[Joint prosthesis infection with Staphyococcus lugdunensis: 7 cases]. / Infections à Staphylocoque lugdunensis sur prothèses articulaires: à propos de 7 cas.

Staphylococcus lugdunensis was described in Lyon in 1988. This coagulase-negative staphylococcus is the cause of diverse infections which are often severe, particularly in the field cardiology where numerous publications are available for reference. The severity of S. lugdunensis infection is related to specific virulence factors associated with significant adherence properties despite good sensitivity to antibiotics. Publications dealing with joint prosthesis infections are sparse and the reports available have noted failure of treatment unless the prosthesis is removed. S. lugdunensis can easily be identified with an Api Id 32 Staph battery from BioMerieux. We analyzed seven cases of joint prosthesis infections with S. lugdunensis observed between 1991 and 2005. Four chronic infections were managed using the classical schema of implant removal then reimplantation, using a two-stage procedure for three and a single stage for one. Combined with adequate antibiotic treatment, this method was successful in all four cases. We did however have three cases of failure (two were secondary to a probable hematogenic infection and the other an early postoperative infection); these cases were operated on by early lavage and antibiotic therapy without success.

[Ten-year surveillance of nosocomial surgical site infections in an orthopedic surgery department]. / Bilan de 10 ans de surveillance du taux d'infections du site opératoire dans un service d'orthopédie.

PURPOSE OF THE STUDY: Surveillance of nosocomial surgical site infections was instituted in our department in June 1991. We report our first nine years experience. MATERIAL AND METHODS: This study concerned the first 9 years (June 1991-June 2000) of a surveillance program designed to monitor nosocomial surgical site infections in our orthopedic surgery department. During this period 9,696 patients underwent surgery, including 2745 for hip replacements and 1016 for knee replacements. The diagnosis of infection was based on the Centers of Disease Control criteria. Beginning in 1997, the program was widened to include all indications for prophylactic antibiotics, being limited before that time to indications for arthroplasty and spinal surgery. RESULTS: The overall rate of infection was 1.25%; 0.55% for hip arthroplasty and 1.77% for knee arthroplasty. The rate of infection among hip surgery patients over the last 5 years was much higher for prosthesis revision (2.37%) than for first-intention implantations (0.16%). The majority of the isolated strains were Gram-positive (84%) including Staphylococcus sp. found in 65% of the cases. Multiple-strains were found in 23% of the infections. The rate of infection improved very significantly over the last five years both for knee arthroplasty and spinal surgery. The rate remained unchanged for hip arthroplasty. DISCUSSION: This 10-year survey enabled us to analyze the difficulties encountered and pinpoint errors or insufficiencies in data recording. We were also able to identify measures to be taken concerning patient follow-up. The improvement in the rate of infection over time appears to be multifactorial, undoubtedly related to wider use of prophylactic antibiotics, progress in hygiene and sterilization methods with institution of a quality assurance program, and team awareness. CONCLUSION: Surveillance of nosocomial infections is a recommended practice. We have found that the information provided can be beneficial if the data is statistically sound, pointing out the need for progress in patient follow-up.

Effect of DNase on the activity of neutrophil elastase, cathepsin G and proteinase 3 in the presence of DNA.

It has been shown previously that DNA binds and inhibits neutrophil elastase (NE). Here we demonstrate that DNA has a better affinity for neutrophil cathepsin G (cat G) than for NE and is a better inhibitor of cat G than of NE. DNase-generated <0.5 kb DNA fragments inhibit NE and cat G as potently as full length DNA. This rationalises our observation that administration of DNase to cystic fibrosis patients does not enhance the NE and cat G activity of their lung secretions. Neutrophil proteinase 3 is not inhibited by DNA and might thus be the most harmful proteinase in inflammatory lung diseases.

Clinical significance of Scedosporium apiospermum in patients with cystic fibrosis.

The incidence of airway colonization by Scedosporium apiospermum and of related sensitization was investigated prospectively in 128 patients with cystic fibrosis over a 5-year period, and results were compared with clinical data. Scedosporium apio-spermum, recovered from sputum samples in 11 of 128 (8.6%) patients, was the most frequent filamentous fungus after Aspergillus fumigatus. Counterimmuno-electrophoresis, used to detect scedosporiosis serologically, was positive in 27 of 128 (21.1%) patients. The discrepancy between the mycological and serological results may be related to immune cross-reactions between Scedosporium apiospermum and Aspergillus fumigatus. However, symptoms of allergic bronchopulmonary disease were observed in two patients chronically colonized by Scedosporium apiospermum. The results clearly demonstrate that the frequency of this fungus is largely underestimated and that it may trigger an inflammatory response, thus suggesting a pathogenic role in patients with cystic fibrosis.

