A novel pneumococcus with a new association

A case of severe invasive pneumococcal disease in a 68 year old female is described. She presented following a holiday in Turkey with an uncommon but well documented complication of Streptococcus pneumoniae bacteraemia; Austrian's triad of meningitis, pneumonia and endocarditis. She then progressed to develop an atypical variant of Guillain Barre syndrome, never previously documented in association with pneumococcal disease. The pneumococcus was identified as serotype 6A and genetic typing by multi-locus sequence typing showed it to be a unique genetic profile (ST4533). We hypothesise that ST4533 may have resulted from genetic re-assortment from streptococci which had colonised the patient in the United Kingdom and bacteria encountered in Turkey. The ability to associate uncommon genotypes with uncommon clinical presentations may improve understanding of the pathogenesis of this organism, and this highlights the need for international invasive pneumococcal disease surveillance.

Low risk of inhibitor formation in haemophilia A patients following en masse switch in treatment to a third generation full length plasma and albumin-free recombinant factor VIII product (ADVATE®)

Previous studies have suggested that development of inhibitors in previously treated patients (PTPs) may be attributable to a switch in factor VIII (FVIII) therapeutic product. Consequently, it is widely recognized that inhibitor development must be assessed in PTPs following the introduction of any new FVIII product. Following a national tender process in 2006, all patients with haemophilia A in Ireland changed their FVIII treatment product en masse to a plasma and albumin-free recombinant full-length FVIII product (ADVATE(®)). In this study, we retrospectively reviewed the case records of Irish PTPs to evaluate risk of inhibitor formation following this treatment switch. One hundred and thirteen patients participated in the study. Most patients (89%) had severe haemophilia. Only one of 96 patients with no inhibitor history developed an inhibitor. Prior to the switch in his recombinant FVIII (rFVIII) treatment of choice, this child had only experienced three exposure days (EDs). Consequently, in total he had only received 6 EDs when his inhibitor was first diagnosed. In keeping with this lack of de novo inhibitor development, we observed no evidence of any recurrent inhibitor formation in any of 16 patients with previously documented inhibitors. Similarly, following a previous en masse switch, we have previously reported that changing from a Chinese hamster ovary cell-produced to a baby hamster kidney cell-produced rFVIII was also associated with a low risk of inhibitor formation in PTPs. Our cumulative findings from these two studies clearly emphasizes that the risk of inhibitor development for PTPs following changes in commercial rFVIII product is low, at least in the Irish population.

Manual therapy for osteoarthritis of the hip or knee - a systematic review

The aim of this systematic review was to determine if manual therapy improves pain and/or physical function in people with hip or knee OA. Eight databases were searched for randomised controlled trials (RCTs). Data were extracted and risk of bias assessed by independent reviewers. Four RCTs were eligible for inclusion (280 subjects), three of which studied people with knee OA and one studied those with hip OA. One study compared manual therapy to no treatment, one compared to placebo intervention, whilst two compared to alternative interventions. Meta-analysis was not possible due to clinical heterogeneity of the studies. One study had a low risk of bias and three had high risk of bias. All studies reported short-term effects, and long-term effects were measured in one study. There is silver level evidence that manual therapy is more effective than exercise for those with hip OA in the short and long-term. Due to the small number of RCTs and patients, this evidence could be considered to be inconclusive regarding the benefit of manual therapy on pain and function for knee or hip OA.

Widespread divergence between incipient Anopheles gambiae species revealed by whole genome sequences

The Afrotropical mosquito Anopheles gambiae sensu stricto, a major vector of malaria, is currently undergoing speciation into the M and S molecular forms. These forms have diverged in larval ecology and reproductive behavior through unknown genetic mechanisms, despite considerable levels of hybridization. Previous genome-wide scans using gene-based microarrays uncovered divergence between M and S that was largely confined to gene-poor pericentromeric regions, prompting a speciation-with-ongoing-gene-flow model that implicated only about 3% of the genome near centromeres in the speciation process. Here, based on the complete M and S genome sequences, we report widespread and heterogeneous genomic divergence inconsistent with appreciable levels of interform gene flow, suggesting a more advanced speciation process and greater challenges to identify genes critical to initiating that process.

The effectiveness of interventions in the management of patients with primary frozen shoulder

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence. In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions. More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.

THE REACTIONS OF HALICYSTIS AND OF VALONIA TO INJECTIONS OF CERTAIN PROTEINS

It is shown (1) that Valonia and Halicystis cells exhibit varying degrees of tolerance to injections of animal peptone, animal proteose, crystallized egg albumen, and diphtheria toxin; (2) that Valonia cells display decreased tolerance to egg albumen in increasing dosages, although Halicystis is completely tolerant of the highest dosage used; (3) that the mortality curves of Valonia injected with egg albumen and of both Valonia and Halicystis injected with diphtheria toxin show the delayed effect characteristic of laboratory mammals when treated similarly; (4) that Valonia cells injected twice with egg albumen exhibit no change in susceptibility to its effects; and (5) that neither species of algae gives evidence of having formed antibodies against the antigens used.

