Bartonella henselae Detected in Malignant Melanoma, a Preliminary Study.

Bartonella bacilliformis (B. bacilliformis), Bartonella henselae (B. henselae), and Bartonella quintana (B. quintana) are bacteria known to cause verruga peruana or bacillary angiomatosis, vascular endothelial growth factor (VEGF)-dependent cutaneous lesions in humans. Given the bacteria's association with the dermal niche and clinical suspicion of occult infection by a dermatologist, we determined if patients with melanoma had evidence of Bartonella spp. infection. Within a one-month period, eight patients previously diagnosed with melanoma volunteered to be tested for evidence of Bartonella spp. exposure/infection. Subsequently, confocal immunohistochemistry and PCR for Bartonella spp. were used to study melanoma tissues from two patients. Blood from seven of the eight patients was either seroreactive, PCR positive, or positive by both modalities for Bartonella spp. exposure. Subsequently, Bartonella organisms that co-localized with VEGFC immunoreactivity were visualized using multi-immunostaining confocal microscopy of thick skin sections from two patients. Using a co-culture model, B. henselae was observed to enter melanoma cell cytoplasm and resulted in increased vascular endothelial growth factor C (VEGFC) and interleukin 8 (IL-8) production. Findings from this small number of patients support the need for future investigations to determine the extent to which Bartonella spp. are a component of the melanoma pathobiome.

Comparing laparoscopic and percutaneous renal biopsy for diagnosing native kidney disease: A matched pair analysis.

BACKGROUND: Percutaneous renal biopsy is a well-established diagnostic procedure in patients with underlying medical renal disease. Aim of this study is to compare the adequacy of the biopsy material, the diagnostic yield, and the complication rates of the trans-peritoneal laparoscopic approach and the image-guided percutaneous approach to renal biopsy in the diagnosis of native kidney disease. METHODS: We performed a matched-pair analysis matching 1:3 40 patients who underwent trans-peritoneal laparoscopic renal biopsy to 120 patients who underwent percutaneous renal biopsy in the same years. Patients were retrospectively analyzed. Differences in adequacy of biopsy material (i.e. number of glomeruli, continuous), diagnostic yield (categorical) and postoperative complications across the two groups were assessed using Wilcoxon Rank sum or χ2 test. RESULTS: Laparoscopic biopsy was associated with a higher number of harbored glomeruli (median 50, IQR 20-77) compared to the percutaneous approach (median 10, IQR 7-15), P<0.001. Adequate biopsies containing at least ten glomeruli were obtained in a significantly higher percentage of patients in the laparoscopic group versus the percutaneous group (92.5% vs. 57.1%, P<0.001). The laparoscopic approach was also associated with a significantly higher diagnostic yield than the percutaneous approach (82.5% vs. 63.5%, P=0.027). Patients who underwent laparoscopic biopsy had no perioperative or postoperative complications, resulting in a significantly lower complication rate than percutaneous biopsy (0% vs. 4%, P<0.001), particularly in the need for transfusion for post-procedure bleeding (0% vs. 1.8%, P<0.001). CONCLUSIONS: In this retrospective matched-pair analysis comparing patients undergoing renal biopsy for medical kidney disease, trans-peritoneal laparoscopic renal biopsy was safer and more effective for the diagnosis of medical renal diseases compared to percutaneous renal biopsy. Prospective trials with a good follow-up are needed to define the best candidate for each approach. LEVEL OF EVIDENCE: 4.

Efficacy and safety of 532-nm and 1,064-nm Q-switched Nd:YAG laser treatment of frictional dermal melanosis over bony prominences (Lifa disease).

BACKGROUND: Frictional dermal melanosis over bony prominences (Lifa disease) is a common pigmentary skin disorder in Iraqi patients. Q-switched lasers are the gold standard treatment of correcting pigmentation; among them are the 532-nm and 1,064-nm lasers. OBJECTIVE: To evaluate the efficacy of these lasers in the treatment of hyperpigmentation due to Lifa disease. PATIENTS AND METHODS: A prospective, comparative, controlled, split-lesion clinical trial study was designed. Nineteen female patients with clinical diagnosis of Lifa disease were enrolled. Each patient was treated for 3 sessions at 2-week intervals. A 532-nm Q-switched Nd:YAG laser was used on the left side and 1,064-nm on the right side of each lesion. Both objective and subjective parameters were assessed 1 and 3 months after the last treatment session. Darkness score, photographic assessment and patient satisfaction, and improvement of itch were recorded, respectively. RESULTS: Seventeen patients completed the study. The color score changes of both sides demonstrated that although both lasers were effective in reducing the pigmentation, the 1,064-nm wavelength had a more significant response. Similar results were obtained for the photographic evaluations and patient satisfaction scores. These changes were sustained throughout the 3 month follow-up. CONCLUSION: Both lasers were effective in the treatment of pigmentation abnormalities caused by Lifa disease. However, the efficacy was greater with the 1,064-nm wavelength.

