Machete injuries in Haiti.

Machete-related wounds are a source of appreciable morbidity in many developing nations. We describe a case of radial nerve injury resulting from a machete attack in Haiti. Twenty-two additional cases of machete-related wounds treated during a 3-month humanitarian mission to Haiti are reported. Sixty-five percent were accidental in nature, occurring from a variety of routine activities, whereas the remainder were secondary to assaults. The upper extremity was injured in 85% of the cases, often resulting in complicated wounds with nerve, tendon, and joint injuries. A treatment protocol for peripheral nerve injuries incurred in austere conditions is presented.

Human cytomegalovirus strain Toledo lacks a virus-encoded tropism factor required for infection of aortic endothelial cells.

Human cytomegalovirus (HCMV) strains were investigated to identify those with altered tropism for endothelial cells. In viral replication kinetics analysis, HCMV strain Toledo replicated poorly in aortic endothelial cells (AECs), and the virus count was reduced by 2-3 log units, in comparison with strain AD169. Virus entry at the cell surface for each strain was equivalent. However, immunofluorescence studies revealed a lack of immediate early viral antigen 72 expression, and direct blot hybridization failed to detect viral genomes in the nucleus of Toledo-infected AECs. Complementation assays were done to determine whether endothelial cell infectivity was dependent on a virus-encoded tropism factor. Pseudotype virus in endothelial cell cultures indicated that AD169 could provide trans factors to rescue Toledo during infection of endothelial cells. Collectively, these results show that a viral function provides an endothelial cell tropism factor for HCMV and plays a role during postentry infection events.

Penetrating trauma to the diaphragm: natural history and ultrasonographic characteristics of untreated injury in a pig model.

HYPOTHESIS: Recent use of minimally invasive techniques to evaluate the chest and abdomen in patients with penetrating thoracoabdominal trauma has led to the discovery of many occult diaphragm injuries. Surgical repair of these injuries is relatively straightforward. However, diagnosis can be difficult, and the natural history of these injuries is controversial. By developing a penetrating diaphragm injury model, the ultrasonographic characteristics and natural history of this injury can be better understood. SETTING: Surgical laboratory of a tertiary care hospital. SUBJECTS: Seven pigs (Sus scrofa), weighing between 55 and 80 kg, received a 3-cm right-sided (n = 3) or left-sided (n = 4) diaphragm injury via thoracoscopy. INTERVENTIONS: Thoracoabdominal x-ray and ultrasonographic examinations were performed preoperatively; at 2, 4, 8, and 12 weeks postoperatively; and when symptoms related to the diaphragm injury occurred. At 12 weeks, or at the time of earlier death, a postmortem thoracoabdominal examination was performed. MAIN OUTCOME MEASURES: x-Ray and ultrasonographic characteristics, and evidence of wound healing, in a penetrating diaphragm injury model. RESULTS: Perioperative recovery occurred in all pigs. No pigs had radiographic evidence of immediate postoperative herniation. Pigs in the right-sided injury group died early (

Latency-associated sense transcripts are expressed during in vitro human cytomegalovirus productive infection.

Published studies have identified novel sense transcripts in latent human cytomegalovirus (HCMV) infection. These cytomegalovirus latency-associated transcripts (CLTs) have start sites upstream from the MIE gene productive start site (PSS). We evaluated the expression of the sense CLTs in an in vitro HCMV productive infection. Transcripts with initiation sites upstream from the PSS were detected in infected human fibroblasts using reverse transcription-polymerase chain reaction and 5' rapid amplification of cDNA ends (RACE) analysis. DNA sequencing of 5' RACE PCR products confirmed that the start sites were consistent with sense CLT expression. Furthermore, ribonuclease protection assay analysis showed that transcripts initiating at the latent start site-1 were most abundant at late times postinfection after transcription from the PSS had decreased. In addition, transcription consistent with sense CLT expression was identified in HCMV-infected dTHP-1 cells, monocyte-derived macrophages, and endothelial cells, as well as in clinical isolate-infected human fibroblasts. These findings clearly demonstrate the expression of sense CLTs during in vitro HCMV infection.

