A case of primary lymphoma of the rectum

The Authors describe a case of primary rectal lymphoma. The primitive involvement of this area is infrequent. The Authors emphasize the difficulty of preoperative diagnosis. The therapeutic approach should allow for correct staging which is only obtained by means of diagnostic studies aimed at excluding multicentric localisation. Sensitivity to radiotherapy has led the Authors to propose it as primary treatment, at least in stage I; surgery must be considered elective in stage II or in cases of need. Chemotherapy is indicated alone or in association with radiotherapy or surgery.     

Dilating guide wire: use of a new ultra-low-profile percutaneous transluminal coronary angioplasty system

The following case reports represent two examples using the newly released Dilating Guide Wire. The balloon-wire system is specifically designed to be used as a steerable percutaneous transluminal coronary angioplasty (PTCA) guide wire. It can be utilized as a predilatation device in combination with a standard PTCA dilating balloon or as a free-standing dilatation catheter. As applied to the following situations, predilatation proved to be an effective time- and step-saving approach when confronting severely stenosed coronary artery lesions.     

Long-term results of laryngotracheal resection for benign stenosis.

OBJECTIVE: We report the long-term results of our 16-year experience with laryngotracheal resection for benign stenosis. METHODS: Between 1991 and 2006, 35 consecutive patients (19 males, 16 females) underwent laryngotracheal resection for subglottic postintubation (32) or idiopathic (3) stenosis. Mean age was 43 years (range 14-71). At the time of surgery 13 patients presented with tracheostomy and 7 with a Dumon stent. The upper limit of the stenosis was from 0.6 to 1.5 cm below the vocal cords. The length of airway resection ranged between 1.5 and 6 cm. Suprahyoid release was performed in two patients and pericardial release in one. Nine patients had psychiatric and/or neurological post-coma disorders. Mean follow-up is over 5 years (61 months; range 3-194). RESULTS: There was no perioperative mortality. Thirty patients (85.7%) had excellent or good anatomic and functional results. Four patients (11.4%) presented restenosis at a distance of 25-110 days from the operation. Restenosis was successfully treated by endoscopic procedures in all four patients. One patient (2.9%) presented anastomotic dehiscence that required temporary tracheostomy closed after 1 year with no sequelae. Three patients (8.4%) had wound infection. Long-term follow-up was uneventful also in patients who had early complications. CONCLUSIONS: Long-term follow-up confirms that laryngotracheal resection is the definitive curative treatment for benign subglottic stenosis. Surgical complications can be successfully managed by non-operative procedures. Despite the occurrence of early complications, excellent and stable results can still be obtained at long term.     

Murder, insanity, and medical expert witnesses.

Recent advances in the ability to study brain anatomy and function and attempts to link these findings with human behavior have captured the attention of the legal system. This had led to the increasing use of the "neurological defense" to support a plea of not guilty by reason of insanity. This article explores the history of the insanity defense and explores the role of the medical expert witnesses in integrating clinical and laboratory findings, eg, computed tomographic scans, magnetic resonance scans, and single-photon emission computed tomographic scans. Three cases involving murder and brain dysfunction are discussed: the first case involves a subarachnoid hemorrhage resulting in visual perceptual and memory impairment; the second case, a diagnosis of Alzheimer's disease; and the third case, the controverted diagnosis of complex partial seizures in a serial killer.     

CD16 surface molecules regulate the cytolytic function of CD3CD16+ human natural killer cells

Monoclonal (IgG) antibodies (MAbs) directed to CD16 molecules efficiently induced lysis of the IgG-binding P815 target cells. A similar effect was observed with selected anti-CD2 MAbs. While combinations of 2 appropriate anti-CD2 MAbs were required for induction of T lymphocyte activation, single stimulatory anti-CD2 MAbs were sufficient for inducing cytolytic function in CD3- CD16+ lymphocytes. In order to study possible regulatory mechanisms existing in the process of activation and induction of the cytolytic machinery of CD3- CD16+ effector cells, we utilized the anti-CD16 OKNK MAb. Being of IgM isotype, the OKNK MAb does not allow cross-linking between CD3- D16+ lymphocytes and target cells. Pre-treatment of effector cells with OKNK MAb sharply inhibited the target cell lysis induced by either anti-CD16 (IgG) MAbs or stimulatory anti-CD2 MAb. Moreover, a strong inhibitory activity of PHA-induced target cell lysis and even of "spontaneous" lysis (at high effector:target ratio) was observed. In contrast, in CD3+ CD16+ clones, OKNK MAb selectively inhibited the cell triggering induced by anti-CD16 MAbs (but not by anti-CD3, anti-CD2 MAbs or PHA). Our data indicate that CD16 receptor molecules expressed by CD3- CD16+ lymphocytes down-regulate cell responses to anti-CD2 MAbs or PHA, and then exert a regulatory role in the cytolytic function of these cells.     