[A systemic amyloidosis presenting as a tracheobronchial amyloidosis]. / Amylose systémique découverte par une atteinte trachéobronchique.

Amyloidosis is a spectrum of disease characterized by the abnormal deposition of fibril amyloid-related proteins in the extracellular space. The most common types of amyloidosis are AL and AA amyloidosis. Amyloidosis is also classified according to the extent of the deposition as systemic or localized. Respiratory amyloidosis is classified as laryngeal, tracheobronchial or parenchymal amyloidosis. Tracheobronchial amyloidosis is classically known as a rare manifestation of the localized disease. A few cases only of systemic amyloidosis presenting as a tracheobronchial disease have been reported. We here report a 26-year-old man who presented with hemoptysis related to a systemic tracheal primary amyloidosis.

[Heart rate variability alteration in patients on chronic hemodialysis]. / Altération de la variabilité sinusale chez les malades en hémodialyse chronique.

BACKGROUND AND AIM: Decrease in heart rate variability (HRV) is a known risk factor for cardiovascular morbidity and mortality. The aim of our study is to evaluate HRV in chronic hemodialysis patients and to determine factors that might decrease or increase it. METHODS: This is a retrospective study including 51 patients, 23 males and 28 females, with a mean of age of 64.5 years (23-84 years) on chronic hemodialysis for end stage renal disease due to various causes. Twenty-four-hour heart rate monitoring was recorded in all patients to evaluate HRV. HRV of hemodialysis patients was compared to normal patients (control). We also looked for correlation between HRV and a number of clinical and biological factors. RESULTS: All HRV parameters were decreased in chronic hemodialysis patients compared to normal controls with a significant difference (p<0.0005). HRV decreases with age (p=0.012), and is lower in diabetic patients (p=0.026). Interestingly, we found that chronic hemodialysis patients on beta-blockers had higher HRV with p=0.011. CONCLUSION: HRV is reduced in chronic hemodialysis patients mainly in old and diabetic patients, but this decrease is less important in those receiving beta-blockers.

[Acute respiratory distress syndrome complicating Ebstein-Barr virus pneumonia]. / SDRA par pneumonie à EBV.

INTRODUCTION: In the immuno-competent adult Ebstein-Barr virus (EBV) infection is a self-limiting disease that resolves spontaneously. CASE REPORT: We report a case of acute respiratory distress syndrome (ARDS) complicating severe EBV pneumonia and requiring prolonged artificial ventilation. The diagnosis was confirmed by specific serology and estimation of the viral load by PCR. Apart from supportive treatment with artificial ventilation the medical treatment included the use of Acyclovir and polyclonal immunoglobulins in the early phase and corticosteroids in the late phase. Recovery was progressive and complete. CONCLUSION: ARDS can complicate EBV pneumonia in an immuno-competent subject. Its management represents a diagnostic and therapeutic challenge.

Hemodynamics and left ventricular mass regression following implantation of the Toronto SPV stentless porcine valve.

Stentless tissue valves may provide more favorable hemodynamics than conventional stented valves. Hemodynamic findings from a large multicenter trial have not been previously reported. The present report describes the hemodynamic findings from a multinational, multicenter study after implantation of the Toronto SPV valve. A total of 577 patients underwent aortic valve replacement with the Toronto SPV valve at 12 sites in 3 countries. Echocardiograms were recorded in the early postoperative period, 3 to 6 months after surgery, 1 year after surgery, and yearly thereafter, with follow-up to 3 years. Gradients decreased and effective orifice area increased in the months after surgery. One year after surgery, mean gradient for valve sizes 20 to 22, 23, 25, 27, and 29 mm was 7.3 +/- 4.4, 7.4 +/- 4.5, 6.1 +/- 3.3, 4.9 +/- 2.4, and 4.0 +/- 2.1 mm Hg, respectively; effective orifice area was 1.3 +/- 0.7, 1.5 +/- 0.5, 1.7 +/- 0.4, 2.0 +/- 0.4, and 2.4 +/- 0.6 cm2, respectively. There was a very low prevalence of significant aortic regurgitation at all time periods. There was significant left ventricular (LV) mass regression between the early and 3- to 6-month periods and between the 3- to 6-month and 1-year postoperative periods. The Toronto SPV valve has an excellent hemodynamic profile supported by significant regression of LV hypertrophy in the year after implantation. Data through 3 years demonstrates maintenance of low gradients and freedom from significant aortic regurgitation.

