Endoscopic biliary therapy using the combined percutaneous and endoscopic technique

Between September 1985 and December 1987, 74 patients underwent attempted endoscopic biliary therapy using a combined percutaneous transhepatic and endoscopic transpapillary approach (combined procedure). All patients had had failed endoscopy-alone procedures and had contraindications to surgery. The indication was palliation of malignant biliary obstruction in 66 cases (41 common bile duct, 25 hilar), assistance with sphincterotomy for the removal of common bile duct stones in 6 cases, and management of benign biliary stenosis in 2 cases. The initial procedure was percutaneous transhepatic access to the biliary tree, which was successful in all but 1 case (99%). The bile duct was drained externally for an average of 3.4 days before the combined procedure. One patient died during this period from hemorrhage associated with liver puncture. Combined procedure was performed in 72 cases and was successful in 60 [53 malignant stricture (53/66 = 80%), five common duct stone (5/6 = 83%), two benign stricture (2/2 = 100%)]. Procedure-related morbidity and mortality, respectively, were 12.5% and 0% for benign disease and 36% and 3% for malignant disease. The total (initial endoscopy included) morbidity and 30-day mortality were 33% and 0%, respectively, for benign disease and 62% and 27% for malignant disease. Subsequently, stent change has been required on 16 occasions, with endoscopy-only successful in 13 (81%) and repeat combined procedure being required in three (19%). The combined procedure improves the ability of endoscopy to offer nonsurgical therapy to poor risk patients with both malignant and benign biliary disease but is associated with significant morbidity and disease-related mortality.     

Immunoregulation in rheumatoid arthritis: evaluation of T lymphocyte function in the control of polyclonal immunoglobulin synthesis in vitro

Immunoglobulin production by peripheral blood B lymphocytes in cultures containing various combinations of B and T cells was studied by a reverse hemolytic plaque forming cell assay in 21 patients with definite rheumatoid arthritis (RA) and 26 normal controls. Responses were markedly enhanced in controls when T cells were irradiated at 3200 rads or T cells bearing Fc receptors for IgG were removed by rosetting prior to coculture with B cells, while no such responses were observed in rheumatoids. In allogeneic cultures and T depleted cultures supplemented by normal T replacing factors, RA B lymphocytes functioned normally. These data suggest that there is an abnormality in immunoregulation that exists at the level of the T cell and that the defect involves T helper cells and/or their interaction with B lymphocytes. An increase in the ratio of T helper:suppressor (OKT4:OKT5) cells due to a reduction in suppressor cells among active RA patients was observed but did not correlate with this defect that was independent of disease activity. These data imply that functional alterations exist in vitro in circulating helper T cells from RA peripheral blood.     

Observations on the warm up phenomenon in angina pectoris

Adaptation to exercise was investigated in 14 men aged 34-69 years (mean 51) with stable exertional angina caused by occlusive coronary artery disease. All underwent exercise electrocardiography to symptom limitation according to the Bruce protocol (first effort), and exercise to the onset of angina (warm up) followed by four minutes' rest, followed by exercise to symptom limitation (second effort). This protocol was repeated after sequential treatment for one month each with nifedipine 10 mg three times a day and with timolol 10 mg twice a day. Warm up significantly increased walking time to the onset of angina by 34.5% and to maximal exercise by 29.5%. The heart rate and rate-pressure product were significantly higher on second effort both at the onset of angina (by 7.0% and 11.1% respectively) and at maximal exercise (by 10.5% and 15.4% respectively). ST segment displacement was not significantly different after warm up. The effect of warm up on walking time to the onset of angina was markedly reduced after treatment with nifedipine but little influenced by timolol. Mean (SE) walking time after warm up on no treatment was 10.1 (0.7) min; after treatment with nifedipine it was 10.0 (0.6) min and after treatment with timolol it was 9.7 (0.4) min. These data demonstrate a substantial improvement in exercise performance after warm up and are consistent with the hypothesis that submaximal exercise in angina pectoris facilitates myocardial oxygen uptake by coronary vasodilatation.     

Association of granulocyte-macrophage colony-stimulating factor with the crystalloid granules of human eosinophils

We have previously shown that normal-density human peripheral blood eosinophils transcribe and translate mRNA for granulocyte-macrophage colony-stimulating factor (GM-CSF) and that the intracellular distribution was granular as assessed by light microscopy immunocytochemistry. The present study was conducted to confirm this apparent association between GM-CSF and the crystalloid granule using a subcellular fractionation method for human eosinophils and immunogold electron microscopy (EM). Highly purified (> 99%, by negative selection using anti-CD16 immunomagnetic microbeads) human peripheral blood eosinophils were obtained from four asthmatic subjects (not taking systemic medication), homogenized and density fractionated (5 x 10(7) cells/subject) on linear Nycodenz gradients. Twenty-four fractions were collected from each cell preparation and analyzed for marker enzyme activities as well as total protein. Dot blot analysis with specific monoclonal antibodies (MoAbs) was used to detect the eosinophil granule proteins major basic protein (MBP) and eosinophil cationic protein (ECP). An anti-CD9 MoAb was used as an eosinophil plasma membrane marker. Lactate dehydrogenase (LDH) was used as a cytosolic marker. Immunoreactivity for GM-CSF was detected by a specific enzyme-linked immunosorbent assay using a polyclonal antihuman GM-CSF antibody and confirmed by dot blot. GM-CSF coeluted with the cellular fractions containing granule markers (MBP, ECP, eosinophil peroxidase, hexosaminidase, and arylsulphatase), but not those containing cytoplasm (LDH+) or membrane (CD9+) markers. EM examination of pooled fractions associated with the peak of GM-CSF immunoreactivity confirmed that they contained crystalloid and small granules, but not plasma membrane. In addition, quantification, using immunogold labeling with an anti/GM-CSF MoAb, indicated preferential localization of gold particles over the eosinophil granule cores of intact cells. Thus, our results indicate that GM-CSF resides as a granule-associated, stored mediator in unstimulated human eosinophils.     

Impact of nationwide measles vaccination campaign among children aged 9 months to 14 years,Zimbabwe, 1998-2001

Zimbabwe (population 11,365,000) introduced nationwide one-dose measles vaccination in 1981. This strategy reached 70%-80% of infants <1 year of age over the next two decades; in 1998, a nationwide supplemental immunization activity (SIA) targeting all children aged 9 months to 14 years achieved 93% coverage. Surveillance data were examined to determine the impact of these strategies. During 1985-1997, there were 8529-49,812 measles cases annually. After the SIA, laboratory confirmation of the first 5 outbreak cases and all sporadic cases was required. In 1999 and 2000, 1343 (88%) of 1534 suspected cases had adequate specimens submitted and 28 (2%) were measles IgM positive. In 2001, of 529 suspected cases, 513 (97%) had adequate specimens and only 7 (1%) were measles IgM positive. These data suggest that indigenous measles transmission in Zimbabwe has been interrupted and that high prevalence of human immunodeficiency virus seropositivity does not hinder vaccination-induced measles control. High vaccination coverage obtained through the routine health care system supplemented by periodic follow-up SIAs will be required to maintain low transmission levels.     

An unusual case of vaccine-associated paralytic poliomyelitis

The present article reports a case involving an immunocompetent, previously well child who, despite two previous doses of inactivated poliovirus vaccine, developed severe flaccid paralysis consistent with polio after receiving oral polio vaccine.