Frequency, severity and duration of immune reconstitution events in HIV-related tuberculosis

SETTING

Patients were enrolled in a prospective trial of rifabutin-based tuberculosis (TB) treatment for human immunodeficiency virus related TB. Antiretroviral therapy (ART) was encouraged, but not required.

OBJECTIVE

To evaluate the frequency, risk factors and duration of immune reconstitution events.

DESIGN

Patients were prospectively evaluated for immune reconstitution events, and all adverse event reports were reviewed to identify possible unrecognized events.

RESULTS

Of 169 patients, 25 (15%) developed immune reconstitution events related to TB. All 25 were among the 137 patients who received ART during TB treatment, so the frequency in this subgroup was 18% (25/137). Risk factors for an immune reconstitution event in multivariate analysis were Black race, the presence of extra-pulmonary TB and a shorter interval from initiation of TB treatment to initiation of ART. The most common clinical manifestations were fever (64%), new or worsening adenopathy (52%) and worsening pulmonary infiltrates (40%). Twelve patients (48%) were hospitalized for a median of 7 days, six underwent surgery and 11 had needle aspiration. The median duration of events was 60 days (range 11-442).

CONCLUSION

Immune reconstitution events were common among patients receiving ART during TB treatment, produced substantial morbidity and had a median duration of 2 months.

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety

BACKGROUND

Several event studies, including the Australian Safety and Quality in Healthcare Study, emphasize gaps in safety for hospitalized patients. It is now recognized that system-based factors contribute significantly to risk of adverse events and this has led to a shift in focus of patient safety from the autonomous responsibility of medical clinicians to a systems-based approach. The aim of this study was to determine medical practitioner awareness of, level of engagement in and barriers to engagement in a systems approach to patient safety and quality.

METHODS

Information from acute and subacute care medical practitioners at a metropolitan public hospital was collected within an anonymous structured electronic survey, a discussion group and key informant interviews.

RESULTS

There were 73 survey respondents (response rate 7.6%). Fifty-one (69.9%) were unaware of the Institute of Medicine report 'To Err is human'. Thirty-six (49.3%) were unaware of the Australian Quality in Healthcare Study and 12 (16.4%) had read the article. There was a positive relation identified between awareness and seniority. There was a low level of participation in systems-focused quality and safety activities and limited understanding of the role of systems in medical error causation. There was uncertainty about the changing role of medical practitioners in patient safety and perceived lack of skills to effectively engage with hospital management about safety and quality issues.

CONCLUSION

Several factors are limiting engagement of medical practitioners in a systems approach to patient safety. Increased educational support is needed and may be best focused within clinical effectiveness activities pertinent to practitioner interest and expertise.

[Pulmonary nocardiosis with trimethoprime/sulphamethoxazole-resistant Nocardia paucivorans in a patient with no signs of immunosuppression]

This is so far the first published case report of a Nocardia paucivorans infection in an immunocompetent patient. A 54-year-old farmer was hospitalised with a history of coughing and fever for a period of five months. There was no indicator of either primary of secondary immunodeficiency in the prior medical history. A chest X-ray showed pneumonic infiltrates in the right middle und lower lobes, which progressed despite of antibiotic therapy with macrolides. A transbronchial biopsy revealed unspecific granulomatous inflammation of soft tissues. N. paucivorans - grew in cultures of sputum, bronchoalveolar lavage, and transbronchial biopsy. Oral antibiotic therapy was started with trimethoprime-sulphamethoxazole (TMP/SMX) and amoxicillin plus clavulanic acid. Susceptibility testing revealed high level resistance to TMP/SMX, which was consequently replaced by ciprofloxacin. Six months later, infiltrates had completely resolved and the patient did not report any residual clinical symptoms. The present case showed once again that nocardiosis is not limited to patients with immunodeficiencies. However, conservative combination therapy with oral antibiotics seems to be sufficiently effective for nocardiosis in the immunocompetent patient. For cases of suspected nocardiosis, a step-wise, risk-based diagnostic and therapeutic procedure is proposed.

Phase II trial of pirfenidone in adults with neurofibromatosis type 1

We performed an open-label phase II trial of oral pirfenidone in 24 patients with neurofibromatosis type 1 (NF1). Tumors were monitored by three-dimensional MRI. At the end of treatment, four patients had a decrease in tumor volume by 15% or more, three had tumor progression, and 17 remained stable. Pirfenidone warrants further investigation in NF1, which has until now lacked an effective control therapy.

Increased case fatality rates following a first acute cardiovascular event in patients with rheumatoid arthritis

OBJECTIVE

Among patients with rheumatoid arthritis (RA), cardiovascular mortality is increased compared with the rate among unaffected peers. In this study, 30-day mortality rates following a first acute cardiovascular event (myocardial infarction or stroke) were compared between RA patients and the general population.