Detection of Chlamydia pneumoniae DNA in CD3+ lymphocytes from healthy blood donors and patients with coronary artery disease.

BACKGROUND: Chlamydia pneumoniae is an intracellular bacterium responsible for respiratory tract infections. Recent studies have implicated this organism in the pathogenesis of atherosclerosis. METHODS AND RESULTS: To address how the organism is transported from lungs to cardiac vessels, we characterized the cell population within peripheral blood mononuclear cells (PBMCs) that harbor C pneumoniae DNA. Adherent and nonadherent PBMCs from 28 patients with coronary artery disease (CAD) and 19 healthy blood donors were evaluated for the presence of C pneumoniae DNA by touchdown nested polymerase chain reaction (nPCR). Of the 28 patients, 10 (36%) had detectable PCR product in their nonadherent and 3 (10%) in their adherent PBMC population. C pneumoniae-specific PCR results were positive for 5 of 19 (26%) healthy blood donors. PCR positivity was detected only in the nonadherent cell population among this group of individuals. Fractionation of nonadherent PBMCs identified C pneumoniae-specific PCR signal among the CD3+ T-cell population exclusively. Of the 18 PCR-positive subjects (13 patients and 5 healthy control subjects), 67% (8 patients and 4 healthy blood donors) tested positive for C pneumoniae-specific IgG serology. Interestingly, 2 patients became PCR negative on a repeated blood draw 5 months after initial detection of C pneumoniae DNA despite retaining C pneumoniae-specific antibodies. CONCLUSIONS: Our results demonstrate marginally significant prevalence of C pneumoniae DNA in patients with CAD compared with healthy subjects (P=0.082). In contrast, the prevalence of IgG seropositivity among the 2 groups did not reach statistical significance (P=0.306). We also provide unequivocal evidence for the presence of C pneumoniae DNA predominantly among the circulating CD3+ T-cell population.

Civilian versus military trauma dogma: who do you trust?

Combat trauma differs from its peacetime counterpart by involving a different spectrum of injuries, occurring in austere environments, dealing with mass casualties, and embodying inherent treatment delays. Thus, civilian trauma practices may be inappropriate in certain combat settings. A review of historical as well as current vivilian and military data is presented for four trauma topics (military antishock trousers, wound debridement, colon wounds, fluid resuscitation) in which civilian and military principles have clashed. The following recommendations are made. (1) Military antishock trousers are still useful in a combat setting. (2) Soft-tissue wound management should be directed by the wound rather than by the weapon. (3) Cautious avoidance of colostomy may be indicated in certain wartime colon wounds. (4) The majority of combat casualties require early vigorous fluid resuscitation. When civilian trauma experience challenges military dogma, it must be carefully considered before being applied to a combat setting.

Peripheral blood CD14(+) cells from healthy subjects carry a circular conformation of latent cytomegalovirus genome.

The majority of the human population harbors latent cytomegalovirus. Although CD14(+) peripheral blood mononuclear cells have been implicated as sites of latency, the conformation of the latent viral genome in these cells is unknown. In this study, the conformation of viral genomic DNA was assessed in CD14(+) cells from healthy virus seropositive carriers using an electrophoretic separation on native agarose gels in combination with polymerase chain reaction detection. Here we show that the viral genome migrates as a circular plasmid with a mobility equivalent to a circular 230-kb Shigella flexneri megaplasmid marker. Neither linear nor complex or integrated forms of the viral genome were detected. This report provides further evidence that the CD14(+) cell population is an important site of viral latency in the naturally infected human host. Detection of the viral genome as a circular plasmid during latency suggests that this virus maintains its genome in a manner analogous to other herpesviruses where latent viral genome conformation has been studied.

