Spinal haematoma after removal of a thoracic epidural catheter in a patient with coagulopathy resulting from unexpected vitamin K deficiency.

Postoperative epidural analgesia is effective and widely utilised after major abdominal surgery. Spinal haematoma is a rare and devastating complication after epidural analgesia. Well-established risk factors for the development of spinal haematoma after neuraxial procedures have been documented. We present the case of a patient with normal pre-operative coagulation parameters who developed a spinal haematoma more than 24 h after removal of an epidural catheter; she had been without oral intake for only 4 days during which time she developed vitamin K-deficient coagulopathy. Clinicians should consider pre-operative screening of coagulation (International Normalised Ratio), or giving vitamin K supplementation, before performing neuraxial procedures in patients who are at risk of developing vitamin K deficiency or coagulopathy in the peri-operative period.

A reappraisal of the role of Gram's stains of tracheal aspirates in guiding antibiotic selection in the surgical intensive care unit.

BACKGROUND: Tracheal aspirate Gram's stains are used to guide antibiotic selection in empiric pneumonia treatment in the surgical intensive care unit (SICU). We questioned whether Gram's stains predict the organism cultured. METHODS: A retrospective review of prospectively collected data. RESULTS: Gram's stains correlated with the cultured organism in 284 of 543 (52%) SICU cultures and in 226 of 403 (56%) trauma intensive care unit (TICU) cultures. Gram-negative rod (GNR) stains yielded GNR organisms in 182 of 205 (89%) SICU cultures and in 160 of 176 (91%) TICU cultures. Gram-positive coccus (GPC) stains yielded GPC organisms in 75 of 228 (33%) SICU cultures and in 52 of 149 (35%) TICU cultures. Noncorrelates in the GPC group were predominantly GNRs (185 of 250 (74%)). CONCLUSION: When the clinical decision has been made that empiric antibiotic coverage is necessary, GNR coverage should be instituted regardless of Gram's stain result. The decision to institute GPC coverage needs to be supported by clinical data other than the Gram's stain.

Synthesis and HIV inhibition activity of 2',3'-dideoxy-3'-C-hydroxymethyl nucleosides.

A series if 2',3'-dideoxy-3'-C-hydroxymethyl purine nucleosides were prepared based on the photochemical ring expansion of a chiral cyclobutanone precursor, (2S)-trans-2,3-bis[(benzoyloxy)methyl]cyclobutanone, in the presence of a 6-substituted purine. Both alpha- and beta-anomers are produced in this transformation. Deprotection was effected by reaction of the photoadducts with saturated methanolic ammonia. Nine purine nucleosides were tested for their inhibitory effect of HIV IIIB virus on H9 cells. The 6-hexyloxy and adenine derivatives 4e,c, respectively, appeared to be most effective at inhibiting viral reproduction with 4c comparable in activity to ddI and AZT.

Hepatitis C antibodies in haemodialysis and pattern of end-stage renal failure in Gassim, Saudi Arabia.

As by the end of 1992, 96 (47 females; 49 females) patients were on regular dialysis treatment for end stage renal failure (ESRF) in 5 haemodialysis HD units, the Gassim region of Saudi Arabia. Because of lack of facilities, paediatric patients were under-represented, age range being 11 to 80 years. Systemic hypertension (47%), followed by hereditary/congenital conditions (23%) and non-insulin dependent diabetes mellitus NIDDM (19%) were the most common causes of ESRF in the region. One patients developed ESRF 14 years after donor nephrectomy. Overall prevalence of HCAb was 50% with a range of 17.24% to 83%. Based, especially, on the findings in two of the units which between them handle 57% (55/96) of the patients, we believe that the practice of machine isolation policy (MIP) rather than blood transfusion is largely responsible for this wide variation in prevalence between the centres. Considering the very high overall prevalence of the Kingdom, we suggest the MIP should no longer be optional and should be part of the universal infection precautions for HD patients. Comparing Gassim with findings from Taif, there may be some variation in the pattern of ESRF between different parts of the Kingdom. More reports will be needed to document this. Donor nephrectomy as a cause of ESRF is being recorded for the first time in the Kingdom. Vigilance is important. Similarly, we believe that sexual intercourse as a probable route of hepatitis C virus HCV transmission is being recorded for the first time in the Kingdom.

Functional analysis of the phosphorylation sites on the human immunodeficiency virus type 1 Vpu protein.

The human immunodeficiency virus type 1 (HIV-1)-encoded vpu product is a small class 1 integral membrane protein that is phosphorylated by the ubiquitous casein kinase II (CKII) in HIV-1-infected cells. The Vpu protein facilitates the release of budding virions from the surface of infected cells and delays the rate of syncytium formation. In this study, we investigated the role of phosphorylation in the biological activity of Vpu. Our results show that phosphorylation of Vpu occurs on serine residues at positions 52 and 56 located in a highly conserved dodecapeptide sequence. Mutation of either Ser 56, or both Ser 52 and Ser 56 impaired the ability of Vpu to delay the rate of syncytium formation while retaining virion release activity at levels comparable to vpu+ proviruses. Flow cytometry analysis indicates that the relative amounts of envelope glycoprotein gp120 expressed at the surface of cells transfected with these vpu mutant proviruses was two- to threefold greater than that observed on cells transfected with a vpu+ provirus. This increased expression of gp120 at the cell surface may explain the more rapid onset of syncytium formation observed in cell transfected with vpu mutant proviruses. These results suggest that Vpu-facilitated virion release and delayed cytopathic effect are the consequence of two distinct functional activities of the protein.

Requirement of the Pr55gag precursor for incorporation of the Vpr product into human immunodeficiency virus type 1 viral particles.

