Neonatal alveolar lymphangioma: A rare benign oral disease case report and literature review

BACKGROUND

Neonatal alveolar lymphangioma (NAL) is a rare benign condition most often reported in the oral cavity of neonates of African descent.

CASE DESCRIPTION

The authors present a case report of bilateral NAL, including follow-up images at 6 months and 17 months. The clinical differential diagnosis includes dental lamina cyst, hemangioma, congenital epulis of the neonate, and melanotic neuroectodermal tumor of infancy. Key differences to assist in making the distinction are described.

PRACTICAL IMPLICATIONS

The distinguishing characteristics of NAL make a clinical diagnosis possible. Accurate clinical recognition of NAL is essential because biopsy is not typically indicated. Because this is a clinical diagnosis, follow-up for 1 year or until complete resolution; biopsy is suggested if clinically indicated for residual or recurrent lesion.

Polypharmacy and potential drug-drug interactions for people with HIV in the UK from the Climate-HIV database

Objectives

People with HIV (PWHIV) are likely to need therapies for comorbidities as they age. We assessed risk of drug–drug interactions (DDIs) in PWHIV.

Methods

The Climate‐HIV electronic recording system was used to cross‐sectionally analyse records from PWHIV aged ≥ 18 years attending four UK HIV units with a current antiretroviral (ARV) prescription in February 2018. Antiretroviral and non‐ARV medications were categorized by clinical significance of DDIs (University of Liverpool DDI tool). Potential DDIs were predicted using treatment guidelines for commonly recorded comorbidities.

Results

Among 4630 PWHIV (44% female), 41% were ≥ 50 years old. The average number of non‐ARV comedications increased from < 1 for patients aged ≤ 24 years to > 5 for patients aged ≥ 75 years; 65% were taking one or more non‐ARV comedications. The median (interquartile range) number of non‐ARVs was 1 (0–2) and 2 (1–5) for those aged < 50 and ≥ 50 years, respectively. Common comorbidities/concurrent health conditions occurred more frequently in patients aged ≥ 50 years vs. < 50 (53% vs. 34%). Boosted protease inhibitors were associated with the highest proportion of contraindicated comedications; dolutegravir and raltegravir had the fewest. For non‐ARVs, sildenafil and quetiapine were most likely to result in DDIs. Guideline‐recommended treatments for hepatitis C, hepatitis B, and tuberculosis had the highest proportions of contraindications when combined with ARV regimens, while treatments for hepatitis C, malignancy, and mental health conditions had the highest proportion of combinations potentially causing DDIs requiring dose monitoring or adjustment.

Conclusions

Non‐ARV use by PWHIV is high and increases with age. Treatment decisions for ageing PWHIV should consider guideline recommendations for comorbidities.

Week 48 Resistance Analyses of the Once-Daily, Single-Tablet Regimen Darunavir/Cobicistat/Emtricitabine/Tenofovir Alafenamide (D/C/F/TAF) in Adults Living with HIV-1 from the Phase III Randomized AMBER and EMERALD Trials

Darunavir/cobicistat/emtricitabine/tenofovir alafenamide (D/C/F/TAF) 800/150/200/10 mg is being investigated in two Phase III trials, AMBER (NCT02431247; treatment-naive adults) and EMERALD (NCT02269917; treatment-experienced, virologically suppressed adults). Week 48 AMBER and EMERALD resistance analyses are presented. Postbaseline samples for genotyping/phenotyping were analyzed from protocol-defined virologic failures (PDVFs) with viral load (VL) ≥400 copies/mL at failure/later time points. Post hoc analyses were deep sequencing in AMBER, and HIV-1 proviral DNA from baseline samples (VL <50 copies/mL) in EMERALD. Through week 48 across both studies, no darunavir, primary PI, or tenofovir resistance-associated mutations (RAMs) were observed in HIV-1 viruses of 1,125 participants receiving D/C/F/TAF or 629 receiving boosted darunavir plus emtricitabine/tenofovir-disoproxil-fumarate. In AMBER, the nucleos(t)ide analog reverse transcriptase inhibitor (N(t)RTI) RAM M184I/V was identified in HIV-1 of one participant during D/C/F/TAF treatment. M184V was detected pretreatment as a minority variant (9%). In EMERALD, in participants with prior VF and genoarchive data (N = 140; 98 D/C/F/TAF and 42 control), 4% had viruses with darunavir RAMs, 38% with emtricitabine RAMs, mainly at position 184 (41% not fully susceptible to emtricitabine), 4% with tenofovir RAMs, and 21% ≥ 3 thymidine analog-associated mutations (24% not fully susceptible to tenofovir) detected at screening. All achieved VL <50 copies/mL at week 48 or prior discontinuation. D/C/F/TAF has a high genetic barrier to resistance; no darunavir, primary PI, or tenofovir RAMs were observed through 48 weeks in AMBER and EMERALD. Only one postbaseline M184I/V RAM was observed in HIV-1 of an AMBER participant. In EMERALD, baseline archived RAMs to darunavir, emtricitabine, and tenofovir in participants with prior VF did not preclude virologic response.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men

We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.