Is tension pneumothorax a threat in trauma laparoscopy?

BACKGROUND: Tension pneumothorax is a reported risk with pneumoperitoneum in the presence of diaphragmatic injuries. A goat model with and without diaphragmatic injury was used to determine if varying levels of intra-abdominal pressure (IAP) result in tension pneumothorax. METHODS: Twenty-four goats were divided equally into four groups: (1) 5 mm Hg IAP control, (2) 15 mm Hg IAP control, (3) 5 mm Hg IAP with diaphragmatic injury, (4) 15 mm Hg IAP with diaphragmatic injury. Chest x-ray films were made and heart rate (HR), mean arterial pressure, central venous pressure (CVP), arterial blood gases, and airway pressure (AP) were measured at 10-minute intervals up to 30 minutes. Significant changes were determined by using the one-way analysis of variance and Mann-Whitney test with alpha set at p < 0.05. RESULTS: In group 4, 100% (all six goats) developed radiographic evidence of tension pneumothorax by 10 minutes. Mean changes from baseline at 20 minutes for the following parameters were all significantly different from controls: HR (p < 0.05), CVP (p < 0.0001), PaO2 (p < 0.001), and AP (p < 0.004). Mortality was 67% (four of six) at 25 minutes. In group 3, 100% (all six goats) of the animals developed radiographic evidence of a simple pneumothorax without mediastinal shift. In this group, there were significant changes in PaO2 (p < 0.003), AP (p < 0.04), and HR (p < 0.05). Mortality was 16% (one of six) at 25 minutes. CONCLUSION: In this goat model of diaphragmatic injury, tension pneumothorax is a significant threat when pneumoperitoneum is maintained at 15 mm Hg IAP. Pneumoperitoneum at 5 mm Hg IAP leads to simple pneumothorax with deleterious effects on oxygenation. Changes in AP, CVP, HR, and PaO2 provide early clues to the development of the problem.

Hereditary C1q deficiency and systemic lupus erythematosus.

We describe a 27-year-old women with systemic lupus erythematosus, C1q deficiency and cytomegalovirus retinitis. She suffered from severe SLE, with cutaneous and CNS involvement, and died of CNS disease aged 28. Review of 29 other published cases of C1q deficiency shows that SLE in these patients is often severe (five with CNS disease, ten with glomerulonephritis). The results of autoantibody studies in this and another patient with C1q deficiency and SLE are presented--both patients had autoantibodies to the extractable nuclear antigens, Sm, RNP and Ro, and one patient had high titres of antibodies to dsDNA. One of the patients had previously been treated with fresh frozen plasma, and antibodies to C1q were present in his serum. Homozygous C1q deficiency is associated with a very high prevalence of severe SLE with the full panoply of autoantibodies characteristic of this disease.

Induction of endogenous human cytomegalovirus gene expression after differentiation of monocytes from healthy carriers.

Monocytes are one site of carriage of the human cytomegalovirus (HCMV) genome in healthy human carriers. However, as there are conflicting data detailing the level of HCMV gene expression during persistence in these cells, we have analyzed monocytes for evidence of viral immediate-early, early, and late transcription by using reverse transcription followed by PCR. We were unable to find evidence of HCMV lytic gene transcription in freshly isolated peripheral blood monocytes from HCMV-seropositive subjects. However, as differentiation of monocytes to monocyte-derived macrophages results in increased permissiveness to infection with HCMV in vitro, we examined whether such differentiation could result in reactivation of endogenous viral gene expression. Here we show that in vitro differentiation of monocytes does result in expression of endogenous HCMV immediate-early genes. Although this differentiation led to reactivation of endogenous viral immediate-early expression, we were unable to detect any early or late viral transcription. Cocultivation experiments correlated with this level of gene induction, as no productive infection was detected. These data strongly suggest a mechanism of persistence of HCMV in the peripheral blood that is independent of HCMV lytic gene expression and that initial phases of lytic gene expression in monocytes can be induced by differentiation of these cells to monocyte-derived macrophages.