The human immunodeficiency virus type 1 (HIV-1) particles consists of two molecules of genomic RNA as well as molecules originating from gag, pol, and env products, all synthesized as precursor proteins. The 96-amino-acid Vpr protein, the only virion-associated HIV-1 regulatory protein, is not part of the virus polyprotein precursors, and its incorporation into virus particles must occur by way of an interaction with a component normally found in virions. To investigate the mechanism of incorporation of Vpr into the HIV-1 virion, Vpr- proviral DNA constructs harboring mutations or deletions in specific virion-associated gene products were cotransfected with Vpr expressor plasmids in COS cells. Virus released from the transfected cells was tested for the presence of Vpr by immunoprecipitation with Vpr-specific antibodies. The results of these experiments show that Vpr is trans-incorporated into virions but at a lower efficiency than when Vpr is expressed from a proviral construct. The minimal viral genetic information necessary for Vpr incorporation was a deleted provirus encoding only the pr55gag polyprotein precursor. Incorporation of Vpr requires the expression but not the processing of gag products and is independent of pol and env expression. Direct interaction of Vpr with the Pr55gag precursor protein was demonstrated by coprecipitation experiments with gag product-specific antibodies. Overall, these results indicate that HIV-1 Vpr is incorporated into the nascent virion through an interaction with the Gag precursor polyprotein and demonstrate a novel mechanism by which viral protein can be incorporated into virus particles.

Identification of tRNAs incorporated into wild-type and mutant human immunodeficiency virus type 1.

We have identified the tRNAs which are incorporated into both wild-type human immunodeficiency virus type 1 strain IIIB (HIV-1IIIB) produced in COS-7 cells transfected with HIV-1 proviral DNA and mutant, noninfectious HIV-1Lai particles produced in a genetically engineered Vero cell line. The mutant proviral DNA contains nucleotides 678 to 8944; i.e., both long terminal repeats and the primer binding site are absent. As analyzed by two-dimensional polyacrylamide gel electrophoresis, both mutant and wild-type HIV-1 contain four major-abundance tRNA species, which include tRNA(1,2Lys), tRNA(3Lys) (the putative primer for HIV-1 reverse transcriptase) and tRNA(Ile). Identification was accomplished by comparing the electrophoretic mobilities and RNase T1 digests with those of tRNA(3Lys) and tRNA(1,2Lys) purified from human placenta and comparing the partial nucleotide sequence at the 3' end of each viral tRNA species with published tRNA sequences. Thus, the absence of the primer binding site in the mutant virus does not affect tRNA(Lys) incorporation into HIV-1. However, only the wild-type virus contains tRNA(3Lys) tightly associated with the viral RNA genome. The identification of the tightly associated tRNA as tRNA(3Lys) is based upon an electrophoretic mobility identical to that of tRNA(3Lys) and the ability of this RNA to hybridize with a tRNA(3Lys)-specific DNA probe. In addition to the four wild-type tRNA species, the mutant HIV-1-like particle contains two tRNA(His) species and three tRNA-sized species that we have been unable to identify. Their absence in wild-type virus makes it unlikely that they are required for viral infectivity.

Stable expression of the transfected HIV-1 env gene in a human B cell line: characterization of gp120-expressing clones and immunobiological studies.

The env gene of human immunodeficiency virus type 1 (HIV-1) encodes gp 120/41 which plays an important role in the viral infection process and pathogenesis. The surface glycoprotein gp120 is a candidate molecule for the development of a subunit vaccine against HIV-1-induced acquired immunodeficiency syndrome (AIDS). However, thorough studies on the immunobiology of this molecule are hampered by the lack of a suitable model. With this background in mind, and in order to learn more on anti-gp120 cellular immunity, we attempted to develop gp120-expressing human cell clones. Thus by transfecting a human lymphoid cell line of B lineage (Raji), which is known to be resistant to the natural killer cell activity, with an expression vector encoding the envelope and vpu, we established three clones that stably express gp120/41 and vpu. The surface glycoprotein gp 120 is also expressed on the cell surface of these clones. The transfected cells from syncytia with CD4+ human cell lines as well as with peripheral blood mononuclear cells (PBMC) leading to the death of the fused cells. This observation represents additional evidence for the eventual depletion of CD4+ viral targets that fuse with adjacent HIV-infected, gp 120-expressing cells. The latent Epstein-Barr virus genome present in the transfected cells, was not induced to express the lytic cycle antigens. The densities of the surface expression of a number of molecules examined remained unchanged in the transfected cells except for the surface IgM, which increased significantly (P < 0.05) in two clones. One of the clones exhibited a significantly (P < 0.05) reduced proliferation rate as compared to the other clones. The transfected cells of all the three clones showed a significantly (P < 0.01) increased susceptibility to lysis by the PBMC from normal, healthy individuals in a 16-hr 51Cr-release assay. This is the first report of the MHC- and antibody-independent lysis of human cells transfected with the HIV-1 surface glycoprotein. The transfected cells also served as targets in a gp120-specific antibody-dependent cellular cytotoxicity assay. We anticipate that the present model will prove very useful for studying the gp120-specific immune responses in HIV-infected individuals.

Use of Angelchik Anti-Reflux Prosthesis for repair of total rectal prolapse in elderly patients.

A modification of the technique suggested by Hopkinson for the repair of rectal prolapse via the perineal route is described. This technique involves the use of an Angelchik Anti-Reflux Prosthesis and is particularly suitable for elderly patients in whom abdominal rectopexy would be hazardous because of general health.

Right hemicolectomy: use of GIA stapler.

The technique of right hemicolectomy using the GIA stapler is very neat, easy, short, safe and uncomplicated.