Usability of a Web-based Software Tool for History Taking in the Emergency Department.

Medical history taking is an important step within the diagnostic process. This study aims to assess the quality and usability (effectiveness, satisfaction, efficiency) of a web-based medical history taking app in the emergency department. During three weeks, patients and junior physicians filled out study questionnaires about the app. Senior physicians rated the quality of medical histories taken by junior physicians and app. In 241 patients, the studied app showed excellent usability with patients not in need of immediate medical attention. Senior physicians rated medical histories as more complete when app was used by patients in comparison to conventional history taking alone (p<0.01). Current app could not substitute medical history taking by physicians, but could definitely rather be used to gather ancillary information.

[On the 150th birthday of César Roux (1857-1918). Memories of the life and work of an important pupil of Kocher]. / Zum 150. Geburtstag von César Roux (1857-1918). Erinnerung an Leben und Schaffen eines bedeutenden Kocher-Schülers.

César Roux was one of the few universal surgeons at the end of the 19th century who dominated all fields of surgery and influenced current surgery with his innovative spirit. Pioneering spirit and the story of the success of modern surgery are linked with his name. On the occasion of his 150th birthday, we recall the memory of this great surgeon. The personality and the history of Professor César Roux form a part of our medical and surgical heritage.

Extracellular processing and presentation of a 69-mer synthetic polypetide to MHC class I-restricted T cells.

The classical pathway for MHC class-I-restricted Ag presentation processes cytosolic Ag synthesized in or delivered into the cytosol for binding to MHC class I molecules in the ER. Alternatively, Ag may be processed and bind class I molecules in endocytic compartments or at the cell surface after regurgitation of processed peptides. We show that a 69-mer synthetic polypeptide that carries the optimal 9-mer Kd-restricted epitope from the Plasmodium berghei circumsporozoite protein, PbCS 245-253, is presented to CD8+ T cells after a short incubation (1-2 h) with target cells. The presentation kinetics correlate with the length of the peptides when shorter peptide analogues are used. This presentation is independent of the transporters associated with antigen processing and presentation (TAP), does not require newly synthesized proteins and does not proceed via regurgitation of intracellularly processed peptides. In contrast, it is substantially decreased in the absence of beta2 microglobulin or serum. Taken together, these data suggest that serum components, such as proteases and beta2 microglobulin, allow the processing and loading of exogenous polypeptides onto empty cell surface class I molecules for presentation to CTL.

CD8+ T-cell protective immunity induced by immunization with Plasmodium berghei CS protein-derived synthetic peptides: evidence that localization of peptide-specific CTLs is crucial for protection against malaria.

Immunization of BALB/c mice (H-2d) with a mixture of major histocompatibility complex (MHC) class I- and MHC class II-restricted synthetic peptides emulsified in incomplete Freund's adjuvant (IFA) induced a high level of specific cytotoxic T lymphocyte (CTL) activity. Peptides 249-260 or 252-260, derived from the circumsporozoite protein of Plasmodium berghei and representing a H-2Kd-restricted CTL epitope, were injected twice subcutaneously or intraperitoneally in BALB/c mice in combination with the tetanus toxin-derived universal T-helper peptide P30 in IFA. No protection was observed after exposure of immunized mice to infected mosquitoes. In contrast, when peptide 252-260-specific CTLs were expanded in vitro and adoptively transferred into naive recipient, mice were partially protected (64%) against a subsequent sporozoite challenge. Furthermore, direct transfer of lymph nodes or spleen cells from mice immunized with the peptide PbCS 252-260 also conferred protection to recipient mice. This protection was long-lasting and similar to that obtained with irradiated sporozoites.

Plasmodium falciparum CS C-terminal fragment: preclinical evaluation and phase I clinical studies.

Preclinical evaluation of synthetic peptides corresponding to the C-terminal regions of the circumsporozoite (CS) protein in various Plasmodia showed that these preparations were immunogenic and safe upon injection in various animal models. Additionally, the corresponding peptide from Plasmodium falciparum was widely recognized by sera and PBL obtained from semi-immune adults living in malaria endemic areas. Moreover, the CS C-terminal peptide derived from P. berghei conferred protection upon challenge with live sporozoites in mice. A GLP preparation of the synthetic peptide corresponding to residues 282-383 of the Pf CS, NF-54 strain is currently evaluated in a open, non-randomized, Phase I human trial. Data obtained after the second antigen injection show that the malaria vaccine Pf CS 282-383 is safe, well tolerated and gives rise to high antibody titre, CD4+ and CD8+ lymphocyte responses.

