Self-reported beta-lactam allergy in government and private hospitals in Cape Town, South Africa

BACKGROUND

Up to a quarter of inpatients in high-income countries (HICs) self-report beta-lactam allergy (BLA), which if incorrect,increases the use of alternative antibiotics, worsening individual health outcomes and driving bacterial resistance. In HICs, up to 95% ofself-reported BLAs are incorrect. The epidemiology of BLA in low- and middle-income African countries is unknown.

OBJECTIVES

To describe the epidemiology and de-labelling outcomes of self-reported BLA in hospitalised South African (SA) patients.

METHODS

Point-prevalence surveys were conducted at seven hospitals (adult, paediatric, government and privately funded, district andtertiary level) in Cape Town, SA, between April 2019 and June 2021. Ward prescription records and in-person interviews were conductedto identify and risk-stratify BLA patients using the validated PEN-FAST tool. De-labelling was attempted at the tertiary allergy clinic atGroote Schuur Hospital.

RESULTS

A total of 1 486 hospital inpatients were surveyed (1 166 adults and 320 children). Only 48 patients (3.2%) self-reported a BLA,with a higher rate in private than in government-funded hospitals (6.3% v. 2.8%; p=0.014). Using the PEN-FAST tool, only 10.4% (n=5/48)of self-reported BLA patients were classified as high risk for true penicillin hypersensitivity. Antibiotics were prescribed to 70.8% (n=34/48)of self-reported BLA patients, with 64.7% (n=22/34) receiving a beta-lactam. Despite three attempts to contact patients for de-labelling atthe allergy clinic, only 3/36 underwent in vivo testing, with no positive results, and 1 patient proceeded to a negative oral challenge.

CONCLUSION

Unlike HICs, self-reported BLA is low among inpatients in SA. The majority of those who self-reported BLA were low risk fortype 1 hypersensitivity, but outpatient de-labelling efforts were largely unsuccessful.

Deletion of bglC triggers a genetic compensation response by awakening the expression of alternative beta-glucosidase

In the plant pathogen Streptomyces scabies, the gene bglC encodes a GH1 family cellobiose beta-glucosidase that is both required for primary metabolism and for inducing virulence of the bacterium. Deletion of bglC (strain ΔbglC) surprisingly resulted in the augmentation of the global beta-glucosidase activity of S. scabies. This paradoxical phenotype is highly robust as it has been observed in all bglC deletion mutants independently generated, thereby highlighting a phenomenon of genetic compensation. Comparative proteomics allowed to identify two glycosyl hydrolases - named BcpE1 and BcpE2 - of which peptide levels were significantly increased in strain ΔbglC. Quantitative RT-PCR revealed that the higher abundance of BcpE1 and BcpE2 is triggered at the transcriptional level, the expression of their respective gene being 100 and 15 times upregulated. Enzymatic studies with pure BcpE proteins showed that they both possess beta-glucosidase activity thereby explaining the genotypic-phenotypic discrepancy of the bglC deletion mutant. The GH1 family BcpE1 could hydrolyze cellobiose and generate glucose similarly to BglC itself thereby mainly contributing to the survival of strain ΔbglC when cellobiose is provided as sole nutrient source. The low affinity of BcpE2 for cellobiose suggests that this GH3 family beta-glucosidase would instead primarily target another and yet unknown glucose-beta-1,4-linked substrate. These results make S. scabies a new model system to study genetic compensation. Discovering how, either the bglC DNA locus, its mRNA, the BglC protein, or either its enzymatic activity controls bcpE genes' expression, will unveil new mechanisms directing transcriptional repression.

Effect of Byrsocarpus Coccineus (Connaraceae) Aqueous Leaf Extract on Pancreatic Islets Volume in Type 2 Diabetic Male Wistar Rats

Diabetes mellitus is a devastating illness associated with alterations in the pancreatic islet of Langerhans and the islet volume constitutes a significant variable in diabetic investigations. This study investigates the volume of pancreatic islets in type 2 diabetic rats following treatment with aqueous extract Byrsocarpus coccineus leaves. Twenty-five male Wistar rats weighing between 100-120g were divided into five groups. Group 1 served as the normal control given distilled water while type 2 diabetes mellitus was induced by a high fat diet feeding for five weeks and a single dose of streptozotocin (35mg/kg, i.p.) in groups 2,3,4 and 5. After confirmation of diabetes, animals in groups 2,3,4 and 5 were administered normal saline, 50 mg/kg metformin, 800 mg/kg Byrsocarpus coccineus leaves leaf extract (BCLE) and 400 mg/kg BCLE respectively for 21 days. The pancreas was harvested, fixed in neutral buffered formalin and processed for stereological and histological analysis. Isotropic uniform random samples were obtained with the orientator grid. Serial sections were cut with a rotatory microtome and stained with Haematoxylin and Eosin. Pancreatic islet volumes were measured with the aid of a Cavalieri estimator grid. The result showed significant (p<0.05) increase in the blood glucose level of the diabetic control group, when compared to the normal control. But blood glucose levels from groups 4 and 5 were significantly (p<0.05) decreased when compared to the diabetic control. Pancreatic islet volume estimations showed a significant decrease in the diabetic control group when compared to the normal control (p<0.05), while pancreatic islet volumes in groups 3, 4 and 5 were significantly increased when compared to the diabetic control group (p<0.05). In a likewise manner the histology of the pancreas of the diabetic control shows damaged pancreatic islet cells and surrounding tissue that was reduced in all the treated group. In conclusion the aqueous extract of Byrsocarpus coccineus has shown an anti- hyperglycaemic effect in the experimental rats and increased the volumes of the pancreatic islet cells as well as ameliorated the pathological changes in the pancreas.

