Tuberculosis surveillance and its discontents: the ethical paradox.

In June 2017, the World Health Organization issued the Guidelines on Ethical Issues in Public Health Surveillance. Using the frame of public health ethics, the guidance declared that countries have an affirmative duty to undertake surveillance and that the global community had an obligation to support those countries whose resources limited their capacity. The centrality of TB surveillance has long been recognized as a matter of public health practice and ethics. Nevertheless, contemporary global realities make clear that TB surveillance falls far short of the goal of uniform notification. It is this reality that necessitated the paradoxical turn to research studies that require informed consent and human subjects' ethical review, the very burdens that mandated notification were designed to overcome.

Suicide by the intraoral blast of firecrackers - experimental simulation using a skull simulant model.

Suicides committed by intraorally placed firecrackers are rare events. Given to the use of more powerful components such as flash powder recently, some firecrackers may cause massive life-threatening injuries in case of such misuse. Innocuous black powder firecrackers are subject to national explosives legislation and only have the potential to cause harmless injuries restricted to the soft tissue. We here report two cases of suicide committed by an intraoral placement of firecrackers, resulting in similar patterns of skull injury. As it was first unknown whether black powder firecrackers can potentially cause serious skull injury, we compared the potential of destruction using black powder and flash powder firecrackers in a standardized skull simulant model (Synbone, Malans, Switzerland). This was the first experiment to date simulating the impacts resulting from an intraoral burst in a skull simulant model. The intraoral burst of a "D-Böller" (an example of one of the most powerful black powder firecrackers in Germany) did not lead to any injuries of the osseous skull. In contrast, the "La Bomba" (an example of the weakest known flash powder firecrackers) caused complex fractures of both the viscero- and neurocranium. The results obtained from this experimental study indicate that black powder firecrackers are less likely to cause severe injuries as a consequence of intraoral explosions, whereas flash powder-based crackers may lead to massive life-threatening craniofacial destructions and potentially death.

Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion.

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

Nodular pulmonary amyloidosis with spontaneous fatal blood aspiration.

Amyloidosis is a multisystem disease, which is characterized by the extracellular deposition of insoluble abnormal fibrils. Histological and subsequent immunohistochemical examinations are necessary for the determination of the diagnosis and the classification of the amyloid type. The most common systemic variant is immunoglobulin-derived light chain (AL) amyloidosis. However, local or organ-limited AL amyloidosis can occur. Isolated pulmonary amyloidosis is a rare condition and frequently an incidental finding at chest scans or during autopsy. Generally, it is associated with a benign prognosis. Here, we present two fatal cases, in which the cause of death was asphyxiation due to severe blood aspiration. During autopsy, several nodules were found in the lungs. Based on histological and immunohistochemical analysis, the diagnosis of an isolated nodular pulmonary AL amyloidosis lambda light chain was made. Amyloid was also present in pulmonary blood vessels, which lead to fragility and finally fatal hemorrhage.

Rare cause of natural death in forensic setting: hemophagocytic syndrome.

We report about the case of a sudden unexpected death of a 25-year-old male suffering from infectious disease. An autopsy was ordered with no final premortem diagnosis. Microscopic and microbiological examination revealed a pneumococcal bronchopneumonia and hemophagocytic lesions in the bone marrow. After integrating clinical and autopsy reports as well as additional postmortem investigations, the cause of death was found to be infectious-triggered hemophagocytic syndrome (HPS) with a final cytokine storm. This seems to be the first reported fatal case of a reactive form of HPS associated to Streptococcus pneumoniae to the best of our knowledge. HPS is a dangerous hyperinflammation with highly characteristic, but nonspecific, laboratory findings and symptoms. Autopsies in such cases must be carefully performed and include systematic tissue sampling done by an experienced pathologist.

Partial amputation of the tongue--self-inflicted or physical assault?

Injuries of the tongue are generally self-inflicted lesions and occur during different diseases or external incidents. The amputation of the tongue is a rare event. In this article, we report about a woman presenting with a complete amputation of the anterior third of the tongue. The morphological findings, which are essential for the differentiation of self-inflicted injuries and injuries caused by a third party, are demonstrated.

The ethics of clinical and epidemiological research.

