Microplastics in urban freshwater streams in Adelaide, Australia: A source of plastic pollution in the Gulf St Vincent.

The pollution of marine environments from plastic waste is anticipated to increase with current increases in plastic production. Reciprocally, escalating research efforts provide an improved understanding, monitoring, awareness, and mitigation of plastic contamination. Freshwater streams are recognised as one of the main contributors of microplastic pollution in marine environments. Presented here is the first investigation on the abundance of microplastic contamination (>20 µm and <5 mm) in freshwater streams in Adelaide, Australia. Composite samples were obtained from the sub-surface waters of eight freshwater streams (Magazine Wetland, Torrens River, Brownhill Creek, Sturt River, Field River, Christie Creek, Onkaparinga River and Pedler Creek), just before their connection to the Gulf St Vincent. Microplastics were found in all samples and microplastic abundance was 6.4 ± 5.5 particles.L-1 across all streams, with significant variations. Microplastic abundances found in the freshwater streams of Adelaide were comparatively higher than those found in areas of similar urbanisation, likely due to the varying methodologies used across studies. This work provides evidence, for the first time, of the prevalence of microplastic contamination in the sub-surface waters of eight freshwater streams in metropolitan Adelaide. These findings reinforce the need for long-term and on-going monitoring of freshwater streams for plastic contamination. Furthermore, spatial and temporal monitoring will allow for the identification in changes to the abundances of microplastics discharging from these sources into the Gulf St Vincent and observe if abundances increase or decrease with any future targeted waste management efforts.

Large homogeneous genome regions (isochores) in soybean [glycine max (L.) merr].

The landscape of plant genomes, while slowly being characterized and defined, is still composed primarily of regions of undefined function. Many eukaryotic genomes contain isochore regions, mosaics of homogeneous GC content that can abruptly change from one neighboring isochore to the next. Isochores are broken into families that are characterized by their GC levels. We identified 4,339 compositionally distinct domains and 331 of these were identified as long homogeneous genome regions (LHGRs). We assigned these to four families based on finite mixture models of GC content. We then characterized each family with respect to exon length, gene content, and transposable elements. The LHGR pattern of soybeans is unique in that while the majority of the genes within LHGRs are found within a single LHGR family with a narrow GC range (Family B), that family is not the highest in GC content as seen in vertebrates and invertebrates. Instead Family B has a mean GC content of 35%. The range of GC content for all LHGRs is 16-59% GC which is a larger range than what is typical of vertebrates. This is the first study in which LHGRs have been identified in soybeans and the functions of the genes within the LHGRs have been analyzed.

Efficacy and safety results with the LifeSite hemodialysis access system versus the Tesio-Cath hemodialysis catheter at 12 months.

PURPOSE: To compare the performance and safety of a fully subcutaneous vascular access device, the LifeSite hemodialysis access system, versus a tunneled hemodialysis catheter, the Tesio-Cath, at 1 year after implantation. MATERIALS AND METHODS: Sixty-eight patients who required hemodialysis received implantation of the LifeSite device or a Tesio-Cath device as a part of this multicenter study. Thirty-four patients were treated in each group. The endpoints observed included blood flow rates and associated venous pressures, overall and device-related adverse events, the need for thrombolytic infusions, device-related infections (DRIs) and associated hospitalizations, and technical device survival. RESULTS: During the 12-month observation period, significantly higher venous pressures were required in patients with the Tesio-Cath to achieve blood flow rates comparable with those achieved with the LifeSite device. Patients in the LifeSite group experienced a significantly lower rate of non-device-related adverse events (P < .001), device-related adverse events (P < .016), need for thrombolytic infusions (P < .002), and DRIs (P < .013) compared with patients in the Tesio-Cath group. There was a trend toward a lower number of hospital days per month for DRIs in the LifeSite group, with the rate for the Tesio-Cath group being twice that in the LifeSite group. The use of the LifeSite device was also associated with a significantly higher probability of device survival for 12 months after censoring for planned removals (P < .031). CONCLUSIONS: The results of the present study demonstrate superior device performance and technical device survival, reduced complications, and the need for fewer interventions with the LifeSite hemodialysis access system compared with a standard hemodialysis catheter during a 1-year time period after implantation.

