Mycoplasma genitalium in asymptomatic patients: implications for screening

OBJECTIVES

Mycoplasma genitalium is well established as a cause of urethritis and has also been associated with cervicitis, endometritis and pelvic infection. Low rates of infection suggest screening may be inappropriate in the general population, but it remains unclear whether asymptomatic patients attending a sexual-health clinic should be tested routinely. The objective of this study was to measure the positivity rate of M genitalium infection in asymptomatic individuals presenting to a sexual-health clinic to inform the need for screening in this population.

METHODS

Asymptomatic patients were identified using a structured questionnaire and tested for M genitalium from genital swabs or urine using two separate polymerase chain reaction (PCR) assays incorporating different primer sequences.

RESULTS

1304 patients were approached over a 6-month period. 743 (57%) patients were symptomatic, and 168 (13%) refused consent, leaving 394 (30%) patients who entered the study. Residual samples were available for 308 (79%) patients, 168 (54%) men and 140 (46%) women. 14/308 (4.5%, 95% CI 2.2 to 6.9%) asymptomatic patients were infected with M genitalium, and an additional 2 (0.6%, 95% CI 0.2 to 2.3%) patients had discrepant PCR results. No significant associations were found between M genitalium infection and age, gender, ethnicity or isolation site.

CONCLUSION

The positivity rate of M genitalium infection in asymptomatic sexual-health clinic attendees is comparable with that of gonorrhoea or chlamydia, and, if evidence of pathogenicity continues to accumulate, a further assessment of the role of routine screening in this setting would be appropriate.

Steroid-free immunosuppression since 1999: 129 pediatric renal transplants with sustained graft and patient benefits

Despite early promising patient and graft outcomes with steroid-free (SF) immunosuppression in pediatric kidney transplant recipients, data on long-term safety and efficacy results are lacking. We present our single-center experience with 129 consecutive pediatric kidney transplant recipients on SF immunosuppression, with a mean follow-up of 5 years. Outcomes are compared against a matched cohort of 57 concurrent recipients treated with steroid-based (SB) immunosuppression. In the SF group, 87% of kidney recipients with functioning grafts remain corticosteroid-free. Actual intent-to-treat SF (ITT-SF) and still-on-protocol SF patient survivals are 96% and 96%, respectively, actual graft survivals for both groups are 93% and 96%, respectively and actual death-censored graft survivals for both groups are 97% and 99%, respectively. Unprecedented catch-up growth is observed in SF recipients below 12 years of age. Continued low rates of acute rejection, posttransplant diabetes mellitus (PTDM), hypertension and hyperlipidemia are seen in SF patients, with sustained benefits for graft function. In conclusion, extended enrollment and longer experience with SF immunosuppression for renal transplantation in low-risk children confirms protocol safety, continued benefits for growth and graft function, low acute rejection rates and reduced cardiovascular morbidity.

[Major alpha-thalassemia: antenatal diagnosis, case report and literature review]

Homozygous alpha-thalassaemia or Bart's hydrops fetalis is a genetic disease with autosomal recessive transmission. The condition is lethal for the fetus because of hypoxia and anemia. For the mother there is an increased risk of the severe forms of preeclampsia and its complications. The diagnosis can be suspected in presence of suggestive ultrasonographic anomalies, where both parents come from South-East Asia or China. Confirmation is based on the identification of the typical deletions or mutation of the alpha globin gene by molecular genetics. We report a rare clinical case of Bart's hydrops fetalis diagnosed because of fetal growth retardation, fetal cardiomegaly and increased size of placenta on the 26 weeks fetal echography. This case underscores the need to include the alpha thalassemias in medical and midwifery education in countries where they were almost inexistent a generation ago.

The prevalence of lymphogranuloma venereum infection in men who have sex with men: results of a multicentre case finding study

Objective:

To determine the prevalence of lymphogranuloma venereum (LGV) and non-LGV associated serovars of urethral and rectal Chlamydia trachomatis (CT) infection in men who have sex with men (MSM).

Design:

Multicentre cross-sectional survey.

Setting:

Four genitourinary medicine clinics in the United Kingdom from 2006–7.

Subjects:

4825 urethral and 6778 rectal samples from consecutive MSM attending for sexual health screening.

Methods:

Urethral swabs or urine and rectal swabs were tested for CT using standard nucleic acid amplification tests. Chlamydia-positive specimens were sent to the reference laboratory for serovar determination.

Main outcome:

Positivity for both LGV and non-LGV associated CT serovars; proportion of cases that were symptomatic.