The global burden of tuberculosis (TB) demands that research be undertaken. The vulnerability of the populations most at risk for TB demands that such research be subject to ethical review to protect their rights and interests. In this brief article we cannot review the vast and important literature bearing on the ethics of clinical and epidemiological research and public health surveillance. Instead, we have focused on three questions that have been at the center of discussion and debate and which have special relevance for TB. First, we examine a question that has special bearing when wealthy nations or international organizations carry out research in poor countries: what does justice require in the post trial period? Second, we examine the question of how the principles of consent and confidentiality may require modification in record-based epidemiological research. Third, we look at the challenges posed by public health surveillance, which in many cases requires case reporting by clinicians to public health agencies. By way of conclusion, we take note of the centrality of enhancing the institutional capacities for ethical review of research in poor nations.

Point-of-use water filtration reduces healthcare-associated infections in bone marrow transplant recipients.

Outbreaks of infection with gram-negative bacteria (GNB) have been linked to hospital water. We sought to determine whether point-of-use (POU) water filtration might result in decreased risk of infection in hospitalized bone marrow transplant (BMT) recipients in the absence of any recognized outbreak. Unfiltered water was sampled from taps in the BMT unit of a major US teaching hospital, and cultured at a reference laboratory. POU bacterial-retentive filters (0.2 mum) were installed throughout the unit, and replaced every 14 days. Infection rates were tracked over a 9-month period, and compared with rates for a 16-month period before POU filtration. Unfiltered water samples from 50% (2 of 4) outlets sampled grew P. aeruginosa (2 of 4) and Stenotrophomonas maltophilia (1 of 4). Clinical infection rates in the unit were significantly reduced from 1.4 total and 0.4 GNB infections per 100 patient days in the period before POU filtration to 0.18 total and 0.09 GNB infections per 100 patient days (P=0.0068 and 0.0431, respectively) in the 9-month period for which filters were in place. Infections during the POU filtration period were due to non-waterborne organisms. Point-of-use (POU) water filtration may significantly reduce infection rates in BMT recipients in the absence of any recognized outbreak.

Laser-induced fluorescence to discriminate between a dental composite resin and tooth.

PURPOSE: Investigation of laser-induced fluorescence of an experimental pigment (Flu) to discriminate between a filling and the tooth and its influence on the material properties of experimental dental composites. MATERIALS AND METHODS: Three experimental composites (EC) were manufactured. The standard contained no Flu, Flu-0.5 contained 0.5%, Flu-1.0 contained 1%. To judge the extent of fluorescence, specimens and fillings placed in natural teeth were irradiated with an infrared laser (980 nm, 120 mW). Flexural strength, modulus of elasticity, depth of cure, water sorption, solubility, and color (CIE-L(*)a(*)b(*)-values) were measured to investigate the influence of Flu on EC. ANOVA was calculated and the statistical significance was p < 0.05. RESULTS: Strong laser-induced green fluorescence was observed so that fillings and tooth structures were clearly discriminated. No influence of Flu on flexural strength and modulus of elasticity occurred. Water sorption and solubility were far below the limits of EN ISO 4049. Increasing Flu concentrations revealed minor but significant reduction of depth of cure, shifts to more white and red and less yellow. SIGNIFICANCE: Flu provides laser-induced fluorescence allowing an easy discrimination between fillings and teeth. Flu did not severely influence the material properties.

Early oriented isothermal crystallization of polyethylene studied by high-time-resolution SAXS/WAXS.

During cooling from the quiescent melt of a highly oriented polyethylene rod, highly oriented proto-lamellae are formed first, which are not crystalline. This is shown in scattering data which are recorded on two-dimensional detectors with a cycle time of 1 s and an exposure of 0.1 s. In the experiments small-angle X-ray scattering (SAXS) and wide-angle X-ray scattering (WAXS) are registered simultaneously during the first 3 min after quenching to a crystallization temperature. A non-uniform thickness between 20 and 100 nm is characteristic for the ensemble of proto-lamellae. During the first minute of isothermal treatment the number of proto-lamellae slowly increases without a change of the thickness distribution. As crystallization starts, the crystallites are not oriented in contrast to the proto-lamellae. During crystallization the layer thickness distribution narrows. The number of lamellae rapidly increases during the following 2 min of isothermal treatment (at 128 degrees C and 124 degrees C). The results are obtained by interpretation of the WAXS and of the multidimensional chord distribution function (CDF), a model-free real-space visualization of the nanostructure information contained in the SAXS data.

Characterization of Vibrio fluvialis-like strains implicated in limp lobster disease.