[The window in the falciform ligament. A rare case of hernia of the small intestine through the falciform ligament]. / Das Fenster im Ligamentum falciforme. Ein seltener Fall einer Hernierung des Dünndarms durch das Ligamentum falciforme.

The most common causes for small-bowel obstructions with subsequent strangulation are intra-abdominal adhesions and external hernias. We report an unusual case of strangulated small-bowel hernia through a congenital window in the falciform ligament. The diagnosis and surgical treatment are discussed.

[Chronic saphenous venous access: an interesting alternative in the case of vena cava superior syndrome]. / Chronischer venöser Zugang uber die Vena saphena. Eine interessante Alternative im Falle des Vena-cava-superior-Syndroms.

An easy venous access improves the quality of life of patients who need prolonged intravenous therapy. In the case of vena cava superior syndrome the classic access in the jugular or subclavian vein can be difficult or even impossible. We report on seven implantations of Port-a-Cath in the inferior vena cava for patients presenting contra-indications to classic venous access to the vena cava superior (five cases of vena cava superior compression syndrome, one tracheostomy and one extended tumor of thoracic wall). We describe the operative technique and we analyze the indications, the results and the complications of this rarely used technique.

[Laparoscopic treatment of small bowel obstruction arising on adhesions]. / Traitement laparoscopique des occlusions du grêle sur brides.

OBJECTIVES: Determine the feasibility of laparoscopy, with the objective as well as the subjective benefits offered to patients, and the possible contra-indications of this type of surgery in the treatment of mechanical intestinal ileus. PATIENTS AND MATERIAL: This concerned 20 patients who came to the hospital with a picture of intestinal obstruction. All had a history of at least one abdominal operation. The diagnosis of mechanical occlusion due to band adhesions was presumed on the basis of the clinical and complementary examinations, particularly x-rays, and confirmed in the course of the operation. All patients were operated by laparoscopy after failure of non-invasive treatment. RESULTS: Results obtained are encouraging since 60% of the patients were successfully treated by laparoscopy alone. The patients' comfort and length of hospital stay are improved by laparoscopy. There is no relation between previous surgical history and the results of the technique. CONCLUSIONS: Most failures were due to the time interval between onset of symptoms and the operation. Early operation therefore seems to increase the chances of success.

IL-12p40-independent induction of protective immunity upon multiple Plasmodium berghei irradiated sporozoite immunizations.

Both IFN-gamma and IL-12 play critical roles in defence against malaria. In a previous study, using Plasmodium yoelii model, C57BL/6 IFN-gamma receptor deficient mice (IFN-gammaR-/-) failed to develop protective immunity after a single immunization with irradiated sporozoites, but were protected after multiple immunizations. In contrast, in another study, BALB/c IFN-gamma gene knockout mice (IFN-gamma-/-) and BALB/c IL-12-deficient mice (IL-12p40-/- and IL-12p35-/-) were unable to mount protective immune response even after multiple immunizations with the same irradiated parasites. To better define the role of IFN-gamma and IL-12p40 in sterile protection, we selected the C57BL/6 model. Wild-type and IL-12p40-/- mice were immunized with a single or multiple doses of P. berghei irradiated sporozoites. While the wild-type mice were able to rapidly produce IFN-gamma and mount a protective immune response after a single immunization with irradiated sporozoites, IL-12p40-/- mice were neither able to produce IFN-gamma nor were protected. However, both strains of mice were able to produce IFN-gamma and were protected after three doses of irradiated sporozoites. Protection was partially and largely mediated by CD4+ T cells and CD8+ T cells, respectively. Thus, IL-12p40 plays an important role in mediating early protection by irradiated sporozoite immunization but is dispensable for protective immunity induced by several immunizations with irradiated sporozoites. Moreover, treatment of hyperimmune IL-12p40-/- mice with rhIL-18 bp-Fc, an inhibitor of IL-18 activity, did not abrogate protection indicating that IL-18 is not required for the effector phase of the immune response; it remains possible, however, that IL-18 may compensate for the lack of IL-12p40 in the induction phase of the immune response.