Results:

The positivity (with 95% confidence intervals) in rectal samples was 6.06% (5.51% to 6.66%) for non-LGV CT and 0.90% (0.69% to 1.16%) for LGV; for urethral samples 3.21% (2.74% to 3.76%) for non-LGV CT and 0.04% (0.01% to 0.16%) for LGV. The majority of LGV was symptomatic (95% of rectal, one of two urethral cases); non-LGV chlamydia was mostly symptomatic in the urethra (68%) but not in the rectum (16%).

Conclusions:

Chlamydial infections are common in MSM attending for sexual health screening, and the majority are non-LGV associated serovars. We did not identify a large reservoir of asymptomatic LGV in the rectum or urethra. Testing for chlamydia from the rectum and urethra should be included for MSM requesting a sexual health screen, but serovar-typing is not indicated in the absence of symptoms. We have yet to identify the source of most cases of LGV in the UK.

Self-taken pharyngeal and rectal swabs are appropriate for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae in asymptomatic men who have sex with men

INTRODUCTION

Self-taken specimens from men who have sex with men (MSM) could be important in reducing high levels of demand on sexual health services. The performance of self-taken specimens for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) from both pharyngeal and rectal sites in asymptomatic MSM was assessed.

METHODS

MSM were examined according to clinic protocol: a rectal and pharyngeal swab for GC culture and a rectal swab for the CT strand displacement assay. An extra set of nurse-taken and self-taken pharyngeal and rectal specimens were also requested and were tested using the Aptima Combo 2 assay and the result compared with the routine clinic result, which was considered the gold standard.

RESULTS

A total of 272 MSM was recruited and the sensitivity and specificity of nurse-taken and patient-taken swabs, respectively, was as follows: rectal GC: 94.9% and 90.1% (nurse); 92.3% and 87.9% (patient); pharyngeal GC: 88.2% and 91.8% (nurse); 100% and 87.8% (patient); rectal CT: 80.0% and 99.6% (nurse); 91.4% and 98.2% (patient). No significant difference in sensitivity or specificity was observed between the nurse-taken and the patient-taken rectal swabs for either GC or CT. For the detection of GC from the pharynx, comparable sensitivities were achieved between nurse-taken and patient-taken swabs (p = 0.5); however, a significant difference in specificity was observed (p = 0.006). This was due to a higher number of false GC-positive self-taken pharyngeal swabs from patients with high rates (90.9%; 10/11) of confirmed concurrent GC infection in different anatomical sites.

CONCLUSIONS

MSM are able to collect self-taken rectal and pharyngeal swabs that are comparable to those taken by clinicians.

Abscess of the abdominal wall resulting from perforated ascending colon cancer

We report an unusual case of abscess of the abdominal wall as the initial symptom of a perforated right-sided colon cancer in a 62-year old man. Clinical examination revealed a non-fluctuating, tender, firm mass approximately 7 x 5 cm in diameter with overlying cellulitis in the right loin. Abdominal examination showed a fixed mass on the right side of the abdomen. Computed tomography (CT scan) confirmed the presence of a mass arising from the right colon with infiltration of the subcutaneous tissue by this intra-abdominal mass. Right hemicolectomy with lymph node dissection and en-bloc partial resection of the adherent parietal wall was performed and the final pathology showed a moderately differentiated mucinous adenocarcinoma. We report a case of ascending colon cancer presenting by an abscess of the abdominal wall.

Acute syphilitic interstitial orchitis mimicking testicular malignancy in an HIV-1 infected man diagnosed by Treponema pallidum polymerase chain reaction

We report a case of acute epididymo-orchitis due to early infectious syphilis, mimicking as testicular malignancy in an undiagnosed HIV-positive individual. He presented with a mass on his testicle and simultaneously had serology consistent with early syphilis. It could not be distinguished from a malignancy, which necessitated urgent orchidectomy. Histology showed endarteritis but no evidence of gummatous involvement. Although treponemes were not detected by staining, the diagnosis was confirmed by the first reported use of Treponema pallidum polymerase chain reaction in a testicular specimen in the UK.

Lymphogranuloma venereum presenting as genital ulceration and inguinal syndrome in men who have sex with men in London, UK

OBJECTIVES

To describe a series of lymphogranuloma venereum (LGV) cases presenting as inguinal syndrome and/or genital ulceration seen among men who have sex with men (MSM) in London, UK.

METHODS

Collaborative retrospective case note review. Clinicians from three London genitourinary medicine (GUM) clinics accessed by large populations of MSM within the current LGV outbreak collected clinical data from confirmed cases of LGV inguinal syndrome or genital ulcer. LGV was confirmed by the detection of LGV-specific DNA from specimens such as bubo aspirates, ulcer swabs, urethral swabs, first void urine and rectal biopsy material.

