Community-Acquired Pseudomonas aeruginosa Meningitis in a Pediatric Patient.

This case report presents a rare and significant case of community-acquired Pseudomonas aeruginosa meningitis in a healthy 13-month-old male patient in rural Liberia. Pseudomonas aeruginosa meningitis, particularly in the absence of predisposing factors, is a rare occurrence with a high mortality rate. The challenges in diagnosing this condition, especially in resource-limited settings, are highlighted. The patient initially presented with fever, seizures, and altered consciousness, and lumbar puncture revealed turbid cerebrospinal fluid (CSF) with elevated white blood cell count. Subsequent CSF culture confirmed Pseudomonas aeruginosa infection. Prompt initiation of appropriate antibiotic therapy, including a push dose of meropenem, resulted in clinical improvement. However, the patient exhibited post-meningitis sequelae, including hearing and visual impairments. Comprehensive follow-up care and rehabilitation services are crucial for managing these long-term complications. By sharing this case, we aim to increase awareness and facilitate early recognition of Pseudomonas aeruginosa meningitis, leading to improved patient care and outcomes in similar clinical scenarios.

Interference of the most frequent haemoglobin variants on quantification of HbA1c: comparison between the LC-MS (IFCC reference method) and three routinely used methods.

AIM: Assaying HbA1c in patients with haemoglobin variants has long been a technical challenge, despite methodological advances that have progressively limited the problem. The purpose of this study was to evaluate the impact of the most frequent haemoglobin variants on three routine separation methods compared with the IFCC reference method. PATIENTS: Blood samples from heterozygous patients (AS, AC, AD, AE) were analyzed using the IFCC reference method (LC-MS), and the results compared with those obtained by capillary electrophoresis (CAPILLARYS 2 Flex Piercing, Sebia) and two HPLC methods using cation-exchange (Variant II, Bio-Rad) and affinity chromatography (Ultra(2), Primus). RESULTS: HbA1c values obtained by the IFCC reference method were comparable to those obtained by the three tested methods whatever the haemoglobin variant. Mean relative biases did not exceed the threshold of 7% (above which differences are generally considered clinically significant), although some individual values were above this limit with Variant II in samples with HbS and for all three methods in samples with HbE. CONCLUSION: This comparative study of the LC-MS reference method and three field methods has demonstrated that these assays are not clinically influenced by the presence of the most common haemoglobin variants. The present results also confirm that the interpretation of HbA1c values in patients with Hb variants remains complex and depends on the assays used and should, in some cases, take into account parameters other than analytical ones (such as differences in glycation rates and half-lives of haemoglobin variants).

Evaluation of the In2it analyzer for HbA1c determination.

AIM: The prominent role of HbA(1c) in the follow-up of glycaemic balance in patients with diabetes mellitus necessitates the use of robust and reliable methods of assay. The purpose of this study was to evaluate the In2it analyzer, a new device allowing HbA(1c) evaluation within 10 min, using 10 microL of blood, in the laboratory or clinical unit, using an affinity-based method. METHODS: The analytical performance of the In2it analyzer was tested for precision, interference and linearity, and correlated with two other analyzers - the high-performance liquid chromatography (HPLC)-based Variant II analyzer in a laboratory, and the immunology-based DCA 2000 analyzer in a clinical unit - for practicability and its compliance with good laboratory practices. RESULTS: HbA(1c) assay is linear from 4 to 14%, with coefficients of variations ranging from 2.4 to 3.9%. In2it correlation was satisfactory with both the HPLC Variant II (r(2)=0.974, P<0.001) and DCA 2000 (r(2)=0.794, P<0.001) analyzers although, with the latter, unpredictable differences were randomly observed. However, the method is free of interference from common haemoglobin variants, labile glycated haemoglobin and carbamylated haemoglobin, hyperbilirubinaemia (<520 micromol/L) and hypertriglyceridaemia (<6 mmol/L). The practicability of the analyzer is good. However, software specifications need to be upgraded, especially for quality-control management, traceability of results and data safety. CONCLUSION: The In2it analyzer is suitable for HbA(1c) assay in small laboratory series and for point-of-care testing, and its analytical performance is satisfactory overall. However, several issues related to software need to be improved for optimal application. Also, special attention should be paid concerning the possibility of underestimation of results in cases of high hypertriglyceridaemia.