Multicenter clinical trial results with the LifeSite hemodialysis access system.

BACKGROUND: The LifeSite Hemodialysis Access System is a subcutaneous access device designed to maximize blood flow while minimizing access-related complications. The purpose of this study was to compare the efficacy and safety of the LifeSite System to a similar but transcutaneous access device, the Tesio-Cath Hemodialysis Catheter. METHODS: The study was conducted in two phases. A multi-center randomized prospective design was utilized for the first phase (Phase 1) where thirty-four patients were enrolled in the Tesio-Cath group and 36 patients into the LifeSite group where 0.2% sodium oxychlorosene was used as an antimicrobial solution for the LifeSite. A nonrandomized, but otherwise identical, second phase of the study followed where a 70% isopropyl alcohol solution was utilized as the antimicrobial solution for 34 additional LifeSite patients (Phase 2). RESULTS: Device function was evaluated in Phase 1 of the trial. Actual blood flow (determined by ultrasound dilution) was greater in the LifeSite versus the Tesio-Cath group (358.7 vs. 331.8 mL/min, P < 0.001 for machine-indicated blood flow of 400 mL/min). Infection comparisons were performed for all three groups encompassing Phase 1 and 2 of the trial; Tesio-Catheter, LifeSite System with oxychlorosene, and LifeSite System with 70% isopropyl alcohol. Device-related infections were defined as systemic bacteremia without another obvious site of origin and exit site infections requiring systemic antibiotics or device removal. This revealed infection rates per 1000 device use days of 1.3 for the LifeSite alcohol group, 3.3 for the Tesio-Cath group, and 3.4 per for the LifeSite oxychlorosene group. There was no statistically significant difference in device related infection rates between the Tesio-Cath and the LifeSite oxychlorosene groups. There were significant differences in infection rate between LifeSite alcohol group and the other two groups (P < 0.05). Device thrombosis was defined by the need for instillation of thrombolytic agents to maintain blood flow>300 mL/min. There was no difference in the need for thrombolytic infusions between the LifeSite oxychlorosene group and the Tesio-Cath group (P = 0.1496); however, the LifeSite alcohol group required significantly fewer thrombolytic infusions than the Tesio-Cath group (P = 0.0295) to maintain adequate blood flow. Device survival at 6 months after stratification by diabetic status and adjusting for age was significantly better in the LifeSite alcohol group (89.9%) than in the LifeSite oxychlorosene group (64.8%, P = 0.0286) and in the Tesio-Cath (69.1%, P = 0.0292) group. CONCLUSIONS: The LifeSite Hemodialysis Access System, when used with 70% isopropyl alcohol as an antimicrobial solution, provides superior performance with a lower infection rate and better device survival than a standard cuffed tunneled hemodialysis catheter.

Vena caval filter placement by intravascular ultrasound.

OBJECTIVE: Placement of vena caval filters under fluoroscopic surveillance incurs significant expense and potential risks associated with the transportation of critically ill patients. Intravascular ultrasound (IVUS) allows direct intraluminal visualization of the vena cava and the renal veins. The purpose of this study is to evaluate the accuracy of vena caval filter placement under IVUS in an animal model. METHODS: Fifteen Simon-Nitinol venal cava filters (C.R. Bard, Inc., Covington, GA) were placed under IVUS guidance into four anesthetized sheep. Twelve were placed transfemorally, and three were placed transjugularly. Accuracy of placement was confirmed with fluoroscopy by measurement between the filter tip and the targeted side branch. RESULTS: The vena caval filters placed femorally averaged 0.33+/-0.42 cm distance from the target vein side branch. Jugular approach filter placement was less accurate. Although two out of three filters placed from the jugular vein were correctly positioned, the distance from the target vein side branch was much greater averaging 2.5+/-1.04 cm. CONCLUSION: Femoral placement of vena caval filters under IVUS is extremely accurate. The transjugular route, however, was technically challenging and standard fluoroscopic vena caval filter placement appears to be more appropriate. Our success with the femoral approach merits further clinical investigation in the use of IVUS for critically ill patients that would benefit from bedside vena caval filter placement.