Imaging changes in the pancreas in cystic fibrosis: a retrospective evaluation of 55 cases seen over a period of 9 years.

BACKGROUND: Pathologic changes of the pancreas have been observed as early as the recognition of the disease termed initially "cystic fibrosis of the pancreas". Atrophy of the gland and its fatty infiltration were considered as usual features. The aim of this study was to follow-up the evolution of cystic fibrosis pancreas and to define its successive stages in correlation with the clinical, biochemical, and imaging findings. METHODS: Fifty-five patients were followed up during 9 years. The patients' genetic backgrounds were systematically performed. Blood lipase levels were analyzed systematically at each consultation of the patients and in the event of bouts of abdominal pains. Imaging using mainly echograms and tomodensitometric scans were regularly performed: echograms every 6 months, and tomodensitometric scans every 1 to 2 years. Magnetic resonance imaging was performed in four patients. RESULTS: Five groups of patients were identified on the basis of tomodensitometric scan findings: normal pancreas (n = 4), incomplete lipomatosis of the pancreas (n = 9), complete lipomatosis of the pancreas (n = 23), cystic pancreas (n = 5), macrocystic pancreas (n = 1), atrophic pancreas (n = 13). Pancreas exocrine function was not correlated with findings. Forty episodes of pancreatitis were observed in seven patients. They had bouts of abdominal pain and elevation of lipase levels. Five of these patients were composite heterozygotes (D508/other). Incomplete lipomatosis represents an intermediate stage leading toward complete lipomatosis or toward atrophy after pancreatitis. CONCLUSIONS: Studies of pancreatic function should be performed routinely in cystic fibrosis, especially in pancreatic sufficiency or in patients with normal pancreas images. Acute pancreatitis should be diagnosed and properly identified to be differentiated from other acute abdominal syndromes occurring in cystic fibrosis.

Serum reg protein level is not related to the beta cell destruction/regeneration process during early phases of diabetogenesis in type I diabetes.

OBJECTIVE: In type I diabetes mellitus, early markers of beta cell damage are needed in order to detect the infraclinical development of the disease. The reg protein may be a good candidate, as the reg gene has been proposed to play a role in the pancreatic beta cell destruction/regeneration process during diabetogenesis in animal models of autoimmune diabetes. The aim of this study was to test the hypothesis whether serum reg protein level could be representative of either the destructive or regenerative process at the beta cell level during the early phases of type I diabetes in humans. DESIGN AND METHODS: We used a highly specific immunoassay to measure serum reg protein level in controls and in three groups of either diabetes prone or diabetic subjects: recently diagnosed diabetic patients, long-standing diabetic patients and islet cell antibody-positive non-diabetic subjects. RESULTS: We found no significant difference between the values observed in these three groups in comparison with control group (90.7+/-18.1ng/ml, 83.1+/-5.6ng/ml, 98.7+/-24.5ng/ml vs 85.5+/- 5.6ng/ml respectively). Moreover, when the insulin reserve was evaluated at 6 months in the recently diagnosed group, serum reg protein levels were not different between patients with or without residual insulin secretion (at onset: 103+/-42 vs 70.3+/-8. 5ng/ml respectively; at 6 months: 79.7+/-25.8ng/ml vs 81.6+/-15ng/ml respectively). In contrast, trypsin levels were significantly lower in every group of diabetic patients. Results were expressed as means +/- S.E.M. and groups compared by Student's t-test (P<0.05). CONCLUSIONS: We conclude that serum reg protein level cannot be used as a marker for the progression of the diabetogenic process in type I diabetes.

[Revision of infected total hip prostheses by ablation reimplantation of an uncemented prosthesis. 57 case reports]. / Reprise des prothèses totales de hanche infectées par ablation réimplantation d'une prothèse sans ciment. Expérience de 57 cas.