[Incidence of sample storage temperature on HbA 1c determination by high performance liquid chromatography method]. / Influence de la température de conservation sur le dosage d'HbA 1c par méthode de chromatographie liquide haute performance.

We have evaluated the conservation prior to HbA(1c) determination of three whole blood samples stored at -80 degrees C, -20 degrees C, 4 degrees C and 20 degrees C, for a maximal duration of one year. HbA(1c) was measured by an ion-exchange high performance liquid chromatography (HPLC) method (Variant II). We have analyzed the HbA(1c) value and the quality of the chromatographic separation for each sample. Storage of whole blood samples at -80 degrees C is good for at least one year. Storage at 4 degrees C is correct for two weeks, without major sample degradation. A more important and earlier degradation occurs at -20 degrees C. The conservation at 20 degrees C (room temperature) is very short. In conclusion, the temperatures of 4 and -80 degrees C are of interest for whole blood storage before HbA(1c) measurement, respectively for short and long term conservations. The temperatures of 20 and -20 degrees C are not recommended.

Programming tumor-reactive effector memory CD8+ T cells in vitro obviates the requirement for in vivo vaccination.

Naive and memory CD8(+) T cells can undergo programmed activation and expansion in response to a short T-cell receptor stimulus, but the extent to which in vitro programming can qualitatively substitute for an in vivo antigen stimulation remains unknown. We show that self-/tumor-reactive effector memory CD8(+) T cells (T(EM)) programmed in vitro either with peptide-pulsed antigen-presenting cells or plate-bound anti-CD3/anti-CD28 embark on a highly stereotyped response of in vivo clonal expansion and tumor destruction nearly identical to that of vaccine-stimulated T(EM) cells. This programmed response was associated with an interval of antigen-independent interferon-gamma (IFN-gamma) release that facilitated the dynamic expression of the major histocompatibility complex class I restriction element H-2D(b) on responding tumor cells, leading to recognition and subsequent tumor lysis. Delaying cell transfer for more than 24 hours after stimulation or infusion of cells deficient in IFN-gamma entirely abrogated the benefit of the programmed response, whereas transfer of cells unable to respond to IFN-gamma had no detriment to antitumor immunity. These findings extend the phenomenon of a programmable effector response to memory CD8(+) T cells and have major implications for the design of current adoptive-cell transfer trials.

[Evaluation of Variant II analyzer equipped with the new 270-2101 NU kit (Bio-Rad) for HbA 1c assay]. / Evaluation de l'analyseur Variant II équipé de la nouvelle trousse 270-2101 NU (Bio-Rad) pour le dosage de l'HbA 1c.

HbA(1c) represents a key parameter in the follow-up of glycemic balance in diabetic patients. It may be assayed by different methods, among which high-pressure liquid chromatography (HPLC). We have evaluated a new method available on HPLC Variant II analyzer (BioRad) equipped with the new kit 270-2101 NU. Chromatographic separation is improved, allowing a better identification of peaks. Intra- and inter-assay coefficients of variation are respectively lower than 1.1% and 1.8%. Linearity is excellent from 3.2% to more than 18%. The correlation with the previous method (kit 270-2101) is good: y (% HbA(1c) new kit) = 0.944x (% HbA(1c) previous kit) + 0.299, r(2) = 0.995. There is no inter-sample contamination. This method is less sensitive to interferences frequently found in practice (labile glycated hemoglobin, carbamylated haemoglobin) than the previous one. Validation is possible in more circumstances when an abnormal hemoglobin is present (especially in case of hemoglobin D or E). As the control of analytic quality is a major element for validation and clinical use of HbA(1c) results, the characteristics of this new method make it a well-suited tool for daily laboratory practice.

