Characterizing Lyme Disease Surveillance in an Endemic State.

Lyme disease (LD) is the most common vector-borne disease in Maryland and the United States. Surveillance for LD is valuable for understanding the burden of the disease, particularly to assess whether the disease is spreading and to appreciate who is affected. However, not all cases of LD in Maryland are reported, and surveillance practices vary across each of Maryland's 24 local health departments (LHDs). To better understand this variability and to systematically characterize the surveillance process, we surveyed Maryland's LHDs regarding LD surveillance. The Maryland Local Health Department Lyme Disease Surveillance Survey has been administered annually since 2011. Questions asked each year included whether all LD reports are investigated or only a subset, and how many reports are not entered into the surveillance database. Since 2011, Maryland has lost surveillance personnel for LD. Each year from 2009 to 2012, a median 3598 (range 2462 to 5722) reports were not entered into the surveillance database and hence not investigated. These reports represent 43-55% of all reports received for the year. Over time, more LHDs chose to streamline their LD investigation approach by investigating only those reports that met the criteria for laboratory evidence of infection: in 2008, 5 (21%) LHDs investigated only a subset of LD reports; by 2013, this increased to 15 (63%). There is wide variability across LHDs in how LD investigations are conducted. Maryland LHDs have experienced a loss of LD surveillance personnel with a concomitant increase in the number of LHDs adopting a streamlined approach to investigating cases. These findings underscore the tremendous burden of LD on the public health agencies and highlight the need for alternative approaches that can both reduce burden and preserve surveillance data quality.

Clinically 'benign' breast lumps: sarcoma in hiding?--Case reports and literature review.

Breast sarcoma is a very rare entity that accounts for less than 1% of all breast malignancies and less than 5% of all soft tissue tumours. Although uncommon, we highlight 2 recent cases encountered at our centre. The aim is to emphasise their apparent benign appearance on physical examination, so that readers will be alerted in a similar clinical setting. Medline was used to search for relevant articles concerning the pathology, treatment modalities and long-term prognosis of patients with this rare illness. We also reviewed soft tissue sarcomas found elsewhere. Articles relating to phyllodes tumour were excluded or only relevant sections used. We discuss the controversy regarding axillary lymph node clearance and the use of radiotherapy. Despite conflicting reports and lack of clinical studies, we believe that a simple mastectomy will suffice as adequate treatment, hence avoiding the undesirable side effects of chemotherapy or radiotherapy.

Agreement or prediction: asking and answering the right question.

INTRODUCTION: Measuring agreement and measuring predictive ability are similar but distinct problems. Failure to appreciate the conceptual and practical differences may lead clinical researchers to give the right answer to the wrong question. METHODS: We illustrate the relation and difference between measuring agreement and predictive ability in a non-technical way. We provide a real example investigating the feasibility of using preoperative breast cancer tumour size measurements to estimate postoperative histological size. The intraclass correlation and R-squared are calculated to ascertain the level of agreement and predictive ability respectively. RESULTS: Analysis of agreement and analysis of predictive ability serve different purposes. The optimal solution found in terms of agreement may be different from that found for prediction. CONCLUSIONS: A careful clarification of the goal of an investigation is important. Using an inappropriate analysis can lead to misleading results, or to results that do not really answer the research question of interest.

Post-operative pain in needlescopic versus conventional laparoscopic cholecystectomy: a prospective randomised trial.

