Transhepatic removal of obstructed Carey-Coons biliary endoprosthesis

A criticism of the use of an endoprosthesis for relief of biliary obstruction has been the difficulty of removing or exchanging the endoprosthesis if it becomes obstructed. We present a simple method of removal that has been successful in four of five patients who presented with an obstructed endoprosthesis 3-7 months after placement.     

Rifampicin-associated acute renal failure: pathophysiologic, immunologic, and clinical features

A 71-year-old woman was treated for a relapsing pulmonary tuberculosis with reinstitution of rifampicin after a medication-free interval of 2 years. After ingestion of the second dose, she developed severe hemolytic anemia and acute renal failure (ARF) necessitating dialysis. We demonstrated the presence in the patient's serum of rifampicin-dependent immunoglobulin G (IgG) and IgM antibodies, which caused red blood cell lysis through interaction with the I antigen on the erythrocyte surface. A review of the literature yielded 48 cases of rifampicin-associated renal failure. A subgroup of 37 patients could be distinguished, which, analogous to our case, suddenly developed ARF and frequently also developed hemolytic anemia and/or thrombocytopenia during intermittent or interrupted treatment. Regarding the pathogenesis of the ARF, renal biopsy consistently revealed tubular lesions. Although intravascular hemolysis with hemoglobinuria may play a role, it is not uniformly present. Our demonstration of an antibody with anti-I specificity provides a possible explanation. The I antigen is also expressed on tubular epithelium and may, therefore, be the target structure through which rifampicin-antibody complexes lead to tubular cell destruction. The other cases of rifampicin-associated ARF were unrelated to this subgroup: two cases of rapidly progressive glomerulonephritis, five cases of acute interstitial nephritis, and four cases of light chain proteinuria were recorded.     

Cytologic features of nipple aspirate fluid using an automated non-invasive collection device: a prospective observational study

Background  

Detection of cytologic atypia in nipple aspirate fluid (NAF) has been shown to be a predictor of risk for development of breast carcinoma. Manual collection of NAF for cytologic evaluation varies widely in terms of efficacy, ease of use, and patient acceptance. We investigated a new automated device for the non-invasive collection of NAF in the office setting.     

ENT Disabilities in Candidates for Recruitment

Background

Recruitment in the Army is subject to medical fitness as per laid down standards. A study of the frequency of referral and rejection gives us an understanding as to where to lay stress in the Ear Nose Throat Examination during recruitment medical. Method: A three year analysis of candidates reporting for review of ENT disabilities was carried out from January 1999 to December 2001.

Results

Of the 1156 candidates, 888(76.8%) were found to be fit. The commonest cause for rejection was Wax in ears in 496 cases (43%). 428(86.3%) were found to be fit on review. Chronic suppurative otitis media (21.9%) and tympanosclerosis (21.3%) were the other causes for rejection.

Conclusion

The desirable situation is wherein the evaluation by the specialist is in minimal variation with that of the initial recruitment medical examination. Awareness to have ears cleaned for wax before appearing for the examination, provision of better examination ambiance and equipment and a short training capsule will be beneficial to reduce the number of review cases to referral hospitals.Key Words: Hearing assessment, recruitment, tympanic membrane     

Diadenosine 5',5'-p1,p4-tetraphosphate deficiency in blood platelets of the Chediak-Higashi syndrome

Diadenosine tetraphosphate (AP4A) is an unusual nucleotide found in a variety of cells, including platelets. It has been suggested that platelet AP4A is stored in the dense granules and is metabolically inactive. We have studied the AP4A content of blood platelets in two patients and three cattle with Chediak-Higashi syndrome (CHS), a hereditary platelet defect with dense granule deficiency. Acid-soluble extractions of whole blood and platelets were neutralized. The adenosine triphosphate (ATP) level was measured by luminescence technique. To measure the AP4A content, the neutralized extract was treated with phosphomonoesterase for removal of ATP. The AP4A content was then measured by coupling the phosphodiesterase and luciferase reaction. The AP4A content was 0.43 nmol/mg protein for normal human platelets and 0.004 nmol/mg protein for CHS platelets. The ATP/AP4A ratio was 67 for normal and 3,023 for CHS platelets. The whole blood AP4A was reduced by 89% in CHS patients who had only a slight decrease in ATP level (26% reduction). Similarly, bovine platelets with CHS showed a marked decrease of AP4A content and a moderate reduction of the ATP level. The platelet ATP/AP4A ratio was 351 and 3,133 for normal and CHS cattle, respectively. Results demonstrate a marked reduction of AP4A in CHS platelets and suggest that AP4A may be a useful marker for the measurement of dense granule content in platelets.     