Rocket grenade injuries: patient management in a field hospital setting.

An incident involving RPG-7 (rocket grenade) injuries was managed in a field hospital in the Middle East. Used by guerrilla forces worldwide, the RPG-7 is exemplary of military weapons that produce extensive fragment-related wounds and associated blast effects. The active duty or reserve military physician must be prepared to diagnose and treat such injuries in a remote setting.

Subsets of CD8+, CD57+ cells in normal, healthy individuals: correlations with human cytomegalovirus (HCMV) carrier status, phenotypic and functional analyses.

Two different subsets of CD8+, CD57+ cells have been defined, one expressing high levels (CD8high+(CD57+)), the other expressing low levels of surface CD8 (CD8low+(CD57+)). Increased numbers of CD8high+(CD57+) cells correlated with previous HCMV infection. By three-colour fluorescence analysis, the CD8high+(CD57+) population expressed T cell markers such as CD3 and CD5, and most were alpha beta T cell receptor (alpha beta TCR)-positive. A significant proportion also expressed CD71 (transferrin receptor) and MHC class I, although little if any CD25 (IL-2R-p55). Some (> or = 40%) co-expressed CD45RA and CD45RO. The CD8low+(CD57+) population expressed classical natural killer (NK) cell markers--CD2, CD16 and CD56. The two subsets were also functionally distinct; CD8high+(CD57+) cells suppressed pokeweed mitogen (PWM)-driven, but not phytohaemagglutinin (PHA)-driven proliferation and immunoglobulin production; CD8low+(CD57+) cells exhibited NK cytotoxic activity which was not increased by interferon-alpha (IFN-alpha). Supernatant from cultured CD8high+(CD57+) cells suppressed PWM-driven immunoglobulin production, but not proliferation, and this effect was abrogated by physical separation with tissue culture inserts. Thus, a T cell subset expressing activation and memory T cell markers with direct non-specific suppressor activity was present in peripheral blood mononuclear cells (PBMC) of healthy subjects with asymptomatic HCMV infection.

Deployment of an Air Transportable Hospital in support of Allied Forces during Operation Provide Comfort: April 29 to July 17, 1991.

The deployment, setup, and operation of an Air Transportable Hospital (ATH) as a primary field hospital for 25,000 Allied Forces during Operation Provide Comfort is presented with a description of the performance and experiences of this unit. More than 3,300 outpatients were seen and treated, and more than 50 patients were operated on at the ATH. In addition, assigned personnel participated as medical augmentees to Kurdish refugees camps, screening and treating more than 13,000 individuals. The success of this deployment validates and expands the concept of the ATH and of Air Force training doctrine.

Polymorphonuclear cells are not sites of persistence of human cytomegalovirus in healthy individuals.

Polymorphonuclear leukocytes (PMNL) have been shown to harbour human cytomegalovirus (HCMV) in viraemic patients, but to date PMNL of asymptomatic healthy subjects have not been examined directly to determine whether this is a normal site of HCMV persistence. Using the polymerase chain reaction (PCR), paired DNA samples prepared from adherent peripheral blood mononuclear cells (PBMC), which are known to be a site of persistence of HCMV, and PMNL of 10 healthy adults were analysed. All of seven individuals who were HCMV seropositive, and one of three who were seronegative gave a reproducible signal for HCMV DNA in their adherent PBMC, whereas none of the paired PMNL DNA samples gave a positive result. The remaining two seronegative subjects showed no HCMV DNA in either the PBMC or PMNL samples. In every case where PCR for HCMV was negative, PCR amplification of a control human gene was used to show there was no inability to amplify the DNA. We conclude that within the leukocyte population of normal asymptomatic HCMV carriers, PMNL do not appear to harbour persistent HCMV whereas adherent PBMC in the same subjects are a site of persistence.

Applying ATLS to the Gulf War.