Experiences of stigma and discrimination in social and healthcare settings among trans people living with HIV in the UK

The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.

Incorporating HIV/hepatitis B virus/hepatitis C virus combined testing into routine blood tests in nine UK Emergency Departments: the "Going Viral" campaign

OBJECTIVES

Routine HIV screening is recommended in those UK hospitals and primary care settings where the HIV prevalence is > 0.2%. For hepatitis B virus (HBV) and hepatitis C virus (HCV), however, testing is targeted at at-risk groups. We investigated the prevalence of these blood-borne viruses (BBVs) during a routine testing pilot in UK Emergency Departments (EDs).

METHODS

During the "Going Viral" campaign (13-19 October 2014), nine UK EDs in areas of high HIV prevalence offered routine tests for HIV, HBV and HCV to adults having blood taken as part of routine care. Patients who tested positive were linked to care.

RESULTS

A total of 7807 patients had blood taken during their ED visit; of these, 2118 (27%) were tested for BBVs (range 9-65%). Seventy-one BBV tests were positive (3.4%) with 32 (45.1%) new diagnoses. There were 39 HCV infections (15 newly diagnosed), 17 HIV infections (six newly diagnosed), and 15 HBV infections (11 newly diagnosed). Those aged 25-54 years had the highest prevalence: 2.46% for HCV, 1.36% for HIV and 1.09% for HBV. Assuming the cost per diagnosis is £7, the cost per new case detected would be £988 for HCV, £1351 for HBV and £2478 for HIV.

CONCLUSIONS

In the first study in the UK to report prospectively on BBV prevalence in the ED, we identified a high number of new viral hepatitis diagnoses, especially hepatitis C, in addition to the HIV diagnoses. Testing for HIV alone would have missed 54 viral hepatitis diagnoses (26 new), supporting further evaluation of routine BBV testing in UK EDs.

Starting treatment according to guidelines evaluation: a multicentre audit of HIV patients in the UK

The aim of this audit was to assess whether HIV patients are being started on antiretroviral therapy (ART) according to British and European guidelines. Data were collected from the Survey of Prevalent HIV Infections Diagnosed (SOPHID) return for 2010 at five major HIV management centres in the UK. Data from this 3873 patient cohort revealed 52 patients who should have been receiving ART according to the guidelines but were not. Of these, 23 patients elected not to start ART despite clinical advice to the contrary. Information required to assist in the decision for earlier ART initiation (CD4 count 350–500 cells/mL) was missing for some patients. Clinicians must pay attention to the regular assessment of patients with a CD4 count of 351–500 cells/mL so that all those who may benefit from earlier treatment are identified. Future research should investigate patient barriers to initiating therapy following recommendation by a clinician.

Hemodynamic correlates of low umbilical cord vitamin D and ionized calcium

Vitamin D deficiency and hypocalcemia are associated with gestational hypertension. Therefore, we hypothesized that umbilical cord [Ca(2+)] and [vitamin D] are correlated with perinatal blood pressures. Mothers and newborns comprised vitamin D sufficient (vitamin D ≥ 50 nM, range 52-111 nM, n = 14), and vitamin D deficient groups (vitamin D < 50 nM, range 13-49 nM, n = 29). Cord [Ca²⁺] was negatively correlated with maternal systolic pressure (SBP) (r = -0.56, p < 0.01) and positively correlated with neonatal SBP (r = +0.55, p < 0.01) in the vitamin D deficient group. We conclude that low umbilical cord [vitamin D] and [Ca²⁺] may predispose mothers to higher and newborns to lower blood pressures.

Exaggerated vasopressor response to exercise and cerebral blood flow velocity

We studied 10 young adults, normotensive at rest, comprising a control group (n = 5) with normal blood pressure responsiveness to exercise and an experimental group exhibiting greater percentage of body fat and body mass index (BMI) than the controls, with exaggerated blood pressure (vasopressor) responsiveness to exercise (EEBPR) (n = 5). Lower absolute and varying oxygen consumption/body weight normalized units of middle cerebral arterial blood flow velocity (MCAV) were found during exercise in the experimental group (P < .01). These findings support the hypothesis that the combination of EEBPR and high BMI is associated with low MCAV that may put such individuals at risk for cerebral hypoperfusion and cognitive deficits.