Failed AAA endograft exclusion due to type II endoleak: explant analysis.

PURPOSE: To report the patient history and analysis of an explanted modular bifurcated endograft that was implanted to exclude an abdominal aortic aneurysm (AAA). CASE REPORT: An 80-year-old man with a 6-cm AAA underwent uneventful endovascular implantation of a bifurcated AneuRx stent-graft. His postprocedural clinical course was uneventful, although persistent contrast enhancement of the aneurysm remained via the inferior mesenteric artery (IMA). By 6 months, an endoleak connecting to the lumbar and mesenteric arteries became apparent. Over the ensuing 12 months, the endoleak and aneurysm enlarged; branch artery embolization was attempted in 4 percutaneous procedures. Despite successful IMA occlusion, the aneurysm continued to increase in diameter and volume, necessitating conversion to a conventional bypass at 20 months. Analysis of the explanted specimen revealed an intact endograft with fibrous incorporation of the stent framework at the proximal and distal fixation sites only; no incorporation of the endograft was noted within the aneurysm. The feeding channel for the endoleak was not identified. CONCLUSIONS: Serial imaging is a vital component of endograft surveillance, and persistent type II endoleaks that cannot be completely embolized endanger the longevity of the aneurysm exclusion. Explant analysis can play an important role in understanding the mechanisms of endograft failure.

Healing response of normal canine aorta and iliac artery to a nitinol stent encapsulated in carbon-lined ePTFE.

PURPOSE: To evaluate the healing response of normal canine arteries to a self-expanding nitinol stent encapsulated in carbon-lined expanded polytetrafluoroethylene (ePTFE). METHODS: Twenty-eight dogs were divided into aortic (n = 18) or iliac (n = 10) groups. In the latter, 2 animals were assigned to implantation intervals of 7, 30, and 90 days, respectively; 4 were designated for 180-day implantation. Half of the animals in each subgroup received a second overlapping stent-graft in one iliac artery. In the aortic cohort, 6 animals were assigned to the 180-day implantation group (2 with dual devices) and 3 to each of the others (1 dual implantation in each group). The devices were evaluated with angiography and intravascular ultrasound at implantation and explantation. After harvesting and gross examination, the specimens were examined microscopically and with scanning electron microscopy. RESULTS: The 49 implanted devices (24 aortic and 25 common iliac) were all widely patent at explantation, save for 2 iliac stents that had moderate (<40%) stenosis. No neointima was present at the 7-day interval. All stents were covered by thin neointima (<150 microm) at 30 days. At 180 days, an endothelial lining was present in the proximal and distal segments of all stents; in 4 of the 6 aortic stents, this endothelial lining was complete, whereas none of the iliac devices had endothelium in the midsegment at 180 days. At 1 year, 2 of the aortic specimens had an incomplete endothelial lining, whereas the lining was complete in the third. There was no evidence of stent-graft migration or inflammation associated with any device. CONCLUSIONS: The carbon-lined ePTFE-encapsulated stent is a novel approach to arterial stenting. The progressive endothelialization and lack of inflammatory reaction may provide improved long-term patency. Further study of this stent-graft design is warranted.

Abdominal pain and hemoperitoneum: sole presenting symptoms for "leaking AAA" after endovascular repair.

PURPOSE: To describe an unusual presentation of impending aortic endograft rupture and successful endovascular rescue. CASE REPORT: A 77-year-old man with an enlarging aortic aneurysm was treated with a Talent bifurcated endoprosthesis; a moderate endoleak that appeared to be related to either proximal or distal fixation sites was noted in the body of the aneurysm. The patient was observed for 1 month, and repeat imaging demonstrated persistent endoleak without major increase in the aneurysm diameter. Another examination was scheduled for 3 months hence, but, 2 months later, the patient presented with abdominal pain and a hemoperitoneum. A proximal extension cuff resolved the leak and led to resolution of the hemoperitoneum. CONCLUSIONS: A leaking aneurysm can be repaired using endovascular techniques in patients with an existing endograft. The need for frequent imaging surveillance of patients with endoleak is underscored.