RESULTS

There were 13 cases detected overall: 5 cases of urethral LGV infection with inguinal adenopathy, 3 cases of genital ulcer with LGV inguinal adenopathy, 3 cases of isolated LGV-associated inguinal buboes, 1 case of a solitary LGV penile ulcer and 1 case with a penile ulcer and bubonulus. Only 6 of the 13 were HIV positive and all tested negative for hepatitis C. The majority of cases reported few sexual contacts in the 3 months preceding their diagnosis.

CONCLUSIONS

Clinical manifestations of LGV in MSM have not been confined to proctitis in the current outbreak in the UK and a small but significant number of inguinogenital cases of LGV have been observed. Epidemiologically, many of the cases described seem to have occurred at the periphery of the current MSM LGV epidemic. Clinicians need to be vigilant for these less common presentations of LGV among MSM and specific diagnostic tests should be done from the relevant lesions.

The 30-day mortality of ruptured abdominal aortic aneurysms: influence of gender, age, diameter and comorbidities

AIM

The aim of this study was to determine the influence of gender, age, the aneurysm diameter and comorbidity on the 30-day mortality after open repair of ruptured abdominal aortic aneurysms (AAA).

METHODS

Between January 1, 1993, and December 31, 2006 all consecutive patients who underwent open repair for a ruptured AAA at the tertiary care of Catharina Teaching Hospital were included in this study (N=186). Patients who underwent endovascular repair of their ruptured abdominal aortic aneurysms were excluded from this study. Patient and procedure characteristics were collected and analyzed in relation to 30-day mortality. The association between age, gender, diameter of AAA and comorbidity with 30-day mortality was analyzed with c2 are and logistic regression; a P value <0.05 was considered significant.

RESULTS

In this study there were 186 patients with ruptured AAA repair with an 30-day mortality of 36.6% (68/186). Among female patient 30-day mortality was 45.8% (11/24) compared with 35.2% (57/162) among male patients (P=0.31). Patients of 80 years and older had a 61.3% (19/31) 30-day mortality where younger patients had 33% (51/155) 30-day mortality (P=0.02). Thirty-day mortality was 47.2% (17/36) for patients with an AAA less than 65 mm compared with 34% (36/104) for patients with an AAA of 65 mm or larger (P=0.16). Multivariate analysis demonstrated age was a significant predictor of ruptured AAA repair mortality (P=0.017).

CONCLUSION

In this study, age was the only significant risk factor of 30-day mortality after open repair in patients with ruptured AAA.

Is new variant Chlamydia trachomatis present in England and Wales?

BACKGROUND

A new variant C trachomatis (nvCT) strain has been recently isolated in Sweden, which has a 377 bp deletion in a portion of the plasmid that is the target area for some C trachomatis nucleic acid amplification tests (NAATs). Consequently, these platforms generate false negative results when presented with this strain.

OBJECTIVE

To determine if nvCT is present in England and Wales.

METHODS

Specimens which had been determined to be C trachomatis positive using an unaffected platform were tested for the presence of the deletion using an in-house nested PCR assay which generated a 253 bp fragment in new variant strains and a 630 bp fragment in wild-type strains. The specimens tested could be divided into two main groups: (a) 933 specimens sourced from patients attending both genitourinary medicine services and the National Chlamydia Screening Programme were forwarded from eight key laboratories within England and Wales; (b) 179 specimens were sourced from men who have sex with men and forwarded from 30 clinics throughout the UK.

RESULTS

A total of 1112 specimens were screened for the presence of the 377 bp deletion. An in-house PCR method showed that 1066 were wild-type strains. Forty-six strains failed to generate an amplicon and were therefore untypable. This is consistent with differences in the analytical sensitivity of different NAATs and probably reflective of low C trachomatis DNA load. No nvCT strains were identified.

CONCLUSION

Currently, there is no evidence that nvCT is present in England and Wales. However, screening and prevalence studies are continuing and UK clinicians and microbiologists should remain vigilant for suspicious, negative results.

Meta-analysis of APOE genotype and subarachnoid hemorrhage: Clinical outcome and delayed ischemia

BACKGROUND

Emerging evidence suggests that the APOE4 allele may increase the risk of a negative outcome in patients with aneurysmal subarachnoid hemorrhage (SAH), but the results are conflicting. A genetic variable predicting the individual clinical course is currently lacking.

OBJECTIVE

To examine the association between the APOE4 allele and a negative outcome. A secondary objective was to investigate the association between the APOE4 allele and delayed ischemia, a major complication of SAH.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Library, CINHAL, LILACS, and www.google.it through March 2006. We hand-searched journals, international conference proceedings, and reference lists of retrieved articles. Individual patient data were requested from the corresponding authors of the original articles. Information on study design, participant characteristics, clinical outcome, delayed ischemia, and confounder distribution were independently abstracted by two investigators.