REACTIONS OF VALONIA AND OF HALICYSTIS TO COLLOIDS

From the results of these tests it is clear that both Halicystis and Valonia have a high degree of tolerance for animal peptone, and a very high degree of tolerance for animal proteose and for egg albumen. The products of bacterial growths fostered by these proteins have a deleterious effect upon both species of algae; but, if it were possible to prevent bacterial growth entirely and at the same time supply proper food, it is probable that Halicystis and Valonia would show normal growth indefinitely in the presence of these three colloids. This is not true where exposure is made to yeast nucleic acid dissolved in sea water containing 0.00093 gm. per cc. of NaOH. Valonia is markedly less tolerant of this medium (perhaps of NaOH rather than the colloid used) than Halicystis. Such differential effects, however, reach a high point in the case of the solutions of diphtheria toxin and of edestin. Halicystis has a very high tolerance for diphtheria toxin, and Valonia a very low tolerance. In the case of edestin, the relationship is reversed. Here Halicystis has a very low tolerance, and Valonia a very high tolerance. In fact, it may be said that diphtheria toxin has no appreciable effect upon Halicystis, and edestin a very slight effect upon Valonia; while diphtheria toxin is extremely toxic to Valonia, and edestin is extremely toxic to Halicystis. We can offer no suggestions, at present, as to the way in which these effects are produced. It is probable that the very thin protoplasmic layer of these species, which is certainly no thicker than 8µ, is sufficient to obstruct the passage of proteins having large molecules, like egg albumen, with a degree of efficiency that is extraordinary. In the tests we have reported, areas of from 20 sq. cm. to 40 sq. cm. have been submitted to the action of a relatively high concentration of egg albumen for several days without permitting the passage of sufficient amounts to give definable tests either with Spiegler's or with Tanret's method,— presumably less than 1 part in 250,000. In the tests of the proteins having much smaller molecules (though the size may not be the explanation), there is some probability that the membranes exhibit a little permeability. The peptone and the proteose of animal origin, or biuret-positive substances derived from them, apparently pass the protoplasmic membranes occasionally in quantities sufficient to give biuret tests. The most probable case of protein passage, however, was that of the proteose of the scarlet runner bean, where specific detection of less than 1 part per 80,000 was possible. In this instance the proteose appeared to pass membranes that were healthy and were functioning normally. But since the cells of the algae had to be destroyed in making the tests, one cannot maintain this point. All one can say is that protein passage was indicated in carefully examined cells of both species, where no breaks in the protoplasmic membrane were discernible, and where samples of the treated cells behaved normally after treatment.

Solvent–detergent plasma as replacement therapy in a pregnant patient with factor V deficiency

This case illustrates the successful treatment of factor V deficiency in pregnancy using solvent-detergent plasma.

Long-term activation of the pro-coagulant response after neoadjuvant chemoradiation and major cancer surgery

Background:

The association between cancer, major surgery and venous thromboembolism (VTE) is well established. Multimodal therapy is increasingly being used as standard treatment for localised gastrointestinal cancer. The aim of this study was to examine the markers of pro-coagulation response and VTE risk in an exemplar multimodal model of pre-operative combination chemotherapy and radiation therapy, followed by complex cancer surgery.

Methods:

Consecutive patients (n=36) with localised oesophageal cancer were studied at baseline after the first and second cycles of chemoradiation, and on post-operative days 1–28, and at 3, 6 and 9 months. Factors regulating the pro- and anti-coagulant response, as well as pro-inflammatory markers including NFκB activation in peripheral blood mononuclear cells, were examined. All patients received enoxaparin 40 mg s.c. postoperatively up to discharge, and underwent pulmonary CT-pulmonary angiography and venography on day 10 postoperatively.

Results:

Four (11%) non-fatal thromboembolic events were documented, all after hospital discharge. Neoadjuvant therapy before surgery activated factor VIII (FVIII) and pro-inflammatory NFκB, and increased D-dimers, pro-thrombin fragment 1+2 (F1+2) and the thrombin-anti-thrombin complex (TAT). Surgery significantly (P<0.05) increased pro-thrombin time (PT), activated partial thromboplastin time, fibrinogen, D-dimers, TAT, F1+2 and FVIII up to 6 months.

Conclusion:

These data highlight the linked pro-coagulant and immunoinflammatory pathways in the multimodal management of oesophageal cancer, and suggest that the duration of current standard thromboprophylaxis regimens warrants further study.

Metformin for obesity in children and adolescents: a systematic review

OBJECTIVE

To summarize the efficacy of metformin in reducing BMI and cardiometabolic risk in obese children and adolescents without diabetes.

RESEARCH DESIGN AND METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs). Double-blind RCTs of > or =6 months duration in obese subjects age < or =19 years without diabetes were included. Our primary outcomes of interest include changes in BMI and measures of insulin sensitivity.

RESULTS

Five trials met inclusion criteria (n = 320 individuals). Compared with placebo, metformin reduced BMI by 1.42 kg/m(2) (95% CI 0.83-2.02) and homeostasis model assessment insulin of resistance (HOMA-IR) score by 2.01 (95% CI 0.75-3.26).

CONCLUSIONS

Metformin appears to be moderately efficacious in reducing BMI and insulin resistance in hyperinsulinemic obese children and adolescents in the short term. Larger, longer-term studies in different populations are needed to establish its role in the treatment of overweight children.