The Association of Mycobacterium avium subsp. paratuberculosis with Inflammatory Bowel Disease.

The association of Mycobacterium avium subspecies paratuberculosis (M. paratuberculosis) with Crohn's disease is a controversial issue. M. paratuberculosis is detected by amplifying the IS900 gene, as microbial culture is unreliable from humans. We determined the presence of M. paratuberculosis in patients with Crohn's disease (CD) (n = 22), ulcerative colitis (UC) (n = 20), aphthous ulcers (n = 21) and controls (n = 42) using PCR assays validated on bovine tissue. Culture from human tissue was also performed. M. paratuberculosis prevalence in the CD and UC groups was compared to the prevalence in age and sex matched non-inflammatory bowel disease controls. Patients and controls were determined to be M. paratuberculosis positive if all three PCR assays were positive. A significant association was found between M. paratuberculosis and Crohn's disease (p = 0.02) that was not related to age, gender, place of birth, smoking or alcohol intake. No significant association was detected between M. paratuberculosis and UC or aphthous ulcers; however, one M. paratuberculosis isolate was successfully cultured from a patient with UC. We report the resistance of this isolate to ethambutol, rifampin, clofazamine and streptomycin. Interestingly this isolate could not only survive but could grow slowly at 5°C. We demonstrate a significant association between M. paratuberculosis and CD using multiple pre-validated PCR assays and that M. paratuberculosis can be isolated from patients with UC.

Use of interferon-gamma release assay for latent tuberculosis infection screening in older adults exposed to tuberculosis in a nursing home.

OBJECTIVES: To assess the additive value of a newly marketed interferon-gamma release assay, QuantiFERON-TB Gold In-Tube (QFT-GIT), to a single tuberculin skin test (TST) for the detection of latent tuberculosis infection (LTBI) in older adults who have been exposed to TB in a nursing home. DESIGN: Contact tracing included clinical examination, chest radiography, TST, and QFT-GIT in TST-negative people (TST< 5 mm). SETTING: A private nursing home. PARTICIPANTS: Seventy-seven individuals (63 elderly residents, 14 young employees) who had been exposed to an active TB case in a private nursing home. MEASUREMENTS: Comparison of TST and QFT-GIT in older adults who have been exposed to TB. RESULTS: For the TST, the positive response rate was 31.7% (n=20) of elderly residents and 43% (n=6) of staff. Positive QFT-GIT results were obtained in seven (16.3%) elderly residents with negative TST, six of whom were aged 80 and older. QFT-GIT increased the percentage of possible LTBI in this group from 31.7% to 42.9%. CONCLUSION: QFT-GIT has a significant additive value to single TST for detecting LTBI in institutionalized older adults, identifying infected subjects anergic to the TST.

How accurately can we detect Mycobacterium avium subsp. paratuberculosis infection?

Mycobacteria have thwarted detection by scientists for centuries. Mycobacterium paratuberculosis is one of the most fastidious of the Mycobacteriaceae, and has been implicated in both animal and human diseases. In domestic livestock, M. paratuberculosis has been associated with Johne's disease, which given its increasing incidence, is currently a cause for concern, due to the potential for M. paratuberculosis to enter our food chain. In addition, a tenuous link has been reported between M. paratuberculosis and Crohn's disease, however evidence to support this link is hampered by the lack of accurate methodologies for detection of M. paratuberculosis in humans. This review compares the sensitivity and specificity of traditional and more recent techniques to the culture and molecular detection of M. paratuberculosis. While serology and culture are popular choices for the livestock industry they have not produced useful data for human infection. Although the advent of molecular biology has enabled faster diagnosis of M. paratuberculosis in human infection, there is currently no gold standard such as culture on which to validate these findings. Even with DNA/RNA detection methods, there is the ever present issue of the genetic relatedness of M. paratuberculosis to other mycobacteria of the Mycobacterium avium complex, some of which also infect humans with very different pathological outcomes. Recent developments in this field include more rapid methods of M. paratuberculosis culture as well as the development of more accurate and sensitive PCR assays. The application of these techniques should offer a greater insight as to the role of M. paratuberculosis in human gastrointestinal diseases.