RESULTS

We included eight observational studies (696 patients for the clinical outcome and 600 for the delayed ischemia analyses). The corresponding authors of all the retrieved publications but one gave their original data. Summary odds ratios (ORs) were calculated by means of the random-effect model. The risk of a negative outcome (OR = 2.558; 95% CI 1.610 to 4.065) and delayed ischemia (OR = 2.044; 95% CI 1.269 to 3.291) were increased in the E4 carriers.

CONCLUSIONS

In patients with subarachnoid hemorrhage, the expression of the E4 allele is associated with a higher risk of a negative outcome and delayed ischemia.

Variation in rates of postterm birth in Europe: reality or artefact?

OBJECTIVE

To compare rates of postterm birth in Europe.

DESIGN

Analysis of data from vital statistics, birth registers, and national birth samples collected for the PERISTAT project.

SETTING

Thirteen European countries.

POPULATION

All live births or representative samples of births for the year 2000 or most recent year available.

METHODS

Comparison of national and regional rates of postterm birth. Other indicators (birthweight, deliveries with a non-spontaneous onset and mortality) were used to assess the validity of postterm rates.

MAIN OUTCOME MEASURES

The proportion of births at 42 completed weeks of gestation or later.

RESULTS

Postterm rates varied greatly, from 0.4% (Austria, Belgium) to over 7% (Denmark, Sweden) of births. Higher postterm rates were associated with a greater proportion of babies with birthweight 4500 g or more. Fetal and early neonatal mortality rates were higher among postterm births than among births at 40 weeks. Countries with higher proportions of births with a nonspontaneous onset of labour had lower postterm birth rates. The shapes of the gestational-age distributions at term varied. In some countries, there was a sharp cutoff in deliveries at 40 weeks, while elsewhere this occurred at 41 weeks.

CONCLUSIONS

These results suggest that practices for managing pregnancies continuing beyond term differ in Europe and raise questions about the health and other impacts in countries with markedly high or low postterm rates. Some variability in these rates may also be due to methods for determining gestational age, which has broader implications for international comparisons of gestational age, including rates of postterm and preterm births and small-for-gestational-age newborns.

Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe

BACKGROUND

The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.

OBJECTIVES

The objectives were to ascertain and compare policies for management of the third stage of labour and immediate management of postpartum haemorrhage in maternity units in Europe following vaginal birth.

DESIGN

Survey of policies.

SETTING

The project was a European collaboration, with participants in 14 European countries.

SAMPLE

All maternity units in 12 countries and in selected regions of two countries in Europe.

METHODS

A postal questionnaire was sent to all or a defined sample of maternity units in each participating country.

MAIN OUTCOME MEASURES

Stated policies for management of the third stage of labour and the immediate management of postpartum haemorrhage.

RESULTS

Policies of using uterotonics for the management of the third stage were widespread, but policies about agents, timing, clamping and cutting the umbilical cord and the use of controlled cord traction differed widely. For immediate management of postpartum haemorrhage, policies of massaging the uterus were widespread. Policies of catheterising the bladder, bimanual compression and in the choice of drugs administered were much more variable.

CONCLUSIONS

Considerable variations were observed between and within countries in policies for management of the third stage of labour. Variations were observed, but to a lesser extent, in policies for the immediate management of postpartum haemorrhage after vaginal birth. In both cases, policies about the pharmacological agents to be used varied widely.

Pre-tertiary hospital care of patients with chronic kidney disease in India

BACKGROUND & OBJECTIVES

There is paucity of data available on how chronic kidney disease (CKD) is treated before referral to a tertiary hospital. This study was conducted to assess pre-tertiary hospital care of patients with CKD 5 at their presentation to nephrology services at a tertiary care hospital.

METHODS

Over a period of 8 months, consecutive patients with CKD 5 presenting at the Nephrology services at Christian Medical College, Vellore, Tamil Nadu, and their relatives were interviewed to assess the pre-tertiary hospital care and knowledge about CKD 5 and its treatment.

RESULTS

A total of 561 patients with CKD 5 were enrolled. The mean duration (months) of known CKD was 12.4 +/- 23.1 and known CKD 5 was 3.2 +/- 3.5. Of these, 369 patients (65.8%) had been under the care of a nephrologist; 305 patients had CKD 5 as the initial presentation of renal illness. Vaccination against hepatitis B had been initiated in only 133 patients (23.7%). Only 172 patients(38%) had an adequately controlled blood pressure. Care under a nephrologist was more likely to result in appropriate investigation, treatment and patient education though blood pressure control did not differ.

