Anomalous gallbladder septum-A case report.

INTRODUCTION: Anomalies and diseases of the biliary system are common with over 20 million cases of biliary disease and an estimated 1.8 million ambulatory visits each year in the United States. Congenital anomalies of the gallbladder are rare and include complete and partial duplications, floating gallbladders, and agenesis. Septations have also been reported in the literature. Case reports have typically described these as longitudinal. Transverse septa, when reported, are associated with inflammation or cholelithiasis. Variations in the cystic duct and vasculature in the portal triad have also been well described. PRESENTATION OF CASE: During the dissection of a 91-year-old female cadaver, an enlarged gallbladder with a partial transverse septum was observed. The gallbladder contained approximately 350 ml of bile, no stones, and had a partial transverse septum near the infundibulum. The hepatic, cystic, and common bile ducts were enlarged, but of normal configuration. Vascular anomalies were also present, including an accessory left hepatic artery from the left gastric artery and an anomalous origin of the right hepatic artery from the superior mesenteric artery. DISCUSSION: This is the first described case of a partial transverse septum with a markedly enlarged gallbladder, dilated duct system, and vascular anomalies in a patient with no evidence of gallstones, inflammation, or scarring. CONCLUSION: With the prevalence of biliary disease and frequent subsequent surgery it is essential to appreciate all anatomical variations to avoid iatrogenic injuries to these structures during surgery.

Anomalous muscles and nerves in the hand of a 94-year-old cadaver-A case report.

INTRODUCTION: During an anatomical dissection of the distal upper extremities, numerous muscular and nervous anomalies were found in the forearm and hand of a 94-year-old cadaver. These anomalies are clinically relevant with regard to medical or surgical interventions. PRESENTATION OF CASE: The presence of a "flexor digiti minimi longus" muscle was observed passing through Guyon's canal; to our knowledge this passageway has never been previously reported. An aberrant first lumbrical with three origins was noted. Additionally, numerous atypical nerves were found innervating the hand; the dorsal branch of the ulnar nerve contributed to cutaneous innervation of the palm of the hand (Kaplan's anastomosis), the superficial ulnar nerve provided muscular innervation to the flexor digiti minimi brevis muscle, and two connections between the common palmar digital branches of the median and superficial ulnar nerves were observed (Berrettini anastomosis). DISCUSSION: Here, we describe an extranumerary muscle associated with the hypothenar group of muscles. We also describe unusual origins of the first lumbrical muscle, and atypical cutaneous and muscular innervation to the palm of the hand. CONCLUSION: Clinically, understanding the existence of these anatomical variations may influence medical care or surgical procedures.

Investigation of an outbreak due to Alcaligenes xylosoxydans subspecies xylosoxydans by random amplified polymorphic DNA analysis.

In 1999, over a 3-week period, Alcaligenes xylosoxydans subsp. xylosoxydans was isolated from five blood cultures and one cerebrospinal fluid specimen from five children hospitalized in a pediatric hematology ward as well as from two respiratory therapy devices of two children hospitalized in an intensive care unit. The infection control unit of the hospital conducted an epidemiological investigation and identified a detergent-disinfectant solution as the source of contamination. Conventional biochemical tests, antimicrobial susceptibility tests and random amplified polymorphic DNA (RAPD) fingerprinting were used to compare clinical and environmental isolates. RAPD analysis proved to be more discriminant than biotyping or antibiotyping in this context and identified the common source of the outbreak.

Composition and gene expression of the cag pathogenicity island in Helicobacter pylori strains isolated from gastric carcinoma and gastritis patients in Costa Rica.

