Induction of systemic antifimbria and antitoxin antibody responses in Egyptian children and adults by an oral, killed enterotoxigenic Escherichia coli plus cholera toxin B subunit vaccine.

We assessed serologic responses to an oral, killed whole-cell enterotoxigenic Escherichia coli plus cholera toxin B-subunit (ETEC-rCTB) vaccine in 73 Egyptian adults, 105 schoolchildren, and 93 preschool children. Each subject received two doses of vaccine or placebo 2 weeks apart, giving blood before immunization and 7 days after each dose. Plasma antibodies to rCTB and four vaccine-shared colonization factors (CFs) were measured by enzyme-linked immunosorbent assay. Immunoglobulin A (IgA) antibodies to rCTB and CFA/I were measured in all subjects, and those against CS1, CS2, and CS4 were measured in all children plus a subset of 33 adults. IgG antibodies to these five antigens were measured in a subset of 30 to 33 subjects in each cohort. Seroconversion was defined as a >2-fold increase in titer after vaccination. IgA and IgG seroconversion to rCTB was observed in 94 to 95% of adult vaccinees, with titer increases as robust as those previously reported for these two pediatric cohorts. The proportion showing IgA seroconversion to each CF antigen among vaccinated children (range, 70 to 96%) and adults (31 to 69%), as well as IgG seroconversion in children (44 to 75%) and adults (25 to 81%), was significantly higher than the corresponding proportion in placebo recipients, except for IgA responses to CS2 in adults. IgA anti-CF titers peaked after one dose in children, whereas in all age groups IgG antibodies rose incrementally after each dose. Independently, both preimmunization IgA titer and age were inversely related to the magnitude of IgA responses. In conclusion, serologic responses to the ETEC-rCTB vaccine may serve as practical immune outcome measures in future pediatric trials in areas where ETEC is endemic.

Detection of cellular and humoral markers (IL-2, IFN-gamma and IgE) in sera of patients with urinary schistosomiasis.

Schistosomiasis continues to be major health problem throughout the developing world. Infection with Schistosoma haematobium is associated with very high morbidity. The work aimed at the determination of role of cellular immune response (IL-2, and IFN-gamma) and specific humoral IgE in protective immunity in human urinary schistosomiasis, as a function of both age and infection intensity including examination of changes in immunoresponsiveness following curative therapy. The study revealed that IL-2,IFN-gamma level were higher in all patients compared to the normal control group and the levels were higher in lightly infected groups than heavily infected ones with no respect to age. IgE levels showed higher values compared to normal individuals and IgE levels were higher in children groups than in adults regardless of the intensity of infection. IL-2, IFN-gamma and IgE levels were higher in patients with mixed S. mansoni and S. haematobium infections than monoinfected patients. Follow up of patients 2 months, 4 months and 12 months after Praziquantel treatment showed that the level of IL-2 and IgE fell back to normal values after 4 months while IFN-gamma remained high, IL-2, IFN-gamma and IgE were raised once more after 12 months.

Right phrenic nerve: anatomy, CT appearance, and differentiation from the pulmonary ligament.

The pulmonary ligament appears on computed tomographic (CT) sections as a thin, high-attenuation line, frequently seen above or at the level of the diaphragm and usually extending from the region of the esophagus. However, another line coursing laterally from the midportion of the inferior vena cava has also been identified as the pulmonary ligament. The authors examined sections from eight cadavers and 80 chest CT examinations to more clearly delineate the pulmonary ligament from this second structure. Anatomic and CT correlation proves that the line seen at the midportion of the inferior vena cava represents the right phrenic nerve and that the right pulmonary ligament is located posterior to it.

Histological changes of the esophageal mucosa in bleeding versus non-bleeding varices.