INTERPRETATION & CONCLUSION

Paucity of symptoms in the initial stages of certain forms of CKD probably led to 50 per cent of patients presenting with CKD 5 as the initial presentation of renal disease. Inadequate vaccination against hepatitis B infection highlights the need for appropriate vaccination. Prevention of CKD and its progression are important targets which requires physician awareness at all levels. Early referral to a nephrologist's care is more likely to result in appropriate investigations and treatment.

The prevalence of proline iminopeptidase negative Neisseria gonorrhoeae throughout England and Wales

BACKGROUND

The accurate laboratory identification of Neisseria gonorrhoeae is an essential element of the diagnosis of gonorrhoea and is particularly important for medicolegal cases. The detection of proline iminopeptidase (Pip) activity is widely used as a marker for gonococci, although Pip negative N gonorrhoeae isolates have been shown to generate false negative identifications when using biochemical kits. This study aimed to determine the frequency of Pip negative gonococci in England and Wales.

METHODS

A total of 2055 isolates were collected from consecutive patients attending 26 genitourinary medicine centres as part of the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP). Upon receipt the identity of all isolates was confirmed using N gonorrhoeae specific monoclonal antibodies and the Pip status was determined using the Gonochek II kit.

RESULTS

The overall prevalence of Pip negative isolates was found to be 4.33%. Significant geographical variation was observed between isolates from centres outside London (p< or =0.001). Variation was also observed within London between the nine different clinics submitting isolates (p = 0.025). There was also a higher frequency of these isolates among men who have sex with men (p< or =0.001), which may account for geographical variations.

CONCLUSION

Pip negative N gonorrhoeae isolates are a very serious cause for concern as currently all biochemical test kits available within the United Kingdom require the presence of the Pip enzyme for an unambiguous identification of this pathogen. Raising awareness of the current prevalence of Pip negative N gonorrhoeae isolates is critical for the successful control of gonorrhoea.

Cyanoacrylate in the treatment of gastric varices complicated by multiple pulmonary emboli

Bleeding gastric varices are increasingly being obliterated with the aid of endoscopic injection of n-butyl-cyanoacrylate (histoacryl) diluted with lipiodol. This glue acts as a tissue adhesive that polymerizes on contact with blood in a gastric varix. Severe glue pulmonary embolism is a rare complication of injection therapy. This case involves a 52-year-old man with fundal gastric varices, who developed multiple pulmonary emboli following glue injection with profound hypoxia requiring hospital admission for 13 days, but with eventual recovery of normal lung function.

Alpha7-acetylcholine receptor antibodies in two patients with Rasmussen encephalitis

Rasmussen encephalitis (RE) sera were screened for antibodies to human alpha7 nicotinic acetylcholine receptors (nAChRs) using electrophysiology, calcium imaging, and ligand binding assays. Sera from two of nine patients with RE blocked ACh-induced currents through alpha7 nAChRs and the ACh-induced rise in intracellular free calcium ([Ca2+]i) and inhibited (125)I-alpha-bungarotoxin binding in cells expressing alpha7 nAChRs. Thus, the alpha7 nAChR is a potential target for pathogenic antibodies in patients with RE.

Malignant bone tumors in Kuwait: a 10-year clinicopathological study

Between 1995 and 2004, 142 malignant bone tumours comprising 76 primary and 66 secondary tumours were identified in the Pathology Department of Al-Sabah Hospital, Kuwait. Pathological fracture was the presenting sign in 35% of the cases. The mean incidence of primary tumours/year was 3.3 cases/million inhabitants. The primary tumours showed a male predilection and 42% occurred below the age of 20 years. The most frequent in the descending order of frequency were Ewing's sarcoma, multiple myeloma, osteosarcoma, chondrosarcoma and non-Hodgkin's lymphoma. The femur was the most common site for secondary tumours; more than half of the tumours with metastases at this site originated in the breast. The high frequency of Ewing's sarcoma is noteworthy and requires further investigation.

env Gene typing of human immunodeficiency virus type 1 strains on electronic microarrays

The NanoChip system was used for subtyping human immunodeficiency virus type 1 (HIV-1) strains using probes complementary to the V1 region of the env gene. Probes for six subtypes (A to D, F, and G) and two circulating recombinant forms (AG and AE) of HIV-1 group M were included. The specificity of these oligonucleotides had been evaluated previously in a DNA enzyme immunoassay. Samples from 112 patient sera were used as templates in a nested reverse transcription-PCR to produce amplicons that were applied to the array. The array was then hybridized successively to pairs of oligonucleotide probes. The strains were assigned a subtype on the basis of their probe hybridization patterns. One strain gave a contradictory pattern and was designated as untypeable by the NanoChip assay. Eighty-eight strains gave hybridization patterns that allowed a correct subtype designation to be made by the NanoChip assay compared to either the sequence or the heteroduplex mobility assay (HMA)-determined subtypes. Thirteen strains that reacted with the subtype A probe (SA2) were incorrectly assigned to subtype A, or to one of the related circulating recombinant types (AE or AG), on the basis of reactions with probe SAE1 or SAG1. The results indicate that these oligonucleotides have relatively low specificities. The probe subtypes of three strains matched the subtypes determined for the gag and pol genes but not the env gene, suggesting that a recombination event may have occurred within the env gene. Overall, the NanoChip assay gave results comparable to those for HMA and sequencing and provides a convenient and cost-effective means by which to subtype HIV-1.