Arthur Purdy Stout (1885-1967), a pioneer of surgical pathology: a survey of his Notes on the Education of an "Oncological" Surgical Pathologist.

Arthur Purdy Stout (1885-1967) started his medical career as a surgical intern and house surgeon at institutions that were to join the Columbia-Presbyterian Medical Center. With virtualy no formal training in pathology and little supervision, he was given the opportunity to work in a laboratory of surgical pathology. He focused his attention on neoplasms and tumor-like conditions, and authored Human Cancer in 1932. This book was organized according to topography of lesions and set a model for the Atlas of Tumor Pathology project. In addition to his many articles and slide seminars, Stout embarked during his "postretirement" years, with the help of residents and fellows, on a systematic study of soft tissue tumors in children. In 1950, he also began his Notes on the Education of an "Oncological" Surgical Pathologist. This manuscript of 427 typewritten pages offers candid details on his development as a surgical pathologist from rather primitive and chaotic beginnings, and on the post-World War II rise of surgical pathology. Notes provides interesting glimpses of his rapidly changing world, particularly of New York, the College of Physicians and Surgeons of Columbia University, and other pathologists. It also portrays an individual absorbed by his work and intent on leaving behind the legacy of a pioneer in the field of surgical pathology.

Mitral valve repair combined with aortic valve replacement.

BACKGROUND AND AIMS OF THE STUDY: Combined aortic and mitral valve replacement continues to result in significant morbidity and mortality. Although mitral repair has improved the results of mitral valve surgery, its influence on combined aortic valve replacement has not been assessed. METHODS: We reviewed 38 consecutive patients who underwent aortic valve replacement (AVR) and mitral repair (MR) between 1985 and 1995. The average age was 57 years; 20 were men and 18 women. Nineteen patients were considered high risk: six had previous cardiac surgery, three were on chronic dialysis, two required emergency surgery for low output syndrome, one had a chronic tracheotomy for chronic lung disease, and seven had left ventricular ejection fraction < 30%. MR consisted of ring application alone in 28 patients, chordal shortening in nine, posterior leaflet transfer in six and posterior leaflet resection in four. AVR was accomplished with 21 bioprostheses, 14 mechanical and three allograft valves. The mean (+/-SD) cross-clamp time was 133 +/- 41 min. Additional procedures included coronary bypass in six patients and tricuspid procedures in three. RESULTS: There were no operative deaths. Six patients died between 4 and 73 months postoperatively. Patient survival was 75% five and 67% 10 years after surgery. The causes of death were heart failure (two cases), and respiratory failure, drug overdose, electrolyte imbalance and unknown (one each). Logistic risk analysis was significant for females and rheumatic valve disease, bacterial endocarditis, and degenerated valve patients. During follow up there were no valve failures or endocarditis, but three embolic episodes occurred without permanent sequel. CONCLUSIONS: With increased surgical expertise, improved myocardial protection of MR combined with AVR offers excellent short- and long-term results, optimal chordal preservation, no valve failure and no endocarditis; it is the ideal choice where anti-coagulation is contraindicated. The prolonged cross-clamp time was well tolerated.

Rudolf Virchow, not just a pathologist: a re-examination of the report on the typhus epidemic in Upper Silesia.

Rudolf Virchow (1821-1902) is mainly remembered as the "father" of cellular pathology; however, he was not just a pathologist. His contributions to anthropology, archeology, ethnography, and history, as well as his involvement in epidemiology, public health, and politics, portray a man with multiple interests, deeply engaged in the controversies of his time. In his Report on the Typhus Epidemics of Upper Silesia of 1848, the young Virchow reveals himself to be a self-assured pathologist, although his postmortem examinations failed to shed much light on typhus. Despite of his shortcomings and biases, Virchow's genius is revealed in his deep appreciation of the importance of the total physical, socio-cultural, economic, and political background of epidemic diseases. One can discern in the Report the making of Virchow, the politician and statesman who will contribute to the modernization of Germany's public health, and of the physician-scholar and physician-citizen who, despite of his shortcomings and militancy, continues to inspire and challenge us today.