Neutron spin rotation measurements

The neutron spin rotation (NSR) collaboration used parity-violating spin rotation of transversely polarized neutrons transmitted through a 0.5 m liquid helium target to constrain weak coupling constants between nucleons. While consistent with theoretical expectation, the upper limit set by this measurement on the rotation angle is limited by statistical uncertainties. The NSR collaboration is preparing a new measurement to improve this statistically-limited result by about an order of magnitude. In addition to using the new high-flux NG-C beam at the NIST Center for Neutron Research, the apparatus was upgraded to take advantage of the larger-area and more divergent NG-C beam. Significant improvements are also being made to the cryogenic design. Details of these improvements and readiness of the upgraded apparatus are presented. We also comment on how recent theoretical work combining effective field theory techniques with the 1/Nc expansion of QCD along with previous NN weak measurements can be used to make a prediction for dϕ/dz in 4He.

An experiment using the same apparatus with a room-temperature target was carried out at LANSCE to place limits on parity-conserving rotations from possible fifth-force interactions to complement previous studies. We sought this interaction using a slow neutron polarimeter that passed transversely polarized slow neutrons by unpolarized slabs of material arranged so that this interaction would tilt the plane of polarization and develop a component along the neutron momentum. The results of this measurement and its impact on the neutron-matter coupling gA2 from such an interaction are presented. The NSR collaboration is also preparing a new measurement that uses an upgraded version of the room-temperature target to be run on the NG-C beamline; and it is expected to constrain gA2 by at least two additional orders of magnitude for λc between 1 cm and 1 μm.

Comment on "Evolutionary transitions between beneficial and phytopathogenic Rhodococcus challenge disease management"

We would like to address a number of concerns regarding this paper (Savory et al., 2017)

Correlating the deep inferior epigastric artery branching pattern with type of abdominal free flap performed in a series of 145 breast reconstruction patients

INTRODUCTION

The deep inferior epigastric perforator (DIEP) flap is currently viewed as the gold standard in autologous breast reconstruction. We studied three-dimensional computed tomography angiography (CTA) in 145 patients undergoing free abdominal flap breast reconstruction to try to correlate deep inferior epigastric artery (DIEA) branching pattern with the type of flap performed and patient outcome. Today, reconstructive breast surgeons have become more experienced in raising DIEP flaps and operative times are becoming more acceptable. However, there remains significant interest in finding ways to aid this challenging dissection.

METHODS

We retrospectively evaluated consecutive patients between January 2007 and August 2008. CTAs were analysed using the Moon and Taylor (1988) classification of the DIEA branching pattern. Data gathered included pre-operative morbidity, type of abdominal wall free flap performed, length of operation, length of stay and complications.

RESULTS

Some 150 breast reconstructions were performed in 145 patients. There were 67 DIEP flaps, 69 MS-2 transverse rectus abdominis myocutaneous (TRAM) flaps and 14 MS-1 TRAM flaps (where MS-1 spares the lateral muscle and MS-2 spares both lateral and medial segments). Proportionally more DIEP flaps were performed in patients with a type 2 branching pattern. There was one flap loss (0.67%).

CONCLUSIONS

In this large CTA series, we found a type 1 (single artery) DIEA pattern most frequently, in contrast to the predominance of the type 2 bifurcating pattern observed previously. The higher proportion of DIEP flaps performed in the type 2 pattern patients is consistent with the documented shorter intramuscular course in this group. We have found CTA useful for faster selection of the best hemiabdomen for dissection and flap loss rates in our unit have reduced from 1.5% to 0.67%.