Elimination of P. berghei liver stages is independent of Fas (CD95/Apo-I) or perforin-mediated cytotoxicity.

Immunization of mammals with irradiated malaria sporozoites protects from a subsequent contact with the parasite. Protective immunity is directed against the pre-erythrocytic stages of the parasite, sporozoites and liver stages. Specific antibodies neutralize part of the infectious sporozoites infected by the mosquito vector, while liver stages are the target of a cellular immune response which is mediated by T cells. In this study, we evaluated the T-cell dependent protection induced by the infection of P. berghei irradiated sporozoites and the contribution of perforin and of the receptor/ligand system CD95/CD95L, two T cell-dependent mechanisms known to mediate elimination of target cells. Wild type, perforin deficient, CD95 mutant, CD95L mutant and perforin deficient/CD95L mutant mice were immunized with P. berghei irradiated sporozoites and submitted to a challenge with infectious sporozoites. All mice immunized with P. berghei irradiated sporozoites were protected against a sporozoite challenge, including perforin deficient/CD95L mutant animals. These results indicate that T cells do not kill malaria-infected hepatocytes via one of the known pathways, but rather that activated parasite-specific T cells produce cytokines which activate in cascade other mechanisms responsible for the intracellular elimination of the parasite.

Fulminant neuroleptic malignant syndrome after perioperative withdrawal of antiParkinsonian medication.

Neuroleptic malignant syndrome is a rare complication when using neuroleptic drugs. We report the case of a patient with severe Parkinson's disease who developed neuroleptic malignant syndrome after withdrawal of his antiParkinsonian medication for elective coronary artery bypass grafting. Sodium dantrolene may be a therapeutic option in severe cases.

Reduction of groin lymphatic complications by application of fibrin glue: preliminary results of a randomized study.

Lymphoceles and lymph fistulas are common complications after exposure of the common femoral artery in the Scarpa triangle because of operative transsection of overlying lymphatics. The purpose of this prospective randomized study was to determine the incidence of groin lymphatic complications and to assess the impact of routine application of fibrin glue on lymphatic structures and subcutaneous tissue prior to closure. All patients undergoing exposure of the common femoral artery in the Scarpa triangle were included in this study. They were divided into two groups according to closure technique. In group A, closure was performed without fibrin glue. In Group B, fibrin glue was applied to lymphatic structures prior to closure. The efficacy of fibrin glue application was estimated on the basis of two criteria: incidence of local complications and amount of lymphatic fluid in the Redon drain. The preliminary findings suggest that application of fibrin glue leads to a significant reduction in the incidence of lymphatic complications after femoral artery exposure in the Scarpa triangle.

The synthetic, oxidized C-terminal fragment of the Plasmodium berghei circumsporozoite protein elicits a high protective response.

A polypeptide of 69 amino acids (PbCS 242-310) encompassing the C-terminal region of the circumsporozoite protein of Plasmodium berghei (PbCS) was generated using solid-phase peptide synthesis. The immunological and protective properties of peptide PbCS 242-310 were studied in BALB/c mice (H-2d). Two subcutaneous injections, in the presence of IFA at the base of the tail, generated (i) high titers of anti-peptide antibodies which also recognized the native P. berghei CS protein, (ii) cytolytic T cells specific for the Kd-restricted peptide PbCS 245-253 and (iii) partial CD8+-dependent protection against sporozoite-induced malaria. The same frequencies of peptide PbCS 245-253 specific CD8+ T cells were found by IFN-gamma ELISPOT in the draining lymph nodes of animals immunized with the short optimal CTL peptide 245-253 or with the polypeptide 242-310, indicating that the longer polypeptide can be processed and presented in vivo in the context of MHC class I as efficiently as the short CTL peptide. Interestingly, higher levels of IFN-gamma producing CD8 T cells and protection were observed when the four cysteine residues present in the C-terminal peptide were fully oxidized. These findings underline the potential importance of the chemical nature of the C-terminal fragment on the activation of the immune system and concomitant protection.