PURPOSE OF THE STUDY: 57 cases of infected total hip prosthesis treated by removal of the implant and implantation of unncemented prosthesis, were studied to evaluate functional and sepsis results. MATERIAL AND METHODS: 57 patients treated by reimplantation of an uncemented total hip prosthesis after removal of the infected prosthesis were observed. 16 patients underwent a single-stage exchange, 41 a two-stage reimplantation. 46 cases were analysed for infection findings (clinical, radiological and biological assessment) and only 34 cases for functional evaluation (PMA scale, Harris score) with a mean follow-up of 6.6 years. The antibiotic therapy was adapted to each patient but generally, the treatment was prolonged. RESULTS: At follow-up time (which might be too short in time), only 2 patients had a recurrence of infection. One had a single-stage exchange (reoperated by two stage exchange with a good final result at 6 years follow-up), the other a two-stage exchange. In both cases we found that postoperative antibiotic therapy was inadequate. Functional results were better with PMA scale (23 good results of 34) than with Harris score (14 excellent or good results only). 5 patients were reoperated for mechanical implant failure. DISCUSSION: Since 1991, we adopted a standardized procedure to treat chronic infected total hip prosthesis including: routine preoperative aspiration of symptomatic prosthesis; removal of the implant and around debridement followed at a later date (6 weeks) by reimplantation using uncemented implants (hydroxyapatite coated implant). Postoperative antibiotic therapy has to be massive (parenteral bitherapy for at least 21 days after each operative stage) and has to last 6 months after reimplantation. This procedure seems reliable and corroborate the validity of two-stage treatment. The using of uncemented implants allows a good bone reconstruction and does not seem to increase the risk of septic recurrence. CONCLUSION: It is quite difficult to find a hard and fast rule in infected prosthesis treatment, because many factors can influence results. The proposed procedure seems reliable, even if antibiotherapy is long and hard, but requires a strong collaboration between bacteriologist infectiologist and surgeon.

Chronic airway colonization by Penicillium emersonii in a patient with cystic fibrosis.

Penicillium emersonii Stolk, the conidial state of Talaromyces emersoniii Stolk, is a heat-resistant fungus usually isolated from soil. In this paper the authors report, to our knowledge, the first human case in which P. emersonii chronically colonized the respiratory tract and induced an immune response in a patient with cystic fibrosis.

Immunoreactive pancreatic Reg protein in sera from cystic fibrosis patients with and without pancreatic insufficiency.

BACKGROUND: The biological function of the Reg protein, a non-enzymic protein produced in fairly large amounts by pancreatic acinar cells, remains elusive. Its susceptibility to proteolysis leading to precipitation of the proteolysis product at neutral pH suggests that it could contribute to the protein plugging observed in cystic fibrosis (CF). AIMS: To study its behaviour in the serum of CF patients with or without pancreatic insufficiency and to compare it with that of other pancreatic secretory proteins. PATIENTS: 170 patients (93 with CF, 55 controls, and 22 with chronic pancreatitis) were studied. METHODS: Reg protein was measured using a specific enzyme immunoassay and its molecular form in CF sera was characterised by gel filtration. Molecular gene expression was investigated by dot-blot hybridisation. RESULTS: Reg protein was present in all CF sera studied from patients with or without pancreatic insufficiency, and in all cases the level was significantly higher than in controls. Its chromatographic behaviour in CF sera was identical with that of the protein present in normal serum. No correlation was found between the levels of Reg protein and trypsin(ogen) (or lipase) in CF, nor in control sera or normal pancreatic juice. Molecular gene expression of the corresponding proteins investigated in pancreatic tissues showed an absence of correlation between the mRNA levels. CONCLUSIONS: Reg protein may not be a secretory exocrine protein like the digestive enzymes but rather a hormone-like secretory substance with an endocrine or paracrine function.

Pancreatic trypsinogen I expression during cell growth and differentiation of two human colon carcinoma cells.

Pancreatic trypsin has been found to induce tight junction or dome formation in some colon cancer cell lines (HT-29, Caco-2), and a tumor-associated trypsinogen, trypsinogen type II, has been isolated from another colon cancer cell line (COLO 205). We have tried to determine if trypsinogen is present and how its expression varies during cell culture in HT-29 Glc+/- and Caco-2 cells, which exhibit enterocytic differentiation, and in HT-29 Glc+ cells, which never differentiate. Trypsinogen mRNA presence and expression were demonstrated in these cells by mRNA hybridization, RT-PCR, cytoimmunofluorescence, Western immunoblot analysis, and gel filtration. Trypsinogen was found to be trypsinogen type I and was mainly in zymogen form in culture media. Differentiating cells exhibited variations in trypsinogen I expression, but cells that remained undifferentiated did not. In the differentiated cells, a high and transient peak in trypsinogen I expression was observed during the first steps of differentiation.