Soluble adhesion molecules E-cadherin, intercellular adhesion molecule-1, and E-selectin as lung cancer biomarkers.

BACKGROUND: Altered levels of circulating adhesion molecules found in several carcinomas, including lung cancer, reflect local loss of diffusion barriers and tumor volume and can be potentially used as biomarkers. In the present study, we investigated the role of soluble E-cadherin (sE-cad), soluble intercellular adhesion molecule-1 (sICAM-1), and soluble E-selectin (sE-sel) as biomarkers in lung cancer. METHODS: Sixty-two patients with recently diagnosed lung cancer, 42 with small cell lung cancer (SCLC), and 20 with non-small cell lung cancer (NSCLC), as well as 29 healthy volunteers were enrolled. Blood samples were collected at the time of diagnosis and measurement of soluble adhesion molecules in the serum samples was performed by enzyme-linked immunoassay using monoclonal antibodies against E-cadherin, E-selectin, and ICAM-1. RESULTS: Serum levels of sE-cad, sE-sel, and sICAM-1 in both SCLC and NSCLC were significantly elevated compared with control subjects (P < .001). In addition, patients with SCLC or NSCLC with distant metastasis had a marked increase of sE-Cad (P < .001), but no such correlation with sE-sel and sICAM-1 was found. CONCLUSIONS: Our findings suggest that sE-cad, sE-sel, and sICAM-1 have an adjunctive diagnostic role in lung cancer. Furthermore, sE-cad may also have a prognostic role and could be a useful biomarker in the prediction of lung cancer outcome.

Rapid communication: first clinical experience with Doli S 220F-XP extracorporeal lithotripter for urinary lithiasis.

PURPOSE: To assess the initial results of the Dornier Doli S 220F-XP extracorporeal lithotripter for the management of solitary urinary calculi. PATIENTS AND METHODS: We prospectively examined the outcome of shockwave lithotripsy (SWL) in the first 140 patients with solitary renal and ureteral lithiasis treated by one urologist with the new power Doli S lithotripter. Ninety-one patients (group A) had renal stones, and 49 patients (group B) had ureteral stones. Data were collected with respect to stone size, location, and fragmentation. RESULTS: In group A, clinical success was documented in 77 patients (84%) at 1 month after lithotripsy. Three months after lithotripsy, 69 patients (75.2%) were stone free and 8 (8.8%) had fragments <4 mm. In group B, 41 patients (83%) achieved clinical success 1 month after lithotripsy. Thirty-eight patients (77%) were stone free 3 months after treatment, and 3 (6%) had fragments <4 mm. Seven patients (7%) in group A and three patients (6%) in group B required re-treatment. The overall efficiency quotient was 67%. No patient developed a perinephric hematoma. Ninety-four percent of the patients reported mild pain during lithotripsy. The majority (91%) mentioned that they were satisfied with this treatment modality for urinary lithiasis (mean visual analog scale satisfaction score 8). CONCLUSIONS: The Doli S 220 F-XP is a safe and effective device for managing calculi throughout the urinary tract.

Electrothermal bipolar coagulation for radical prostatectomies and cystectomies: a preliminary case-controlled study.