Studies were undertaken to characterize and determine the pathogenic mechanisms involved in a newly described systemic disease in Homarus americanus (American lobster) caused by a Vibrio fluvialis-like microorganism. Nineteen isolates were obtained from eight of nine lobsters sampled. Biochemically, the isolates resembled V. fluvialis, and the isolates grew optimally at 20 degrees C; none could grow at temperatures above 23 degrees C. The type strain (1AMA) displayed a thermal reduction time (D value) of 5.77 min at 37 degrees C. All of the isolates required at least 1% NaCl for growth. Collectively, the data suggest that these isolates may embody a new biotype. Pulsed-field gel electrophoresis (PFGE) analysis of the isolates revealed five closely related subgroups. Some isolates produced a sheep hemagglutinin that was neither an outer membrane protein nor a metalloprotease. Several isolates possessed capsules. The isolates were highly susceptible to a variety of antibiotics tested. However, six isolates were resistant to erythromycin. Seventeen isolates harbored plasmids. Lobster challenge studies revealed that the 50% lethal dose of a plasmid-positive strain was 100-fold lower than that of a plasmid-negative strain, suggesting that the plasmid may enhance the pathogenicity of these microorganisms in lobsters. Microorganisms that were recovered from experimentally infected lobsters exhibited biochemical and PFGE profiles that were indistinguishable from those of the challenge strain. Tissue affinity studies demonstrated that the challenge microorganisms accumulated in heart and midgut tissues as well as in the hemolymph. Culture supernatants and polymyxin B lysates of the strains caused elongation of CHO cells in tissue culture, suggesting the presence of a hitherto unknown enterotoxin. Both plasmid-positive and plasmid-negative strains caused significant dose-related intestinal fluid accumulations in suckling mice. Absence of viable organisms in the intestinal contents of mice suggests that these microorganisms cause diarrhea in mice by intoxication rather than by an infectious process. Further, these results support the thermal reduction data at 37 degrees C and suggest that the mechanism(s) that led to fluid accumulation in mice differs from the disease process observed in lobsters by requiring neither the persistence of viable microorganisms nor the presence of plasmids. In summary, results of lobster studies satisfy Koch's postulates at the organismal and molecular levels; the findings support the hypothesis that these V. fluvialis-like organisms were responsible for the originally described systemic disease, which is now called limp lobster disease.

The laser diffractoscope - a new and fast system to analyse red blood cell flexibility with high accuracy.

Red blood cell (RBC) flexibility is one of the determining parameters of the microcirculation. As capillaries are smaller in diameter than RBC, RBC can only pass through by deformation. Reduced flexibility is associated with a reduced microcirculation. In obstetrics, pre-eclampsia and intrauterine growth retardation are regarded as diseases exhibiting a reduced microcirculation. With this new system it might be possible to achieve new data concerning the microcirculation in these diseases. The laser diffractoscope is based on laser light diffraction and computer-assisted image analysis. It offers the ability to determine the flexibility of RBC in whole blood with high accuracy between 0 and 30 Pa. Two hundred microlitres of whole blood are required, and the analysis is carried out in less than 5 min, with a standard deviation < or =1%. The laser diffractoscope is a new system which offers the ability to measure RBC deformability with high accuracy in a short time. Evaluation of reproducibility and validity, as well as comparison with data from other measuring systems, proves the excellence of the laser diffractoscope. An example of its application is shown by analysing the deformability of RBC in 10 uncomplicated pregnancies at term.

Efficacy and safety of gemtuzumab ozogamicin in patients with poor-prognosis acute myeloid leukemia.

The objective of this work was to determine the safety and efficacy of gemtuzumab ozogamicin in patients with poor prognosis acute myeloid leukemia (AML). Patients with the following diagnoses/characteristics were treated with 1-3 infusions of gemtuzumab ozogamicin at a dose of 9 mg/m2: (1) relapse of AML < or = 6 months of first complete remission (CR); (2) AML refractory to chemotherapy at initial induction or at first relapse; (3) AML in second or greater relapse; (4) myeloid blast crisis of chronic myeloid leukemia (CML); (5) untreated patients > or = 70 years or > or = 55 years with abnormal cytogenetics (excluding inv 16, t(15;17) and t(8;21)) and/or an antecedent hematologic disorder; (6) refractory anemia with excess blasts in transformation (RAEBT). Forty-three patients, ages 19-84 (mean 62), were treated, including 7 patients with untreated AML age > 70 years, 2 with untreated RAEBT, 14 with AML first salvage (first remission 0-6 months), 15 with AML > or = second salvage and 14 with myeloid blast phase of CML. The overall response rate was 14%, with 4/43 (9%) patients achieving CR and 2/43 (5%) achieving CR without platelet recovery. The most significant toxicity was neutropenic fever, which occurred in 84% of patients. In conclusion, in patients with relapsed/refractory AML, gemtuzumab ozogamicin has a comparable response rate to single-agent chemotherapy and may offer a more favorable toxicity profile.