pFiD188, the linear virulence plasmid of Rhodococcus fascians D188

Rhodococcus fascians is currently the only phytopathogen of which the virulence genes occur on a linear plasmid. To get insight into the origin of this replicon and into the virulence strategy of this broad-spectrum phytopathogen, the sequence of the linear plasmid of strain D188, pFiD188, was determined. Analysis of the 198,917 bp revealed four syntenic regions with linear plasmids of R. erythropolis, R. jostii, and R. opacus, suggesting a common origin of these replicons. Mutational analysis of pFi_086 and pFi_102, similar to cutinases and type IV peptidases, respectively, showed that conserved region R2 was involved in plasmid dispersal and pointed toward a novel function for actinobacterial cutinases in conjugation. Additionally, pFiD188 had three regions that were unique for R. fascians. Functional analysis of the stk and nrp loci of regions U2 and U3, respectively, indicated that their role in symptom development was limited compared with that of the previously identified fas, att, and hyp virulence loci situated in region U1. Thus, pFiD188 is a typical rhodococcal linear plasmid with a composite structure that encodes core functions involved in plasmid maintenance and accessory functions, some possibly acquired through horizontal gene transfer, implicated in virulence and the interaction with the host.

Posttransplantation calcineurin inhibitor-induced hemolytic uremic syndrome: single-center experience

INTRODUCTION

Calcineurin inhibitor (CNI) induced HUS, although rare, can be a serious complication of renal transplantation. Classical syndrome of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury may not be fully manifested.

METHODS

We retrospectively analyzed our data in 950 kidney recipients under follow-up in our center (1994-2008). We reviewed the kidney biopsies performed for these patients to exclude conflicting diagnoses like antibody mediated rejection.

RESULTS

HUS was diagnosed in 12 patients (1.26%). None of them had HUS as the original kidney disease. Cyclosporine was the primary immunosuppression in 9 and tacrolimus in 3 patients. The median day of onset was 7 days. Manifestations were anemia (100%), thrombocytopenia (75%), elevated reticulocyte count (62.5%), fragmented red blood cells (8.3%), elevated lactate dehydrogenase (LDH) enzyme (83.3%), increased fibrin degradation product (FDP) (83.3%), reduced haptoglobin level (42.9%) and hyperbilirubinemia (25%). CNI elimination was the first step in the management. Transfusion of fresh frozen plasma (FFP) was used in 10 patients and plasma exchange with FFP in the other two. All grafts recovered function. Cyclosporine or tacrolimus were reintroduction in two patients after complete clinical and laboratory recovery. Both patients developed recurrence of HUS. While the former did not the latter did recover on further treatment of HUS.

CONCLUSION

Anemia, thrombocytopenia, elevated LDH and FDP are the most frequent manifestations of HUS. Early CNI elimination and fresh plasma transfusion can revert CNI induced HUS and save the graft. Reintroduction of CNI may be deleterious to the graft and should be avoided.

The Gram-positive side of plant-microbe interactions

Plant growth and development are significantly influenced by the presence and activity of microorganisms. To date, the best-studied plant-interacting microbes are Gram-negative bacteria, but many representatives of both the high and low G+C Gram-positives have excellent biocontrol, plant growth-promoting and bioremediation activities. Moreover, actinorhizal symbioses largely contribute to the global biological nitrogen fixation and many Gram-positive bacteria promote other types of symbioses in tripartite interactions. Finally, several prominent and devastating phytopathogens are Gram-positive. We summarize the present knowledge of the beneficial and detrimental interactions of Gram-positive bacteria with plants to underline the importance of this particular group of bacteria.

Follow up and evaluation of the Victorian first-trimester combined screening programme for Down syndrome and trisomy 18

OBJECTIVE

The objective of this study was to follow up and evaluate the statewide first-trimester combined screening programme for Down syndrome and trisomy 18 at Genetic Health Services Victoria, Australia.

DESIGN

Retrospective population cohort.

SETTING

Maternal Serum Screening Laboratory records.

SAMPLE

All women screened between February 2000 and June 2002 (16,153 pregnancies).

METHODS

Screening results were matched to Victorian perinatal and birth defect data via record linkage, with an ascertainment of 96.8% of pregnancy outcomes. Manual follow up with health professionals increased ascertainment to more than 99%.

MAIN OUTCOME MEASURES

Fetal Down syndrome or trisomy 18, and combined screen results, to calculate test characteristics.

RESULTS

Using a risk threshold of 1 in 300 at time of ultrasound, the sensitivities for standard first-trimester combined screening and augmented 13-week combined screening for Down syndrome were 87.3 and 90.5% and the false-positive rates (FPR) were 4.1 and 3.9%, respectively. The sensitivity for trisomy 18 was 66.7% (10/15, 95% CI 42.8-90.5%) with a 0.4% FPR and 15.2% positive predictive value (1 in 250 risk threshold).

CONCLUSIONS

The combined use of record linkage and manual follow-up techniques was effective in ascertaining more than 99% of pregnancy outcomes for calculations of accurate test characteristics of the combined screen. The sensitivity for Down syndrome at Genetic Health is comparable to similar populations. However, the sensitivity for trisomy 18 is lower than that elsewhere, which may reflect the overall low birth prevalence of trisomy 18 and associated small numbers in this particular cohort.