Self class I molecules protect normal cells from lysis mediated by autologous natural killer cells

The surface expression of given HLA class I alleles protects target cells from lysis mediated by natural killer (NK) clones specific for these (or related) alleles. We could define two groups of NK clones specifically recognizing either Cw4 and related C alleles (“group 1”) or Cw3 and related C alleles (“group 2”), respectively. Monoclonal antibodies (mAb) to class I molecules should interfere with the interaction between NK receptors and class I molecules, thus resulting in lysis of protected target cells. However, none of the numerous available mAb to class I molecules had this effect. Therefore, we attempted to select new mAb on the basis of their ability to induce lysis of Cw4- or Cw3-protected lymphoblastoid cell lines by “group 1” or “group 2” NK clones, respectively. From mice immunized with phytohemagglutinin (PHA)-activated lymphocytes expressing either Cw3 or Cw4 alleles, two mAb were selected, the 6A4 (IgG1) and the A6-136 (IgM), on the basis of their ability to induce lysis of protected target cell. Both mAb immunoprecipitated molecules which, in sodium dodecyl sulfate-polyacrylamide gel electrophoresis, gave two bands of 45 and 12 kDa, typical of the class I heavy chain and β2 microglobulin, respectively. It has been proposed (but not proven), that self major histocompatibility complex class I molecules protect normal cells from autologous NK cell lysis. Thus, we used the 6A4 and A6-136 mAb to assess this possibility directly. Cw4-specific (“group 1”) and Cw3-specific (“group 2”) NK clones were isolated from donors expressing the corresponding (or related) protective C alleles. None of these clones lysed autologous PHA-induced blasts, used as target cells. However, addition of the F(ab′)₂ of 6A4 mAb or the A6-136 mAb resulted in lysis of autologous target cells by “group 1” or “group 2” NK clones, respectively. These data provide direct evidence that the expression of class I molecules protects normal cells from lysis by autologous NK cells.     

Specificity of human T lymphocytes expressing a gamma/delta T cell antigen receptor. Recognition of a polymorphic determinant of HLA class I molecules by a gamma/delta clone

Alloreactive clones expressing T cell receptor (TcR) gamma/delta were derived by limiting dilution from CD3+ CD4- CD8- WT31- populations stimulated in allogeneic mixed lymphocyte culture. These clones specifically lysed phytohemagglutinin-induced blast cells bearing the stimulating alloantigens, whereas they had no effect on autologous or allogeneic unrelated target cells. Analysis of the reactivity with monoclonal antibodies (mAb) specific for two different subsets of TcR gamma/delta (BB3 and delta-TCS-1) showed that five out of nine clones were BB3+, whereas the remaining reacted with delta-TCS-1. Therefore, we can conclude that both subsets of TcR gamma/delta+ cells are able to specifically recognize and lyse allogeneic cells. mAb directed against the CD3-TcR gamma/delta molecular complex strongly inhibited the specific cytolytic activity of TcR gamma/delta+ clones, whereas they had no effect on the lysis of the natural killer-sensitive K-562 target cells mediated by the same clones. An alloreactive delta-TCS-1+ clone (LM12) was further characterized for its specificity. LM12 clone had been derived after stimulation in mixed lymphocyte culture against donor M.M. (HLA typing: Aw68, 24; B35, w55; DR1, 7). The analysis of a large panel of phytohemagglutinin-induced target cells revealed that only the HLA-A24+ target cells were lysed. The direct evidence that the A24 molecule represented the restriction element was provided by experiments using A24-transfected murine P815 target cells. Thus, clone LM12 efficiently lysed A24-transfected P815 cells, but not the same cells untransfected or transfected with the Cw3 gene. Therefore, it appears that polymorphic determinants of class I major histocompatibility complex molecules can be the target of TcR gamma/delta+ alloreactive cell recognition.     

Social class, mode of admission, severity of illness and hospital mortality: an analysis with "All patient refined DRG" of discharges from the Molinette hospital in Turin

Data available from the standard hospital discharge database (SDO) allow us to explore differences in health conditions according to different indicators of socioeconomic status (SES). We analysed all the patients aged 30-59, discharged from the S. Giovanni Battista (Molinette) hospital (the main general hospital in Turin, Italy) during three years (1996-1998) (n = 49949). Three health indicators were used as outcomes: a) emergency admission; b) severity of illness (according to the "All Patient Refined DRGs" subclasses); c) hospital mortality. Patients were compared for each outcome according to two different SES indicators: a) level of education; b) employment status. Logistic regression models (both conditional and unconditional) were used to adjust for several potential confounders. Patients with lower education (up to 5 years of schooling), compared to those with 13 or more years of schooling, showed a higher probability of being admitted through the emergency ward (29.1% vs 23.3%), with an odds ratio (OR) = 1.56-95% confidence interval (95% CI) = 1.45-1.68; of being classified in higher severity subclasses of illness (23.3% vs 17.7%, OR = 1.14; 95% CI = 1.07-1.22) and of dying in hospital (2.3% vs 1.6%). However, after adjustment for other prognostic factors (as severity of illness and specific expected mortality), this association disappeared (OR = 1.05, 95% CI = 0.84-1.32). Similar, but somewhat stronger, associations were observed when comparing the unemployed versus the employed. The corresponding figures (ORs; 95% CI) were 1.57 (1.42-1.74) for emergency admission; 1.31 (1.18-1.45) for severity of illness and 1.55 (1.10-2.16) for hospital mortality. In conclusion, this study showed that SES differentials in health are clearly measurable through routine hospital information systems, and documented that patients of low SES, particularly unemployed, experienced a delayed access to hospital, were admitted in poorer general health conditions and had a more unfavourable prognosis.