Human pancreatic reg protein immunoenzymatic assay and molecular form in serum.

A direct sandwich immunoassay was developed to quantify the human reg protein, a non enzymatic pancreatic acinar protein the biological function of which remains elusive. Polystyrene balls were coated with specific IgG fraction as the first antibody and horseradish peroxidase labelled IgG was used as a second antibody. The linearity of the assay was good over a concentration range of 1.25-100 ng/ml and the good parallelism obtained between the standard and the assay dilution curves in serum and pancreatic juice indicates the absence of non-specific interfering reactions. Gel filtration of serum showed that the reg protein was eluted in the fractions corresponding to the proteins of around 25 kDa and that the chromatographic behaviour of the serum protein was identical to that of the purified pancreatic protein when added to serum. This assay was simple, specific, sensitive and reproducible and may permit the determination of low levels of reg protein in different biological fluids.

Developmental gene expression of trypsinogen and lipase in human fetal pancreas.

BACKGROUND: Very few studies have been reported on the expression of human pancreatic genes during fetal development. We have shown very low lipase immunoreactivity compared with elevated trypsinogen immunoreactivity in a previous immunohistological study of human fetal pancreas during development. METHODS: The expression of these two selectively expressed genes of the exocrine pancreas, trypsinogen and lipase were investigated. The developmental profiles of the corresponding mRNA's were determined from the 13th gestational week. RESULTS: For the two genes, fetal mRNA levels throughout gestation remained significantly lower than the corresponding adult levels. No correlation was found between trypsinogen and lipase gene expression in the fetal pancreas, whereas such a correlation was present in adult pancreas. This may be explained by differences in maturity of the pancreas.

Exocrine pancreatic function in cystic fibrosis.

Pancreatic dysfunction in cystic fibrosis (CF) begins in utero and, at birth, in most cases, cystic fibrosis is characterized by an elevated level of serum immunoreactive trypsin (IRT). If most patients with CF typically present insufficient pancreatic exocrine function, 10-15% of CF patients have pancreatic sufficiency and this status is genetically determined by one or two 'mild' mutations in CF transmembrane conductance regulator (CFTR). However, with age, these patients can develop pancreatic insufficiency.

Production of elastase, exotoxin A, and alkaline protease in sputa during pulmonary exacerbation of cystic fibrosis in patients chronically infected by Pseudomonas aeruginosa.

Secretion of Pseudomonas aeruginosa elastase, exotoxin A, and alkaline protease in sputum during bronchopulmonary exacerbations was examined in 18 cystic fibrosis patients chronically infected with this microorganism. The patients were studied during one or several exacerbation periods necessitating hospitalizations of 12 to 20 days. In all cases, P. aeruginosa was present in bronchial secretions at admission and was not eradicated after treatment. The P. aeruginosa density decreased significantly after antibiotic therapy but remained greater than 10(6) CFU/g of sputum in most cases. Significant amounts of P. aeruginosa exoproteins were measured in total homogenized bronchial secretions by immunoenzymatic assays. The detection of higher levels of exoproteins at admission, the significant decrease after treatment, and the absence of exoproteins during intercrisis phases constituted arguments for a renewal of virulence of P. aeruginosa during exacerbations. Nevertheless, the concomitant changes in bacteria load and the triggering of the inflammatory process and immune complex formation could also contribute to pulmonary exacerbations.

Immunoenzymometric assays for alkaline protease and exotoxin A from Pseudomonas aeruginosa: development and use in detecting exoproteins in clinical isolates from patients with cystic fibrosis.

Using immunoenzymometric assays, the production of elastase, alkaline protease and exotoxin A was determined in culture supernatants of 35 strains of Pseudomonas aeruginosa isolated from patients suffering from cystic fibrosis. The assays were simple, specific, sensitive and reproducible, and permitted the determination of low levels of exoproteins. A large strain variability of exoprotein production was found. Most of the strains secreted all three exoproteins, but six out of the 35 strains (17%) did not secrete at least one of the three (< 0.3 microgram/l). A significant correlation was observed between elastase and exotoxin A productions (r = 0.697, p < 0.001).

