of 40 children nasal endoscopy was combined with a "stepwise" systematic probing in an attempt to improve the outcome and reduce the number of repeat procedures. RESULTS: Combined nasal endoscopy and probing improved the understanding of outflow obstruction in young children. The success of the procedure depended upon the level of the obstruction within the outflow system. Formation of a false passage was seen in six cases (15%). The probe was rerouted under direct visualisation in these cases to form a functioning passage. Reasons for failure were identified in those who did not have a successful outcome and only one repeat procedure was required. CONCLUSION: Using nasal endoscopy the area of lacrimal outflow obstruction at the lower end of the nasolacrimal duct can be observed directly and it is possible to guide the progress of probing under direct vision. This gives better information about the nature of the obstruction, minimises the formation of false passages, and allows a wider range of treatment options under a single anaesthetic.

Cryopreservation of rabbit and cat corneas at -18 to -24 degrees C.

A simple method of corneal cryopreservation, in which corneas were frozen at -18 to -24 degrees C, was examined. Rabbit and cat corneas were placed successively in solutions of 50% fetal calf serum in McCarey-Kaufman medium with an increasing glycerol and glucose content. They were then frozen and stored in a -20 degrees C domestic freezer. Rabbit corneas stored in this way were examined in vitro by light and scanning electron microscopy, and both rabbit and cat corneas were also assessed after orthotopic allotransplantation into adult recipient animals. Functional corneal grafts were obtained with rabbit and cat tissue that had been cryopreserved for 3-4 weeks and 1 week, respectively. Endpoint analysis (by light and scanning electron microscopy) of grafts that had survived for 50 days indicated the presence of an intact corneal endothelial monolayer. The corneal endothelium slowly degenerated as the storage time was increased. Importantly, however, the endothelium appeared to withstand the freezing and thawing processes and we conclude that it may be possible to store corneas at temperatures above -196 degrees C, without the need for complex, low-temperature cryopreservation systems.

The technique of nasendoscopy in the evaluation of nasolacrimal duct obstruction in children.

Epiphora in infancy is most commonly the result of failure of canalisation of the nasolacrimal duct and most cases resolve spontaneously within 12 months. Lacrimal probing is the standard operative treatment when conservative expectant management fails. While this carries a high success rate, it does not reliably localise the site of obstruction, can create a false passage and may induce traumatic stenosis in the lacrimal passages. Nasendoscopy in conjunction with the lacrimal probing overcomes these problems as the procedure is performed under direct vision. The precise site of opening of the nasolacrimal duct is ascertained, the nature of obstruction established and the risks of false passage creation minimised. We report this technique of endoscopic assessment of lacrimal probing, and the outcome results of twenty such procedures performed on thirteen children.

Vascular trauma in Penang and Kuala Lumpur Hospitals.

OBJECTIVES: The nature of vascular trauma varies greatly between continents and across time. The aim of this study was to prospectively analyse the demographics, pathology, management and clinical outcomes of vascular injuries in two urban Malaysian hospitals and review of international literature on vascular trauma. From this information, preliminary management and preventive implications will be described. METHODS: Eighty-four consecutive cases of trauma requiring vascular surgery were prospectively analysed over three years at Hospital Kuala Lumpur and Hospital Pulau Pinang, Malaysia. Extensive patient demographic and injury data, including the mechanism of injury, associated injuries, angiographic findings, operative details and post-operative complications, were systematically gathered. RESULTS: Most vascular injuries were incurred by males (76/84), with 37% (28/76) of them aged between 21 and 30 years. Malays were most frequently injured (n = 36) followed by Chinese and Indians. Road traffic accidents (n = 49) substantially outnumbered all other causes of injury. Lower limb injuries (n = 57) occurred more than twice as often as upper limb injuries (n = 27). Complete arterial transections (n = 43) and intimal injuries (n = 27) were more common than arterial lacerations (n = 10) and pseudoaneurysms (n = 4). The most frequently damaged vessels were the popliteal/tibioperoneal trunk (n = 33). All patients received urgent Doppler ultrasound assessment and, where possible, ankle-brachial systolic index measurement. Of all patients, 40 received an angiogram, haemodynamic instability making this investigation impractical in others. Primary arterial repair was the most frequently employed surgical procedure (n = 54) followed by autogenous reverse long saphenous vein (LSV) interposition graft (n = 14), embolectomy (n = 5) and PTFE interposition graft (n = 3). The most common post-operative complication was wound infection (n = 11). Amputation, as a last resort, was required in 13 cases following either primary or autogenous reverse LSV repair complicated by sepsis or critical ischaemia. CONCLUSIONS: Vascular trauma, especially in conjunction with severe soft tissue, nerve or orthopaedic injury carries colossal physical, psychological, financial and social costs. Associated nerve and venous injury portended poor outcome in this study. Whilst orthopaedic trauma was a common association, the concurrence of occult vascular trauma and soft tissue injury without fracture emphasises the crucial importance of thorough and rapid clinical vascular assessment, investigation and surgical intervention. Fasciotomy, especially for the lower limb, is important for the prevention of compartment syndrome and its, limb-threatening sequelae. Primary preventive road safety promotion and interventions, with attention to high-risk groups (young males and motorcyclists), is urgently required.