Mode d’accouchement des femmes avec une présentation du siège à terme dans l’étude PREMODA (PREsentation et MODe d’accouchement)

OBJECTIVES

The purpose of this work was to report labor and birth management practices for term breech presentation in France and Belgium in 2001-2002 and to describe indications for cesarean sections (before labor, emergency situations) in breech presentations.

MATERIAL AND METHODS

The PREMODA cohort is a survey population which included 19408 deliveries, 8108 of which were term breech presentations.

RESULTS

Infants were delivered by cesarean section before labor (59.1%), emergency cesarean section during labor (18.4%) or vaginally (22.5%). The decision for cesarean section before labor was empirical (breech presentation) in 44.3% of the cases. Half of the cesarean sections performed during labor (n=704, 49.3%) were planned C-sections. Overall, 67.8% of the breech presentations were delivered during planned cesarean sections (before or during labor). When vaginal delivery was attempted, the rate of vaginal birth was 70%.

CONCLUSION

These early results reveal a high rate of cesarean section as well as differences in inter-regional practices. Considering all cesarean sections performed before labor, the most frequent indication was an empirical decision because of the breech presentation. An increased rate of planned cesarean section does not reduce the rate of vaginal delivery when attempted.

Does the use of a specialised paediatric retrieval service result in the loss of vital stabilisation skills among referring hospital staff?

AIMS

To compare the proportion of airway and vascular access procedures performed by referring hospital staff on critically ill children in two discrete time periods, before and after widespread use of a specialised paediatric retrieval service.

METHODS

Transport data were obtained from retrieval logs of all children for whom a paediatric retrieval team was launched in each of two time periods (October 1993 to September 1994; and October 2000 to September 2001).

RESULTS

The overall intubation rate was similar in the first and second time periods (83.9% v 79.1%). However, 31/51 (61%) retrieved children were intubated by referring hospital staff in 1993-94, compared to 227/269 (84%) in 2000-01. Referring hospital staff gained central venous access in 11% v 18% and arterial access in 22% v 19% of retrieved children in the first and second time periods respectively. This was in spite of a significant reduction in the proportion of children on whom these procedures were performed.

CONCLUSION

Referring hospital staff are performing a greater proportion of initial airway and vascular access procedures undertaken in the stabilisation of sick children retrieved by a specialised paediatric retrieval team. The provision of this service has not resulted in the loss of vital skills at the local hospital.

Short-term outcome of isolated and associated congenital heart defects in relation to antenatal ultrasound screening

OBJECTIVE

To investigate the outcome of fetuses affected by congenital heart defects (CHD), either detected or undetected at ultrasound screening, according to their complexity and severity.

DESIGN

The study group comprised 3633 malformed fetuses entered into the Eurofetus database of which 798 had CHD. We compared the short-term outcome in cases where a CHD was detected by ultrasound screening with that in cases where a CHD was not detected. Isolated and associated CHD (ICHD and ACHD) and the degree of severity of defects were considered separately. Outcome data included termination of pregnancy (TOP), intrauterine fetal death, neonatal death (< 6 days after birth), gestational age at diagnosis and at delivery, mode of delivery and birth weight.

RESULTS

Of the 798 fetuses with CHD, 595 had ICHD and 203 had ACHD. The diagnosis of an anomaly was made significantly earlier in ACHD cases. TOP was chosen in 28% of cases with a prenatal diagnosis of CHD, 20% for ICHD and 37% for ACHD (P < 0.001). The survival rate of antenatally diagnosed fetuses was lower in those with ACHD than in those with ICHD (P < 0.001) and lower for fetuses with antenatal diagnosis than with postnatal diagnosis (P < 0.001); this was due to significant differences in the complexity and severity of the defect. Premature delivery (< 32 weeks) was more frequent in fetuses in which an antenatal diagnosis of CHD had been made. Severe CHD were diagnosed earlier and were associated with a higher rate of TOP and spontaneous loss.