[Production of elastase, exotoxin A and alkaline protease during bronchopulmonary exacerbations in patients with mucoviscidosis chronically infected by Pseudomonas aeruginosa]. / Production d'élastase, exotoxine A et protéase alcaline au cours des exacerbations bronchopulmonaires chez les patients mucoviscidosiques porteurs chroniques de Pseudomonas aeruginosa.

The authors have studied the production of exoproteins by Pseudomonas aeruginosa in the sputa of 18 patients suffering from cystic fibrosis, during 29 bronchopulmonary exacerbations and also after the recovery of a stable state. Significant levels of exoproteins were detected but with a large heterogenity of intra and inter individual variations. A significant decrease in the production of the three exoproteins was found after twelve days of antibiotherapy, without any correlation between exoprotein levels and colony forming units in the sputa. During the intercrisis phase, exoproteins levels were practically undetectable. These facts and the good correlation between clinical symptoms support the hypothesis of a renewal of virulence of Pseudomonas aeruginosa during these periods of bronchopulmonary exacerbation in cystic fibrosis.

Direct double antibody sandwich immunoassay for Pseudomonas aeruginosa elastase.

A direct sandwich enzyme immunoassay was developed in order to quantify Pseudomonas aeruginosa elastase. As a solid phase the wells of a microtitre plate were coated with specific IgG and horseradish peroxidase labelled IgG was used as the second antibody. The detection limit of the assay was 0.26 ng/ml and a good agreement was found with elastolytic activity determined using elastin-Congo red. This assay was simple, specific, sensitive and reproducible, and permits the determination of low levels of elastase.

Immunohistochemical study of secretory proteins in the developing human exocrine pancreas.

We have studied, by immunohistochemical methods using specific antisera, the development of three glycoproteins of human pancreatic secretion: lipase, carboxyl ester hydrolase (CEH) and the P19 protein (precursor of the non glycosylated protein X or "pancreatic thread/stone protein"). We have compared their development to that of trypsinogens (Tgs) and chymotrypsinogen A (ChTgA), as well as to that of FAP (feto acinar pancreatic protein), a glycoprotein associated with the differentiation of human pancreas. Our studies show the characteristic appearance and development of lipase, the immunoreactivity of which appears later (at the 21st week of pregnancy) than it does for Tgs and ChTg (at the 16th week of pregnancy). Moreover, the lipase labelling is first observed in a few acini dispersed in the pancreas and then spreads out progressively to be present in all the acini after the age of 15 days. By contrast, as soon as they appear, Tgs and ChTg are observed uniformly in all acinar cells. The intensities of the lipase, Tgs and ChTg labellings increase greatly at birth. The ontogenesis of CEH does not follow that of lipase but that of Tgs and ChTg. The ontogenesis of P19 is parallel to that of Tgs. As previously observed, FAP presents a maximal immunoreactivity at the 24th-27th weeks of pregnancy, which decreases slowly up until birth.

Levels and molecular forms of immunoreactive trypsin and chymotrypsin in amniotic fluids from normal and cystic fibrosis fetus: evidence for a lack of activation of proteolytic zymogens in cystic fibrosis fetus.

We previously suggested that an activation defect of pancreatic proteolytic zymogens in newborns suffering from cystic fibrosis (CF) might contribute (by an adaptative-like process) to the significant increase of the serum trypsin level observed in the disease at birth. To give support to this hypothesis we studied two pancreatic enzymes: trypsin 1 (IRT) and chymotrypsin A (IRChT) by noncompetitive enzyme immunoassays in amniotic fluids taken at 17-18 weeks of pregnancy. In normal fluids (102), the levels of the two enzymes were widely dispersed between 5 and 100 micrograms/L. A similar pattern was observed for the fluids with a 1 in 4 risk of CF with a normal outcome (24). In contrast, the levels of pancreatic enzymes in the fluids with affected fetus (40) were always below 45 micrograms/L for IRT and 55 micrograms/L for IRChT and most of them were under 20 micrograms/L for both enzymes. The molecular forms of IRT and IRChT in amniotic fluids were studied by gel filtration. In amniotic fluids with affected fetus, a major form of IRT was eluted in a position consistent with the elution of proteins around 25 kDa and two peaks of IRChT were eluted at 75 kDa and 25 kDa. These patterns are similar to those observed in normal serum when zymogens are present and are quite different from the patterns obtained by gel filtration of amniotic fluids with normal outcome.(ABSTRACT TRUNCATED AT 250 WORDS)