Ecology and physiology of the emerging opportunistic fungi Pseudallescheria boydii and Scedosporium prolificans

Summary. Nutritionally physiological patterns of Pseudallescheria boydii (Microascaceae) and the related species Scedosporium prolificans were established. Differences between the two species were found in assimilation of sucrose, ribitol, xylitol and L-arabinitol. In contrast, no physiological distinction could be made between the three intraspecific variants of P. boydii which have been recognized on the basis of nDNA/DNA homology data and of morphological and clinical differences. Some potential virulence factors were studied in the fungi mentioned above and in some related anamorphs. All species were capable of anaerobic growth, but differed in their temperature relations.
Zusammenfassung. Assimilations-Muster von Pseudallescheria boydii (Microascaceae) und der verwandten Art Scedosporium prolificans wurden untersucht. Dabei wurden Art-Unterschiede in der Assimilation von Saccharose, Ribitol, Xylitol und L-Arabinitol festgestellt. Im Gegensatz dazu wurden keine physiologischen Unterschiede zwischen den drei Varianten innerhalb der Art P. boydii nachgewiesen. Damit lassen sich die bisher verwendeten Merkmalsunterschiede, bzw. nDNA/DNA Homologie-Werte sowie morphologische und klinische Characteristika, nicht bestätigen. Einige mögliche Virulenz-Faktoren bei den oben beschriebenen sowie auch bei einigen verwandten Arten, wurden untersucht. Alle Arten erwiesen sich im gleichen Maß zum anaeroben Wachstum befähigt, unterscheiden sich aber in ihrem Temperaturverhalten.     

Acute humoral rejection in kidney transplantation: II. Morphology, immunopathology, and pathologic classification

The incidence of acute humoral rejection (AHR) in renal allograft biopsies has been difficult to determine because widely accepted diagnostic criteria have not been established. C4d deposition in peritubular capillaries (PTC) of renal allografts has been proposed as a useful marker for AHR. This study was designed to test the relative value of C4d staining, histology, and serology in the diagnosis of AHR. Of 232 consecutive kidney transplants performed at a single institution from July 1995 to July 1999, all patients (n = 67) who developed acute rejection within the first 3 mo and had a renal biopsy with available frozen tissue at acute rejection onset, as well as posttransplant sera within 30 d of the biopsy, were included in this study. Hematoxylin and eosin and periodic acid-Schiff stained sections were scored for glomerular, vascular, and tubulointerstitial pathology. C4d staining of cryostat sections was done by a sensitive three-layer immunofluorescence method. Donor-specific antibodies (DSA) were detected in posttransplant recipient sera using antihuman-globulin-enhanced T cell and B cell cytotoxicity assays and/or flow cytometry. Widespread C4d staining in PTC was present in 30% (20 of 67) of all acute rejection biopsies. The initial histologic diagnoses of the C4d(+) acute rejection cases were as follows: AHR only, 30%; acute cellular rejection (ACR) and AHR, 45%; ACR (CCTT types 1 or 2) alone, 15%; and acute tubular injury (ATI), 10%. The distinguishing morphologic features in C4d(+) versus C4d(-) acute rejection cases included the following: neutrophils in PTC, 65% versus 9%; neutrophilic glomerulitis, 55% versus 4%; neutrophilic tubulitis, 55% versus 9%; severe ATI, 75% versus 9%; and fibrinoid necrosis in glomeruli, 20% versus 0%, or arteries, 25% versus 0%; all P < 0.01. Mononuclear cell tubulitis was more common in the C4d(-) group (70% versus 100%; P < 0.01). No significant difference between C4d(+) and C4d(-) acute rejection was noted for endarteritis, 25% versus 32%; interstitial inflammation (mean % cortex), 27.2 +/- 27% versus 38 +/- 21%; interstitial hemorrhage, 25% versus 15%; or infarcts, 5% versus 2%. DSA were present in 90% (18 of 20) of the C4d(+) cases compared with 2% (1 of 47) in the C4d(-) acute rejection cases (P < 0.001). The pathology of the C4d(+) but DSA(-) cases was not distinguishable from the C4d(+), DSA(+) cases. The C4d(+) DSA(-) cases may be due to non-HLA antibodies or subthreshold levels of DSA. The sensitivity of C4d staining is 95% in the diagnosis of AHR compared with the donor-specific antibody test (90%). Overall, eight grafts were lost to acute rejection in the first year, of which 75% (6 of 8) had AHR. The 1-yr graft failure rate was 27% (4 of 15) for those AHR cases with only capillary neutrophils versus 40% (2 of 5) for those who also had fibrinoid necrosis of arteries. In comparison, the 1-yr graft failure rates were 3% and 7%, respectively, in ACR 1 (Banff/CCTT type 1) and ACR 2 (Banff/CCTT type 2) C4d(-) groups. A substantial fraction (30%) of biopsy-confirmed acute rejection episodes have a component of AHR as judged by C4d staining; most (90%), but not all, have detectable DSA. AHR may be overlooked in the presence of ACR or ATI by histology or negative serology, arguing for routine C4d staining of renal allograft biopsies. Because AHR has a distinct therapy and prognosis, we propose that it should be classified separately from ACR, with further sub-classification into AHR 1 (neutrophilic capillary involvement) and AHR 2 (arterial fibrinoid necrosis).     

