High titer anti-HIV antibody reactivity associated with a paraprotein spike in a homosexual male with AIDS related complex

We observed a human immunodeficiency virus (HIV)-infected homosexual male with AIDS related complex (ARC) who had a serum globulin level of 80 g/L. Serum protein electrophoresis revealed a gamma globulin fraction of 40 g/L, of which 50% (20 g/L) was contained within a paraprotein spike, comprised predominantly of IgG kappa. This patient also had high titer anti-HIV antibodies in his serum, which were Western blot reactive at a final dilution of 1:500,000, and recognized gp120env, p66pol, p55gag, p53pol, p41gag, and p24gag. Because paraproteins in the past have been shown to be directed against specific antigens, we purified this patient's paraprotein using a modified high performance liquid chromatography (HPLC)-hydroxylapatite procedure and tested the purified paraprotein for anti-HIV antibody activity. The purified paraprotein retained anti-HIV antibody activity to a final dilution of 1:100,000, and recognized p66pol, p55gag, p53pol, p41gag, and p24gag. The recognition of both "gag" and "pol" gene products suggested that the purified paraprotein might not be monoclonal in origin. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) demonstrated that the purified paraprotein contained at least two immunoglobulin light chain species (Mol wt 30 to 33 Kd). Affinity chromatography of the purified paraprotein using a p24- Sepharose 4B matrix separated the "gag" and "pol" antibody activities. Immunoglobulin gene rearrangement analysis of a bone marrow aspirate (which contained 15% plasma cells) failed to reveal a clonal population of immunoglobulin producing cells. We conclude that this patient's paraprotein accounted for most of the anti-HIV activity present in whole serum, and that this paraprotein was not monoclonal in origin.     

Adrenergic support during anesthesia in experimental endotoxin shock: norepinephrine versus dobutamine

The effects of norepinephrine and dobutamine were compared during endotoxin shock in dogs anesthetized either with enflurane (E: 1.5%, N = 12) or with i.v. ketamine (K: 5 mg.kg-1 + 0.2 mg.kg-1.min-1, N = 12). An i.v. bolus of 1.5 mg.kg-1 E. coli endotoxin was followed by saline infusion to restore left-sided filling pressures at baseline. With E, heart rate, mean arterial pressure and stroke index decreased (P less than 0.01). The decrease in oxygen delivery (DO2) and in oxygen consumption (VO2) was associated with an increase in blood lactate. In contrast, K anesthesia was associated with remarkable hemodynamic stability. DO2 was well maintained, VO2 decreased (P less than 0.01) and blood lactate did not change. Under E anesthesia, mean arterial pressure increased more with norepinephrine and heart rate increased more with dobutamine. Under K anesthesia, cardiac index, stroke index and left ventricular stroke work index increased similarly with both agents. In both groups DO2 and VO2 increased markedly. The amount of fluid infused was higher with dobutamine than with norepinephrine. Thus, enflurane but not ketamine had depressant cardiovascular effects at the doses used in this model. With both anesthetics, norepinephrine and dobutamine could effectively improve cardiac function. Dobutamine could therefore represent a valuable alternative to norepinephrine for cardiovascular support during anesthesia in septic shock.     

Clinical and structural results of open repair of an isolated one-tendon tear of the rotator cuff

BACKGROUND: The clinical outcomes of open rotator cuff repair are well established, but the structural results and their effect on clinical outcome are poorly known. We assessed the structural changes in the musculotendinous units after open rotator cuff repair and correlated these findings with the clinical outcome to establish a benchmark for future series. METHODS: Thirty-two consecutive standardized open repairs of a single tendon tear of the rotator cuff were analyzed in twenty-one men and eleven women with an average age of 59.0 years. The supraspinatus tendon was involved in twenty-two patients and the subscapularis tendon, in ten. The clinical outcome, including the Constant score, was assessed prospectively for all patients at an average of thirty-eight months postoperatively. The structural outcome was assessed on standardized magnetic resonance imaging scans. RESULTS: The mean overall subjective shoulder value was 82.8% of the value for a normal shoulder. On the average, the age and gender-adjusted Constant score increased from 63.9% preoperatively to 94.5% postoperatively (p < 0.0001); the score for pain, from 6.8 points to 13.2 points (p < 0.0001); and the score for activities of daily living, from 11.2 points to 17.9 points (p < 0.0001). The overall rerupture rate was 13% (four of the thirty-two shoulders). All reruptures were distinctly smaller than the original tear. Muscular atrophy or fatty infiltration did not significantly decrease after the tendon repair. In fact, fatty infiltration in the supraspinatus (p < 0.0053) and infraspinatus (p < 0.003) muscles increased significantly. CONCLUSIONS: Direct open repair of a complete, isolated tear of one tendon of the rotator cuff resulted in significant subjective and objective improvement and very high patient satisfaction. Successful direct repair was not associated with a decrease in preoperative muscular atrophy and was associated with increased fatty infiltration of the muscle.     

Late diagnosis of HIV infection among individuals with low, unrecognised or unacknowledged risks in England, Wales and Northern Ireland

A small number of UK nationals who have a low, unrecognised or unacknowledged risk for HIV present late in the course of HIV infection; often after frequent attendances to primary care physicians. Information from in-depth interviews with individuals diagnosed with HIV in England, Wales and Northern Ireland (EW&NI) was analysed. Those diagnosed because of HIV-related symptoms (late diagnoses) were compared with those diagnosed for other reasons. Of the 286 individuals interviewed, 157 (55%) had HIV-related symptoms at the time of diagnosis, and 129 were tested for other reasons. A greater proportion of those diagnosed late were male and older. Of the 157 late diagnoses, 77 were considered to have acquired HIV heterosexually in the UK, 19 heterosexually abroad, 16 through 'high-risk' behaviours, 15 heterosexually by a 'high-risk' partner, four through blood transfusion and the remainder through an unusual or unknown route. A significantly higher proportion of those diagnosed late had had a long-standing relationship. None had been informed by a current or ex-partner of their HIV status. Primary care physicians should consider HIV as a possibility when patients without an apparent risk for HIV-infection present with symptoms indicative of possible immune suppression. Sensitive partner notification practices that enable a greater number of individuals to inform their partners should be explored.     

Laparoscopic anatomical (hepatic) left lateral segmentectomy—technical aspects

Laparoscopic liver surgery is a tremendous challenge. The authors report a left liver lobectomy and removal by a total laparoscopic approach. Anatomical left lateral laparoscopic segmentectomy was performed on a woman who had a symptomatic hepatic adenoma. The patient was discharged after an uncomplicated postoperative recovery; the hospital stay and convalescence period were very short. The cosmetic result was good.