Pulmonary hemorrhage resulting from bungee jumping

Pulmonary hemorrhage is a relatively common complication of blunt chest trauma. Occasionally, it may result from pulmonary barotrauma after scuba diving or from sports activities not associated with barotrauma such as long breath-hold diving. We report a case of symmetric diffuse upper lobe hemorrhage resulting from a bungee jump in a previously healthy man. Bungee jumping is an increasingly popular sport with relatively few reported injuries. To our knowledge pulmonary hemorrhage in this setting has not yet been described.     

PIN-1 promoter polymorphisms in mild cognitive impairment and susceptibility to Alzheimer's disease: a preliminary report

BACKGROUND AND AIMS: Peptydil prolyl cis-trans isomerase (PIN-1), which specifically regulates the conformational changes following phosphorylation of several proteins, targets the inactive hyper-phosphorylated tau on the Thr231-Pro motif and directly restores its biological function. Interestingly, PIN-1 is oxidatively inhibited not only in Alzheimer's disease brain but also in the hippocampi of mild cognitive impairment (MCI) subjects. The PIN-1 gene is characterized by two single nucleotide polymorphisms (SNPs) in the promoter region which are associated with the risk of Alzheimer's disease. The aim of this study was to analyse the genotype and allele distributions of these PIN-1 SNPs in MCI subjects diagnosed respectively as amnestic MCI (a-MCI) and multiple impaired cognitive domains (mcd-MCI) on the basis of cognitive features. METHODS: -667 T/C and -842 C/G SNPs were genotyped by polymerase chain reaction (PCR) amplification and direct sequencing in 43 MCI subjects, with the intention of comparing -667 and -842 SNP frequencies with those previously described in 111 Alzheimer's disease patients (AD) and 73 healthy controls (HC). RESULTS: The allele frequencies of the -842 C/G SNP in a-MCI subjects are similar to those of AD subjects, while those of mcd-MCI are comparable to HC (G allele 83% in both a-MCI and AD; 95% and 94% in mcd-MCI and HC, respectively). A similar trend is also observed in -842 C/G genotypes. CONCLUSIONS: Since a-MCI is thought to be the preclinical form of AD, the similar genotype distribution of -842 SNP in AD and a-MCI, but not in mcd-MCI, suggests that it is potentially involved in the conversion of a-MCI to AD. In conclusion, these findings support the theory that polymorphisms of the PIN-1 gene can affect neurodegeneration and its clinical progression.     

Mycobacterium tuberculosis in Ontario,Canada: Insights from IS6110 Restriction Fragment Length Polymorphism and Mycobacterial Interspersed Repetitive-Unit-Variable-Number Tandem-Repeat Genotyping