Diagnostic utility of urethral smears in predicting urethral chlamydia in HIV-infected men

We collected data from 218 HIV-infected men to assess the usefulness of the urethral smear and symptoms in predicting Chlamydia trachomatis infection. Prevalence of urethral chlamydia was 9%. A polymorphonuclear leucocyte (PMNL) count ≥5 was 73% sensitive and 71% specific for C. trachomatis infection. Adjusted odds ratio for risk of chlamydial infection was significant for urethral irritation (7.48; 1.54–36.4), a PMNL count of 20 or more (9.83; 2.52–8.4) and a PMNL count of 5–19 (4.10; 1.34–12.5). We had to perform 50 urethral smears in HIV-positive men without symptoms to treat one case of C. trachomatis at the time of visit. Findings suggest that the presence of symptoms, in particular urethral irritation may be associated with chlamydial urethritis and that the higher the urethral PMNL count, the more likely it is for C. trachomatis to be detected. The findings in this study also lend further support to recent guidelines that urethral microscopy is not useful in asymptomatic men and hence should be abandoned.

Integrated community-based sexual health services for young people in urban areas: are we meeting the needs of the local community?

Community-based sexual health services (SHS) are intended to improve access for people who may have difficulty attending traditional genitourinary medicine clinics. The objective of this study was to review uptake of sexually transmitted infection (STI) testing in an outreach clinic for those under 25 in an area where Black and minority ethnic groups comprise the majority of the local population. A retrospective case-notes review was undertaken of those attending. Standards were that Fraser guidelines should be completed in all under 16-year-old and all clients should be offered STI testing, HIV testing and contraception (if applicable) in accordance with local standards. One hundred and seventeen clients attended. Ten percent self-reported ethnicity was Asian. Thirty-six (31%) clients tested for chlamydia. Thirty (26%) had an HIV test. Five (14% of those tested) had a positive nucleic acid amplification test for chlamydia. Five (13%) of those requesting long term contraception had STI testing. This service has successfully improved access to STI screening. However, there may have been missed opportunities to offer tests in those requesting contraception. Under-representation of those of non-white ethnicity suggests access to SHS may be a particular problem and further work is required to improve the sexual health of the local community.

Changes in the provision of post-exposure prophylaxis for HIV after sexual exposure following introduction of guidelines and publicity campaigns

In July 2004, British Association of Sexual Health and HIV (BASHH) published guidelines for post-exposure prophylaxis following sexual exposure (PEPSE) and the Terence Higgins Trust (THT) launched a campaign promoting PEPSE among men who have sex with men (MSM). We evaluated subsequent changes in PEPSE attendances. Individuals requesting PEPSE in 2004 were identified from clinic databases. Comparisons of clinical data, exposure characteristics and follow-up were made pre and post campaign. Data were available for 197/216 (91%) PEP attendances. The proportion requesting PEP following sexual exposure increased significantly following the campaign. The majority commencing PEPSE were MSM, with the proportion of MSM increasing significantly from 36/46 (78%) pre to 76/80 (95%) following the campaign. Most prescriptions were in high-risk groups and within guidelines. Times to initiation and completion rates were unchanged. Access to PEPSE following the THT campaign and introduction of BASHH guidelines increased. Promotion of earlier initiation of PEPSE and improvement of completion and follow-up is required.

The systematic monitoring of transfusion microbiology test kit performance

The Transfusion Microbiology Test Systems Monitoring Group (TMTSMG) was established as a National Blood Service (NBS) working group to monitor the performance of the microbiology screening assays used within the NBS Testing Laboratories. The group's primary objective was to ensure that technical performance (especially sensitivity, specificity and wastage) remains consistent with that established during validation. This includes the identification and investigation of significant variation in performance and any untoward incidents. The group is also responsible for optimizing transfusion microbiology working practice across the NBS through nationally agreed standards and procedures. Over the past 9 years, a total of 44 assays from 15 suppliers have been monitored. Five assays have been withdrawn from use as a result of identified poor performance; two hepatitis B virus surface antigen assays owing to poor sensitivity, two syphilis agglutination assays with nonspecific (false) reactive rates sustained above contract limits and one human cytomegalovirus antibody assay that persistently failed the manufacturer's quality control criteria. This approach has enabled the differentiation of genuine kit performance issues from 'natural variation' in kit performance, and local instrumentation or training issues. The NBS has been able to address the issues with suppliers much earlier and resolve minor issues before they became major problems. In addition, a lot release system has been developed and implemented, comprising a formal, centralized initial scientific assessment of each new manufacturer's lot, followed by 'delivery acceptance' testing at each site. This system helps to ensure that the evaluated minimum sensitivity and specificity of the assays is maintained from 'lot to lot'.