Endovascular exclusion of descending thoracic aortic aneurysms and chronic dissections: Initial clinical results with the AneuRx device.

OBJECTIVE: The objective of this study was to analyze a single-center experience in which descending thoracic aortic aneurysms (TAAs) were treated with a new self-expanding endovascular prosthesis (Medtronic AVE). METHODS: Twenty-six patients (13 men, 13 women) with American Society of Anesthesiology grades II to IV and ages ranging from 53 to 92 years (average, 74 years) consented as part of a Phase I Food and Drug Administration-approved trial. Treated lesions included TAAs that were 5 to 10 cm in diameter, 12 diffuse dilations or fusiform aneurysms, and four saccular aneurysms. There were also nine chronic dissections (2 aneurysmal dilations and 7 symptomatic acute recurrent dissections). Three patients (2 with diffuse/fusiform and 1 with dissection) presented with hemothorax, contrast extravasation, or both. RESULTS: Twenty-five of the 26 patients who consented (96% technical success) were treated successfully with no surgical conversions. Eighteen patients have been followed up from 1 to 22 months (average, 9 months). One patient is lost to follow-up, and six patients have died (24%). One procedure-related death (4%) occurred within the 30-day postoperative period and was caused by diffuse embolization. There were no device-related deaths. Five additional patients (20%) have died during the study of comorbid conditions. Complications included one massive myocardial infarction 24 hours after the procedure requiring balloon counterpulsation and long-term dialysis, one cardiac tamponade resulting from central line placement before the procedure, one progression of aneurysm dilation proximal to the device at 1 year, and one bilateral lower extremity paralysis occurring 12 hours after successful deployment. Seven patients (5 women) had femoral artery reconstructions or iliac artery grafts to repair injuries during deployment catheter passage. Other significant parameters included average procedure time (2 hours 40 minutes; range, 1 hour 30 minutes to 5 hours 30 minutes), 450 cc average blood loss (n = 25; 100-3000 cc) being replaced by means of autotransfusion with only two patients receiving banked blood products, and an average 2 days to resumption of normal diet, 1 day in the intensive care unit, and 5 days' hospitalization postprocedure in uncomplicated cases (n = 22). One patient had an endoleak immediately after the procedure that sealed without treatment. Follow-up of all patients ranging from 1 to 22 months (average, 9 months; n = 18) demonstrates continued exclusion of the aneurysm with no endoleaks and either stable or decreasing aneurysm volume, except in one patient with volume increase and no obvious etiology who continues to be investigated. CONCLUSIONS: The study suggests that endovascular prosthesis exclusion of TAAs with an AneuRx self-expanding tubular device may be effective in many patients who are at significant risk for open surgical repair and substantiates further clinical investigation to confirm these findings.

Computed tomography assessment of abdominal aortic aneurysm morphology after endograft exclusion.