A collection of 1,308 clinical Mycobacterium tuberculosis isolates from Ontario, Canada, was genotyped by IS6110 restriction fragment length polymorphism (RFLP) and mycobacterial interspersed repetitive-unit-variable-number tandem-repeat (MIRU-VNTR) analysis. RFLP or >12 MIRU-VNTR loci were necessary for resolution of Indo-Oceanic strains. The low clustering rate and high strain diversity indicate that, in Ontario, most tuberculosis results from reactivation of latent infections.Tuberculosis (TB), which is caused by pathogens of the Mycobacterium tuberculosis complex (MTBC), remains a global scourge (19). In Canada, the average incidence rate is 5.0 cases/100,000 people, but the burden of disease varies across the country. In 2007, the four Atlantic provinces accounted for only ∼1% of TB cases, whereas ∼42% of new cases occurred in the province of Ontario (11). The Public Health Laboratories (PHL) of the Ontario Agency for Health Protection and Promotion provide diagnostic testing for TB in Ontario. The TB and Mycobacteriology Laboratory at PHL-Toronto is the largest facility of its kind in Canada, processing 50,000 patient samples plus 2,000 referred acid-fast positive cultures, with 600 to 650 new cases of TB detected annually (8, 11). Historically, the PHL has employed IS6110 restriction fragment length polymorphism (RFLP) for genotyping. Despite its utility, IS6110 RFLP is labor-intensive and only performed upon request. The current turnaround time of 21 days also makes the method incompatible with the PHL goal of universal, real-time MTBC genotyping. More recently, mycobacterial interspersed repetitive-unit-variable-number tandem-repeat (MIRU-VNTR) typing has been introduced (6, 7, 9, 15). The current PHL strategy relies upon agarose gel electrophoresis for comparison of PCR products. This method is low throughput, and gel-to-gel variability confounds comparison of samples processed at different times. Here, we describe implementation and validation of an improved MIRU-VNTR strategy and its utility for analysis of a large clinical strain collection.The semiautomated MIRU-VNTR strategy was derived from the 12-loci method of Cowan et al. (6, 7). Briefly, multiplex PCR was performed with dye-labeled primers in 96-well plates. For each reaction, 5 ng of template DNA was combined with 11 μl of a master mix (Red Taq; Sigma-Aldrich, Oakville, Canada) containing three primer pairs. PCR conditions were 95°C for 10 min and 34 cycles of 94°C for 30 s, 62°C for 30 s, and 72°C for 60 s, with a final extension at 72°C for 7 min. PCR amplification was confirmed by electrophoresis on 1% Tris-borate-EDTA agarose gels. Samples were diluted 1:20 in sequence loading solution (Beckman Coulter, Mississauga, Canada) containing a 600-bp sequencing standard (Beckman Coulter) and then subjected to fragment analysis on a CEQ8800 genetic analysis system (Beckman Coulter). To reduce the manual labor and potential for human error associated with extensive pipetting, a Biomek NX Span-8 automation workstation (Beckman Coulter) was programmed to set up the initial PCRs and dilute PCR products for fragment analysis.To validate the method, a blinded set of 99 DNA samples was provided by the Public Health Research Institute (NJ). Strain identities and MIRU-VNTR patterns were unblinded only after complete 12-digit patterns were generated for all 99 DNA samples. Concordance between PHL and Public Health Research Institute results was 100%.To evaluate the utility of MIRU-VNTR in Ontario, typing was performed on 1,308 clinical samples from the PHL strain collection for which IS6110 RFLP profiles were also available. Strains were identified as MTBC by using DNA probes (AccuProbe; Gen-Probe, San Diego, CA) and were originally isolated during 1999 to 2001. Strains identified as Mycobacterium bovis or M. bovis BCG and samples containing multiple Mycobacterium species were excluded from analysis. For cases with multiple cultures, only the first isolate was used. Genomic DNA was extracted according to standard protocols (17) in a dedicated biosafety containment facility.MIRU-VNTR and IS6110 RFLP data were analyzed with BioNumerics 5.0 (Applied Maths, St-Martin Latem, Belgium). RFLP patterns were compared using band-based Dice statistics with 1% position tolerance such that clustered strains exhibited bands of identical number and position. Strains clustered by MIRU-VNTR were identical at all 12 loci. Analysis by MIRU-VNTR plus IS6110 RFLP employed the unweighted-pair group method with arithmetic mean. MTBC lineages were assigned by comparison to the MIRU-VNTR reference strain database (1).Independently, both methods revealed a large number of unique profiles and some clustered isolates (Table ​(Table1).1). Maximum strain resolution was achieved when both methods were combined. In general, RFLP was superior for multiband IS6110 strains, whereas resolution of single-band IS6110 isolates required MIRU-VNTR. Initial typing at 12 MIRU-VNTR loci generated two large “pseudoclusters.” One contained East Asian lineage strains (pattern 223325173533; n = 110), which are known to be poorly resolved by these 12 loci (12, 16). The second was comprised of strains from the Indo-Oceanic lineage (pattern 254326223432; n = 80). This group was typed at 12 additional loci (15). Even though four of the new loci were invariant, extended typing generated 47 new patterns (Fig. ​(Fig.1).1). Thirty-five Indo-Oceanic strains had unique profiles, whereas the remaining isolates formed 12 MIRU-VNTR-defined clusters (6 clusters with 2 isolates in each cluster, 3 with 3 each, 1 with 4, and 2 with 10 each). However, 11 of these could be resolved further by RFLP.Open in a separate windowFIG. 1.Improved typing of the Indo-Oceanic pseudocluster. Whereas all strains (n = 80) shared the same, original 12-loci pattern (254326223432), typing at 12 additional loci produced 47 distinct patterns, including 35 unique profiles. The remaining strains formed 12 clusters (6× n = 2; 3× n = 3; 1× n = 4; 2× n = 10), most of which could be further resolved by RFLP. However, one pair (cluster A) was identical by both methods, and two (clusters D and G) exhibited single band shifts. Conversely, one RFLP-defined pair (cluster M) exhibited differences at two loci upon extended MIRU-VNTR typing. For each strain, IS6110 RFLP profiles and repeat values at the extended MIRU-VNTR loci are shown. Relationships between strains are indicated by the phylogenetic (unweighted-pair group method with arithmetic mean) tree, and strains in MIRU-VNTR-defined clusters are labeled (clusters A to L).