BACKGROUND: Needlescopic cholecystectomy (NC) utilises instruments and ports smaller than 3 mm in diameter compared with the 5 mm ones used in conventional laparoscopic cholecystectomy (LC). Post-operative pain control and recovery has been thought to be superior in NC, when compared with historical controls with LC, but has not been proven in a prospective fashion. PATIENTS AND METHODS: A prospective randomised trial of NC versus LC for patients with symptomatic gallstone disease, with standardisation of post-operative analgesia and daily assessment of post-operative pain, using a 5-point visual analogue scale. RESULTS: There were 64 eligible patients randomised into NC (28) and LC (36). Four patients who had NC were converted to LC due to technical problems. Another three and six patients from the NC and LC groups, respectively, had conversion to open surgery. Post-operative pain scores were low in both groups. Mean pain scores for those with successful NC and LC were: 1.24 versus 1.43 for the day of operation (P = 0.49), 0.86 versus 0.83 for the first day post-operatively (P = 0.92) and 0.75 versus 0.81 for the second post-operative day (P = 0.87). The mean number of intra-muscular analgesic injections required were 0.76 versus 0.83 after NC and LC, respectively (P = 0.93). There were no significant differences between the two groups in the time taken to return to feeding, eating a normal diet and discharge from hospital. CONCLUSION: There is no advantage of NC over LC in terms of post-operative pain or recovery. Nevertheless, NC can be performed safely and expediently and has an excellent cosmetic outcome and high patient acceptability.

Removal of a dinner fork from the stomach by double-snare endoscopic extraction.

Long and pointed foreign objects in the stomach are difficult to remove by endoscopy, and they can cause complications such as perforation and impaction. The endoscopic removal of long and pointed objects involves the following principles: (1) presenting the blunt end cephalad to prevent perforation or impaction during extraction; (2) orienting the long axis of the object in the line of extraction; and (3) applying traction to the foreign body without losing grip. Currently practised methods of extraction, which use a protector hood or an overtube, do not address these three principles. We report on a case in which an ingested metal dinner fork was removed from the stomach by using a double wire-loop snare technique. This method uses two snares to hold the object and allows the endoscopist to change the presentation, orient the axis, and maintain traction to allow the safe removal of long and pointed objects.

Novel effects of the acyl-coenzyme A:Cholesterol acyltransferase inhibitor 58-035 on foam cell development in primary human monocyte-derived macrophages.

We examined the effect of acyl-coenzyme A:cholesterol acyltransferase (ACAT) inhibitors on intracellular cholesterol stores in primary human monocyte-derived macrophages (HMMs) during foam cell formation. HMMs were exposed to acetylated low density lipoprotein (acLDL, 500 microg protein per mL) with or without 58-035 (1 to 10 microg/mL) or CI-976 (2 microg/mL) for 2 to 48 hours. Total cholesterol (TC) and esterified cholesterol (EC) mass was significantly lower while unesterified cholesterol (UC) increased slightly in cells incubated with acLDL plus ACAT inhibitors. Sterol mass was also measured in cells coincubated with acLDL (500 microg protein per mL) with or without 58-035 (2 microg/mL), high density lipoprotein (HDL, 400 microg protein per mL), or HDL+58-035 for 48 hours. TC and EC were 23% and 55% lower, respectively (P<0.0004), while UC was 11% higher (P<0.04) in cells incubated with acLDL plus 58-035. In contrast, coincubation with HDL alone did not significantly affect TC, EC, or UC mass compared with acLDL alone. The effect of 58-035 could not be explained by cytotoxicity, because adenine release, secreted lactate dehydrogenase, glucose utilization, and cell protein were similar in cells exposed to acLDL regardless of the presence of 58-035. We investigated several potential mechanisms for the decreased TC mass, including increased UC efflux and decreased acLDL binding and uptake. Efflux was measured in cells exposed to [1,2-(3)H]cholesteryl oleate-labeled acLDL, unlabeled control acLDL, and native untreated acLDL (500 microg protein per mL) with or without 58-035 (5 microg/mL) for 24 or 48 hours. UC efflux increased in a time-dependent manner from cells exposed to acLDL plus 58-035 compared with cells exposed to acLDL alone (P<0. 04). High-affinity binding was measured in cells exposed to (125)I-acLDL (5 microg protein per mL) with or without excess unlabeled acLDL (100 or 500 microg protein per mL) for 4 hours at 4 degrees C. Specific acLDL binding, uptake, and total degradation were significantly lower when 58-035 was present during cholesterol enrichment compared with cells exposed to acLDL alone (P<0.001). Unlike the effects of ACAT inhibitors on foam cell formation in rodent macrophages, these compounds lowered TC accumulation in HMMs during foam cell formation by limiting the uptake of acLDL and enhancing UC efflux. They may offer promise as drug therapies for atherosclerosis.