OBJECTIVES: Assessment of the long-term function of endografts to exclude abdominal aortic aneurysm (AAA) includes determination of aneurysm dimensions and morphologic changes that occur after implantation. This study reports the dimensional analysis of patients treated with AneuRx bifurcated endoprostheses with postintervention, 1-year (n = 51), 2-year (n = 28), and 3-year (n = 10) postimplantation contrast computed tomography data. METHODS: Maximal diameter (D) and cross-sectional area (CSA) of the AAA were measured from axial computed tomography images. Total volume, AAA thrombus volume (AAA volume minus the volume of the device and luminal blood flow), diameter of the aorta at the level of the renal arteries and within the device, distance from the renal arteries to the device, length of the device limbs, and the angle of the proximal neck were also determined at the same follow-up intervals after deployment with computed tomography angiograms reconstructed in an interactive environment. RESULTS: Fifty-one of 98 consecutively treated patients with the AneuRx bifurcated prosthesis (29 "stiff" and 22 "flexible" body devices) had complete data from the postprocedure and follow-up computed tomography studies available for analysis. Max D, CSA, total volume of the AAA, and AAA thrombus volume decreased sequentially from year to year compared with the postimplantation values. D and CSA decreased or were unchanged in all except four patients, two who had unrestricted enlargement of the aneurysm with eventual rupture and one who had surgical conversion for continued expansion despite four diagnostic angiograms and attempted embolizations. Total volume of the AAA increased in 11 of 51 patients at 1 year, eight of whom had endoleaks at some interval during the follow-up. Thrombus volume increased more than 5% in four of these patients, including the two with eventual rupture and the one conversion. Patients with endoleaks who had spontaneous thrombosis or were successfully treated either remained at the same volume or had decreased volume on subsequent examinations. D at the renal arteries increased an average of 0.9 mm during the first year, with a concomitant increase of 2.8 mm within the proximal end of the device related to the self-expanding nature of the Nitinol suprastructure. Subsequent enlargement of the proximal neck continued at a slow rate in some cases but never exceeded the diameter of the endoluminal device. The distance from the renal arteries to the device increased by an average of 3 mm over the first year, with the greatest increases occurring in patients with a "stiff" body device and those with rapid regression (>10% total volume) in 1 year. As regression of the AAA occurred, the angle of the proximal neck varied from -5 degrees to +25 degrees from the original alignment. Limb length varied from -8 mm to +10 mm, with no consistent pattern for the change, that is, ipsilateral or contralateral limb. CONCLUSION: Significant variation in the quantitation of aneurysm size occurs depending on the technique of computed tomography assessment used. In most patients diameter assessment is adequate, although volumetric analysis appears to be very helpful in certain patients who do not show aneurysm regression, or in whom the diameter increases or where endoleaks persist. Three-dimensional reconstruction and volumetric analysis are also useful to assess the mechanism by which the endovascular device accommodates to morphology changes and to determine criteria for reintervention.

Role of bacterial association and penetration on destruction of Escherichia coli O157:H7 in beef tissue by high pH.

This study was undertaken to determine if association with collagen enables Escherichia coli O157:H7 to resist high-pH treatments and to determine the effects of high pH on the survival of E. coli O157:H7 within different layers of beef tissue. E. coli O157:H7 was inoculated onto purified bovine type I collagen on 12-mm2 circular glass coverslips, plain 12-mm2 circular glass coverslips (control), and 12-mm2 irradiated (cobalt-60) lean beef tissue. The rates of destruction of E. coli O157:H7 inoculated on coverslips in pH 10.5 NaHCO3-NaOH buffer at 35 degrees C were determined at various sampling times. E. coli O157:H7 cells associated with collagen and treated in the same manner were also examined using scanning electron microscopy to determine if association with collagen enabled the organism to resist high-pH treatments. The inoculated tissue was treated in pH 13.0 NaHCO3-NaOH buffer at 25 degrees C, and penetrating cells of E. coli O157:H7 were recovered using a cryostat technique. There was no significant difference (P < 0.05) between the rates of destruction of collagen-associated E. coli O157:H7 and non-collagen-associated E. coli O157:H7 following exposure to high-pH treatments. Scanning electron micrographs showed that collagen-associated E. coli O157:H7 cells appeared physically damaged by exposure to high-pH treatments, and association of E. coli O157:H7 to collagen did not increase the resistance of the organism to destruction by high-pH rinses. No significant differences were seen between 20 ml of NaHCO3-NaOH buffer at pH 13.0 (treatment) and 20 ml of distilled water at pH 7.0 (control) when E. coli O157:H7 cells were recovered in beef tissue at depths of up to 2,000 microm (P < 0.05). The ability of E. coli O157:H7 to penetrate beef tissue may be an important factor in reducing the effectiveness of high-pH treatments in killing this organism on beef tissue. This finding should be considered in the future when designing treatments to decontaminate beef carcasses.

Posttraumatic carotid cavernous fistula: frequency analysis of signs, symptoms, and disability outcomes after angiographic embolization.