Markedly elevated neonatal immunoreactive trypsinogen levels in the absence of cystic fibrosis gene mutations is not an indication for further testing

AIMS

To investigate the immunoreactive trypsinogen (IRT) values above the usual 99th centile laboratory cut-off and determine the value of offering further testing to those infants with a markedly elevated IRT but no cystic fibrosis transmembrane regulator (CFTR) gene mutation identified by the screening programme.

METHODS

All babies born in Victoria, Australia, between 1991 and 2003, were screened by IRT followed by CF gene mutation analysis.

RESULTS

Of the 806,520 babies born, 9268 with the highest IRT levels had CFTR mutation analysis. There were 123 DeltaF508 homozygotes and 703 heterozygotes (86 with CF, 617 carriers). A total of 8442 babies had no CFTR gene mutation, of whom 18 (0.21%) had CF. The total number of CF babies with IRT greater than the laboratory cut-off was 227 (2.4%). The IRT results of the CF patients were distributed normally, with the majority above the laboratory cut-off of newborn IRT results. There was no evidence of an excess of babies with CF in the very highest levels of IRT above the 99th centile.

CONCLUSIONS

Only a small proportion of babies with a neonatal IRT >99th centile have CF. Additional CF testing for infants with an elevated IRT but no CFTR gene mutation has an extremely low yield, no matter how high the IRT result.

BK virus nephropathy in renal transplant recipients in Kuwait: a preliminary report

INTRODUCTION

BK virus nephropathy (BKVN) is a significant cause of graft loss among renal transplant recipients. The treatment outcomes of BKVN have been variably reported in the literature.

PATIENTS AND METHODS

We prospectively investigated BKV infection and BKVN among a population of renal transplant recipients with suspected BKV infection. The 42 subjects who all had acute allograft dysfunction, were categorized in three groups: those with clinical, laboratory, and histological findings that did not suggest acute rejection, drug toxicity, or obstruction (group 1, n = 24); those with findings that suggested probable acute cellular rejection but did not respond to antirejection treatment (group 2, n = 10); and those whose renal histology suggested BKVN (group 3, n = 8). Polymerase chain reaction analysis was done to detect BKV DNA in urine and blood samples from each subject. BKV DNA was detected in 19 (45%) urine samples with 11 of these subjects (26.1% of total) having BK viremia as well.

RESULTS

No evidence of BKVN was detected histologically in seven subjects with isolated BK viruria, while the others proved to be JC virus infections. Among the 11 subjects with BK viremia, eight had BKVN based on renal histology at the time of diagnosis with BKV infection, while the other three subsequently developed histological features of BKVN. BKVN developed after 5.3 +/- 2.5 (2 to 44) months after transplantation. The serum creatinine at time of BKVN diagnosis was 158.9 +/- 58 (87 to 285) micromol/L. All subjects were initially treated with a 50% reduction in immunosuppressive drug doses. Further decreases in immunosuppression were performed in all patients with close monitoring of renal function. All subjects were followed up for a of 18.2 +/- 5 (12 to 26) months. Two grafts were lost not due to BKVN, and one patient was lost to follow-up during this period. The latest serum creatinine in eight recipients is 113 + 20 (81 to 138) micromol/L, which is better than the renal function at diagnosis.

CONCLUSION

The prevalence of BKVN in suspected BKV infection was 26%. Although the study period was short (30 months), BK viremia strongly correlated with BKVN, which seemed to be successfully treated with reduction in immunosuppression.

The 'RITE' use of the Fricke flap in periorbital reconstruction

PURPOSE

To revisit an important but outmoded periorbital reconstructive technique. We present cases to illustrate the usefulness of the Fricke flap and describe a method of rapid intraoperative tissue expansion (RITE), which can enhance the applicability and effectiveness of the Fricke flap. A comparison between those cases performed with and without adjunctive RITE was not made due to the low numbers available.

METHODS

A retrospective review of clinical cases.

RESULTS

A total of 20 cases in which the Fricke flap was used for periorbital reconstruction were reviewed. The mean patient age was 64.7 years; the male-to-female ratio was 1:1. The patient follow-up ranged from 1 to 8 years with a mean of 4.2 years. The most common cause (65%) of periorbital defect was excision of eyelid malignancy. Necrosis of the terminal segment of the flap requiring further surgical intervention occurred in 10% (2/20). In both of these cases, the surgeons were trainees, with the complications being due to poor surgical technique. In the first case, the flap base was too narrow and in the second case, the distal end of the flap was thinned excessively. The functional result was excellent in 10/20 (50%), good in 5/20 (25%), fair in 3/20 (15%), and poor in 2/20 (10%). The cosmetic result was excellent in 3/20 (15%), good in 12/20 (60%), fair in 3/20 (15%), and poor in 2/20 (10%).

CONCLUSION

The Fricke flap is an important and, in selected cases, an indispensable technique in periorbital reconstruction.