METHODS

All cases of a first acute cardiovascular event between July 1, 2001 and November 30, 2003 in Victoria, Australia were identified from hospital discharge data. Individuals were classified as having RA when an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification code for RA was recorded at the index admission or during the previous 5 years. Thirty-day mortality rates were determined from linkage to the state death registry.

RESULTS

A total of 29,924 patients experienced a first cardiovascular event during the study period, 359 (1.2%) of whom had RA. Thirty-day cardiovascular mortality was 17.6% in RA patients versus 10.8% in non-RA patients. In fully adjusted models, the odds ratio (OR) for cardiovascular death in RA patients following a first acute cardiovascular event was 1.6 (95% confidence interval [95% CI] 1.2-2.2). Analysis of index event subgroups revealed that this increased case fatality rate in patients with RA was accounted for almost entirely by excess deaths following myocardial infarction. The adjusted ORs for cardiovascular death in RA after myocardial infarction and stroke were 1.9 (95% CI 1.3-2.7) and 1.2 (95% CI 0.7-2.0), respectively.

CONCLUSION

RA patients have a substantially increased risk of 30-day case fatality following myocardial infarction, but not stroke, compared with non-RA patients. This higher case fatality rate is likely to contribute to the observed overall excess of cardiovascular deaths in RA populations.

Donor methylenetetrahydrofolate reductase genotype is associated with graft-versus-host disease in hematopoietic stem cell transplant patients treated with methotrexate

Methotrexate (MTX), used as a graft-versus-host disease (GvHD) prophylactic agent in hematopoietic stem cell transplantation (HSCT), exerts its effect via folate cycle inhibition. A critical enzyme involved in folate metabolism is 5,10-methylenetetrahydrofolate reductase (MTHFR). We examined the association of a single nucleotide polymorphism (SNP) at position 677 in the MTHFR gene on GvHD outcomes in allogeneic HSCT patients administered MTX. MTHFR genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) on 193 HSCT patients and donors. A total of 140 patients were transplanted with an HLA-matched related donor and 53 with an unrelated donor. GvHD outcomes were compared between genotypes by univariate and multivariate analysis. The combined donor 677CT and TT genotypes were associated with a decreased incidence of GvHD (acute and chronic combined) in HSCT recipients with an HLA-matched related donor (75% at 1 year in the CT and TT group compared with 91% in the wild type CC group, P=0.01), increased time to onset of first GvHD (P=0.001) and time to first GvHD treated with systemic therapy (P=0.022). Unrelated donor MTHFR genotype was not associated with outcome parameters and no associations of recipient genotype in either related or unrelated donor cohorts were observed.

Effect of the covalent modification of horseradish peroxidase with poly(ethylene glycol) on the activity and stability upon encapsulation in polyester microspheres

Encapsulation of proteins in polyester microspheres by coacervation methods frequently causes protein inactivation and aggregation. Furthermore, an often-substantial amount of the encapsulated proteins is released within the first 24 h from the microspheres. To overcome these problems poly(ethylene glycol) (PEG) was employed as excipient and protein-modifying agent. The model protein horseradish peroxidase (HRP) was chemically modified or co-lyophilized with PEG of differing molecular weights, namely PEG(5000), PEG(20000), and PEG(40000). The lyophilized preparations were encapsulated in poly(D,L-lactide-co-glycolic) acid (PLGA) microspheres by a coacervation method. Covalent modification of HRP with PEG increased the encapsulation efficiency (EE) from 83% to about 100% while PEG when used as an excipient reduced the EE. Encapsulation caused aggregation of ca. 5% of non-modified HRP and the residual specific activity was only 57%. Covalent modification with PEG reduced HRP aggregation to less than 1% and improved its residual activity to more than 95%. When PEG was used as excipient similar results were found with respect to a reduction in encapsulation-induced aggregation, but no more than 80% of residual activity was obtained even for the best formulation after encapsulation. It was also found that covalent modification of HRP with PEG substantially reduced the unwanted initial "burst" release observed during the initial 24 h of in vitro release from about 70% to 23%. Furthermore, HRP activity and stability were also improved during in vitro release for HRP-PEG conjugates. The data show that covalent modification of proteins with PEG might be useful to improve protein stability during coacervation encapsulation and subsequent release as well as to increase EE and reduce the burst release.

A nonneuronal 5-hydroxytryptamine receptor 3 induces chloride secretion in the rat distal colonic mucosa

BACKGROUND

The 5-HT3 receptor is a serotonin receptor believed to reside on enteric neurons. However, several studies belie an exclusive neural localization. Our hypothesis is that the 5-HT3 receptor agonist, 2-methyl-5-HT (2Me5HT), induces chloride secretion despite neural blockade, which can be blocked by a 5-HT3 receptor antagonist.