OBJECTIVE: To increase awareness and understanding of posttraumatic carotid cavernous fistula (PTCCF) with the intent to expedite diagnosis and treatment of this disabling injury, a 14-year retrospective review of patients with angiographically identified PTCCF was conducted at this Level I trauma center. A frequency analysis of signs, symptoms, and disability was performed. The impact on disability of demographics, number of embolization attempts required for closure of the PTCCF, and time from injury to diagnosis was assessed by t test for independent samples. RESULTS: Nine patients were diagnosed with 10 PTCCFs. Mean patient age was 41.5 years. All patients with PTCCF had basilar skull fracture, loss of consciousness, bruit, and chemosis; 90% had exophthalmos; 70% had visual changes; 50% complained of headache; and 80% had some lasting disability. Mean age of patients with partial to total disability was 47 years, while the mean age of patients without lasting disability was 19.5 years (p = 0.013). No statistical correlation could be found between disability and sex, blunt versus penetrating injury, days to diagnosis, or number of embolization attempts. CONCLUSION: Patients sustaining head trauma with basilar skull fractures and presenting with the described signs and symptoms should be evaluated for PTCCF. Risk of disability does not appear to be influenced by number of attempts at embolization or time to diagnosis. However, age may have a significant impact on outcome.

Therapeutic efficacy of multiple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody combined with low-dose weekly methotrexate in rheumatoid arthritis.

OBJECTIVE: To evaluate the efficacy, pharmacokinetics, immunogenicity, and safety of multiple infusions of a chimeric monoclonal anti-tumor necrosis factor alpha antibody (cA2) (infliximab; Remicade, Centocor, Malvern, PA) given alone or in combination with low-dose methotrexate (MTX) in rheumatoid arthritis (RA) patients. METHODS: In a 26-week, double-blind, placebo-controlled, multicenter trial, 101 patients with active RA exhibiting an incomplete response or flare of disease activity while receiving low-dose MTX were randomized to 1 of 7 groups of 14-15 patients each. The patients received either intravenous cA2 at 1, 3, or 10 mg/kg, with or without MTX 7.5 mg/week, or intravenous placebo plus MTX 7.5 mg/week at weeks 0, 2, 6, 10, and 14 and were followed up through week 26. RESULTS: Approximately 60% of patients receiving cA2 at 3 or 10 mg/kg with or without MTX achieved the 20% Paulus criteria for response to treatment, for a median duration of 10.4 to >18.1 weeks (P < 0.001 versus placebo). Patients receiving cA2 at 1 mg/kg without MTX became unresponsive to repeated infusions of cA2 (median duration 2.6 weeks; P=0.126 versus placebo). However, coadministration of cA2 at 1 mg/kg with MTX appeared to be synergistic, prolonging the duration of the 20% response in >60% of patients to a median of 16.5 weeks (P < 0.001 versus placebo; P=0.006 versus no MTX) and the 50% response to 12.2 weeks (P < 0.001 versus placebo; P=0.002 versus no MTX). Patients receiving placebo infusions plus suboptimal low-dose MTX continued to have active disease, with a Paulus response lasting a median of 0 weeks. A 70-90% reduction in the swollen joint count, tender joint count, and C-reactive protein level was maintained for the entire 26 weeks in patients receiving 10 mg/kg of cA2 with MTX. In general, treatment was well tolerated and stable blood levels of cA2 were achieved in all groups, except for the group receiving 1 mg/kg of cA2 alone, at which dosage antibodies to cA2 were observed in approximately 50% of the patients. CONCLUSION: Multiple infusions of cA2 were effective and well tolerated, with the best results occurring at 3 and 10 mg/kg either alone or in combination with MTX in approximately 60% of patients with active RA despite therapy with low-dose MTX. When cA2 at 1 mg/kg was given with low-dose MTX, synergy was observed. The results of the trial provide a strategy for further evaluation of the efficacy and safety of longer-term treatment with cA2.

Comparison of the Difco EZ Coil rapid detection system and Petrifilm test kit-HEC for detection of Escherichia coli O157:H7 in fresh and frozen ground beef.