[Interference of labile glycated hemoglobin on HbA(1c) assay by a high pressure liquid chromatography method]. / Interférence de l'hémoglobine glyquée labile sur le dosage de l'HbA(1c) par une méthode de chromatographie liquide haute performance.

HbA(1c) assay by high pressure liquid chromatography remains submitted to interferences, among which that of labile HbA(1c) in 1 to 2% of samples. We have evaluated the interference of labile HbA(1c) on HbA(1c) assay using Variant II analyzer (Biorad), by in vitro formation of labile glycated haemoglobin and by evaluation of two protocols of elimination of labile HbA(1c) (wash and incubation of red blood cells in saline solution, or incubation in the wash/dilution solution of the analyzer). Levels of labile HbA(1c) higher than 4.5 % lead to underestimation of HbA(1c). The different protocols tested proved efficient and were adapted to routine conditions. The fastest method is the incubation of red blood cells in the wash/dilution solution for at least two hours, or more if labile fraction is unusually high.

Type I Interferons are essential for the efficacy of replicase-based DNA vaccines.

The immunogenicity and efficacy of nucleic acid vaccines can be greatly enhanced when antigen production is under the control of an alphaviral replicase enzyme. However, replicase-mediated mRNA overproduction does not necessarily result in enhanced antigen level. Instead, the strong adaptive immune response of alphavirus replicon-based vectors is due to their production of double-stranded RNA (dsRNA) intermediates, which trigger innate immunity. Because viral infections are known to trigger innate immune responses that lead to the rapid production of Type I Interferons (IFNs), namely IFN-alpha and IFN-beta, we investigated the role of Type I IFNs in the enhanced immunogenicity of replicase-based DNA vaccines. In vitro, cells transfected with replicase-based plasmids produce significantly more Type I IFNs than cells transfected with a conventional DNA plasmid. In vivo, replicase-based DNA vaccines yield stronger humoral responses in the absence of Type I IFN signaling but the lack of this signaling pathway in IFN-alphabeta receptor-/- (knockout) mice abolishes T cell mediated efficacy against tumors of both conventional and alphavirus replicase-based DNA vaccines. Moreover, the co-delivery of an IFNalpha-encoding plasmid significantly improved the efficacy of a weakly immunogenic conventional plasmid. These results suggest a central role for Type I IFNs in the mechanism of replicase-based DNA vaccines and indicate that vaccines can be enhanced by enabling their capacity to triggering innate anti-viral defense pathways.

The in vivo expansion rate of properly stimulated transferred CD8+ T cells exceeds that of an aggressively growing mouse tumor.

It has been hypothesized that rapidly dividing tumor cells can outpace adoptively transferred antitumor lymphocytes when tumors are large. However, this hypothesis is at odds with clinical observations indicating that bulky tumors can be destroyed by small numbers of adoptively transferred antitumor T cells. We sought to measure the relative growth rates of T cells and tumor cells in a model using transgenic CD8(+) T cells specific for the gp100(25-33) H-2D(b) epitope (called pmel-1) to treat large, well-established s.c. B16 melanoma. We tested the effect of the immunization using an altered peptide ligand vaccine alone or in combination with interleukin-2 (IL-2) by analyzing the kinetics of T-cell expansion using direct enumeration. We found that pmel-1 T cells proliferated explosively during a 5-day period following transfer. Calculations from net changes in population suggest that, at the peak of cell division, pmel-1 T cells divide at a rate of 5.3 hours per cell division, which was much faster than B16 tumor cells during optimal growth (24.9 hours per cell division). These results clearly indicate that the notion of a kinetic "race" between the tumor and the lymphocyte is no contest when adoptively transferred cells are stimulated with immunization and IL-2. When appropriately stimulated, tumor-reactive T-cell expansion can far exceed the growth of even an aggressively growing mouse tumor.

Removal of homeostatic cytokine sinks by lymphodepletion enhances the efficacy of adoptively transferred tumor-specific CD8+ T cells.