A novel instrument to quantify the tension of upper and lower eyelids

An instrument was developed for the objective measurement of passive lid tension of the upper and lower eyelid. Eyelid tension is defined as the first derivative of the force over elongation function. Lid tension was determined by gripping the eyelid at the eyelashes and displacing the lid while measuring the force exerted by the eyelid. Two motorised spindles provided motion control of the gripper in anterior/posterior and nasal/temporal directions. Each axis was fitted with a sensitive force transducer to record the force while stretching and relaxing the eyelid. Motion control, data collection and data analysis were computer controlled, with various user-selectable options for measurement speed, direction and end-of-measurement conditions. Calibration of the instrument reduced the maximum error of the recorded forces to +/- 10 mN. Repeatability for on-eye measurements was verified by multiple measurements on the same eye under identical conditions. Preliminary results from a pilot study, investigating differences between Asian and Caucasian lid tension showed no statistically significant difference between the two groups.

Contribution of cytochrome P450 metabolites of arachidonic acid to hypertension and end-organ damage in spontaneously hypertensive rats treated with l-NAME

1 The purpose of this study was to examine the effect of inhibition of the formation of cytochrome P450 metabolites of arachidonic acid with 1-aminobenzotriazole (ABT) on the development of hypertension and end-organ damage in spontaneously hypertensive rats (SHR) chronically treated with nitric oxide synthesis inhibitor L-NAME (SHR-L-NAME). 2 Administration of L-NAME in drinking water (80 mg l(-1)) to SHR for 3 weeks significantly elevated mean arterial blood pressure (MABP) (223 +/- 4 mmHg) as compared to SHR controls drinking regular water (165 +/- 3 mmHg). The administration of ABT (50 mg kg(-1) i.p. alt diem) for 6 days significantly attenuated elevation of blood pressure in SHR-L-NAME (204 +/- 4 mmHg). 3 L-NAME-induced increase in urine volume and protein was significantly lower in ABT-treated animals. 4 The impaired vascular responsiveness to noradrenaline and isoprenaline in the perfused mesenteric vascular bed of SHR-L-NAME-treated animals was significantly improved by ABT treatment. 5 Morphological studies of the kidneys and hearts showed that treatment with ABT minimized the extensive arterial fibrinoid necrosis, arterial thrombosis, significant narrowing of arterial lumen with marked arterial hyperplastic arterial changes that were observed in vehicle treated SHR-L-NAME. 6 In isolated perfused hearts, recovery of left ventricular function from 40 min of global ischaemia was significantly better in ABT-treated SHR-L-NAME. 7 These results suggest that in hypertensive individuals with endothelial dysfunction and chronic NO deficiency, inhibitors of 20-HETE synthesis may be able to attenuate development of high blood pressure and end-organ damage.

Strongyloidiasis: challenges in diagnosis and management in non-endemic Kuwait

Among immunocompromised individuals, hyper-infection with Strongyloides stercoralis may occur and lead to fatal strongyloidiasis. To clinicians and laboratory diagnosticians in non-endemic countries such as Kuwait, this severe infection poses a particular problem. The clinical histories and signs and symptoms of four Kuwaiti cases of S. stercoralis hyper-infection were reviewed. Each of the four was found not only to have lived in an area where S. stercoralis was endemic but also to have been treated with immunosuppressive steroids (for medical problems unrelated to the nematode infection). When they presented with undiagnosed hyper-infections their clinical features were confusing. Three of the cases, all with low eosinophil counts, died but the other, who was treated with thiabendazole, survived. In the light of these observations, healthy medical examinees who had recently moved from endemic zones were checked for asymptomatic S. stercoralis infection, both by stool examination and ELISA-based serology. Of 381 stool samples investigated over a 3-month period, 183 (48%) were found positive for helminths, 7% for S. stercoralis. Of 198 individuals from endemic zones who were screened after another medical examination, 71 (35.8%) were found positive for intestinal helminth parasites, including one (1.45%) infected with S. stercoralis. Although ELISA appear reliable in making a presumptive diagnosis of strongylodiasis, the results of such assays are not very specific and are best interpreted in conjunction with the patient's clinical status. The concurrent administration of anthelminthics to patients prescribed steroids who, because they live or have lived in an area where S. stercoralis is endemic, are at risk of infection with the nematode, should be considered.

Delta-F508 cystic fibrosis mutation is not linked to intussusception: implications for rotavirus vaccine

OBJECTIVE

To determine whether the cystic fibrosis (CF) delta-F508 gene mutation predisposes to intussusception, and so selects infants who should not receive rotavirus vaccine.

METHODS

Stored neonatal screening blood spots, retrieved from 81 infants with intussusception and from 79 controls, were tested for the presence of the CF delta-F508 gene mutation.

RESULTS

Prevalence of the mutation was similar in blood specimens from intussusception patients and from controls.