The Difco EZ Coli Rapid Detection System was compared to the 3M Petrifilm method for detection of Escherichia coli O157:H7 in raw ground beef. Raw meatballs (25 g) were inoculated with 10 to 15 cells of Escherichia coli O157:H7, stored for various times and at different temperatures, and then stomached for 2 min in 225 ml of EZ Coli enrichment broth, which was then incubated at 42 degrees C for 18 to 24 h. A 1-ml sample of the enrichment broth was loaded into the top of the detector tips and the remaining EZ Coli broth held at 35 degrees C before streaking onto MacConkey sorbitol agar and tryptic soy agar with yeast extract. A duplicate set of meatballs were tested using the 3M Petrifilm Test Kit-HEC for hemorrhagic Escherichia coli O157:H7. In this method raw meatballs (25 g) were enriched for 6 h in modified EC broth containing novobiocin at 37 degrees C prior to inoculation of the Petrifilm E. coli Count Plates, which were incubated at 42 degrees C for 18 h. The immunoblot ELISA was performed following this incubation. Presumptive positive isolates from both methods were confirmed using Oxoid E. coli Latex Agglutination and Difco Pasco ID Tripanels. Both methods permitted detection of 10 to 15 cells of E. coli O157:H7 per ml (i) immediately following inoculation, (ii) after 3 days of refrigerated storage at 8 degrees C, and (iii) after 30 days in frozen storage at -20 degrees C. The Difco EZ Coli Detection System proved to be a simpler and faster screening method with identification of negative and presumptive positive samples within 15 to 18 h.

Combination endovascular and open treatment of peripheral arterial occlusive disease performed by surgeons.

The endovascular treatment of peripheral arterial occlusive disease has historically been performed by interventional radiologists and cardiologists. With additional training in endovascular techniques, surgeons become uniquely suited to manage arterial lesions with both endovascular and conventional surgical techniques. Over a 14-month period, 13 patients underwent combination endovascular and open reconstruction on limbs with peripheral arterial occlusive disease. There were 10 males and 3 females. The mean age was 66 years. All procedures were performed in the operating room by surgery residents under the direct supervision of vascular surgeons. After intraoperative angiography, 26 arterial lesions underwent percutaneous transluminal angioplasty (aorta, 1; common iliac, 14; external iliac, 10; superficial femoral, 1). Twenty-five of 26 lesions were further treated with intraluminal stent placement, the lone exception being a case of superficial femoral artery angioplasty. Concomitant open reconstruction was performed on all limbs, 14 as outflow and 1 as inflow. There were two cases of procedural morbidity and one perioperative death secondary to myocardial infarction. There were no wound-related complications. The mean ankle-brachial index of the affected lower extremity improved from 0.41 (+/- 0.15) to 0.74 (+/- 0.14) at 30 days. Mean follow-up was 8 months (range, 2-14). Based on our early experience, simultaneous combination endovascular and open reconstruction of multisegment arterial occlusive disease can be performed safely and efficiently by surgeons.

Suppression of fever and the acute-phase response in a patient with juvenile chronic arthritis treated with monoclonal antibody to tumour necrosis factor-alpha (cA2).

Juvenile chronic arthritis (JCA) is the commonest chronic rheumatic disorder of childhood. Although conventional therapy of JCA continues to improve, many patients experience long-term ill health as a result of their disease or treatment. In adult rheumatoid arthritis (RA), similar concerns have led to the development of therapies designed to interfere in key disease processes. One such therapy is cA2, a chimeric neutralizing monoclonal antibody to the inflammatory cytokine, tumour necrosis factor-alpha (TNF-alpha). The administration of cA2 in adult RA has led to impressive short-term suppression of disease, with a good safety profile. Here, we report the first use of cA2 in childhood arthritis, choosing a patient with severe systemic-onset JCA, resistant to conventional therapies. The patient received two i.v. infusions of cA2, each at a dose of 10 mg/kg, separated by 1 week. The treatment was well tolerated and induced rapid control of fever, anorexia and serositis, together with downregulation of interleukin (IL)-6, soluble TNF receptors (sTNFR) and IL-1ra, and the acute-phase proteins C-reactive protein (CRP) and serum amyloid A (SAA). In contrast, we saw no significant improvement in joint pain or tenderness. Our findings suggest that TNF-alpha is a mediator of fever and other systemic aspects of disease in systemic JCA. TNF-alpha blockade as a treatment modality in JCA deserves further study.