Paradoxes of health decentralization policies in Brazil]

The constitution of Brazil directs that the country's health system, the Unified Health System (Sistema Unico de Saúde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazil's federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazil's health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.     

Computed tomography severity index is an early prognostic tool for acute pancreatitis

BACKGROUND: Acute pancreatitis is a severe disease with unpredictable course and outcomes. It is especially hard to identify early those patients who will have a fulminant course. In a prospective observational study, we tested the hypothesis that the CT Severity Index (CTSI), established within 48hours after admission, is prognostic for morbidity and mortality and can predict the necessity for admission to an ICU. STUDY DESIGN: From January 1994 to October 2002, all patients with the diagnosis of first time acute pancreatitis underwent spiral CT with intravenous contrast within 48hours of admission. The extent of inflammation and necrosis was assessed to define the CTSI. Patients were initially managed in an ICU in a standardized fashion. Complications and mortality were registered in a systematic manner. RESULTS: Seventy-nine patients were admitted with acute pancreatitis. The overall complication rate was 57%; mortality was 9%. In patients with a CTSI of 0 to 3, these rates were 42% and 2%, respectively; in those with CTSI of 4 to 6, 81% and 19%, respectively; and in those with CTSI of 7 to 10, 100% and 33%, respectively. Outcomes of subsequent CT scans did not alter the initial prognosis. Early CTSI correlated well with the incidence of complications, sepsis, mortality, and necessity for ICU admission. CONCLUSIONS: Acute pancreatitis is associated with marked morbidity and mortality. Initial admission to an ICU and standardized conservative treatment are justified for all patients. Early establishment of the CTSI is an excellent prognostic tool for complications and mortality. Patients with a CTSI of 0 to 3 can safely be discharged from the ICU.     

Efficacy and safety of recombinant urate oxidase (rasburicase) for treatment and prophylaxis of hyperuricemia in children undergoing chemotherapy

Rasburicase has been defined as a potent urolytic agent for management of malignancy-associated hyperuricemia. We reviewed the data of 26 children with malignancy at risk for TLS who received rasburicase for treatment or prophylaxis of acute hyperuricemia, producing a significant decrease in uric acid level in all the patients. Tolerance of treatment was excellent. Rasburicase is a safe, highly and rapidly effective agent in the treatment and prevention of malignancies-associated acute hyperuricemia.     

Optimized protocols for the simultaneous preparation of primary neuronal cultures of the neocortex, hippocampus and cerebellum from individual newborn (P0.5) C57Bl/6J mice

Knockout mouse models allow preparation of primary neuronal cultures from distinct brain regions in order to investigate the underlying neuronal pathomechanisms of human metabolic diseases associated with severe, regionally distinct brain pathologies (e.g. Zellweger syndrome, the most severe form of a peroxisomal biogenesis disorder). However, homozygous mouse pups with Zellweger syndrome usually die shortly after birth. Therefore, in this study, we established optimized protocols for the simultaneous preparation and cultivation of serum-free primary neuronal cultures from distinct brain regions (medial neocortex, hippocampus and cerebellum) from individual newborn (P0.5) C57Bl/6J mice. For each of the three types of neuronal cultures, we have optimized the isolation procedures and cultivation conditions including coating substrates, enzyme digestion, mode of trituration, seeding density and composition of the culture medium. As indicated by indirect immunofluorescence using antibodies against NeuN, GFAP and CNPase, the purity of the distinct neuronal cultures was high. The percentage of oligodendrocytes was less than 1% in all neuronal cultures. Only 5% astrocytes were present in cortical, 7% in hippocampal and 10% in cerebellar cultures. Cytosine arabinofuranoside (AraC) treatment reduced the percentage of astrocytes only significantly in hippocampal cultures, however, increased the percentage of apoptotic neurons in hippocampal and cortical cultures.     