CONCLUSION

Testing for the CF delta-F508 mutation at birth is unlikely to identify infants predisposed to intussusception, and therefore is not relevant to rotavirus vaccine programs.

High serum prostate-specific antigen levels in the absence of prostate cancer in Middle-Eastern men: the clinician's dilemma

OBJECTIVE

To investigate the common causes of total serum prostate-specific antigen (PSA) values of> 10 ng/mL in an Arab population, as in the USA and Europe the risk of prostate cancer is considered high in men with such PSA levels.

PATIENTS AND METHODS

Serum total PSA was measured in men presenting to our hospital as part of the investigation for prostate cancer screening and/or in elderly men with prostatism. Men with a serum PSA level of> 10 ng/mL were further investigated by transrectal ultrasonography (TRUS) of the prostate and biopsy of suspicious lesions for histological diagnosis. In addition, the percentage of free PSA, PSA velocity and PSA density were determined. All the patients included in this study were men of Arab origin residing in Kuwait.

RESULTS

In all, 1700 men (mean age 55.6 years, range 35-94) were assessed; of these, 161 had a serum PSA of> 10 ng/mL, attributable to benign prostatic hyperplasia (BPH) in 110 (68%), BPH with histological features of prostatitis in 33 (21%) and prostate cancer in 18 (11%). TRUS of the prostate in 143 of the 161 men with either BPH or BPH with prostatitis showed varying grades of intraprostatic calcifications in 22 (15%). Both PSA density and percentage free PSA did not contribute to determining the causes of total PSA levels of> 10 ng/mL. There was a progressive decline in PSA in all patients with BPH and prostatitis, except one who at re-biopsy had prostate cancer (T1N0M0, G1).

CONCLUSION

Total PSA values of> 10 ng/mL in Arab men may be a result of BPH, BPH with prostatitis or prostate cancer, in that order. A gradual decline in total PSA (decreased PSA velocity) with time to < 4 ng/mL often confirms the diagnosis of BPH with prostatitis. The percentage of free PSA and PSA density may not be helpful in diagnosing prostate cancer with certainty in these patients. Compared with Caucasians in the USA and Europe, BPH and BPH with prostatitis appear to be more frequent causes of serum PSA levels of> 10 ng/mL in Arab men.

Catheter angiography and angioplasty in patients with scleroderma

The objectives of this study were (i) to identify patterns of angiographic disease in scleroderma patients with and without other vascular risk factors and (ii) to define patients with scleroderma in whom angiography and angioplasty is useful. The records of 26 patients with scleroderma who underwent angiography and angioplasty over an 8-year period were reviewed. Angiographic disease patterns were assessed using a modified Brewster classification. Angiography of the upper limb demonstrated distal disease alone in 86% of patients, both with and without other vascular risk factors such as smoking. In the lower limb there was a highly significant association between the presence of other vascular risk factors and macrovascular disease potentially amenable to angioplasty, and conversely between the absence of other vascular risk factors and distal disease in the lower limb. Good early but poor late clinical results were achieved in three of five patients who underwent angioplasty. Angiography of the upper limb is likely to demonstrate distal disease alone, and angiography and angioplasty of the lower limb may be useful only if other vascular risk factors are present.

Newborn screening for congenital hypothyroidism, Victoria, Australia, 1977-1997. Part 2: Treatment, progress and outcome

A controlled longitudinal prospective study is reported of physical and neuropsychological progress up to 12 years in 152 children with congenital hypothyroidism (CH), detected by newborn screening in the Australian state of Victoria and born between the onset of screening in mid-1977 and December 1988. Linear growth of the CH children was normal. Throughout they were slightly heavier and the median head circumference was slightly larger compared with reference data. Those with thyroid aplasia required a marginally larger dose of thyroxine to achieve euthyroidism. Assessment of cognitive outcome in the children with permanent primary CH revealed the mean scores at 2, 5 and 8 years to be from 8.5 (p<0.001) to 10.2 (p<0.001) points lower than in a group of 60 euthyroid controls. However, there was large overlap and, of the affected children, only 10.1% at 2 years, 3.9% at 5 years and 6.8% at 8 years fell more than 2 SD below the means of the euthyroid controls. On univariate analysis, variables shown to have significant correlation with cognitive outcome at 8 years in the CH children were newborn activity, baseline TT4 and FTI, initial T4 dosage, socio-economic classification, maternal age, maternal education and presence of a serious accompanying disorder. On multiple regression analysis, significant variables were baseline bone age, maternal age and education, and presence of a serious accompanying disorder. No single thyroidal or extra-thyroidal variable could be identified to account for the discrepancy between the children with CH and the controls.