METHODS

Rat distal colon was stripped of its muscularis, mounted as mucosal sheets in Ussing chambers, and short-circuited. Adjacent sheets were pretreated with 1 micromol/L of the neurotoxin, tetrodotoxin, and incubated with 2Me5HT (50 micromol/L) alone or with a 5-HT3 (0.3 micromol/L ondansetron or 0.3 micromol/L tropisetron) or a 5-HT4 (0.3 micromol/L GR11808) receptor antagonist. Short-circuit current (I(sc)) was measured continuously.

RESULTS

2Me5HT caused an increase in I(sc), which was significantly (P <.01, repeated measures analysis of variance) inhibited by ondansetron (n = 8) and tropisetron (n = 5) but not by GR11808.

CONCLUSIONS

A 5-HT3 receptor is present at the mucosal level that mediates chloride secretion by a nonneural pathway.

p16INK4A, CDC6, and MCM5: predictive biomarkers in cervical preinvasive neoplasia and cervical cancer

AIM

To analyse and compare expression patterns of three potential biomarkers-p16(INK4A), CDC6, and MCM5-and evaluate their use as predictive biomarkers in squamous and glandular cervical preinvasive neoplasia.

METHODS

Immunocytochemical analysis of p16(INK4A), MCM5, and CDC6 expression was performed on 20 normal, 38 cervical intraepithelial neoplasia 1 (CIN1), 33 CIN2, 46 CIN3, 10 squamous cell carcinoma, 19 cervical glandular intraepithelial neoplasia (cGIN), and 10 adenocarcinoma samples. Staining intensity was assessed using a 0-3 scoring system. p16(INK4A), MCM5, and CDC6 expression was also examined in ThinPrep slides exhibiting mild, moderate, and severe dyskaryosis. Human papillomavirus (HPV) was detected using a modified SYBR green assay. Fluorogenic polymerase chain reaction (PCR) and solution phase PCR were used for specific HPV typing.

RESULTS

All three markers showed a linear correlation between expression and grade of dysplasia. p16(INK4A) and MCM5 protein expression was upregulated in all grades of squamous and glandular dysplasia. CDC6 protein was preferentially expressed in high grade lesions and in invasive squamous cell carcinoma.

CONCLUSION

p16(INK4A) expression was closely associated with high risk HPV infection-all grades of squamous and glandular cervical lesions were immunohistochemically positive. MCM5 staining intensity was independent of high risk HPV infection, highlighting its potential as a biomarker in both HPV dependent and independent cervical dysplasia. CDC6 may be a biomarker of high grade and invasive lesions of the cervix, with limited use in low grade dysplasia. p16(INK4A) was the most reliable marker of cervical dysplasia. Combinations of dysplastic biomarkers may be useful in difficult diagnostic cases.

Study on the dynamics of algal bloom and its influence factors in Tolo Harbour, Hong Kong

In this paper, the semi-enclosed bay named Tolo Harbour and Channel in Hong Kong, which was frequently attacked by red tides, was used as a case study. Data sets related to marine water quality, river nutrients, and meteorological conditions recorded between 1988 and 1999 were chosen for statistical analysis. A multivariate analysis showed that algal growth, represented by the chlorophyll a concentration, had obvious spatial and temporal variations in the study area. The chlorophyll a concentration had a consistently decreasing trend from the inner part of the Harbour and surface waters to the outer part and bottom waters. The temporal variations had a markedly seasonal variation with high bioproductivity in spring and winter. There were long-term fluctuations in the chlorophyll a concentration with a high-low-high pattern in the study period. Nutrients and hydrological and meteorological conditions were important factors of algal bloom. Besides nitrogen, which was the most critical factor of algal bloom for the whole water body, total phosphorus in the surface waters and phosphate (PO4) and silica (SiO2) in the bottom waters also showed strongly positive or negative correlations with the chlorophyll a level. For the meteorological conditions, global solar radiation was the key factor of massive algal bloom in the study period, while rainfall and wind direction were the most important factors of seasonal variation.