Molecular phylogeny of hybridizing species from the genus Spartina Schreb. (Poaceae).

Interspecific hybridization events have been reported in the genus Spartina Schreb. (Poaceae), involving the east American species Spartina alterniflora, and including either introgression (e.g., with the western American Spartina foliosa) or allopolyploid speciation (e.g., with the Euro-African Spartina maritima). Molecular phylogenetic analysis of the genus has been undertaken in order to understand phylogenetic relationships and genetic divergence among these hybridizing species. Twelve Spartina species have been sequenced for two nuclear DNA regions (ITS of ribosomal DNA, and part of the Waxy gene) and one chloroplast DNA spacer (trnT-trnL). Separate and conditional combined phylogenetic analyses using Cynodon dactylon as the outgroup have been conducted. Spartina is composed of two lineages. The first clade includes all hexaploid species: the Euro-African S. maritima (2n = 60), the East-American S. alterniflora (2n = 62) and the West-American S. foliosa (2n = 60). Spartina alterniflora appears as a closely related sister species to S. foliosa. Although belonging to the same lineage, Spartina maritima appears consistently more genetically differentiated from S. alterniflora than S. foliosa. The tetraploid species S. argentinensis (2n = 40) is placed at the base of this first clade according to the Waxy data, but its position is not well resolved by the other sequences. The second well-supported main lineage within genus Spartina includes the other tetraploid American species. Significant incongruence has been encountered between the waxy based tree and both the ITS and trnT-trnL trees concerning the position of S. densiflora, suggesting a possible reticulate evolution for this species. The results agree with hybridization patterns occurring in Spartina: introgression involving closely related species (S. alterniflora and S. foliosa) on one hand, and alloploid speciation involving more differentiated species (S. alterniflora and S. maritima) on the other hand.

A phase II trial evaluating the safety and effectiveness of the AastromReplicell system for augmentation of low-dose blood stem cell transplantation.

To reduce the number of apheresis procedures and maintain the usual rate of hematopoietic recovery in patients treated with high-dose chemotherapy, we studied the effect of adding a small volume of ex vivo expanded bone marrow to low doses of CD34(+) blood stem cells. Thirty-four patients with breast cancer received G-CSF (10 microg/kg/day) priming followed by a limited volume (50-100 ml) bone marrow aspiration and standard 10-liter aphereses. Marrow was expanded ex vivo using the AastromReplicell system and infused along with low doses of blood-derived CD34(+) cells, collected in one apheresis. Thirty-one evaluable patients received a median CD34(+) blood stem cell dose of 0.7 x 10(6)/kg (range, 0.2-2.5) and 4.7 x 10(7) nucleated cells/kg (range, 1.98-8.7) of ex vivo expanded marrow. All patients recovered with normal blood counts and engrafted 500 neutrophils/microl and 20 000 platelets/microl in a median of 10 and 13 days, respectively. Multivariate analysis revealed that, in addition to CD34(+) lineage negative cell quantity, the quantity of stromal progenitors contained in the ex vivo expanded product correlated with engraftment outcome (r = 0.551, P = 0.004). Our results indicate that ex vivo expanded bone marrow is capable of facilitating engraftment when combined with low doses of mobilized blood derived CD34(+) cells.

Molecular phylogenetics of Acacia (Fabaceae: Mimosoideae) based on the chloroplast MATK coding sequence and flanking TRNK intron spacer regions.

The tribe Acacieae (Fabaceae: Mimosoideae) contains two genera, the monotypic African Faidherbia and the pantropical Acacia, which comprise about 1200 species with over 950 confined to Australia. As currently recognized, the genus Acacia is subdivided into three subgenera: subg. Acacia, subg. Aculeiferum, and the predominantly Australian subg. Phyllodineae. Morphological studies have suggested the tribe Acacieae and genus Acacia are artificial and have a close affinity to the tribe Ingeae. Based on available data there is no consensus on whether Acacia should be subdivided. Sequence analysis of the chloroplast trnK intron, including the matK coding region and flanking noncoding regions, indicate that neither the tribe Acacieae nor the genus Acacia are monophyletic. Two subgenera are monophyletic; section Filicinae of subgenus Aculeiferum does not group with taxa of the subgenus. Section Filicinae, eight Ingeae genera, and Faidherbia form a weakly supported paraphyletic grade with respect to subg. Phyllodineae. Acacia subg. Aculeiferum (s. s.) is sister to the grade. These data suggest that characters currently used to differentiate taxa at the tribal, generic, and subgeneric levels are polymorphic and homoplasious in cladistic analyses.