Treatment with a chimeric CD4 monoclonal antibody is associated with a relative loss of CD4+/CD45RA+ cells in patients with rheumatoid arthritis.

This study investigates immunogenicity and in vivo effects on T-cells of long-term CD4 monoclonal antibody treatment of patients with rheumatoid arthritis. Patients were treated with several dosage regimens of a chimeric CD4 monoclonal antibody entitled cM-T412 over the course of 1 year. The circulating CD4+ T-cell count sharply decreased after the first cM-T412 injection and slowly recovered after the last injection. Within the CD4+ subset there was a selective depletion of CD45RA+ T cells, HLA-DR+, and CD25+ cells, providing evidence that activated/memory CD4+ cells resist the effect of CD4 monoclonal antibodies. Studies on cytokine production by peripheral blood mononuclear cells cultures in vitro revealed no differential effect on the production of interleukin-4 compared to interferon-gamma, indicating that a shift from a Th1 to a Th2 lymphokine production profile was not achieved. Human anti-monoclonal antibodies (HAMA) were induced in a minority of the patients predominantly after the first treatment course. All the sera containing HAMA specifically inhibited the binding of cM-T412 to T-cells. However, HAMA formation does not interfere with the biological effect of repeated cM-T412 administration since the degree of CD4 depletion following repeated administration of cM-T412 to patients with and without blocking antibodies was similar. We conclude that the currently available data are of critical importance in the interpretation of the obtained clinical experience and for further development of this therapeutic strategy.

Beneficial effect of treatment with a monoclonal anti-tumor necrosis factor-alpha antibody on markers of coagulation and fibrinolysis in patients with active Crohn's disease.

Crohn's disease has frequently been associated with coagulation abnormalities, causing intravascular deposition of fibrin and local infarction which can subsequently compromise the gut mucosa. Also, arterial and venous thromboembolic complications of larger vessels appear to be associated with Crohn's disease. Coagulation activation in patients with Crohn's disease could be a result of increased serum and tissue levels of cytokines, as reported. We prospectively studied parameters of coagulation and fibrinolysis in 10 patients with active Crohn's disease, who were subsequently treated with a monoclonal anti-tumor necrosis factor-alpha (TNF) antibody. Ten consecutive patients with active Crohn's disease (CDAI > 150), not responding to a daily dose of at least 20 mg prednisolone, received a single infusion of human/mouse chimeric anti-TNF antibody cA2. All evaluable patients attained complete clinical and endoscopic

Increased MRI activity and immune activation in two multiple sclerosis patients treated with the monoclonal anti-tumor necrosis factor antibody cA2.

There is evidence that treatment with an antibody to tumor necrosis factor alpha (TNF alpha) improves an animal model of multiple sclerosis (MS) and is beneficial in two systemic inflammatory disease in humans, but there are no reports about anti-TNF treatment of MS. Therefore, we treated two rapidly progressive MS patients with intravenous infusions of a humanized mouse monoclonal anti-TNF antibody (cA2) in an open-label phase I safety trial and monitored their clinical status, gadolinium-enhanced brain magnetic resonance imaging (MRI), and peripheral blood and cerebrospinal fluid (CSF) immunologic status. We did not notice any clinically significant neurologic changes in either patient. The number of gadolinium-enhancing lesions increased transiently after each treatment in both patients. CSF leukocyte counts and IgG index increased after each treatment. The transient increase in the number of gadolinium-enhancing lesions that followed each infusion of cA2 together with the increase in cells and immunoglobulin in the CSF of each patient suggest that the treatment caused immune activation and an increase in disease activity. These results suggest that further use of cA2 in MS is not warranted and that studies of other agents that antagonize TNF alpha should be carried out with frequent monitoring of gadolinium-enhanced MRIs.