Perforated leiomyosarcoma of Meckel's diverticulum.

Two cases of perforated leiomyosarcoma of Meckel's diverticulum are presented. There are only 59 cases reported in current literature, including 4 perforations. Although the condition is rare, leiomyosarcoma is the commonest tumour of Meckel's diverticulum. Its clinical presentation include abdominal pain, intestinal bleeding, abdominal mass, intestinal obstruction and less commonly, acute perforations. Both our cases presented with perforations which is unusual. Despite this late presentations both were resectable and both had no distant or local metastasis. One of our patients was 89 years old at presentation and has been disease-free 3 years after resection. The other patient was 69 years old and has also been disease-free.

Incidental cholecystectomy--an old problem reconsidered.

This paper reexamines the issues and indications for incidental cholecystectomy when gallstones are present during laparotomy for an unrelated condition. Seventy-nine such patients were studied between 1988 and 1993--66 had incidental cholecystectomy (both elective and emergency) while asymptomatic gallstones were left alone in 13 patients for various reasons. There was little morbidity and no mortality arising directly from biliary surgery. Interestingly, four bile cultures from the asymptomatic gallbladders grew bacteria and this could explain why patients may develop severe disease postoperatively if their gallbladders were left alone. The added cholecystectomy resulted in an acceptable extension of 22 to 23 minutes in the operative time without compromising the patients' safety.

Selective association between MHC class I-restricted T cell receptors, CDS, and activated tyrosine kinases on thymocytes undergoing positive selection.

Developing T cells undergo distinct selection processes that determine the TCR repertoire. Positive selection involves the differentiation of immature thymocytes capable of recognizing antigens complexed with self-MHC molecules to mature T cells. Besides the central role of TCR engagement by MHC in triggering selection; the interaction of CD8 and CD4 with MHC class I and class II, respectively; is thought to be important in regulating the selection process. To study potential mechanisms involved in positive selection of CD8+ cells, we have analyzed mice expressing a unique transgenic TCR. The transgenic receptor recognizes the HY male Ag in the context of the MHC class I molecule, H2-Db. We describe that CD8 and the TCR are selectively associated in thymocytes of mice expressing the restricting MHC, but not in thymocytes of mice expressing a nonrestricting MHC. pp56lck and pp59fyn, the tyrosine kinases associated with CD8 and TCR, respectively, were found to be present in this complex in an activated form. No comparable TCR-CD4 complex formation was found in thymuses undergoing positive selection to CD8+ cells. The formation of a multimolecular complex between CD8 and TCR, in which pp56lck and pp59fyn are activated, may initiate specific signaling programs involved in the maturation of CD8+ cells.

In vitro transcription and translation of group B rotavirus strain IDIR gene 8 and immunoprecipitation by human sera.

Group B rotaviruses (GBRs) are associated with episodes of acute diarrhea in humans and a variety of animal species. To date, these agents have not been well adapted to growth in tissue culture, and evaluation of human sera for antibodies directed against GBRs has been hindered by the inability to obtain standardized and highly purified preparations of GBR antigens. In order to evaluate the reactivities of antisera with a highly specific antigen, we prepared a full-length cDNA clone of gene 8 of the IDIR strain of GBR. This clone was transcribed with T7 RNA polymerase, and the resulting RNA was translated in vitro with rabbit erythrocyte lysates. The polypeptide expressed from IDIR gene 8 was specifically precipitated by antibody directed against IDIR but not by antibody directed against ADRV (adult diarrhea rotavirus) or bovine strains of GBR. Subsequent immunoprecipitation reactions confirmed the presence of anti-IDIR antibodies among the U.S. population. Of 129 human serum specimens, 3 specifically immunoprecipitated the IDIR gene 8 polypeptide.