Newborn screening for congenital hypothyroidism, Victoria, Australia, 1977-1997. Part 1: The screening programme, demography, baseline perinatal data and diagnostic classification

Clinical, demographic and laboratory data from infants with congenital hypothyroidism (CH) born in the Australian state of Victoria from the commencement of neonatal screening in mid-1977 until December 1988 are reported. These provide a baseline for a 12-year prospective longitudinal study on physical and neuro-psychological outcome until mid-1997, the subject of a second paper. Infants with CH were detected using a primary TT4 screening test. Demographic data were collected prospectively using a clinical assessment protocol. Nearly all affected infants underwent 99mTc pertechnetate scanning at the initial assessment to determine the underlying aetiology of their hypothyroidism. 704,723 infants were screened and 199 with permanent primary hypothyroidism (one in 3,541) were identified. The most common aetiologies were thyroid ectopia (46%), thyroid aplasia (33%), and 'dyshormonogenesis' (11%). The clinical abnormalities classically described in CH were more evident in infants with aplasia, and the striking female preponderance in infants with thyroid dysplasia (syn. dysgenesis) was confirmed. Other features included increased frequencies of 'dyshormonogenesis' in infants of parents of Middle-Eastern origin and of labour induction in infants with dysplasia. A closed posterior fontanelle was not found in any infant with thyroid aplasia.

Comparison of adipose tissue changes following administration of rosiglitazone in the dog and rat

Rosiglitazone (BRL-49653-C), a thiazolidinedione, is a potent agonist for the nuclear hormone receptor peroxisome proliferator-activated receptor gamma (PPARgamma). Thiazolidinediones have been reported to induce adipocyte differentiation in vitro and there is limited data on their effects in vivo. The objective of this study was to compare the effects of rosiglitazone on adipocyte differentiation between dogs and rats. Morphological (light and ultrastructural) and morphometric evaluations were conducted on perirenal adipose tissue from dogs that have been treated for 1 month with 0.4, 5, 60 mg/kg/day and rats treated for the same period with 80 mg/kg/day. There was a dose-related change in the phenotype of white adipose tissue in dogs, reflected by an increase in nuclear numerical density (up to threefold) and cytoplasmic area fraction (up to 2.1-fold). In addition, there was an enlargement of the nuclei and a reduction in the size of the white adipocyte lipid vacuoles. Ultrastructural changes included an increase in the number of mitochondria per adipocyte. In the rat, similar changes were seen in nuclear numerical density (1.5-fold increase) and cytoplasmic area fraction (2.2-fold increase). There were also increased numbers of mitochondria per cell in white adipocytes giving them similar numbers of mitochondria to brown adipocytes. In the brown adipocytes, there was a reduction in cytoplasmic area fraction with a corresponding increase in the size of the lipid filled vacuoles in other words there was a converging of the phenotypes of the white and brown adipose tissues.

Fine needle aspiration biopsy of azoospermic testes. Could it replace histologic biopsy?

OBJECTIVE

To evaluate the possibility of replacing histologic biopsy of azoospermic testes by fine needle aspiration (FNA) for diagnostic and management purposes.

STUDY DESIGN

Twenty-seven patients were examined under general anesthesia, and 53 testes were biopsied by FNA. Fifty-four testes were biopsied for histologic examination. Histology and cytology of each testis were compared to assess the discrepancy or concordance between the diagnoses.

RESULTS

Twenty-seven testes showed complete concordance of cytology and histology, and 13 testes showed a mild degree of discrepancy. A severe degree of discrepancy was seen in 13 testes. In the majority of discrepant cases, FNA biopsy diagnosis was more sensitive in detecting evidence of full or advanced maturation. In one case of discrepancy, the histologic finding was Sertoli cells only, and cytology revealed focal full maturation. In vitro fertilization using sperm from this case was successful.

CONCLUSION

FNA biopsy of testes in azoospermia is a fast, reliable and minimally traumatic method. The prospects for utilizing FNA biopsy material in assisted and microassisted fertilization are promising.

Newborn screening for cystic fibrosis in Victoria: 10 years' experience (1989-1998)

OBJECTIVE

To review the effectiveness of statewide newborn screening for cystic fibrosis (CF) in Victoria over the first 10 years of the program (1989-1998).

DESIGN

Population study involving screening of newborns by immunoreactive trypsinogen (IRT) testing on Day 3-5, followed by either repeat IRT testing (1989-1990) or delta F508 mutation analysis (1991-1998).

PATIENTS AND SETTING

All babies screened for CF in a newborn screening program in Victoria in 1989-1998.

MAIN OUTCOME MEASURE

The diagnosis of CF.

RESULTS

Of 635,157 babies born in Victoria in the 10 years, 191 were diagnosed with CF. A further 30 cases were detected antenatally, giving an incidence of 1/2874 (95% CI, 1/2519-1/3294). CF was detected early in 182 babies (95.3% of affected babies in the screened cohort)--136 by screening, 35 because they had meconium ileus, and 11 because they were siblings of older children with CF. Nine cases of CF were missed by screening. Of these nine babies, four did not have an elevated neonatal IRT level, one had a normal IRT level at repeat testing at 4-6 weeks (1989-1990), three did not have a delta F508 mutation (1991-1998), and one had a false negative sweat test result. Six of the nine missed babies (67%) were diagnosed within four months of birth.