Percutaneous needle autopsy sampling.

Despite the recognized advantages of a complete postmortem examination, autopsy rates continued to decline in recent decades. This study compares postmortem needle sampling to the complete, conventional autopsy to determine whether needle sampling is a viable alternative when consent for a complete autopsy is denied. A prospective study where postmortem percutaneous biopsies were obtained from the heart, the lungs, the liver, the kidney, and any other clinically relevant tissue or body fluid before the complete autopsy in 20 consecutive patients is presented. Cultures of the lungs, the spleen, and any other suspicious body fluid were also obtained. Liver and heart were recovered from all 20 of the patients, lung from 18 (90%), and kidney from 16 cases (80%). The cause of death was confirmed in 67% of the patients. Needle sampling correlated with the complete autopsy in 87% of the additional major diagnoses and with equally pertinent negative results. Postmortem needle lung cultures correlated with the complete autopsy in 17 (85%) of 20 patients and 16 (80%) of 20 spleen cultures. Cultures of the brain (one patient), cerebrospinal fluid (two patients), peritoneum (two patients), and serum (one patient) correlated 100% when compared to the complete autopsy. A complete autopsy is the goal of every postmortem examination. Postmortem "biopsies" can be an alternative option in certain situations and may be more acceptable to relatives of the deceased when consent for a complete autopsy is declined.

Successful reconstruction of a complex traumatic carinal disruption.

Complex traumatic tracheobronchial disruption often results in mortality or prolonged morbidity. This case report highlights a successful strategy for diagnosis and management of an unusually extensive carinal disruption in a patient with multiple trauma.

The validity of classic symptoms and chest radiographic configuration in predicting pulmonary tuberculosis.

OBJECTIVE: Patients admitted to the pulmonary isolation service to rule out tuberculosis (TB) were prospectively studied to identify predictors of smear-positive TB. METHODS: History of symptoms--cough, sputum production, fever, weight loss, night sweats, hemoptysis, anorexia, and dyspnea; medical history--TB, tuberculin skin test (TST) status, TB contact; and social factors--crowding index, history of incarceration or living in a shelter, and employment status were obtained in face-to-face interviews. Chest x-rays (CXRs) were scored as typical, atypical, or negative. Serial morning sputa were collected. RESULTS: Complete data were collected on 101 patients; 44 had pulmonary TB; 33 patients were smear positive and considered infectious; 11 patients were smear negative but culture positive. There was no difference between TB and non-TB patients with respect to HIV status and social risk factors. Significant differences were found between patients who were smear positive for TB and smear negative with respect to cough, sputum, and typical CXR (79%, 76%, and 79% sensitivity, respectively). Eleven patients without TB had an atypical CXR and denied cough, sputum, and weight loss. Only one patient with TB presented this way. CONCLUSION: Even in high-risk populations, symptoms of cough, sputum, weight loss for less than 2 weeks, and the absence of a typical CXR are strong negative predictors for TB.

Mitral valve repair in patients over the age of 70 years.

The question of whether to repair or replace the mitral valve in the elderly remains unanswered. The purpose of our study is to describe our experience with mitral valve repair (MVR) using Carpentier's technique in patients 70 years and older. Fifty consecutive patients underwent MVR between 1984-1992. There were 30 female patients. All had 2 + or more mitral regurgitation (MR). The valve pathology included ischemic (n = 28), myxomatous (n = 7) and rheumatic (n = 6), leaflet prolapse (n = 11) and healed bacterial endocarditis (n = 3). The clinical findings included: myocardial infarction (n = 17), congestive heart failure (n = 18), atrial fibrillation (n = 14) and pulmonary hypertension (n = 10). The surgical technique involved placement of a Carpentier ring (n = 41) or Duran ring (n = 3), resection of leaflets (n = 9), shortening of the chordae (n = 8) and commissurotomy (n = 6). At surgery, coronary bypass was carried out in 32 patients while the aortic valve was replaced in five and repaired in one. Postoperative complications included atrial fibrillation (n = 14), transient neurologic events (n = 4), heart block requiring pacemaker (n = 3) and prolonged intubation (n = 4). Echocardiogram carried out postoperatively showed 2 + MR in three patients, 1 + in four, and a trace or none in the remaining (n = 39). No patient required re-operation for MR. Three patients (6%) died within 30 days after surgery due to low output (n = 1), malignant ventricular arrhythmia (n = 1) and heart block with cardiac arrest (n = 1).(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma levels of a squamous cell carcinoma-associated antigen in athymic nude mice bearing human squamous cell carcinoma xenografts of oral origin. With preliminary clinical data.