Depletion of immune elements before adoptive cell transfer (ACT) can dramatically improve the antitumor efficacy of transferred CD8+ T cells, but the specific mechanisms that contribute to this enhanced immunity remain poorly defined. Elimination of CD4+CD25+ regulatory T (T reg) cells has been proposed as a key mechanism by which lymphodepletion augments ACT-based immunotherapy. We found that even in the genetic absence of T reg cells, a nonmyeloablative regimen substantially augmented CD8+ T cell reactivity to self-tissue and tumor. Surprisingly, enhanced antitumor efficacy and autoimmunity was caused by increased function rather than increased numbers of tumor-reactive T cells, as would be expected by homeostatic mechanisms. The gammaC cytokines IL-7 and IL-15 were required for augmenting T cell functionality and antitumor activity. Removal of gammaC cytokine-responsive endogenous cells using antibody or genetic means resulted in the enhanced antitumor responses similar to those seen after nonmyeloablative conditioning. These data indicate that lymphodepletion removes endogenous cellular elements that act as sinks for cytokines that are capable of augmenting the activity of self/tumor-reactive CD8+ T cells. Thus, the restricted availability of homeostatic cytokines can be a contributing factor to peripheral tolerance, as well as a limiting resource for the effectiveness of tumor-specific T cells.

Vaccine-stimulated, adoptively transferred CD8+ T cells traffic indiscriminately and ubiquitously while mediating specific tumor destruction.

It has been suggested that antitumor T cells specifically traffic to the tumor site, where they effect tumor destruction. To test whether tumor-reactive CD8(+) T cells specifically home to tumor, we assessed the trafficking of gp100-specific pmel-1 cells to large, vascularized tumors that express or do not express the target Ag. Activation of tumor-specific CD8(+) pmel-1 T cells with IL-2 and vaccination with an altered peptide ligand caused regression of gp100-positive tumors (B16), but not gp100-negative tumors (methylcholanthrene 205), implanted on opposing flanks of the same mouse. Surprisingly, we found approximately equal and very large numbers of pmel-1 T cells (>25% of all lymphocytes) infiltrating both Ag-positive and Ag-negative tumors. We also found evidence of massive infiltration and proliferation of activated antitumor pmel-1 cells in a variety of peripheral tissues, including lymph nodes, liver, spleen, and lungs, but not peripheral blood. Most importantly, evidence for T cell function, as measured by production of IFN-gamma, release of perforin, and activation of caspase-3 in target cells, was confined to Ag-expressing tumor. We thus conclude that CD8(+) T cell-mediated destruction of tumor is the result of specific T cell triggering at the tumor site. The ability to induce ubiquitous homing and specific tumor destruction may be important in the case of noninflammatory metastatic tumor foci.

Bedside to bench and back again: how animal models are guiding the development of new immunotherapies for cancer.

Immunotherapy using adoptive cell transfer is a promising approach that can result in the regression of bulky, invasive cancer in some patients. However, currently available therapies remain less successful than desired. To study the mechanisms of action and possible improvements in cell-transfer therapies, we use a murine model system with analogous components to the treatment of patients. T cell receptor transgenic CD8+ T cells (pmel-1) specifically recognizing the melanocyte differentiation antigen gp100 are adoptively transferred into lympho-depleted mice bearing large, established, 14-day subcutaneous B16 melanoma (0.5-1 cm in diameter) on the day of treatment. Adoptive cell transfer in combination with interleukin interleukin-2 or interleukin-15 cytokine administration and vaccination using an altered form of the target antigen, gp100, can result in the complete and durable regression of large tumor burdens. Complete responders frequently develop autoimmunity with vitiligo at the former tumor site that often spreads to involve the whole coat. These findings have important implications for the design of immunotherapy trials in humans.

Apoptosis is essential for the increased efficacy of alphaviral replicase-based DNA vaccines.