Growth of group A rotaviruses in a human liver cell line.

Recent observations in children with rotavirus gastroenteritis and in infant mice given rotavirus vaccine by oral administration suggest that this well-known gastrointestinal pathogen may infect the liver. To examine this possibility, the susceptibility of Hep G2 cells to infection with a variety of rotavirus strains was tested. These cells were used because they are considered to be well differentiated and exhibit many liver-specific functions. The Hep G2 cells supported the growth of the simian strain rhesus rotavirus (MMU 18006), a strain currently being used in vaccine trails, but did not support the growth of any human strain (D, DS1, Price or ST3). The rhesus rotavirus infection was cytopathic and resulted in release of lactate dehydrogenase. Rhesus rotavirus growth in Hep G2 cells displayed trypsin-enhanced infectivity and was inhibited by pretreatment of cells with Arthrobacter ureafaciens neuraminidase but not with neuraminidase from Clostridium perfringens. Hep G2 cells were also permissive for another simian strain (SA11), a bovine strain (UK) and single gene substitution reassortants containing VP7 (the major outer capsid neutralization protein) from a human rotavirus strain and the remaining 10 genes from either rhesus rotavirus or UK. In general, UK and its reassortants produced lower levels of antigen than did rhesus rotavirus and its reassortants. Hep G2 cells and other hepatic cell lines may prove to be useful tools to explore the hepatotropic potential of wild-type rotaviruses and candidate vaccine strains.

Protease inhibitors suppress the in vitro and in vivo replication of rotavirus.

Rotaviruses are major causes of infectious gastroenteritis in humans and other animals. We found that a variety of protease inhibitors suppressed the replication of the SA-11 strain of rotavirus in MA-104 cell cultures. Three of these compounds, leupeptin, pentamidine, and bis (5-amidino-2-benzimidazolyl) methane (BABIM) also restricted the intestinal replication of the murine strain of rotavirus when protease inhibitor and virus were administered simultaneously to suckling mice. Repeated administration of BABIM resulted in significantly reduced levels of intestinal rotaviral antigen even if administration of the compound was begun as late as 48 h after viral inoculation. Additionally, BABIM-treated animals had significantly less intestinal replication of rotavirus than did placebo-treated controls when placed in a heavily rotavirus-contaminated environment. The use of protease inhibitors represents a novel approach to the control of this important gastrointestinal pathogen and is a potential modality for the prevention and treatment of diseases caused by other enteric viruses, for which proteolytic cleavage is necessary for efficient replication.

Identification of a group-reactive epitope of group B rotaviruses recognized by monoclonal antibody and application to the development of a sensitive immunoassay for viral characterization.

Group B rotaviruses (GBRs) are fastidious agents which cause enteric disease in humans and a number of other animal species. Detailed study of the role of GBRs in human disease has been hampered by the lack of immunoreagents suitable for large-scale studies. We developed a monoclonal antibody which recognizes a group-reactive antigen contained in a number of strains of GBRs. When utilized in conjunction with a hyperimmune guinea pig antiserum to GBR, this monoclonal antibody can be used in an enzyme immunoassay system to detect a wide range of GBRs. Alternatively, this monoclonal antibody can be combined with sera obtained from GBR-infected animals to devise assays which are largely specific for the homologous strain of GBR. Reactivity was not noted in either system with strains of group A or group C rotaviruses or with other members of the family Reoviridae. These results indicate that GBRs contain both group-reactive and species-specific antigens which are distinct from those found in group A rotaviruses. The availability of well-defined immunoreagents will facilitate detailed studies of GBR infections in humans and animals.

Antibodies to rotaviruses in chickens' eggs: a potential source of antiviral immunoglobulins suitable for human consumption.