There is considerable controversy as regards the exact cause of bleeding from esophageal varices. This study examined changes in the mucosa of such patients in an effort to understand the underlying mechanisms. Fifty patients were studied, 20 with a history of variceal bleeding and 30 without who served as controls. Endoscopic biopsies were taken from the inter-variceal mucosa within 5 cm from the cardia and were examined histopathologically. The results showed dilated intra-epithelial blood-filled channels within the squamous epithelium and the lamina propria in all bleeders, and in 50% of the non-bleeders. Evidence of esophagitis was also more pronounced in bleeders (50%) than in non-bleeders (23.3%). It is our opinion that esophagitis and the presence of dilated blood-filled channels may play a role in the initiation of variceal bleeding.

Management of causalgia after peripheral nerve injury.

The authors report on a series of patients with severely painful disorders of peripheral nerves--they review the modern theories on the nature of causalgia and reflex sympathetic dystrophy. Peripheral causes include spontaneous discharges from neuroma sprouts, their sensitivity to adrenergic compounds, ectopic generator activity in abnormally myelinated fires and increased firing in dorsal root ganglia. Central causes include spontaneous activity of deafferented nerves in the dorsal horn and development of response to new receptive fields. The natural history of such disorders is poor--many patients suffering pain for 10 years or more--the clinical picture is characterized by spontaneous burning pain and allodynia and hyperpathia, chronicity, osteoporosis, skin and nail changes and deformities. The basis of treatment is sympathetic blockade using intravenous guanethedine on alternate days. At least 6 blocks are given as the majority of patients do not respond until the 5th or 6th block. Each block is followed by desensitization and intensive rehabilitation. The authors emphasize that sympathetic blockade is only one, albeit the most important, modality in a multi-faceted treatment programme. Surgical attempts to relieve pain almost uniformly failed--causing as they do further neuronal changes peripherally and centrally. Recurrences depend on the degree of initial response. Those who obtained virtually complete relief of pain had a lower recurrence rate but a high proportion needed repeated sessions of treatment at yearly intervals. Follow-ups must therefore be indefinite.

The assessment and management of the failed back, Part II.

Despite adequate surgery a number of patients have a return of back pain and sciatica following operation, the so-called failed back. The results of a prospective study of 101 patients entering an intensive rehabilitation programme for the failed back is described. The programme consists of a team approach to the patient and his problems, using a variety of techniques to produce pain relief. Non-organic pain represents a significant problem in the failed back; 58% of patients were completely or substantially relieved of their pain. Transcutaneous nerve stimulation was found to be the single most useful treatment with exercise second. Non-organic pain was able to be relieved by this programme.

A comparative study of the aetiological factors in shoulder pain.

Sixty patients presenting consecutively with shoulder pain to a rheumatology clinic have been studied. There was a significant association of shoulder capsulitis with diabetes mellitus and antecedent trauma when compared with supraspinatus tendonitis (SST). There were no immunological or other biochemical differences between the capsulitis and SST patients. The results suggest that patients with shoulder capsulitis should be investigated to exclude diabetes mellitus particularly when there is no history of antecedent trauma.

A placebo-controlled trial of steroid injections in the treatment of supraspinatus tendonitis.

In this report of a double-blind placebo-controlled trial of steroid injections for supraspinatus tendonitis, there was no statistical difference in the improvement in pain score between the two groups at 2 and 8 weeks of follow-up or in analgesic consumption. This trial casts further doubt on the efficacy of such treatment in soft tissue lesions around the shoulder.

Sperm antibodies in serum and semen in men with bilateral congenital absence of the vas deferens.

Sperm antibodies were evaluated in serum and semen of 14 cases with bilateral congenital absence of the vas deferens, by agglutination and complement dependent tests. The level of the various immunoglobulin fractions were determined by the single radial immuno diffusion method. Sperm agglutinins were present in serum in 71% of cases and in 29% in semen. Immunoglobin (Ig) M was not detected in semen of both patient and control groups, while IgG and IgA were absent in the semen of patients.

Stabilizing mechanisms preventing anterior dislocation of the glenohumeral joint.