Alphaviral replicons can increase the efficacy and immunogenicity of naked nucleic acid vaccines. To study the impact of apoptosis on this increased effectiveness, we co-delivered an anti-apoptotic gene (Bcl-X(L)) with the melanocyte/melanoma differentiation antigen TRP-1. Although cells co-transfected with Bcl-X(L) lived longer, produced more antigen and elicited increased antibody production in vivo, co-delivery of pro-survival Bcl-X(L) with antigen significantly reduced the ability of the replicase-based vaccine to protect against an aggressive tumor challenge. These data show for the first time that the induction of apoptotic cell death of transfected cells in vivo is required for the increased effectiveness of replicase-based vaccines. Our findings also provide an explanation for the paradoxical observation that replicase-based DNA vaccines are much more immunogenic than conventional constructs despite reduced antigen production.

Tumor regression and autoimmunity after reversal of a functionally tolerant state of self-reactive CD8+ T cells.

Many tumor-associated antigens are derived from nonmutated "self" proteins. T cells infiltrating tumor deposits recognize self-antigens presented by tumor cells and can be expanded in vivo with vaccination. These T cells exist in a functionally tolerant state, as they rarely result in tumor eradication. We found that tumor growth and lethality were unchanged in mice even after adoptive transfer of large numbers of T cells specific for an MHC class I-restricted epitope of the self/tumor antigen gp100. We sought to develop new strategies that would reverse the functionally tolerant state of self/tumor antigen-reactive T cells and enable the destruction of large (with products of perpendicular diameters of >50 mm2), subcutaneous, unmanipulated, poorly immunogenic B16 tumors that were established for up to 14 d before the start of treatment. We have defined three elements that are all strictly necessary to induce tumor regression in this model: (a) adoptive transfer of tumor-specific T cells; (b) T cell stimulation through antigen-specific vaccination with an altered peptide ligand, rather than the native self-peptide; and (c) coadministration of a T cell growth and activation factor. Cells, vaccination, or cyto-kine given alone or any two in combination were insufficient to induce tumor destruction. Autoimmune vitiligo was observed in mice cured of their disease. These findings illustrate that adoptive transfer of T cells and IL-2 can augment the function of a cancer vaccine. Furthermore, these data represent the first demonstration of complete cures of large, established, poorly immunogenic, unmanipulated solid tumors using T cells specific for a true self/tumor antigen and form the basis for a new approach to the treatment of patients with cancer.

[Peri-lunate wrist dislocation: long-term outcome]. / Luxation péri-lunaire du carpe: résultats à long terme.

PURPOSE OF THE STUDY: We report our experience with 25 peri-lunate posterior wrist dislocations and compare outcome with data in the literature searching for prognostic factors. MATERIAL AND METHODS: Our series included 24 men and one woman, mean age 36 years. Twenty-three patient were less than 50 years old at the time of the accident. Diagnosis was established late in five patients. All patients were reviewed clinically and radiologically with a mean follow-up of 57 months. We differentiated pure dislocations (n=16) from trans-scapho-lunate dislocations (n=9). The pure dislocations included six type 1 and ten type 2 in the Witvoët and Allieu classification. We also distinguished groups by open or closed treatment, with or without pinning, and with or without suture of the scapho-lunate ligament. Screw fixation was used in case of scaphoid fracture. Post-operative cast immobilization was 45 days on the average, followed by three months of rehabilitation exercises. RESULTS: Residual pain of variable intensity was reported by 22 patients but subjectively, 21 patients considered outcome to be good or very good. Wrist movement was greatly impaired in eight patient with a 60 degrees flexion-extension arc. All patients had a 20% reduction in force compared with the healthy side. According to the Green and O'Brian functional score, outcome was poor in four wrists. The scapholunate space and the sapholunate angles were abnormal in seven wrists. Reduction was insufficient in only one case with the scapholunate space measuring 5 mm after trans-scapho-lunate dislocation. In most of the cases, these poor functional and/or radiographic results coincided with carpal instability which developed early or late after trauma. The most bothersome element in other cases was wrist stiffness. The trans-scapho-lunate dislocations appeared to evolve more favorably than the pure dislocations, but could also cause carpal instability. DISCUSSION: There is a real functional impairment after posterior peri-lunate dislocation. The differences in outcome we observed were not statistically correlated with type of treatment, probably because of the small number of patients, but did reveal certain tendencies. Closed reduction did not always avoid the development of carpal instability and gave only average results. Percutaneous pinning or open reduction did not improve outcome in pure dislocations. It might be good to use scapho-lunate suture more often to obtain better healing and reduce the risk of carpal instability, as has been suggested by certain teams.