The composition and in vitro expression of the cag pathogenicity island genes in a group of Helicobacter pylori strains obtained from patients suffering from chronic gastritis-associated dyspepsia (n = 26) or gastric carcinoma (n = 17) were analyzed. No significant difference in the distribution of the 10 studied regions was found between the cases and the controls. Nine strains did not harbor any of the selected regions: eight (30.8%) isolated from patients with gastritis only and one (5.9%) from a patient with gastric carcinoma. No association was found between the number of repeated sequences at the 3' end of the cagA gene or the presence of tyrosine phosphorylation motifs and the clinical origin of the strains. The virB10 homolog gene was the sole gene studied to be significantly expressed more often in cancer strains than in gastritis strains (P = 0.03).

Distribution of open reading frames of plasticity region of strain J99 in Helicobacter pylori strains isolated from gastric carcinoma and gastritis patients in Costa Rica.

The plasticity region of Helicobacter pylori strain J99 is a large chromosomal segment containing 33 strain-specific open reading frames (ORFs) with characteristics of a pathogenicity island. To study the diversity of the plasticity region, 22 probes corresponding to 20 ORFs inside the plasticity region and two ORFs on its boundaries were hybridized to genomic DNA isolated from clinical strains of H. pylori from patients with gastritis or gastric adenocarcinoma. Highly variable hybridization patterns were observed. The majority of the clinical strains presented a hybridization profile similar to that of J99; thus, these ORFs are not J99 strain specific. No association was found between a particular hybridization pattern and the clinical origin of the strain. Nevertheless, two single ORFs (JHP940 and JHP947) were more likely to be found in gastric cancer strains. They may be new pathogenicity markers. An in vitro expression study of these ORFs was also performed for the J99 strain, under different conditions. Thirteen ORFs were consistently expressed, six were consistently shut off, and three were expressed differentially. Most of the constitutionally expressed genes were located on the 3' part of the plasticity region. Our results show that the plasticity region, rather than being considered a pathogenicity island per se, should be considered a genomic island, which represents a large fragment of foreign DNA integrated into the genome and not necessarily implicated in the pathogenic capacity of the strain.

Serum antibody responses to Helicobacter pylori and the cagA marker in patients with mucosa-associated lymphoid tissue lymphoma.

The lymphoma of the mucosa-associated lymphoid tissue (MALT) of the stomach has been linked to Helicobacter pylori infection, but the mechanisms involved in B-cell proliferation remain elusive. In a search for putative H. pylori-specific monoclonal immunoglobulin production, an H. pylori strain was isolated from 10 patients with MALT lymphoma and used to detect the specific serum antibody response to the homologous strain by immunoblotting. Moreover, the antigenicity of the different strains was compared by using each of the 10 sera. We found that the different strains induced highly variable patterns of systemic immunoglobulin G antibody response, although several bacterial antigens, such as the 60-kDa urease B, were often recognized by the different sera. The cagA marker was detected in the strains by PCR with specific primers and by dot blot analysis, and the CagA protein was found in the sera of 4 of the 10 patients by immunoblotting. In conclusion, MALT lymphoma patients, like other patients with H. pylori gastritis, exhibit a polymorphic systemic antibody response, despite an apparently similar antigenic profile. The CagA marker of pathogenicity is not associated with this disease.

Direct detection of Helicobacter pylori resistance to macrolides by a polymerase chain reaction/DNA enzyme immunoassay in gastric biopsy specimens.