During a 3-month deployment to Silopi, Turkey, for Operation Provide Comfort, the 39 TACG Air Transportable Hospital (ATH) managed 32 cases of severe military trauma. Fifty-two operations were necessary, 78% of which were performed at the ATH. Advanced Trauma Life Support (ATLS) protocols were applied to all of the patients. Only 14% of the 52 procedures were ATLS-learned skills. Also, only 30% of the patients could be managed solely by ATLS in the first 6 hours, the average time of ATH responsibility. ATLS alone is insufficient wartime readiness preparation for the military physician.

A significant age shift of the human parvovirus B19 antibody prevalence among young adults in Japan observed in a decade.

A seroepidemiological study on human parvovirus (B19) in Japan was undertaken with serum samples randomly collected from healthy Japanese populations (416 in 1973, 675 in 1984 and 508 in 1987/88). All samples were tested for anti-B19 IgG antibody by the indirect antigen-capture ELISA. The antibody prevalence for ages 0-9 years old in 1984 was significantly higher (16%) than that in 1973 (2%), whereas those for ages 20-29 years and 30-39 years were significantly lower in 1984 (20% and 56%) than in 1973 (67% and 80%) (p < 0.005). After the erythema infectiosum (EI) outbreak in 1986/87, the antibody prevalences for ages 5-9, 10-14 and 15-19 years were 40-85% in Fukuoka, 0-10% in Gunma, and 21-41% in Chiba reflecting each EI incidence in these three prefectures, whereas those for ages 20-29 years remained low (< 20%). These data indicate that B19 virus was transmitted mainly among children and no significant incidence of B19 virus infection in adults has occurred since 1973, resulting in a notable shifting of B19 susceptibility toward older ages including child-bearing females.

Repression of human cytomegalovirus major immediate early gene expression in a monocytic cell line.

We have previously shown that a major site of persistence of human cytomegalovirus (HCMV) in healthy carriers is in peripheral blood monocytes. However, monocytes are difficult to infect in vitro with HCMV, and HCMV gene expression cannot be reproducibly detected in peripheral blood cells of healthy carriers. Here we show that the monocytic cell line THP1 is non-permissive for HCMV infection due to a block in expression of the HCMV major immediate early (IE) promoter. This repression is correlated with the presence of a differentiation-specific cellular factor which binds to the imperfect dyad symmetry and the 21 bp enhancer repeats of the major IE promoter regulatory region and which has characteristics of MBF1, a factor which we have previously defined in HCMV non-permissive, undifferentiated teratocarcinoma cells. Both differentiation of THP1 cells into macrophages, which results in a decrease in this factor, or deletion of the factor's binding sites from the IE promoter/enhancer lifts this repression and permits expression from the major IE promoter.

Monocytes are a major site of persistence of human cytomegalovirus in peripheral blood mononuclear cells.

We have used the nested polymerase chain reaction (PCR) combined with fluorescence-activated cell sorting to define sites of latency of human cytomegalovirus (HCMV) in the peripheral blood of healthy subjects. Peripheral blood mononuclear (PBM) cells were separated into T cell or non-T cell populations and monocytes, and were then analysed by PCR for the presence of HCMV DNA. In five of six seropositive subjects, HCMV was found predominantly in the non-T cell population. Further analysis suggested that the virus was present in adherent cells and CD14+ cells. In three of nine seronegative subjects we could demonstrate HCMV DNA, which we do not believe was due to contamination, reproducibly by PCR. In one of these seronegative subjects, HCMV DNA was present predominantly in the non-T cell fraction of PBM cells. No HCMV DNA was detectable in the remaining six seronegative subjects. We conclude that, within the PBM cells of normal asymptomatic seropositive and some seronegative subjects, HCMV is present predominantly in the monocyte fraction. In addition, the detection of HCMV sequences in seronegative subjects may indicate that infection with HCMV is more widespread than conventional seroepidemiology suggests.