The prevalence of antibodies to human rotaviruses in commercially available eggs and egg products that are suitable for human consumption was investigated. The yolks of virtually all of the individual eggs and pasteurized pooled egg preparations contain antirotavirus antibodies detectable by means of enzyme immunoassay systems. Also, the eggs and egg preparations are capable of inhibiting the growth of two strains of rotaviruses in tissue culture. Chromatographic studies indicated that the antigen-binding activity is limited largely to the immunoglobulin fractions of the egg yolks. The antibody levels in eggs can be increased by the immunization of hens with purified rotavirus preparations, and the immunoglobulins isolated from the eggs of immunized hens can prevent the development of rotavirus gastroenteritis in experimentally infected animals. Egg preparations might serve as a practical source of antiviral antibodies suitable for consumption by infants and young children.

Sialic acid glycoproteins inhibit in vitro and in vivo replication of rotaviruses.

We investigated the interactions of rotaviruses with glycoproteins and cells that support rotaviral replication. We found that a wide range of naturally occurring glycoproteins, including ovalbumins and ovomucoids from chicken and turkey eggs, and mucin derived from bovine submaxillary glands, inhibit the replication of rotaviruses in MA-104 cells. Our studies further indicated that the glycoproteins bind directly to rotaviruses and that virus-glycoprotein binding is dependent largely upon interactions with sialic acid oligosaccharides. We found that accessible sialic acid oligosaccharides are required for efficient rotavirus infection of MA-104 cells, thus demonstrating that sialic acid oligosaccharides play an important role in the interactions of rotaviruses with both glycoproteins and cells that support rotaviral replication. Bovine submaxillary mucin and chicken ovoinhibitor can also prevent the shedding of rotavirus antigen and the development of rotavirus gastroenteritis in a mouse model of rotavirus infection. Our findings document that a range of glycoproteins inhibit the in vivo and in vitro replication of rotaviruses and suggest that the alteration in the quantity or chemical composition of intestinal glycoproteins is a potential means for the modulation of enteric infections.

Homotypic and heterotypic antibodies for prevention of experimental rotavirus gastroenteritis.

We investigated the abilities of homologous and heterologous antibody preparations to neutralize murine rotavirus in a mouse model of rotavirus infection. We found that incubation of virus with murine sera obtained from animals experimentally infected with the homologous epizootic diarrhea of infant mice strain of rotavirus resulted in inability of the virus to cause symptomatic disease in infant mice. Sera from nonimmune mice and mice infected or immunized with a heterotypic strain of rotavirus did not effectively neutralize virus in this system. On the other hand, neutralization was noted after incubation of virus with a number of immunoglobulins from other animal and human sources. The neutralizing activity of the preparations in the murine model correlated partially, but not completely, with the level of in vitro neutralizing antibody to the murine strain of rotavirus measured in a tissue culture system. In most cases, asymptomatic infection after feeding of the virus and the antibody preparation resulted in subsequent generation of an active immune response in infected animals.

Antibody to human rotavirus in cow's milk.

Rotavirus infection is an important cause of gastroenteritis in infants and young children. Since the virus replicates in the intestinal lumen, we investigated the presence and effectiveness of rotavirus antibody in three forms of milk: raw milk, pasteurized milk, and commercially available infant formulas. Both raw and pasteurized milk contained detectable levels of IgG1 antibody directed at rotavirus. On the other hand, little or no anti-rotavirus antibody was detected in commercially available infant formulas or other sterile milk preparations. The milk samples with rotavirus antibody were capable of inhibiting the replication of simian, bovine, and human rotaviruses in tissue culture. In addition, they were capable of protecting mice from infection and disease in a murine model of rotavirus infection. On the other hand, the formula preparations were incapable of modifying the in vitro replication of rotavirus strains in tissue culture and did not prevent symptomatic gastroenteritis in the mouse model. We conclude that the alteration of milk-processing procedures or the addition of effective antibodies to milk preparations commonly used in the nutrition of young children may alter the clinical course of rotavirus infection or decrease the transmission of rotavirus throughout susceptible populations.