Upper gastrointestinal bleeding in Kuala Lumpur Hospital, Malaysia.

Despite advancements in endoscopy and pharmacology in the treatment of peptic ulcer disease the overall mortality has remained constant at 10% for the past four decades. The aim of this study was to determine the age, gender, racial distribution, incidence and causes of endoscopically diagnosed cases of upper gastrointestinal (UGI) bleeding to summarise treatments undertaken and to report their outcome. A prospective study of UGI bleeding in 128 patients was performed in two surgical wards of Kuala Lumpur Hospital, involving both elective and emergency admissions. The study group comprised of 113 (88.2%) males and 15 (11.7%) females. The mean age was 51.9 years (range 14 to 85 years) and 37.5% (48 of 128 patients) were older than 60 years. The Indian race was over-represented in all disease categories. Smoking (50.1%), alcohol consumption (37.5%), non-steroidal anti-inflammatory drugs (NSAIDs) (17.2%), traditional remedies (5.5%), anti-coagulants (2.3%) and steroids (0.8%) were among the risk factors reported. Common presenting symptoms and signs included malaena (68.8%), haematemesis (59.4%) and fresh per rectal bleeding (33.6%). The commonest causes of UGI bleeding were duodenal ulcer (32%), gastric ulcer (29.7%), erosions (duodenal and gastric) (21.9%), oesophageal varices (10.9%) and malignancy (3.9%). UGI bleeding was treated non-surgically in 90.6% of cases. Blood transfusions were required in 62.6% (67/107) of peptic ulcer disease patients. Surgical intervention for bleeding peptic ulcer occurred in around 10% of cases and involved under-running of the bleeding vessel in most high risk duodenal and gastric ulcer patients. The overall mortality from bleeding peptic ulcer disease was 4.7%. Six patients died from torrential UGI haemorrhage soon after presentation, without the establishment of a cause. Active resuscitative protocols, early endoscopy, more aggressive interventional therapy, early surgery by more senior surgeons, increasing intensive care unit beds and more active participation of multidisciplinary teams in co-ordinating management are among remedial measures advocated. Broader educational preventive strategies should target the causes of UGI bleeding.

Quantitative CT densitometry for predicting intracerebral hemorrhage growth.

BACKGROUND AND PURPOSE: Intracerebral hemorrhage growth independently predicts disability and death. We hypothesized that noncontrast quantitative CT densitometry reflects active bleeding and improves predictive models of growth. MATERIALS AND METHODS: We analyzed 81 of the 96 available baseline CT scans obtained <3 hours post-ICH from the placebo arm of the phase IIb trial of recombinant factor VIIa. Fifteen scans could not be analyzed for technical reasons, but baseline characteristics were not statistically significantly different. Hounsfield unit histograms for each ICH were generated. Analyzed qCTD parameters included the following: mean, SD, coefficient of variation, skewness (distribution asymmetry), and kurtosis ("peakedness" versus "flatness"). These densitometry parameters were examined in statistical models accounting for baseline volume and time-to-scan. RESULTS: The coefficient of variation of the ICH attenuation was the most significant individual predictor of hematoma growth (adjusted R(2) = 0.107, P = .002), superior to BV (adjusted R(2) = 0.08, P = .006) or TTS (adjusted R(2) = 0.03, P = .05). The most significant combined model incorporated coefficient of variation, BV, and TTS (adjusted R(2) = 0.202, P = .009 for coefficient of variation) compared with BV and TTS alone (adjusted R(2) = 0.115, P < .05). qCTD increased the number of growth predictions within ±1 mL of actual 24-hour growth by up to 47%. CONCLUSIONS: Heterogeneous ICH attenuation on hyperacute (<3 hours) CT imaging is predictive of subsequent hematoma expansion and may reflect an active bleeding process. Further studies are required to determine whether qCTD can be incorporated into standard imaging protocols for predicting ICH growth.