INTRODUCTION: Hemostasis is of utmost importance in urologic cancer surgery. The aim of this initial case-controlled study was to evaluate the use of an electrothermal biporal coagulator (Ligasure device) in major urologic procedures, including open radical prostatectomies and radical cystectomies. MATERIALS AND METHODS: Over the years 2001 to 2002, 58 patients aged 56-74 years (mean: 65 years) underwent open radical prostatectomies and open radical cystectomies performed by the same surgeon, employing either conventional ligation in the control group (radical prostatectomy, n = 15; radical cystectomy n = 9) or the Ligasure device in the study group (radical prostatectomy, n = 24; radical cystectomy n = 10) to ensure blood vessel patency. Effectiveness and postoperative outcomes were evaluated. RESULTS: The 2 groups were similar regarding demographic and clinical variables. The mean operation time was significantly shorter in the Ligasure group compared with the control group for both the prostatectomy (125 minutes vs. 144 minutes, p < 0.001) and the cystectomy procedures (253 minutes vs. 281 minutes, p < 0.001). The mean intra-operation blood loss was significantly lower in the Ligasure group compared with the control group for both prostatectomy (569 ml vs. 685 ml, p = 0.04) and cystectomy procedures (637 ml vs. 744 ml, p = 0.02). Intraoperative blood transfusion was only required in 2 patients (1 radical prostatectomy, 1 radical cystectomy) in the Ligasure group and in 7 patients in the control group respectively (p = 0.01). There was no effect of surgical specimen size on operation time for both prostatectomy (r = -0.03, p = 0.8, n = 39) and cystectomy procedures (r = 0.02, p = 0.9, n = 19). There were no serious intra-operation or postoperative complications related to the use of the Ligasure device. CONCLUSIONS: Ligasure radical prostatectomy and radical cystectomy are safe, and significantly decrease both the operation time and the blood loss, when compared to the conventional ligation method.

Spontaneous perirenal hemorrhage: a 10-year experience at our institution.

OBJECTIVE: To report our experience in patients with spontaneous perirenal hemorrhage (SPH) seen at our institution over a 10-year period. MATERIAL AND PATIENTS: Over the years from 1992 to 2002, 13 patients with SPH without a history of trauma, were treated at our hospital. There were 5 male and 8 female patients with a mean age of 55.7 years (range 36-79 years). The patients' records were reviewed retrospectively with respect to etiology, clinical presentation, radiologic findings and therapeutic management of SPH. RESULTS: All patients were presented with flank or abdominal pain. Radiological evaluation included ultrasonography (U/S) in 7 cases and computed tomography (CT) in 13 cases. An underlying renal mass was indentified employing U/S in 2 cases and using CT in 10 cases respectively. The etiology of SPH was determined in 12 cases. The most common causes were angiomyolipoma (5 patients) and renal cell carcinoma (4 patients). Out of the remaining 4 cases with SPH, one was associated with anticoagulant therapy; polyarteritis nodosa and Wegener angeitis were the underlying diseases in 2 cases respectively; finally, the etiology could not be determined in 1 case. All but two patients were managed surgically. Complete nephrectomy was performed in 6 cases, partial nephrectomy in 4 and simple evacuation of the haematoma was performed in 1 case. CONCLUSIONS: SPH presence should arouse suspicions concerning its etiology, since the most common cause is a renal tumor and approximately 50% of such tumors are malignant. CT scanning is a useful imaging modality for the initial evaluation of SPH, permitting identification of the underlying cause in most instances.

Decreasing prevalence of pleural calcifications among Metsovites with nonoccupational asbestos exposure.

STUDY OBJECTIVES: Twenty years ago, we reported on a very high prevalence of pleural calcifications (PCs) and malignant mesothelioma among inhabitants of Metsovo, in northwestern Greece. It was shown that both abnormalities were related to asbestos exposure from a whitewash containing tremolite. The fading use of this material has resulted in a decreased incidence of mesothelioma (one third of the original incidence). The aim of the present study was to examine whether PCs among Metsovites has followed a similar trend. DESIGN: Retrospective study. SETTINGS: University Hospital of Ioannina, a tertiary teaching hospital, "G. Hadjikosta" Hospital, a tertiary hospital in Ioannina, and Metsovo Health Center, a primary care center in the town of Metsovo. PATIENTS: Chest roentgenograms of 307 Metsovites, obtained between from 1998 to 2002 were examined. The prevalence of PCs was compared to the one noted 20 years ago. RESULTS: A significantly lower prevalence of calcifications was observed now among younger Metsovites (< 60 years of age). In both studies, there was an increasing rate of PC with age. CONCLUSIONS: The findings of the present study strengthen the incrimination of the whitewash containing tremolite in the development of PCs in Metsovites. The withdrawal of its use in the area has resulted in a null prevalence of PCs in individuals < 40 years old.