A human squamous cell carcinoma (SCC) of oral origin was transplanted into athymic mice that were then divided into six groups. The mice were killed at 1 to 6 weeks after tumor transplantation; the sixth group was killed 1 week after excision of SCC grafts. Plasma samples were obtained from each mouse at the time of death for the determination of SCC-associated antigen (SCCAA), a cytoskeletal protein fraction of about 48,000 daltons originally derived from SCC of the uterine cervix. The plasma SCCAA level rose gradually and proportionately to the growth of SCC xenografts from a baseline of 0.66 ng/ml [standard error (SE) + 0.12] to the preoperative peak of 8.44 ng/ml (SE + 1.86) at 5 weeks, to fall precipitously to the postoperative level of 1.05 ng/ml (SE + 0.27) at 6 weeks. No rise in plasma SCCAA level was observed in mice bearing a human malignant melanoma, and only modest rises were observed in mice bearing human adenocarcinomas and oat cell carcinoma. In this experimental model rising plasma SCCAA levels were found to be dependable indicators of SCC tumor growth. These observations and preliminary data on SCCAA levels in patients with or without SCC of the head and neck lend support to the clinical usefulness of serial plasma SCCAA determinations in monitoring patients with SCC of the oral cavity.

Filiform large-cell lymphomas. An ultrastructural and immunohistochemical study.

Ten cases of "undifferentiated" large-cell tumors were ultrastructurally characterized by cells with abundant filiform cytoplasmic projections without intercellular junctions. These cases were studied by means of the avidin-biotin-peroxidase complex (ABC) technique applied to formalin-fixed, paraffin-embedded sections using antibodies against high- and low-molecular weight keratins (Ker), vimentin (Vi), epithelial membrane antigen (EMA), S-100 protein, leucocyte common antigen (LCA), kappa (K) and lambda (L) light chains, Leu-M1, lysozyme (Ly), alpha-1 antitrypsin (A1AT) and alpha-1 antichymotrypsin (A1ACT). All 10 cases were negative for Ker and EMA but positive for Vi. S-100 was present only in scattered dendritic cells. LCA was identified in seven cases. In the three LCA-negative cases, two stained for Leu-M1, and one of these also showed intracytoplasmic L; one was negative for all markers but Vi. None of the tumors showed any significant staining for Ly, A1AT, or A1ACT. Our findings indicate that these tumors are nonepithelial and nonneuroectodermal, and that they are best classified as non-Hodgkin's lymphomas. The possibility that some of the filiform large-cell lymphomas may be derived from dendritic reticular cells cannot be excluded.

Intraperitoneal administration of an I125 labelled monoclonal antibody for localization of human colorectal cancer in the nude mouse.

The monoclonal antibody (MoAb) HMGF-1 was evaluated in the radioimmunodetection of human colonic cancer transplanted intraperitoneally (i.p.) into athymic nude mice. This antibody reacts with a component of the human milkfat globule, as well as a wide range of epithelial cells and adenocarcinomas of various origins. Purified MoAb was iodinated with 125I and administered i.p. into nu/nu mice bearing (i.p.) xenografts of human colonic adenocarcinoma (X56). Differential tissue counts of radioactivity demonstrated preferential localization of the antibody in i.p. and subcutaneous (s.c.) tumor tissue as compared to normal tissues. Maximum per cent dose per g of tumor (25.17 +/- 1.37), maximum tumor: blood ratio (4.45 +/- 0.14) and maximum tumor: tissue ratios (34.2 +/- 0.12) were obtained at the optimal labelling time of 5 days after antibody injection. Selective localization to tumor was confirmed with a control anti-hepatitis virus MoAb of the same isotype and by localization studies in non-tumor bearing athymic mice. Half lives of the persistence of the iodine 125 in the tumor bearing and non tumor bearing mice were 5 and 7 days, respectively, indicating approximate antibody half lives. Whole body scans showed distinct tumor images without the use of subtraction techniques. This pilot experimental study demonstrates the feasibility of i.p. administration of labelled antitumor MoAb in the imaging of i.p. tumors in an athymic mouse system. Whether or not these observations are applicable to the human situation remains to be carefully established.