CONCLUSIONS

The severity of CHD has a positive influence on the sensitivity of screening but a negative influence on the outcome. CHD that are not diagnosed antenatally include a high proportion of benign malformations. This explains the apparent paradox of a poorer outcome in fetuses in which a CHD was detected prenatally compared to those fetuses in which the defect was undetected prenatally. However, prenatal diagnosis provides parents with the option of TOP or of preventive care in specialized centers.

Sensitivity of ultrasound screening for congenital anomalies in unselected pregnancies

OBJECTIVE

To assess the influence of heart defect frequency and severity on screening sensitivity of the entire spectrum of congenital anomalies (CA) and on detection rate of congenital heart defect (CHD) when performing routine ultrasound screening in unselected pregnant women.

STUDY DESIGN

Secondary analysis was performed on data from Eurofetus, a large international collaborative study of ultrasound screening for CA in unselected populations. The present study addressed the relations (i) between the frequency of CHD in the screened population and the global sensitivity of ultrasound in detecting CA; (ii) between frequency of ventricular septum defect (VSD) and detection rate of CA and CHD; and (iii) between seriousness of CHD and CHD sensitivity.

RESULTS

A negative correlation (p<0.001) between CHD frequency and CA sensitivity was observed in this study. Likewise, a negative correlation was also found between frequency of VSD and sensitivity for CA or CHD detection (p<0.001). In addition, a positive significant relationship (p<0.001) was observed between sensitivity and severity of CHD.

CONCLUSION

A low CHD frequency introduces bias in CA and CHD sensitivity evaluation. Incomplete assessment of fetal and neonatal malformations brings on systematic error, leading to the pre-eminence of severe defects in the studied population sample and artificially improving sensitivity figures. On the other hand, from a clinician's viewpoint, the higher sensitivity for severe defect is welcomed, since their detection is most crucial for appropriate management.

Influence of glucose dosage on interpretation of intravenous glucose tolerance tests in lean and obese cats

Intravenous glucose tolerance tests (IVGTTs) are used in cats and other species to assess insulin sensitivity. Several dosages have been reported but the dosage that maximally stimulates insulin secretion in cats has not been determined nor has it been compared in lean and obese animals. IVGTTs were performed in 4 lean and 4 obese spayed female cats with 5 glucose dosages: 0.3 (A), 0.5 (B), 0.8 (C), 1.0 (D). and 1.3 (E) g/kg body weight (BW). Each cat received each dosage in a random design. The glucose disposal rate was significantly different only between lean and obese cats at the highest glucose dosage. The area under the curve for insulin increased significantly among A, B, C, and D in lean and among A, B, and C in obese cats but not between D and E in lean and among C, D, and E in obese cats. Baseline insulin secretion was significantly higher (P = .03) and 1st peak insulin secretion was approximately 50% lower in obese as compared to lean cats (P = .03). Lean but not obese cats reached baseline insulin concentrations at all dosages at 120 minutes. We conclude that the glucose dosage for maximal insulin secretion is 1.0 g/ kg BW in lean and 0.8 g/kg BW in obese cats, supporting routine use of 1 g/kg BW to maximally stimulate insulin secretion regardless of body composition. Obese cats showed an abnormal insulin secretion pattern, indicating a defect in insulin secretion with obesity and insulin resistance.

CD80-mediated induction of immunostimulation in two ocular melanoma cell lines is augmented by interferon-gamma

Although the transfection of the T-cell costimulatory molecule CD80 cDNA into human tumours can augment their immunogenicity in vitro, its expression alone is ineffective in many tumour systems. We evaluated the influence of CD80 expression on the immunostimulatory activity of ocular melanoma cell lines and determined whether IFN-gamma could enhance the effect. Two ocular melanoma cell lines were transfected with CD80 cDNA. The immunostimulatory capacity of the CD80+ transfectants was determined by their ability to stimulate the proliferation of allogeneic peripheral blood mononuclear cells (PBMC). The influence of additional accessory molecules on PBMC proliferation was assessed by pre-treating the CD80 transfectants with IFN-gamma. The CD80+ transfectants induced proliferation of allogeneic PBMC. IFN-gamma treatment of the tumour cells induced upregulated expression of MHC class I, de novo expression of MHC class II and CD54, and enhanced the ability of the CD80+ transfectants to stimulate PBMC proliferation. CD4+ T cells were not required for the proliferative response against untreated CD80+ tumour cells but were necessary for the augmentation of proliferation observed following IFN-gamma treatment. CD80+ ocular melanoma cells possess immunostimulatory potential which is augmented by IFN-gamma induced upregulation of cell surface molecules. Further studies on the role of costimulatory molecules in inducing anti-tumour immunity in ocular melanoma may help to define new strategies for application of immunotherapeutic approaches to treat this aggressive disease.