Alphavirus-based DNA vaccine breaks immunological tolerance by activating innate antiviral pathways.

Cancer vaccines targeting 'self' antigens that are expressed at consistently high levels by tumor cells are potentially useful in immunotherapy, but immunological tolerance may block their function. Here, we describe a novel, naked DNA vaccine encoding an alphavirus replicon (self-replicating mRNA) and the self/tumor antigen tyrosinase-related protein-1. Unlike conventional DNA vaccines, this vaccine can break tolerance and provide immunity to melanoma. The vaccine mediates production of double-stranded RNA, as evidenced by the autophosphorylation of dsRNA-dependent protein kinase R (PKR). Double-stranded RNA is critical to vaccine function because both the immunogenicity and the anti-tumor activity of the vaccine are blocked in mice deficient for the RNase L enzyme, a key component of the 2',5'-linked oligoadenylate synthetase antiviral pathway involved in double-stranded RNA recognition. This study shows for the first time that alphaviral replicon-encoding DNA vaccines activate innate immune pathways known to drive antiviral immune responses, and points the way to strategies for improving the efficacy of immunization with naked DNA.

Structure and substitutions in fluorapatite.

Fluorapatite, Ca10(PO4)6F2. is a widely spread form of calcium phosphate present particularly in biological material. Human hard tissues contain crystals structurally related to apatite. Fluoride can be found in various natural sources and is also used for its beneficial action in caries prevention. Fluorapatite belongs to the spatial group P6(3/m) (C(6h)2) and consists of 3 ions: F-, Ca2+, PO4(3-). In the present paper, we have carried out a crystallographic study of the fluorapatite structure and of the changes induced by the substitutions. The fluorapatite structure and the presence of a large number of ionic bonds make fluorapatite a very suitable host for many substituents, some of them harmless for the human organism, some not. According to the substitution site, we can describe four types of substitution. The F- substitution, also called Type A substitution, is the main one, and the best known. Only the Ca2+ substitution implies changes in the crystal structure. However, some questions remain, in particular for the PO4(3-) substitution, which is the main substitution present in the biological calcium phosphates.

[Raman spectrometry applied to calcified tissue and calcium-phosphorus biomaterials]. / Spectrometrie raman appliquee aux tissus calcifies et aux biomateriaux phospho-calciques.

The rigid part of the human body consists essentially of carbonated apatite (calcium phosphate). Biologists don't have any tools to study this "mineral" phase, though its origin is organic. A new approach of some compounds like enamel or bone is obtained with the Raman micro-characterisation by a very fine analysis of chemical bonds in a micrometric scale. This method allows the characterisation, the analysis and the dosage of ions, like carbonate, acid phosphates, proteins and fatty acids. The identification of other organic or mineral compounds (e.g. calcium carbonate, calcium oxide, substitutant ions...) is also possible. The Raman microspectrometry can also be used to study the chemical and physical properties of biomaterials and their evolution after implantation in a dental or bone site. On synthetical calcium phosphate, beta-TCP, brushite and hydroxyapatite can be distinguished and the impurities found in plasma spray deposits can be measured. The detection of alpha-, beta-, or gamma-pyrophosphates could be obtained in some commercial beta-TCP. The Raman microspectrometry is the only non-destructive method which allows the identification of the chemical bonds in a micrometric scale and gives the "fingerprint" of the studied component.