TABLE 1.

Clustering results from MIRU-VNTR and IS6110 RFLP genotyping

Immunoglobulin E (IgE) Responses to Paramyosin Predict Resistance to Reinfection with Schistosoma japonicum and Are Attenuated by IgG4

Schistosomiasis remains a public health concern in developing countries, and rapid reinfection fostered by continued exposure to contaminated water sources necessitates a vaccine to augment current mass treatment-based control strategies. We report isotype-specific (immunoglobulin A [IgA], IgE, IgG1, IgG4, and IgG) antibody responses to soluble worm antigen preparation and the recombinant vaccine candidates rSj97, rSj67, and rSj22 from a Schistosoma japonicum-infected cohort in Leyte, the Philippines, where schistosomiasis is endemic. Sera were collected from infected individuals 1 month posttreatment with praziquantel, and antibody responses were measured using a bead-based multiplex platform. Reinfection was monitored by stool sampling every 3 months, and data up to 1 year were included in the analysis (n = 553). In repeated-measures models, individuals with detectible IgE responses to rSj97 had a 26% lower intensity of reinfection at 12 months posttreatment compared to nonresponders after adjusting for age, gender, village, exposure, pretreatment infection intensity, and clustering by household (P = 0.018). In contrast, IgG4 responses to rSj97 as well as rSj67 and rSj22 were associated with markedly increased reinfection intensity. When stratified by IgG4 and IgE responder status, individuals with IgE but not IgG4 responses to rSj97 (n = 16) had a 77% lower intensity of reinfection at 12 months compared to individuals with IgG4 responses but not IgE responses (n = 274), even after adjusting for potential confounders (P = 0.016). Together with our previously described protective cytokine responses, these data further support paramyosin as a leading vaccine candidate for human schistosomiasis japonica and underscore the importance of careful adjuvant selection to avoid the generation of blocking IgG4 antibody responses.Schistosomiasis, caused by parasitic helminths of the genus Schistosoma, remains a major public health concern and currently infects 200 million individuals with 600 million individuals at risk of infection in 74 developing countries (19). National control strategies focusing on mass chemotherapy with praziquantel have significantly reduced severe liver and urinary tract pathology; however, rapid reinfection with consequent subtle morbidities such as anemia, malnutrition, and cognitive impairment persist despite years of annual treatment (30). Continued exposure to contaminated water sources mandates alternative control strategies such as vaccine-linked chemotherapy (3).In vitro studies have demonstrated that schistosome larvae are susceptible to damage in the presence of sera from infected individuals together with leukocytes from uninfected donors, suggesting that parasite-specific antibody-dependent cellular cytotoxicity (ADCC) plays a key role in parasite elimination (8). Subsequent investigations identified the role of protective immunoglobulin E (IgE), IgA, and IgG antibody isotypes (11, 23, 29) and the participation of eosinophils and mast cells in orchestrating this attack (7, 12). However, several studies have also demonstrated the presence of inhibitory antibodies which block schistosomular killing (22, 28). In particular, the antibody isotype IgG4 is a poor initiator of ADCC and blocks killing by competing with protective isotypes (29). These data suggest that schistosomes induce both protective and antagonistic antibody responses, which may alter the balance between parasite elimination and immune evasion (3).Consonant with in vitro studies, several immunoepidemiologic surveys conducted in areas where schistosomiasis is endemic have demonstrated associations between antibody responses to crude parasite antigens and reinfection outcomes in humans. Protective IgE responses to worm (17, 24) and egg (43) antigens have been described across schistosome species, as well as IgA responses mediating antifecundity effects (23). These cohort studies have also described antiparasite IgG4 (16, 24, 32), IgM, and IgG2 (5, 22, 28) as isotypes associated with susceptibility.Based on a model of antibody-mediated protection, the antigenic targets of both protective antibody isotypes and protective monoclonal antibodies have been identified in parasite extracts and genomic libraries. Numerous candidates have been identified (4), and a panel of the most promising of these was evaluated in immunoepidemiologic studies in Egypt (2), Brazil (35), and to a limited extent in China and the Philippines (1, 32). Despite this progress (3), only one vaccine candidate (Schistosoma haematobium glutathione S-transferase) has advanced to early-phase clinical trials (10).We have previously described cytokine responses to crude antigen preparations (soluble worm antigen preparation [SWAP], SEA) and defined vaccine candidates (Sj97, Sj67, and Sj22) in a cohort of schistosomiasis-infected individuals between 7 and 30 years old and residing in Leyte, the Philippines (31). Here, we extend this work by measuring isotype-specific (IgA, IgE, IgG1, IgG4, and total IgG, henceforth referred to as IgG) antibody responses to these antigens in the same cohort and evaluating their association with resistance to reinfection over 12 months of posttreatment follow-up. We report that IgE responses to rSj97 are associated with resistance to reinfection and are attenuated by IgG4.     