P16INK4A positivity in benign, premalignant and malignant cervical glandular lesions: a potential diagnostic problem

A wide array of immunohistochemical markers have been evaluated with respect to their specificity in staining dysplastic cervical cells in cervical biopsies and cervical cytological smears. However, there is still a significant demand for better biomarkers to identify neoplastic cervical glandular and squamous epithelial cells precisely. The CDKN2A gene, located on chromosome 9p21, encodes the tumour suppressor protein, p16INK4A, which decelerates the cell cycle by inactivating CDK4 and CDK6. The aim of this study was to compare and contrast the expression pattern of p16INK4A in benign and neoplastic glandular lesions and tubo-endometrioid metaplasia. All cases in each category displayed some p16INK4A expression. Adenocarcinoma and in situ cases showed a combination of intense nuclear and cytoplasmic staining. It was observed that all cases of tubo-endometrioid metaplasia showed occasional nuclear positivity and definite cytoplasmic staining. These findings may have important implications for the potential utility of p16INK4A as a biomarker for glandular dysplastic lesions. While p16INK4A has been demonstrated to be an excellent marker of cervical dysplasia in squamous neoplastic lesions of the cervix, it has potential pitfalls in cervical glandular lesions that may limit the utility of this biomarker in resolving the nature of suspicious glandular lesions, particularly in cytopathology.

Use of 2D histograms for volume rendering of multidetector CT data: development of a graphical user interface

RATIONALE AND OBJECTIVES

Direct volume rendering reveals 3D information on anatomic structures without preprocessing the data. This increases the interest in this technique as a diagnostic tool. A fast and simple method for setting transfer functions is crucial for clinical routine work. However, this is still a complex task. Present commercial workstations are usually limited to design galleries and window/level functionality.

MATERIALS AND METHODS

We present a graphical user interface for volume rendering of multidetector row CT data that permits a much more flexible specification of rendering parameters. A 2D histogram of CT density versus gradient magnitude facilitates the understanding of the spatial connections of different tissues. The incorporation of gradient magnitude into the transfer function domain allows discrimination of features of interest that are not distinguishable on CT density alone. Penetration length, color, and gradient magnitude are depicted on a stack of 2D slices according to the settings of the opacity transfer function and the viewing direction. A gallery of thumbnails with presets of transfer functions is interactively adapted if the volume is rotated or cropped.

RESULTS

This allows for fast evaluation of numerous rendering protocols at once. The interface was evaluated with CT data covering skeletal trauma, pathologies of the thorax/abdomen, and CT angiography.

CONCLUSION

We observed that high-quality visualizations could be obtained with reasonable interaction times. The 2D histogram and penetration length displays provided valuable insight into the dataset that made the specification of transfer functions a goal-oriented process.

The value of perinatal immune responses in predicting allergic disease at 6 years of age

BACKGROUND

Characterizing early abnormalities in immune development of allergic individuals provides an important basis for defining disease pathogenesis and future prevention strategies. This study compares patterns of early immune responses in an established cohort based on allergic outcomes and allergen skin prick test (SPT) reactions at 6 years of age.

METHODS

Children from an original birth cohort (n = 60) consisting of 44 high risk (HR) (family history of allergy) and 16 low risk (LR) (no family history) were reassessed at 6 years of age. Detailed clinical information about allergic disease was obtained (n = 53) and a subgroup (n = 31) consented to have allergen SPT to common food and inhalant allergens. Data from previous immunological assessments performed at birth, 1 and 2 years of age, including lymphoproliferation and cytokine [interleukin (IL)-4, IL-5, IL-6, IL-10, IL-13 and interferon (IFN)-gamma] responses to ovalbumin (OVA), house dust mite (HDM), cat allergen (Fel d 1), phytohaemaglutinin (PHA) and tetanus toxoid, were re-analysed based on the 6-year clinical outcomes.

RESULTS

Twenty-eight HR and three LR children had a clinical history of allergic disease at 6 years of age including doctor diagnosed asthma (n = 17) and/or eczema (n = 24). Most children (78%) with atopy at 6 years had positive SPT to the allergens tested, and 70% had symptoms within the last year. Children at genetic risk (family history) of allergy had weaker (P = 0.017) polyclonal T helper 1 (Th1) IFN-gamma responses in the neonatal period compared with LR children. Although children with allergic disease at 6 years also tended to have weaker neonatal IFN-gamma responses compared to those with no symptoms, but this was not quite significant (P = 0.05). A positive SPT to HDM at 6 years was associated with higher IL-13 responses to HDM at 1 year (P = 0.02), whereas allergic disease at 6 years was associated with higher IL-5 messenger RNA (mRNA) responses to HDM at 1 year (P = 0.01). Despite these associations, regression analysis demonstrated that the only significant early predictors of allergic sensitization at 6 years of age were a family history of allergic disease, and atopic symptoms at 2 years. Importantly, none of the early immunological parameters measured were significantly predictive of allergic disease or allergic sensitization in these 6-year-olds.

CONCLUSIONS

Although our observations suggest that subtle differential alterations in cytokine responses during early immune development are associated with different aspects of subsequent atopy, there are still no early predictive biomarkers of disease. A positive family history of allergy remains the dominant predictive factor.