UTILITY OF BONE MARROW AND LIVER BIOPSIES FOR STAGING CUTANEOUS T-CELL LYMPHOMA

Background. The wide use of staging procedures, looking for visceral involvement in patients with cutaneous T-cell lymphoma (CTCL), is controversial, especially in the early stages. In this study, we analyzed the results of bone marrow biopsy and laparoscopy with liver biopsy in a series of 43 patients with CTCL. Methods. Clinicopathologic stages were established by a modification of the TNM system proposed in 1979. Results of staging procedures were correlated with blood cell counts and laboratory tests. The usefulness of the staging procedures was analyzed particularly in patients without clinical or biologic evidence of extracutaneous disease. Results. The patient's median age was 66 years; 35 patients were men and eight women. The clinicopathologic stages were as follows: T1: 3 cases; T2: 15; T3: 14; T4: 11; NO: 15; N1: 28; MO: 38; Ml: 5; BO: 37; and B1: 6 cases. Internal lymph node disease, diagnosed by lymphangiography and/or abdominal scanning, was demonstrated in 37% of patients. Bone marrow infiltration was seen in 12% of patients and was the only form of visceral involvement. All liver biopsies were negative. Serum lactate dehydrogenase (LDH) levels were raised in patients with lymph node disease; it was the only laboratory test that correlated with extracutaneous involvement. Staging procedures changed three of the nine patients with a clinical T1-T2N0M0B0 stage (33%) to a more advanced stage. The abdominal lymph node evaluation allowed a reclassification from NO to N1 in two of nine cases (22%); one of the remaining cases was reclassified from MO to M1 on the basis of bone marrow biopsy results. Conclusions. Our results indicate that bone marrow biopsy is a useful investigational procedure for determining extracutaneous disease in CTCL. Peritoneoscopy with liver biopsy rarely is informative; however, as our study does not include a very large number of patients, these preliminary conclusions must be confirmed in the future by including more cases.     

Differences in the catalytic efficiencies of allelic variants of glutathione transferase P1-1 towards carcinogenic diol epoxides of polycyclic aromatic hydrocarbons

Previous studies have identified allelic variants of the human glutathione transferase (GST) Pi gene and showed that the two different encoded proteins with isoleucine (GSTP1-1/I-105) or valine (GSTP1-1/V- 105) at position 105, respectively, differ significantly in their catalytic activities with model substrates. Moreover, recent epidemiological studies have demonstrated that individuals differing in the expression of these allelic variants also differ in susceptibility to tumour formation in certain organs, including such in which polycyclic aromatic hydrocarbons (PAH) may be etiological factors. In the present study the catalytic efficiencies (kcat/Km) of these GSTP1-1 variants were determined with a number of stereoisomeric bay-region diol epoxides, known as the ultimate mutagenic and carcinogenic metabolites of PAH, including those from chrysene, benzo[a]pyrene and dibenz[a,h]anthracene. In addition, GSTP1-1 mutants in which amino residue 105 is alanine (GSTP1-1/A-105) or tryptophan (GSTP1-1/W-105) have been constructed and characterized. GSTP1-1/V-105 was found to be more active than GSTP1-1/I-105 in conjugation reactions with the bulky diol epoxides of PAH, being up to 3-fold as active towards the anti- and syn-diol epoxide enantiomers with R-absolute configuration at the benzylic oxiranyl carbon. Comparing the four enzyme variants, GSTP1-1/A- 105 generally demonstrated the highest kcat/Km value and GSTP1-1/W-105 the lowest with the anti-diol epoxides. A close correlation was observed between the volume occupied by the amino acid residue at position 105 and the value of kcat/Km. With the syn-diol epoxides, such a correlation was observed with alanine, valine and isoleucine, whereas tryptophan was associated with increased kcat/Km values. The mutational replacement of isoleucine with alanine or tryptophan at position 105 did not alter the enantio selectivity of the GSTP1-1 variants compared with the naturally occurring allelic variants GSTP1-1/I-105 and GSTP1- 1/V-105. Since the amino acid at position 105 forms part of the substrate binding site (H-site) the effect of increasing bulkiness is expected to cause restricted access of the diol epoxide and proper alignment of the two reactants for efficient glutathionylation. In conclusion, the present study indicates that individuals who are homozygous for the allele GSTP1* B (coding for GSTP1-1/V-105) display a higher susceptibility to malignancy because of other factors than a decreased catalytic efficiency of GSTP1-1/V-105 in the detoxication of carcinogenic diol epoxides of benzo[a]pyrene or structurally related PAH.