BACKGROUND: The increasing use of macrolides especially in the treatment of Helicobacter pylori infection has led to an increase in resistant strains. The resistance of H pylori to macrolides, especially clarithromycin, is one of the major causes of eradication failure. In H pylori, clarithromycin resistance is due to point mutations localised in domain V of 23S rRNA. AIM: To develop a molecular technique based on amplification of a relevant fragment of the 23S rRNA and colorimetric hybridisation in liquid phase to detect directly in biopsy specimens the type of mutation associated with resistance of H pylori to clarithromycin. METHODS: Gastric biopsy samples from 61 patients were submitted to this test. The results were compared with standard methods (determination of minimal inhibition concentration, polymerase chain reaction/restriction fragment length polymorphism, and/or DNA sequencing) in order to evaluate the test and to define the cut off values, specificity, and sensitivity. RESULTS: The 14 biopsy samples in which H pylori was not detected did not give a positive result in any assay, and the 14 samples harbouring strains susceptible to clarithromycin gave a positive result with the wild type probe as expected. The 33 biopsy specimens containing resistant strains always gave a positive signal with one of the probes detecting resistant organisms, but in eight cases they also reacted with the wild type probe, indicating that a mixture of resistant and susceptible organisms was present. CONCLUSION: The importance of this new assay is that it allows the detection of multiple genotypes corresponding to either heterogeneous genotypes or mixed infections. Moreover, it allows in a single step not only the detection of H pylori but also the determination of its susceptibility to clarithromycin directly in biopsy specimens without the need for culture.

Detection of point mutations associated with resistance of Helicobacter pylori to clarithromycin by hybridization in liquid phase.

When the standard procedure for determining antibiotic susceptibility of bacteria is used, the results are delayed, especially for bacteria that grow slowly, such as Helicobacter pylori. Treatment for this bacterium may involve clarithromycin, a compound for which resistance has been associated with point mutations on the 23S rRNA gene. This resistance is currently found in organisms isolated from 0 to 15% of patients and jeopardizes the success of the treatment. We have designed a test involving amplification and colorimetric hybridization in the liquid phase to detect the mutation at the molecular level. First, four reference strains, including the wild type and three strains with the mutations A2143C, A2143G, and A2144G, were used to optimize the method. Amplification was carried out with primers previously published. The amplified products were added to probe-coated microtiter wells. A DNA enzyme immunoassay was used to detect the hybrids. The optimal conditions of the hybridization were defined for each probe. Nineteen H. pylori strains resistant to clarithromycin and 22 susceptible according to phenotypic data were submitted to restriction with BsaI and BbsI, and part of the 23S rRNA gene was sequenced in order to determine the mutation involved for the resistant strains. The new assay showed a complete correlation with the reference methods, except for one strain. Cross-hybridizations as well as application of the reaction to other bacteria did not lead to optical densities higher than the cutoff values chosen with the receiving operating characteristic curve. This method can be easily standardized and gives a result within a day. Its application directly to the biopsy specimens or infected gastric juice is planned in the future.

Nitazoxanide, a potential drug for eradication of Helicobacter pylori with no cross-resistance to metronidazole.

Nitazoxanide, a thiazolide compound, and its desacetyl derivative, tizoxanide, have antimicrobial properties against anaerobic bacteria, as well as against helminths and protozoa. Because the treatment of Helicobacter pylori infection may be jeopardized by metronidazole resistance, nitazoxanide and tizoxanide were tested in vitro against these bacteria. The MICs of these two compounds were determined by agar dilution and were compared to those of metronidazole. Exposure to subinhibitory concentrations of nitazoxanide was also carried out by the method of Szybalski (W. Szybalski and V. Bryson, J. Bacteriol. 64:489-499, 1952). The MICs of nitazoxanide and tizoxanide for 103 strains ranged from 0.25 to 8 microg/ml, with the MIC at which 50% of strains are inhibited (MIC50) being 1 microg/ml and the MIC90 being 4 microg/ml, and no resistant strain was detected, whereas strains resistant to metronidazole were detected. When 10 strains were successively subcultured on medium containing nitazoxanide, no significant change in the MICs of this compound was observed. A pilot study of nitazoxanide for the treatment of H. pylori infection was carried out with 86 patients in association with 20 mg of omeprazole. An eradication rate of 83% (95% confidence interval, 64% to 94%) was obtained in a per-protocol analysis in the group receiving 1 g of nitazoxanide orally twice daily, and a few side effects were observed. The failures could not be explained by the selection of resistant strains since the MICs of nitazoxanide were similar for six pairs of isolates (proven to be the same strain by random amplified polymorphic DNA analysis in four cases) cultured before and after the treatment failure. Nitazoxanide exhibits good antimicrobial activity against H. pylori without the problem of acquired resistance which is encountered with metronidazole and has been demonstrated to have a satisfactory effect in a dose-ranging pilot study. It is therefore a good candidate to be included in treatment regimens aimed at the eradication of H. pylori.