Risk of undiagnosed infection in men attending a sexual assault referral centre

OBJECTIVES

To investigate men undergoing forensic examination at the Haven, a specialist centre for the management of sexual assault in south London.

METHODS

Forensic notes of 92 men attending the Haven from May 2000 to August 2003 were identified and a detailed review performed.

RESULTS

Males ranged in age from 12 to 51 years, with 83% within the range 12-35 years. 78% were white. Of those who were sexually active (n=82) 30% were heterosexual, 34% were homosexual, and the remainder provided no information regarding sexual orientation. Most clients were referred by the police (n=79) and attended within 3 days of the alleged assault (n=73). Many of the victims had increased vulnerability to assault-for example, through alcohol or drug consumption or mental health difficulties. One assailant was reported in 61 cases but two or more assailants in 26. Women were reported as assailants in four cases. The sexual assault was frequently accompanied by other physical assault (n=45). Use/threat of a weapon was reported in 18 cases. Rape or attempted rape was reported in 59 cases and was the most common assault. Non-genital injuries were documented in 37 men (40%). Anal injuries were seen in 31 (34%). The non-attendance rate at follow up was 41%. Post-exposure prophylaxis (PEP) against HIV was commenced in 31 men (34%). 23 of the 54 men (43%) reporting rape and 14 of the 31 (45%) with anal injuries initiated PEP.

CONCLUSIONS

The number of men presenting after sexual assault is likely to increase but despite significant risk many do not engage with medical care. This carries an unknown risk of HIV and other STI transmission.

Age-related serum levels of insulin-like growth factor-I, -II and IGF-binding protein-3 following myocardial infarction

Aging retards the repair process by decreasing hormone secretion from the somatotrophic axis, which plays a major role in tissue reconstruction after injury. The aim of this study was to determine the effect of aging on serum insulin-like growth factor-I (IGF-I), IGF-II and IGF-binding protein-3 (IGFBP-3) levels following myocardial infarction (MI). For four consecutive days, we monitored the variation of serum IGF-I, IGF-II and IGFBP-3 concentrations in 26 patients aged 19-71 years who were diagnosed with MI. Serum IGF-I, IGF-II and IGFBP-3 were measured daily by double antibody radioimmunoassay. Daily serum IGF-I concentrations showed a significant negative correlation with age (r = -0.528, P< 0.001). Total serum IGF-I was significantly (P = 0.002) higher in the younger age group (patients under 50 years) compared to the older group (50 years and over); 206 +/- 16 ng/ml vs 136 +/- 12 ng/ml. During this investigation, younger patients (under 50 years) showed no significant daily variations in IGF-I levels compared to older patients (50 years and over) who presented a significant decline (P = 0.012). Total serum IGF-II in both groups decreased significantly with time. Total serum IGFBP-3 in the younger age group was significantly higher (P = 0.046) than in the older age group (3.42 +/- 0.18 microgram/ml vs 2.95 +/- 0.13 microgram/ml). MI patients in both groups showed significantly lower IGF-I and IGF-II (IGFs) with higher IGFBP-3 compared to age- and sex-adjusted levels of normal adults (controls). The present results confirm that age and cardiac condition affect IGFs and IGFBP-3 levels. We are inclined to believe that older patients with a cardiac condition are less able to maintain their blood IGF-I levels during the recovery period compared to younger patients. Given the biological impact of IGF-I on regeneration, this could explain why older patients take longer to recover and heal poorly in comparison to younger patients.

Safety and efficacy of hepatitis C virus antibody screening of blood donors with two sequential screening assays

BACKGROUND

Reactive samples in hepatitis C virus (HCV) antibody screening of blood donors are currently referred for a confirmatory assay. This scheme is not optimally efficient and is expensive because of the lack of specificity and cost of confirmatory tests, as well as the need to discard false-positive donations. As in some human immunodeficiency virus antibody-confirmatory schemes, the safety and efficacy of confirming anti-HCV with two sequential screening assays were evaluated.