Student-centered distance learning in health and medical informatics

Learning and teaching of health and medical Informatics is currently supported by web based material, which in the main has been derived from traditional texts. Aided by contributions from the expert community, the web site of the handbook of Medical Informatics has been developed to incorporate increased interactivity (with question and answers related to each section). This approach has proved beneficial to both student and teacher. To further increase the interactivity of the WWW we investigate the suitability of authoring tools for developing complex simulations and interactive tutorials, using an example from the area of quantitative decision support (Bayes Theorem). We propose that these tools provide a suitable platform for the preparation and delivery of collaboratively produced HMI courses, which address open and distance learning and pedagogic issues.

Essential role for estrogen in protection against Vibrio vulnificus-induced endotoxic shock

Little is known about the underlying mechanisms that result in a sexually dimorphic response to Vibrio vulnificus endotoxic shock. V. vulnificus is a gram-negative bacterium, considered one of the most invasive and rapidly fatal human pathogens known. However, 85% of individuals that develop endotoxic shock from V. vulnificus are males. Using the rat, we have developed a model for V. vulnificus endotoxic shock that mimics the sexually dimorphic response in humans. Gonadectomy in females results in increased mortality, and estrogen replacement results in decreased mortality in both gonadectomized males and females. These results demonstrate that estrogen is providing protection against V. vulnificus lipopolysaccharide-induced endotoxic shock.

Sphingosine-1-phosphate lyase has a central role in the development of Dictyostelium discoideum

Sphingosine-1-phosphate, a product of sphingomyelin degradation, is an important element of signal transduction pathways that regulate cell proliferation and cell death. We have demonstrated additional roles for sphingosine-1-phosphate in growth and multicellular development. The specific disruption in Dictyostelium discoideum of the sphingosine-1-phosphate lyase gene, which encodes the enzyme that catalyzes sphingosine-1-phosphate degradation, results in a mutant strain with aberrant morphogenesis, as well as an increase in viability during stationary phase. The absence of sphingosine-1-phosphate lyase affects multiple stages throughout development, including the cytoskeletal architecture of aggregating cells, the ability to form migrating slugs, and the control of cell type-specific gene expression and terminal spore differentiation. This pleiotropic effect, which is due to the loss of sphingosine-1-phosphate lyase, establishes sphingolipids as pivotal regulatory molecules in a wide range of processes in multicellular development.

Evaluation of the quality of care for severe obstetrical haemorrhage in three French regions

OBJECTIVE

To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage.

DESIGN

Retrospective questionnaire survey.

SETTING

Three administrative regions of France.

POPULATION

All women who were pregnant or had recently given birth during the year before the survey.

METHODS

A European survey (MOMS-B) defined severe haemorrhages as blood loss > or = 1500mL. A specific questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-five cases of severe haemorrhage were reviewed and classified into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and 'mixed' care were both considered substandard. The 165 cases were coded and then studied with uni- and multivariate analysis (logistic regression with SAS and SPSS software).

RESULTS

Of the 165 cases identified, 51% (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (<500 births per year) were the factors associated with substandard care.

CONCLUSION

Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the first time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be confirmed by others.

Proteomic analysis of a developmentally regulated secretory vesicle

Secretion of spore coat proteins from the prespore secretory vesicles (PSVs) in Dictyostelium discoideum is a signal mediated event that underlies terminal cell differentiation, and represents an important case of developmentally regulated secretion. In order to study the biochemical mechanisms that govern the regulated fusion of the PSVs with the plasma membrane and the subsequent secretion of their cargo, we purified this organelle from prespore cells. Analysis of protein extracts of highly purified PSVs indicated that, in addition to the cargo of structural spore coat proteins, many more proteins are associated with the PSVs. Their identification is paramount to the understanding of the mechanism of regulated secretion in this system. In this study we have taken the first comprehensive proteomic approach to the analysis of an entire, previously uncharacterized, organelle, with the goal of identifying the major proteins associated with the PSVs. We show that in addition to the structural spore coat proteins, the PSVs contain the enzymes needed for proper spore coat assembly (thioredoxin 2 and 3), regulatory proteins which we predict receive and transduce the developmental signal for secretion (rab7 GTPase, PI-3 kinase, NDP kinase and the calcium binding proteins calfumirin-1 and calreticulin) as well as proteins that interact with the cytoskeleton to mediate movement of the PSVs to the plasma membrane (actin binding proteins coactosin and profilin 1). In addition, the results suggest that proteins can play multiple roles in the cell, and that protein function can be dictated in part by subcellular localization. The identification of the PSV proteins is allowing us to develop testable hypotheses about the roles of these proteins within the functional context of developmentally regulated secretion.