Absence of mucosa-associated colonic Helicobacters in an Australian urban population.

Application of nested PCR for Helicobacter species to 416 samples obtained at colonoscopy from 15 patients with Crohn's disease, 12 with ulcerative colitis, and 43 controls revealed H. pylori DNA in only 6 individuals with no disease association. No other Helicobacter species were detected in ileal or colonic samples.

Independent predictors of failure of shockwave lithotripsy for ureteral stones employing a second-generation lithotripter.

PURPOSE: To define factors associated with the failure of shockwave lithotripsy (SWL) in the treatment of ureteral stones. PATIENTS AND METHODS: We retrospectively studied 405 men and 283 women (mean age 52.6 years) who underwent SWL with a second-generation lithotripter in the period 1994 to 2001. We evaluated available clinical and radiologic features that might have been related to failure of SWL therapy. RESULTS: Treatment was successful in 502 patients (73%). The 186 patients (27%) in whom treatment failed underwent endourologic alternatives or open surgery. Multivariate logistic regression analysis revealed that unsuccessful outcome was significantly related to: (1) pelvic ureteral stones (odds ratio [OR] 4.02; 95% CI 1.97, 8.19); (2) stone size >10 mm (OR 3.46; 95% CI 2.16, 5.53); (3) obstruction (OR 1.93; 95% CI 0.99, 3.77); and (4) obesity (OR 1.87; 95% CI 0.95, 3.77). Although the predictive value of each individual parameter was relatively low (15.3%-27.9%) the cumulative risk was 82.95% when patients had all four features. The strongest independent predictors of failure were pelvic stones and stones >10 mm (cumulative predictive value 57.3%). CONCLUSIONS: These variables may enable identification of a subgroup of patients who will fail initial SWL. These patients may be candidates for endourologic alternatives as first-line treatment.

Nephron-sparing surgery for localized renal cell carcinoma with a normal contralateral kidney: a European three-center experience.

OBJECTIVES: To assess the long-term effectiveness and safety of nephron-sparing surgery for the treatment of localized renal cell carcinoma with a normal contralateral kidney. METHODS: Since 1973, 118 patients have undergone nephron-sparing surgery for renal cell carcinoma on an elective basis at our institutions. The vast majority of these tumors were incidental findings, with a mean tumor diameter of 3.35 cm (range 0.7 to 5.6). The median follow-up was 8.5 years (range 0.5 to 18), and of those patients alive, 27 (28%) were followed up for more than 10 years. RESULTS: The pathologic stage was pT1N0M0 in 110 cases (93.2%) and pT3aN0M0 in 8 (6.7%); 59 were grade 1, 52 were grade 2, and 7 were grade 3. Complications occurred in 4 patients, including retroperitoneal bleeding in 1 treated by reoperation, urinomas in 2, and ureteral stricture in 1 treated conservatively. Renal function remained normal during the whole follow-up period, and slight proteinuria was observed in 13 patients. The 10-year distant and local recurrence rate was 4% and 3.9%, respectively. The cancer-specific 5, 10, and 15-year survival rate was 97.3%, 96.4%, and 96.4%, respectively. CONCLUSIONS: Our experience, based on a long median follow-up, suggests that nephron-sparing surgery on an elective basis can achieve long-term survival for the treatment of incidental and low-stage renal cell carcinomas without compromising the efficacy of cancer treatment.

Giant ureteral stone in association with primary megaureter presenting as an acute abdomen.

A 20-year-old woman presented with abdominal pain of 4-h duration and of sudden onset. A plain abdominal radiograph showed a giant ureteral stone measuring 12 cm causing ureteral obstruction. Abdominal ultrasound revealed severe dilatation of the two upper thirds of the left ureter and a hydronephrotic ipsilateral kidney. Subsequent renal scan demonstrated that it was a non-functional kidney while the contralateral kidney was normal. A left nephroureterectomy was performed.