Survival of benthic foraminifera under hypoxic conditions: results of an experimental study using the CellTracker Green method.

We present results of an experimental study, in which benthic foraminiferal faunas have been kept under strongly hypoxic conditions. Sixteen short sediment cores from a 35m deep site in the Adriatic Sea were incubated for a maximum of 69days. Some of the cores were air-bubbled and remained well oxygenated throughout the experiment. The other cores were bubbled with nitrogen; the overlying waters of these cores became strongly hypoxic, whereas the sediment remained virtually without oxygen. Live foraminifera have been inventoried with the CellTracker Green method. Our results show that all dominant taxa survive strongly hypoxic conditions. Nouria polymorphinoides and Nonionella turgida show a clear tendency to move to the sediment surface in the nitrogen-bubbled cores, whereas Bulimina spp. and Eggerella scabra do not show such a migrational response. We suggest that this is a response to the concentration of nutritional resources at the sediment-water interface.

Nitinol - its use in vascular surgery and other applications.

OBJECTIVES: to describe the physical properties of shape-memory alloys and the surgical, scientific and commercial applications of nitinol, in particular. DESIGN AND METHODS: a Medline, Internet and library search with contributions from commerce to describe the alloy's structure, behaviour and biocompatibility, and design for devices constructed from nitinol. RESULTS: nitinol has the properties of thermal shape memory and superelasticity that make it ideal for many vascular and general surgical prostheses and disposables, and for various commercial applications. CONCLUSIONS: further research into shape-memory alloys from scientific and commercial groups should widen their use in vascular and endovascular surgery.

[Study of vitamin D deficiencies in the aged]. / Contribution à l'étude des déficiences en vitamine D chez les sujets âgés.

Plasma levels of 25-hydroxycalciferol (25-OH-D) and the biological parameters of phosphocalcium metabolism were determined in 55 patients institutionalized in a geriatric hospital in Geneva. They were compared with two control groups, one of the same age and the other younger. The mean plasma 25-OH-D level of the hospitalized patients was 22.7 +/- SD 13.6 microgram/l, which is significantly lower (p less than 0.001) than the mean level obtained from both the control group of the same age (46.2 +/- SD 20.1 microgram/1 25-OH-D) and the control group of young subjects (48.6 +/- SD 16.8 microgram 25-OH-D/1). Among the 55 hospitalized patients, 27 (49%) had a deficient 25-OH-D plasma level lower than 20 microgram/1. Compared to the control group of the same age, the group of hospitalized subjects had lower mean plasma level of inorganic phosphate (27.1 +/- SD 4.34 mg/1; p less than 0.01) and an elevated mean plasma level of alkaline phosphatase (46.9 +/- SD 16.5 UI/1; p less than 0.005). For those 27 patients deficient in 25-OH-D, a positive correlation exists between the plasma values of 25-OH-D and the total calcium (r = 0.584). The high incidence of biological indicators of osteomalacia found in the group of hospitalized patients suggests that vitamin D deficiency is a current problem of the elderly in Switzerland necessitating a review of the prophylactic measures now in use.

[Effect of 2 phosphonates on the osteolysis induced by tumor extracts]. / Effet de deux diphosphonates sur la lyse osseuse induite par des extraits tumoraux.

An in-vitro model is proposed to test the potential effect of diphosphonates in treatment or preventing bone metastases. This model involves culturing of neonatal mice calvaria in sterile conditions in an appropriate medium and measuring 45Ca release from bone to medium, the mice being injected with 45Ca on the day of birth. Tumour extracts added to the medium usually increase the bone lysis; this effect is significantly decreased when the mice have been treated with either ethane-hydroxy-diphosphonate (EHDP) or dichloromethylene-diphosphonate (Cl2MDP). These experiments represent a first step in a group of experiments with a view to clinical trials in cases of bone metastases.