Management of postintubation membranous tracheal rupture

BACKGROUND: Postintubation tracheobronchial laceration is a rare complication of general anesthesia. A renewed interest in this disorder induced us to review our experience on its treatment, focusing on the evolution of the surgical approach, and describing a technical variation of the transcervical approach. METHODS: From January 1994 to December 2002 we treated 13 patients with diagnosis of postintubation tracheobronchial laceration. The treatment was nonsurgical in 3 patients (1-cm-long tear) and surgical in the other cases. Two lesions extending to the main bronchi were repaired through a right thoracotomy as well as four lesions limited to the trachea observed before January 2001. After this date we used the transcervical approach for entirely intratracheal lesions: in three cases we performed an anterior transverse tracheotomy and in one case a transverse and midline vertical incision (T tracheotomy). RESULTS: Both conservative and surgical therapy were successful in all the cases. Two patients in the thoracotomy group had a transient right vocal cord palsy. No morbidity was observed with the cervical approach. Normal healing of the sutures was evidenced by an endoscopic follow-up 30 days later. CONCLUSIONS: In our experience nonsurgical treatment is advisable in small (length < 2 cm) uncomplicated tears. Concerning surgery, thoracotomy is indicated in tracheal lacerations extending to the main bronchi, whereas the transcervical approach is preferred for intratracheal tears because of its efficacy in reaching and suturing the lesions extending to the carina and for its limited invasiveness.     

<Superscript>99m</Superscript>Tc-EDDA/HYNIC-TOC and <Superscript>18</Superscript>F-FDG in thyroid cancer patients with negative <Superscript>131</Superscript>I whole-body scans

Several studies have reported on the expression of somatostatin receptors in patients with differentiated thyroid cancer (DTC). The aim of this study was to evaluate the imaging abilities of a recently developed technetium-99m labelled somatostatin analogue, ^99mTc-EDDA/HYNIC-TOC (^99mTc-TOC), in terms of precise localisation of disease. The study population comprised 54 patients (24 men, 30 women; age range 22–90 years) with histologically confirmed DTC who presented with recurrent or persistent disease as indicated by elevated Tg levels after initial treatment. All patients were negative on the iodine-131 post-therapy whole-body scans. Fluorine-18 fluorodeoxyglucose positron emission tomography (¹⁸F-FDG PET) was performed in a subgroup of 36 patients. The study population consisted of two groups: Group A (n=22) comprised patients with disease recurrence as shown by elevated Tg levels but without detectable pathology. In group B (n=32), pre-existing lesions were known. Among the 54 cases, SSTR scintigraphy was true positive in 33 (61.1%), true negative in 4 (7.4%) and false negative in 17 (31.5%) cases, which resulted in a sensitivity of 66%. A total of 138 tumour foci were localised in 33 patients. The fraction of true positive ^99mTc-TOC findings was positively correlated (P<0.01) with elevated Tg levels (higher than 30 ng/ml). Despite two false positive findings, analysis on a lesion basis demonstrated better diagnostic efficacy with ¹⁸F-FDG PET (P<0.001); however, it also revealed substantial agreement between the imaging techniques [Cohens kappa of 0.62 (0.47–0.78)]. In conclusion, scintigraphy with ^99mTc-TOC might be a promising tool for treatment planning; it is easy to perform and showed sufficient accuracy for localisation diagnostics in thyroid cancer patients with recurrent or metastatic disease.     

99mTc depreotide scan compared with 99mTc-MDP bone scintigraphy for the detection of bone metastases and prediction of response to hormonal treatment in patients with breast cancer

BACKGROUND: The purpose of this study was to determine the potential role of Tc depreotide scintigraphy for the evaluation of bone metastases compared with Tc methylenediphosphonate (MDP) bone scintigraphy and for the prediction of treatment response in breast cancer patients in whom first- or second-line hormonal therapy was to be initiated. METHODS: Twelve patients with a diagnosis of advanced breast cancer were included. All patients underwent both a bone scan and a depreotide scan and at least one other conventional imaging procedure, including plain film radiography (n=11), computed tomography (n=6) or magnetic resonance imaging (n=5), for confirmation of metastatic disease. The mean time interval between the bone scan and the depreotide scan was 30.6 days. Follow-up data were retrieved from routine clinical evaluation by means of physical examination, imaging and blood analysis. RESULTS: On a patient basis we found a sensitivity, specificity and accuracy of, respectively 100%, 50% and 83.3% for the bone scan and 62.5%, 100% and 75% for the depreotide scan in the diagnosis of bone metastasis. In eight patients with available follow-up data two with a positive depreotide scan remained stable and five of six patients with a negative depreotide scan had progressive disease. CONCLUSION: In this small series of breast cancer patients Tc depreotide scintigraphy proves less sensitive but more specific as compared to Tc-MDP bone scintigraphy in measuring the extent of bone metastasis. On the other hand Tc depreotide scintigraphy elucidates, non-invasively, tumour characteristics and may be indicative for prognosis and response to hormonal treatment.