Resumption of daily physical activity after day-case laparoscopic cholecystectomy

Background  Laparoscopic cholecystectomy has been proven to be safe and feasible as a day-case procedure. Few studies investigated postoperative activity resumption. The goal of this study was to objectively assess daily physical activity after day-case laparoscopic cholecystectomy and evaluate the effect of encouragement of patients. Methods  This prospective controlled study measured daily physical activity in an unselected patient population undergoing day-case laparoscopic cholecystectomy by using an accelerometer for 1 week before surgery to 1 week after. First, a control group received standard care. Subsequently, an intervention group was encouraged to swift resumption of daily physical activity by means of standardized advice combined with individualized activity goals. Outcome measures were activity scores, visual analogue scores (VAS) for pain and nausea and subjective factors limiting activity. Results  Sixty-four patients completed the study (n = 28 in the control group, n = 36 in the intervention group). In the control group, 36% of the patients reached their preoperative activity level after 1 week, as compared to 50% in the intervention group (p = 0.19). Resumption of daily physical activity during the first postoperative week in the intervention group was not significantly different from the control group [repeated measures analysis of variance (MANOVA), p = 0.05]. However, in contrast with men, women in the intervention group did show a faster recovery of daily physical activity as compared to the control group (MANOVA, p = 0.02). Although there was no significant difference in postoperative VAS scores for pain and nausea between both groups, patients in the intervention group experienced pain less often as a limiting factor (p = 0.006). Conclusion  Recovery of daily physical activity exceeded 1 week in most patients undergoing day-case laparoscopic cholecystectomy. The use of an accelerometer and standardized encouragement accelerated recovery in women.     

Memory performance on the California Verbal Learning Test of children with benign childhood epilepsy with centrotemporal spikes

Verbal learning and retrieval, as well as the use of learning strategies, were assessed in 24 children with benign epilepsy with centrotemporal spikes (BECTS) and 16 controls, using the California Verbal Learning Test—Children’s Version. Neuropsychological data were correlated with EEG features. Compared with age-matched controls, the children with BECTS younger than 10 exhibited significant learning difficulties and were less efficient in using a semantic clustering strategy, whereas no such difference emerged for subjects older than 10. This suggests that the capacity for spontaneous use of a more efficient strategy matures later in children with BECTS. Moreover, the majority of those younger than 10 had multifocal anomalies, suggesting that the difficulties encountered might be caused by the presence of additional foci.     

Impaired perfusion after myocardial infarction is due to reperfusion-induced deltaPKC-mediated myocardial damage

OBJECTIVE: To improve myocardial flow during reperfusion after acute myocardial infarction and to elucidate the molecular and cellular basis that impedes it. According to the AHA/ACC recommendation, an ideal reperfusion treatment in patients with acute myocardial infarction (AMI) should not only focus on restoring flow in the occluded artery, but should aim to reduce microvascular damage to improve blood flow in the infarcted myocardium. METHODS: Transgenic mouse hearts expressing the deltaPKC (protein kinase C) inhibitor, deltaV1-1, in their myocytes only were treated with or without the deltaPKC inhibitor after ischemia in an ex vivo AMI model. deltaV1-1 or vehicle was also delivered at reperfusion in an in vivo porcine model of AMI. Microvascular dysfunction was assessed by physiological and histological measurements. RESULTS: deltaPKC inhibition in the endothelial cells improved myocardial perfusion in the transgenic mice. In the porcine in vivo AMI model, coronary flow reserve (CFR), which is impaired for 6 days following infarction, was improved immediately following a one-minute treatment at the end of the ischemic period with the deltaPKC-selective inhibitor, deltaV1-1 ( approximately 250 ng/kg), and was completely corrected by 24 h. Myocardial contrast echocardiography, electron microscopy studies, and TUNEL staining demonstrated deltaPKC-mediated microvascular damage. epsilonPKC-induced preconditioning, which also reduces infarct size by >60%, did not improve microvascular function. CONCLUSIONS: These data suggest that deltaPKC activation in the microvasculature impairs blood flow in the infarcted tissue after restoring flow in the occluded artery and that AMI patients with no-reflow may therefore benefit from treatment with a deltaPKC inhibitor given in conjunction with removal of the coronary occlusion.