STUDY DESIGN AND METHODS

Three combinations of two anti-HCV screening assays were used to test 75,874 blood donors. Results were compared with the routine testing scheme and HCV RNA detection in any enzyme immunoassay-repeatably reactive samples.

RESULTS

The use of an alternative screening assay for repeat testing decreased the proportion of enzyme immunoassay-positive donors from 0.28 to 0.05 percent. All samples that were "confirmed" as positive by the standard combination of immunoassays and all HCV RNA-positive samples were detected by the sequential screening assays. No samples that had discordant results on primary and secondary screening assays were confirmed by recombinant immunoblot assay or were found to contain detectable HCV RNA.

CONCLUSION

The combination of screening assays for anti-HCV confirmation was as safe as, cheaper than, and nearly as efficient as the standard testing scheme.

Feasibility and usefulness of an efficient anti-HBc screening programme in blood donors

Post-transfusion hepatitis B remains a risk for recipients of hepatitis B surface antigen (HBsAg) screened blood. Anti-hepatitis B core antibody (anti-HBc) screening may help reduce this risk. To evaluate its usefulness, 9,238 East Anglian blood donors were screened for anti-HBc. Those with isolated anti-HBc were identified with two confirmatory anti-HBc and anti-HB surface antibody (anti-HBs) assays. The prevalence of anti-HBc reactions in screening and confirmatory assays was 1.29% and 0.35%, respectively. The level of reactivity was significantly higher when two anti-HBc assays gave concordant results or, being concordant, were anti-HBs positive. All isolated anti-HBc-positive units (0.04%) were negative for additional HBV markers including DNA tested with nested polymerase chain reaction (PCR). A 0.31% prevalence of past HBV infection was found in this population, all carrying both anti-HBc and anti-HBs antibody, most above the protective level (0.1 IU/ml). The proposed screening schemes would limit the number of deferred donors and discarded units and keep the testing time within the remit of routine blood banking practices for an additional cost of approximately 1 pound per unit. However, no evidence was found in this donor population to suggest that anti-HBc screening would significantly reduce the incidence of post-transfusion hepatitis B.

Chronic administration of growth hormone-releasing factor increases wound strength and collagen maturation in granulation tissue

The effects of chronic administration of growth hormone-releasing factor (GRF) on wound healing were studied in rats. Cutaneous wound strength was measured by tensometry at 5, 10, and 14 days postwounding in rats implanted with a slow-release pellet which contained a compressed mixture of a fatty acid and [desamino Tyr1, D-Ala2, Ala15]hGRF(1-29)NH2 or the fatty acid alone. There was a significant increase in wound tensile strength in GRF-treated rats compared to controls at each measurement: Day 5, 130 +/- 12 vs 97 +/- 14 g; Day 10, 402 +/- 18 vs 280 +/- 11 g; Day 14, 830 +/- 17 vs 614 +/- 14 g (P less than 0.01 for each value). Granulation tissue obtained from subcutaneously implanted polyvinyl alcohol sponges encased in silicone tubing was also studied. The amount of collagen deposited in the granulation tissue was estimated by measuring the hydroxyproline (Hyp) content of sponges retrieved 5, 10, and 14 days postinsertion from GRF-treated and control rats. Hyp content (nmole/mg sponge) was similar in both treated and control animals at each measurement: Day 5, 1.7 +/- 0.2 vs 2.2 +/- 0.2; Day 10, 31.9 +/- 4.1 vs 26.7 + 0.4; and Day 14, 41.6 +/- 7.3 vs 38.5 +/- 4.4. Hyp/proline, Hyp/glycine, and glycine/total amino acid ratios, evaluated after 10 days, were also similar in both groups. Collagen from the granulation tissue of sponges retrieved after 14 days from treated and control rats was studied by electron microscopy (magnifications, 7,100 and 22,720).(ABSTRACT TRUNCATED AT 250 WORDS)

Novel plate culture method to improve the microbiological diagnosis of peritonitis in patients on continuous ambulatory peritoneal dialysis

A novel economical plate culture technique incorporating Tween 80 was used for the isolation of organisms from dialysis effluent in cases of continuous ambulatory peritoneal dialysis peritonitis. It was found to be convenient for routine laboratory use and increased the yield of positive plate cultures in specimens without antibiotics from 53 to 75% (P less than 0.01) and in specimens containing antibiotics from 24 to 38% (P less than 0.05). It allowed for the identification and susceptibility testing of isolates 24 h earlier than did broth culturing and a more ready appreciation of mixed cultures and contaminants.