Schweizerische medizinische Wochenschrift最新文献

Varicella zoster and herpes simplex viruses cause latent infections by persisting in human cells. Reactivation has been associated with increasing age, immunosuppression, cancer, stress, fever, exposure to ultraviolet light, and tissue damage. Based on three cases reported to the Swiss Drug Monitoring Centre SANZ, we postulated previously that vaccinations may trigger reactivation of herpes virus infections due to vaccine-induced immunomodulation. In the meantime, 10 new cases of reactivated herpes virus infections soon after vaccinations have been reported. They involved 5 women and 5 men with an age range between 16 and 60. In only one case had a trauma preceded, otherwise healthy subjects with no known relevant comorbidity were vaccinated. The clustering of reports after publication points to a previous underreporting of similar cases. This may be explained by the fact that both vaccinations and reactivations of herpes virus infections are frequent, and a causal link is not suspected. However, these new cases do not prove causality, and extensive epidemiological or experimental studies are needed to elucidate the possible link between vaccination and reactivation of herpes virus infections.

Apart from their antigen-recognising function, immunoglobulins have other physicochemical properties. The best described is cryoprecipitation of monoclonal and/or polyclonal immunoglobulins. The cryoprecipitation phenomenon is unique for each cryoglobulin, and depends on the intrinsic properties of the monoclonal immunoglobulin, the protein environment, temperature and the surrounding ionic concentrations. The complement activating properties of monoclonal immunoglobulins are also unique. We have described a series of monoclonal immunoglobulins which are able to activate the classical pathway of complement without the formation of antigen/antibody complexes. Analysis of the properties of these monoclonal immunoglobulins suggests new therapeutic strategies in oncology. Monoclonal chimeric antibodies, combining antibody specific against tumour antigens and strong complement activation, may be more damaging to tumor cells than currently used antibodies.

The implications of current ethical concerns in the field of genetic research and applications are discussed. Genetic diagnosis is perceived as ethically ambivalent both in general and in its individual applications. Genetic testing, by inviting participation, reflects this ambivalence and can be taken as the basis for both a "right to know" and a "right not to know". The connection between prenatal diagnosis and abortion is also complex and cannot be regarded as ethically clearcut. In these circumstances the legislator must exercise caution in regulating genetic diagnosis in its present state of development.

Death receptors are a growing family of transmembrane proteins which can detect the presence of specific extracellular death signals and rapidly trigger cellular destruction by apoptosis. The best studied to date is Fas (CD95). Expression and signalling by Fas and its ligand (FasL, CD95L) is a tightly regulated process essential for key physiological functions in a variety of organs, including the maintenance of immune homoeostasis. Recently, strong evidence has shown that dysregulation of Fas expression and/or signalling contributes to the pathogenesis of toxic epidermal necrolysis and acute graft-versus-host disease. With these new developments, strategies for modulating the function of Fas signalling have emerged and opened up novel therapeutic possibilities. Specific blockade of Fas, for example with intravenous immunoglobulin preparations containing specific anti-Fas antibodies, has shown great promise in the treatment of toxic epidermal necrolysis and may also be useful in the treatment of acute graft-versus-host disease. Further developments in this field may have important clinical implications for the treatment of such diseases.

Objectives: To examine the clinical, radiographic and laboratory findings in patients with tuberculous lymphadenitis and to analyse the investigational strategies which lead to the diagnosis of tuberculous lymphadenitis.

Methods: Retrospective study including 16 HIV-negative patients at the Cantonal Hospital, Winterthur with tuberculous lymphadenitis diagnosed between 1994 and 1999.

Results: The majority of patients presented with local symptoms and without signs of severe systemic disease. All the PPD skin tests performed were positive. Cultures for M. tuberculosis were more often positive using fine-needle aspiration than surgical biopsy. We found a lack of systematic diagnostic strategy.

Conclusions: We suggest a standardised investigation procedure. When tuberculous lymphadenitis is suspected, the first diagnostic step consists of a PPD skin test and fine-needle aspiration for acid fast smear, mycobacterial culture and cytology. Surgical biopsy should be done if the cytological and mycobacteriological results of fine-needle aspiration are not diagnostic.

The rise in health costs is due to the tremendous advances in medical science and other causes, such as a system offering a unique financial stimulus for health professionals to provide more services, non-functioning competition, patients' demand for every possible form of treatment as rapidly as possible, a compliant political community and also new players such as consultants, the ethics industry, lawyers and nursing academics. On the other hand, the public is not willing to pay more in taxes and health insurance premiums. The resultant dilemma sooner or later forces restrictions on health care which can be called either optimisation, rationalisation or rationing.

Thus far there has been very little research on violence in relation to age. This is due to various problems: the definition and delimitation of the term "violence" is unclear, and violence is considered an interactive event in which everyone involved is both victim and perpetrator. Violence is a taboo topic which people prefer to conceal, and those involved do not talk about the violence they experience. The different forms of violence are physical violence, psychic violence, neglect, restraint, financial exploitation and structural violence. Views on the incidence of violence vary: one certainty is that it occurs in care relationships and that psychic violence and neglect are commoner than physical violence. There is no doubt about the correlatives of violence: limited cognitive abilities, disruptive behaviour, troubled relationships, overtaxing, exhaustion and inappropriate structures. Medical care requires awareness of the problem, facing up to one's own violent behaviour, and knowledge of the risks, causes and consequences of violence. Only in this way is effective prevention and intervention possible. Empirical research offers an approach to future prevention and rehabilitation. People required to deal with violence are under a heavy burden, and decisions must often be made in conflict situations. The law provides a framework, which nevertheless allows scope for action. Ethical guidelines may be of great assistance in this context.

Violence against and by the elderly is a day-to-day concern when working with old and very old people. However, the symptoms are undifferentiated and only discernible if carers come to terms with the (violent) history of those involved. The author's aim is not to provide answers to a complex problem but to contribute to the greater mutual understanding which would prevent the emergence of new traumas.

Pseudomembranous enterocolitis generally occurs after antibiotic treatment. The standard treatment is oral metronidazol or vancomycin. Nevertheless, relapses of Clostridium difficile enterocolitis are observed in 10-25% of cases. Factors associated with recurrences include endogenous reinfection by spore formation, selective IgG1 or IgA deficiency or infection with mutated strains of Clostridium difficile. Recurrent Clostridium difficile enterocolitis may be treated with repeat oral vancomycin combined with Sacchoromyces boulardii, with intravenous immunoglobulin for severe colitis.

Infection by cytomegalovirus (CMV) in immunocompetent patients is rare, and if it occurs it is most often associated with ulcerative colitis. This case illustrates a CMV infection in a patient with an ulcerative colitis combined with CMV-induced protein losing enteropathy, a condition reported in immunocompetent individuals in only a very few cases worldwide. It demonstrates the importance of differentiating between a flare-up of ulcerative colitis and CMV colitis. The indication for antiviral therapy is discussed. A 76-years-old patient with a 23-year history of leftsided ulcerative colitis presented with acute pancolitis sparing the rectum. He showed no evidence of impaired host defence, nor has he ever had taken immunosuppressive drugs. Disseminated primary CMV infection involving of the colon, the oesophagus and the small intestine with protein losing enteropathy was diagnosed on the basis of histology, culture and serology. In view of the long duration of the illness and the highly active infection, antiviral therapy with ganciclovir was given and led to a dramatical improvement of all disease manifestations. The patient subsequently remained in remission from ulcerative colitis for three years.