Macrolide resistance in Helicobacter pylori: rapid detection of point mutations and assays of macrolide binding to ribosomes.

Resistance of Helicobacter pylori to macrolides is a major cause of failure of eradication therapies. Single base substitutions in the H. pylori 23S rRNA genes have been associated with macrolide resistance in the United States. Our goal was to extend this work to European strains, to determine the consequence of this mutation on erythromycin binding to H. pylori ribosomes, and to find a quick method to detect the mutation. Seven pairs of H. pylori strains were used, the parent strain being naturally susceptible to macrolides and the second strain having acquired an in vivo resistance during a treatment regimen that included clarithromycin. The identity of the strains was confirmed by random amplified polymorphic DNA testing with two different primers, indicating that resistance was the result of the selection of variants of the infecting strain. All resistant strains were found to have point mutations at position 2143 (three cases) or 2144 (four cases) but never on the opposite DNA fragment of domain V of the 23S rRNA gene. The mutation was A-->G in all cases except one (A-->C) at position 2143. Using BsaI and BbsI restriction enzymes on the amplified products, we confirmed the mutations of A-->G at positions 2144 and 2143, respectively. Macrolide binding was tested on purified ribosomes isolated from four pairs of strains with [14C]erythromycin. Erythromycin binding increased in a dose-dependent manner for the susceptible strain but not for the resistant one. In conclusion we suggest that the limited disruption of the peptidyltransferase loop conformation, caused by a point mutation, reduces drug binding and consequently confers resistance to macrolides. Finally, the macrolide resistance could be detected without sequencing by performing restriction fragment length polymorphism with appropriate restriction enzymes.

Resistance of Helicobacter pylori to macrolides and nitroimidazole compounds. The current situation.

Macrolides and nitroimidazoles are among the antibiotics currently used for Helicobacter pylori eradication for which an acquired resistance may occur. Macrolides bind tightly to H. pylori ribosomes and inhibit protein synthesis. Resistance has been found associated with a lack of binding and to a point mutation in position 2058 or 2059 of the 23S ribosomal RNA genes (domain V). This resistance is easy to detect and is clinically relevant. There is a decrease of up to 40% in the success rate of triple therapies including clarithromycin when there is a resistance of H. pylori to this compound. Nitroimidazoles must be reduced to be active on the bacterial DNA. Resistance is associated with a lack of reduction of the NO2 group. But this reduction can be influenced by the redox potential of the environment. The genetic background is not yet known. There are discrepancies between the different methods used to test susceptibility to nitroimidazole; the best method which is now in the process of being standardized, is the agar dilution method. The clinical relevance of this resistance has been questioned. However, despite all the problems highlighted, there is still a difference between strains categorized as susceptible or resistant with regard to the eradication rate of H. pylori. This difference is greater when nitroimidazole is associated with amoxicillin rather than with clarithromycin.

The distally-based radial forearm free flap with valvulotomy of the cephalic vein; a preliminary report.

The radial forearm free flap is widely used in microsurgical reconstruction where a thin, hairless flap is required. While the radial artery may be based either proximally or distally, the venous drainage is generally proximally based in order to provide normal flow through the valves. We have utilised this flap in two patients, based distally on both the radial artery and cephalic vein by removing the valves of the cephalic vein. This technique has been employed widely in peripheral vascular surgery of the lower limb and is called the "in-situ" technique. We have found it to be efficacious in taking a proximal skin paddle, which decreases donor site morbidity and allows for a long vascular pedicle. This paper reports on these two patients and describes the technique of valvulotomy of the cephalic vein.