IMMUNOLOGICAL IDENTIFICATION OF FOOT-PAD ISOLATES AS MYCOBACTERIUM LEPRAE BY LEPROMIN REACTIVITY IN LEPROSY PATIENTS

Lepromin, a product containing Mycobacterium leprae from patients' tissues, fails to elicit skin reactions in lepromatous patients; this non-reactivity was utilized as a means of identifying the mycobacterium isolated in mouse foot-pads from leprosy patients. To do this a suspension of acid-fast bacilli prepared from mouse foot-pads infected with a typical isolate was compared to human lepromin. The isolate was in fourth passage, and the multiplication since first isolation had diluted the original inoculum to insignificant levels. Three preparations were tested: A, A foot-pad preparation containing 1.6 x 10⁷ organisms/ml, B, lepromin diluted to the same bacillary content, and C, undiluted lepromin containing 4.2 x 10⁷ organisms/ml. The reactions were compared in 34 lepromatous and 30 tuberculoid patients. All 34 lepromatous patients were negative in both early (Fernandez) and late (Mitsuda) reactions to all 3 antigens. In the tuberculoid patients the late reactions were positive in 66.7, 70.0 and 90.0 per cent to antigens A, B, and C, respectively. The size of the reactions to A and B were closely correlated in the individual patients. Experience in leprosy patients with suspensions prepared from 16 other mycobacterial cultures is reported or reviewed. None of them produced reactions that correlated with those of lepromin. Thus the lack of reactivity to lepromin of lepromatous patients appears to be a specific phenomenon. The results provide evidence that the foot-pad isolates and M. leprae are immunologically identical.     

Attenuation of acute and chronic pulmonary emboli

PURPOSE: To compare retrospectively the attenuation coefficients of acute and chronic pulmonary embolism (PE). MATERIALS AND METHODS: Institutional review board approval was obtained, and informed consent was waived. The study was compliant with requirements of the Health Insurance Portability and Accountability Act. All patients with chronic PE, from July 2001 to January 2004, were identified via a radiology report search system; of the 39 identified, 25 were excluded because the thrombi were too small to measure or were obscured by streak artifacts or because there was no corroborative evidence of chronic PE. Of 27 consecutive patients with acute PE who were also identified, two were excluded because of streak artifacts. The final study group included six women and eight men with chronic PE (mean age, 50 years; range, 26-76 years) and 11 women and 14 men with acute PE (mean age, 61 years; range, 33-83 years) (P = .01 for age). Images were acquired with a four-detector row computed tomographic scanner and 1.25-mm collimation. Two readers made independent attenuation measurements of the largest thrombus in each patient at a workstation. Statistical analysis included calculation of means and standard deviations, the t test, and the Bland-Altman test. RESULTS: Reader 1 found mean attenuation of 90 HU +/- 30 (range, 54-155 HU) for chronic PE and 33 HU +/- 15 (range, 6-63 HU) for acute PE (P < .001). Reader 2 found mean attenuation measurements of 83 HU +/- 32 (range, 32-135 HU) for chronic PE and 33 HU +/- 14 (range, 13-65 HU) for acute PE (P < .001). The mean attenuation for both readers was 33 HU for acute PE (95% confidence interval: 26, 41 HU) and 87 HU for chronic PE (95% confidence interval: 66, 107 HU). The Bland-Altman test demonstrated agreement between readers. CONCLUSION: The mean attenuation measurement in chronic PE is significantly higher than in acute PE.     

Fluoroscopically guided low-volume peritendinous corticosteroid injection for Achilles tendinopathy. A safety study

BACKGROUND: The safety and efficacy of corticosteroid injection for the treatment of Achilles tendinopathy is not known, with some reports indicating the hazard of tendon rupture and others extolling the efficacy of such injections. This study was undertaken to assess the safety of fluoroscopically guided corticosteroid injections into the peritendinous space for the treatment of Achilles tendinopathy. METHODS: A series of patients was treated with fluoroscopically guided corticosteroid injections into the space surrounding the Achilles tendon. Major and minor complications were recorded, as were the number of repeat injections, the duration of symptomatic relief attained with the injection, and a subjective rating of symptoms related to the Achilles tendon. RESULTS: Of eighty-three patients who had been treated, seventy-eight were available for follow-up and forty-three met our requirement for a minimum two-year follow-up (average duration of follow-up, 37.4 months). No major complications and one minor complication occurred in the forty-three patients. Seventeen (40%) of the patients reported improvement after the procedure, twenty-three (53%) thought that their condition was unchanged, and three (7%) felt that their condition was worse than it had been prior to the injection. CONCLUSIONS: This retrospective cohort study establishes the safety of low-volume injections of corticosteroids for the treatment of Achilles tendinopathy when the needle is carefully inserted into the peritendinous space under direct fluoroscopic visualization.     

Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia

Objective While patients with fibromyalgia report symptoms consistent with cervical myelopathy, a detailed neurological evaluation is not routine. We sought to determine if patients with fibromyalgia manifest objective neurological signs of cervical myelopathy.Methods Two hundred and seventy patients, 18 years and older, who carried the diagnosis of fibromyalgia but who had no previously recognized neurological disease underwent detailed clinical neurological and neuroradiological evaluation for the prevalence of objective evidence of cervical myelopathy and radiological evidence of cerebellar tonsillar herniation (Chiari 1 malformation) or cervical spinal canal stenosis.Results Patients were primarily women (87%), of mean age 44 years, who had been symptomatic for 8 years (standard deviation, 6.3 years). The predominant complaints were neck/back pain (95%), fatigue (95%), exertional fatigue (96%), cognitive impairment (92%), instability of gait (85%), grip weakness (83%), paresthesiae (80%), dizziness (71%) and numbness (69%). Eighty-eight percent of patients reported worsening symptoms with neck extension. The neurological examination was consistent with cervical myelopathy: upper thoracic spinothalamic sensory level (83%), hyperreflexia (64%), inversion of the radial periosteal reflex (57%), positive Romberg sign (28%), ankle clonus (25%), positive Hoffman sign (26%), impaired tandem walk (23%), dysmetria (15%) and dysdiadochokinesia (13%). MRI and contrast-enhanced CT imaging of the cervical spine revealed stenosis. The mean antero-posterior (AP) spinal canal diameter at C2/3, C3/4, C4/5, C5/6, C6/7 and C7/T1 was 13.5 mm, 11.8 mm, 11.5 mm, 10.4 mm, 11.3 mm and 14.5 mm respectively, (CT images). In 46% of patients, the AP spinal diameter at C5/6 measured 10 mm, or less, with the neck positioned in mild extension, i.e., clinically significant spinal canal stenosis. MRI of the brain revealed tonsillar ectopia >5 mm in 20% of patients (mean=7.1±1.8 mm), i.e., Chiari 1 malformation.Conclusion Our findings indicate that some patients who carry the diagnosis of fibromyalgia have both signs and symptoms consistent with cervical myelopathy, most likely resulting from spinal cord compression. We recommend detailed neurological evaluation of patients with fibromyalgia in order to exclude cervical myelopathy, a potentially treatable condition.     

Simultaneous measurement of rotations of myosin,actin and ADP in a contracting skeletal muscle fiber

The rotation of myosin heads and actin were measured simultaneously with an indicator of the enzymatic activity of myosin. To minimize complications due to averaging of signals from many molecules, the signal was measured in a small population residing in a femtoliter volume of a muscle fiber. The onset of rotation was synchronized by a sudden release of caged ATP. The orientation of cross-bridges was measured by anisotropy of recombinant fluorescent regulatory light chains exchanged with native regulatory light chains. The orientation of actin was measured by anisotropy of phalloidin added to actin filaments. The enzymatic activity of myosin was measured by dissociation of fluorescent ADP from the active site. The onset of all three events occurred at the same time. This suggests that in contracting muscle, actin does not move independently of myosin and that ATP hydrolysis is strongly coupled to the rotation of cross-bridges.     

Perioperative steroids in tonsillectomy using electrocautery and sharp dissection techniques

OBJECTIVE: To determine the effect of preoperative dexamethasone sodium phosphate administration on posttonsillectomy morbidity for electrocautery ("hot") and sharp ("cold") dissection techniques. DESIGN: Prospective, randomized, double-blind study. SETTING: University pediatric hospital and county teaching hospital.Subjects A total of 219 children, aged 9 months to 12 years, undergoing tonsillectomy.Intervention Participants who underwent tonsillectomy were randomly assigned to receive either intravenous dexamethasone sodium phosphate (1 mg/kg) or placebo. OUTCOME MEASURES: Pain scores, oral intake, and emesis on postoperative day (POD) 1. RESULTS: A total of 106 subjects (62 undergoing hot and 44 cold tonsillectomies) received preoperative steroids, and 113 (56 hot and 57 cold tonsillectomies) received placebo. On POD 1, pain scores reported by patients (P =.02), parents (P =.002), and physicians (P<.001) were significantly lower in subjects receiving steroids than in those receiving placebo. Emesis was reduced from a mean of 2.1 (placebo group) to 1.2 episodes (steroid group) (P =.02). Oral intake improved from 24.5% of normal diet (placebo) to 31.7% (steroid group) (P =.004). When all 4 groups were compared (cold placebo, cold steroid, hot placebo, and hot steroid), pain scores reported by physicians and parents were significantly lower in the cold steroid group than in the other groups. CONCLUSIONS: Perioperative dexamethasone use reduces posttonsillectomy morbidity in pediatric patients in the early postoperative period after hot or cold tonsillectomy. The combination of steroid and cold dissection technique provided the greatest advantage in reducing posttonsillectomy subjective pain levels.     

A rapid agglutination assay to detect anti-streptokinase antibodies

Background Streptokinase resistance may cause suboptimal thrombolytic therapy. Aim To develop a rapid latex-bead assay to detect streptokinase antibodies. Methods Sera were obtained from 16 patients presenting with acute myocardial infarction (MI) before treatment with streptokinase and 1 and 6 months post treatment, and from 100 controls. Sera were assayed for anti-streptokinase antibodies using a functional streptokinase-neutralising assay. Results Streptokinase-neutralising activity was low in controls (54±5U/ml) and patients prior to treatment (101±18), increasing to 2,110±823 and 1,017±169 at 1 and 6 months (mean±SEM). The latex assay had a sensitivity of 94% and a specificity of 93% for detecting individuals with >350U/ml of streptokinase resistance, which is sufficient to neutralise the drug clinically. Conclusions Estimation of streptokinase resistance using an enzyme immunoassay and a latex bead assay correlated well with serum neutralising activity. This assay can rapidly identify patients who have a high level of streptokinase-neutralising activity.