Pilot trial of interleukin-2 with granulocyte colony-stimulating factor for the mobilization of progenitor cells in advanced breast cancer patients undergoing high-dose chemotherapy: expansion of immune effectors within the stem-cell graft and post-stem-cell infusion.

PURPOSE: To evaluate whether administration of interleukin-2 (IL-2) with granulocyte colony-stimulating factor (G-CSF) improves mobilization of immune effector cells into the stem-cell graft of patients undergoing high-dose chemotherapy and autografting. PATIENTS AND METHODS: We performed a trial of stem-cell mobilization with IL-2 and G-CSF in advanced breast cancer patients receiving high-dose chemotherapy with cyclophosphamide, thiotepa, and carboplatin and stem cells followed by IL-2. The trial defined immune, hematologic, and clinical effects of IL-2 in this setting. RESULTS: Of 32 patients enrolled, nine received G-CSF alone for mobilization. Twenty-one of 23 patients mobilized with IL-2 plus G-CSF had stem cells collected with more mononuclear cells than those receiving G-CSF (19.3 v 10.4 x 10(8)/kg; P =.006), but fewer CD34(+) progenitor cells (6.9 v 22.0 x 10(6)/kg; P =.049). The IL-2 plus G-CSF-mobilized patients had greater numbers of activated T (CD3(+)/CD25(+)) cells (P =.009), natural killer (NK; CD56(+)) cells (P =.007), and activated NK (CD56 bright(+)) cells (P: =.039) than those patients mobilized with G-CSF. NK (P =.042) and lymphokine-activated killer (LAK) (P =.016) activity was increased in those mobilized with IL-2 + G-CSF, whereas G-CSF-mobilized patients had a decline in cytolytic activity. In the third week posttransplantation, immune reconstitution was superior in those mobilized with IL-2 plus G-CSF based on greater numbers of activated T cells (P =.003), activated NK cells (P =.04), and greater LAK activity (P =.003). The 16 of 21 IL-2 + G-CSF-mobilized patients with adequate numbers of stem cells (> 1.5 x 10(6) CD34(+) cells/kg) collected engrafted rapidly posttransplantation. CONCLUSION: The results demonstrate that G-CSF + IL-2 can enhance the number and function of antitumor effector cells in a mobilized autograft without impairing the hematologic engraftment, provided that CD34 cell counts are more than 1.5 x 10(6) cells/kg. Mobilization of CD34(+) stem cells does seem to be adversely affected. In those mobilized with IL-2 and G-CSF, post-stem-cell immune reconstitution of antitumor immune effector cells was enhanced.

A molecular phylogeny of the endemic Australian genus Gastrolobium (Fabaceae: Mirbelieae) and allied genera using chloroplast and nuclear markers.

Gastrolobium (Fabaceae: Mirbelieae) is an endemic Australian genus that produces toxic sodium monofluoroacetate. A phylogenetic reconstruction of Gastrolobium and the related genera Brachysema, Callistachys, Jansonia, Nemcia, Oxylobium, and Podolobium is presented, using sequence data from three regions-the psbA-trnH intergenic spacer and the trnK 5' intron from chloroplast DNA and the 3' end of the external transcribed spacer (ETS) from nuclear ribosomal DNA. Gastrolobium is shown to be paraphyletic, with Brachysema, Jansonia, Nemcia, and Oxylobium lineare nesting within it, and Nemcia is shown to be polyphyletic within Gastrolobium. Past key morphological characters, such as fluoroacetate content and characters associated with pollination syndrome, are shown to be homoplastic, with fluoroacetate possibly a plesiomorphic condition lost in more derived species. Podolobium is also shown to be polyphyletic, with the P. ilicifolium group sister to Gastrolobium and the P. alpestre group sister to Callistachys, a member of the Oxylobium group. It is recommended that Gastrolobium be expanded to include Brachysema, Jansonia, Nemcia, and Oxylobium lineare, while further work is required to test the sister-group relationship between Podolobium s.s. (sensu stricto) and Gastrolobium.