We investigated the stabilizing mechanism of the glenohumeral joint that prevents anterior dislocation by anatomical dissections of the subscapularis, the shoulder capsule, and the superior, middle, and inferior glenohumeral ligaments in thirty-six shoulders of embalmed cadavera. We also performed roentgenographic studies of ten unembalmed cadaver shoulders in which radiopaque markers were used to demonstrate the position, tightness, and laxity of the subscapularis muscle and of the middle and inferior glenohumeral ligaments during external rotation of the shoulder at zero, 45, and 90 degrees of abduction. The subscapularis muscle and the three glenohumeral ligaments were cut in different sequences to determine their relative contributions to stability (limitation of external rotation). The conclusions from these experiments were that at zero degrees of abduction, the subscapularis muscle stabilizes the joint to a large extent; at 45 degrees of abduction, the subscapularis, middle glenohumeral ligament, and anterosuperior fibers of the inferior glenohumeral ligament provide the stability; and as the shoulder approaches 90 degrees of abduction, the inferior glenohumeral ligament prevents dislocation during external rotation.

The anterior aspect of the knee joint.

The anterior structures of forty-eight knees were dissected analyzed quantitatively. Correlations were established among the twelve measured parameters of the distal quadriceps complex. Patellar height, width, and thickness tended to correlate with the dimensions of the soft-tissue structures and not with each other. To a high degree of predictability, the shape of the patella correlated with several parameters of the quadriceps complex. The width of the lateral patellofemoral ligament was the parameter most closely related to patellar shape.

Jaccoud's arthropathy. A case report and necropsy study.

We present a case of Jaccoud's arthropathy in a 59-year-old woman. She developed painless correctable ulnar deviation at the metacarpophalangeal joints of both hands following 4 attacks of rheumatic fever. Radiology did not show the hook lesions previously described, but we do not consider this sign essential for the diagnosis. There was no clinical evidence of rheumatoid arthritis. We were able to examine 3 complete joints from the left little finger at necropsy. Pathological examination of this kind has been possible only once before. The histological findings were fibrous thickening of the joint capsule, secondary degenerative changes, presumably due to longstanding joint deformity, and no evidence of significant synovial pathology.

The anterior cruciate ligament. A functional analysis based on postmortem studies.

In forty fresh human cadaver knees the function of the anterior cruciate ligament and of its two component parts, the posterolateral part and the anteromedial band, were studied by cutting these ligaments and others in different sequences and combinations and then manually stressing the knees. The anterior drawer sign cannot be obtained unless the anteromedial band is severed. The postolateral part and the medial collateral ligament are, respectively, the secondary and tertiary restraints limiting the anterior drawer sign. Both internal and external rotation are limited by the anterior cruciate ligament, especially when the knee is in extension. The anterior cruciate ligament also limits hyperextension.

The anterior drawer sign: what is it?

1. The anterior drawer is a test of anterior cruciate ligament integrity. 2. The anterior cruciate ligament is composed of two parts: the anteromedial band and the posterolater bulk. 3. The anteromedial band is the primary check against anterior drawer. 4. Other structures may contribute to the resistance of anterior drawer only if the anteromedial band has been injuried. 5. The posterior cruciate ligament is a check against posterior drawer. 6. In long term follow-up, the presence of anterior drawer is associated with poor overall results.

The cruciate ligaments of the knee joint. Anatomical, functional and experimental analysis.

The anatomical and functional details of the cruciate ligamants of the knee were studied on 20 cadaver knees and 24 fresh knees. Each anterior cruciate ligament was found to consist of 2 parts: a distinct anteromedial band (AMB) and a main posterolateral part. The exact geometry of the ligaments and their relationship to bony landmarks were recorded in detail. The state of the cruciate ligaments, i.e. tightness or looseness was recorded in the various positions of the knee as the basis for classification of the function of the various anatomical components. Selective cutting of the anterior cruciate ligament resulted in an increase of anterior drawer flexion and extension. External and internal rotation were increased in both flexion and extionsion. Hyperextension also was increased. It is suggested that the AMB of the anterior cruciate is responsible for the in anteroposterior drawer with flexion. The selective cutting of the posterior cruciate ligament demonstrated that it is important in the flexed knee and produces an.increased posterior drawer sign. Rotational stability was unchanged in extension, but altered in flexion after cutting the posterior cruciate.