CONCLUSION

Newborn screening for CF in Victoria has proven effective in detecting most babies with CF in the newborn period. However, a sweat test should be requested when the clinical features suggest the diagnosis of CF, even if the child has been screened.

Thymic size and lymphocyte restoration in patients with human immunodeficiency virus infection after 48 weeks of zidovudine, lamivudine, and ritonavir therapy

Human immunodeficiency virus (HIV) infection is associated with progressive loss of circulating CD4+ lymphocytes. Treatment with highly active antiretroviral therapy (HAART) has led to increases in CD4+ T lymphocytes of naive (CD45RA+62L+) and memory (CD45R0+RA-) phenotypes. Thymic computerized tomography scans were obtained on 30 individuals with HIV disease to investigate the role of the thymus in cellular restoration after 48 weeks of HAART. Individuals with abundant thymic tissue had higher naive CD4+ T lymphocyte counts at weeks 2-24 after therapy than individuals with minimal thymic tissue. Individuals with abundant thymic tissue had significantly larger increases in naive CD4+ cells during the first 4 weeks of therapy. These individuals were also more likely to experience viral rebound despite comparable initial declines in plasma HIV-1 RNA. These findings suggest that there is a complex relationship among the thymus, viral replication, and lymphocyte restoration after application of HAART in HIV disease.

Acquired subglottic cysts in the low birth weight, pre-term infant

Although subglottic cysts have previously been reported as a cause of airway obstruction in the neonate, they have previously been considered to be a relatively rare cause. Cystic narrowing of the subglottis has been associated with endotracheal intubation. With improving survival of pre-term infants the incidence of the condition could be expected to rise. Prior to 1996, only 58 cases had been reported in the literature. We believe that the true incidence of the condition has been considerably under-reported. Over a six-month period our unit diagnosed five cases of compressible cysts in the subglottis in low birth weight, pre-term infants. All patients underwent diagnostic microlaryngobronchoscopy and vaporization of the cysts by CO2 laser. Three children required more than one procedure. In all cases a satisfactory airway was achieved. The pathogenesis, diagnosis and treatment of the condition is discussed.

The impact of newborn screening on cystic fibrosis testing in Victoria, Australia

Newborn screening for cystic fibrosis (CF) by examining the levels of immunoreactive trypsinogen was introduced in Victoria in 1989. This was modified by the addition of testing for the common CF gene mutation, delta F508, in 1990. Problems with the first newborn screening protocol were overcome with the addition of the DNA test as there was no need to contact the majority of families, there was a reduced number of sweat tests, and less anxiety was experienced by parents. The mode of diagnosis changed from failure to thrive, steatorrhoea, rectal prolapse, and family history to diagnosis through newborn screening. Newborn screening dramatically reduced the time of diagnosis of CF to approximately six weeks or less in the majority of cases. Since the introduction of newborn screening, the uptake of prenatal diagnosis in CF families has increased two and a quarter fold.

CT-SPECT fusion plus conjugate views for determining dosimetry in iodine-131-monoclonal antibody therapy of lymphoma patients

A method for performing 131I quantitative SPECT imaging is described which uses the superimposition of markers placed on the skin to accomplish fusion of computed tomography (CT) and SPECT image sets.

METHODS

To calculate mean absorbed dose after administration of one of two 131I-labeled monoclonal antibodies (Mabs), the shape of the time-activity curve is measured by daily diagnostic conjugate views, the y-axis of that curve is normalized by a quantitative SPECT measurement (usually intra-therapy), and the tumor mass is deduced from a concurrent CT volume measurement. The method is applied to six B-cell non-Hodgkin's lymphoma patients.

RESULTS

For four tumors in three patients treated with the MB1 Mab, a correlation appears to be present between resulting mean absorbed dose and disease response. Including all dosimetric estimates for both antibodies, the range for the specific absorbed dose is within that found by others in treating B-cell lymphoma patients. Excluding a retreated anti-B1 patient, the tumor-specific absorbed dose during anti-B1 therapy is from 1.4 to 1.7 mGy/MBq. For the one anti-B1 patient, where quantitative SPECT and conjugate-view imaging was carried out back to back, the quantitative SPECT-measured activity was somewhat less for the spleen and much less for the tumor than that from conjugate views.

CONCLUSION

The quantitative SPECT plus conjugate views method may be of general utility for macro-dosimetry of 131I therapies.

Cystic hydatid disease: pitfalls in diagnosis in the Middle East endemic area

Ultrasound (US) and computerized tomography (CT) have made a significant contribution to accurately localizing focal lesions. Such imaging techniques have been found useful in assessing a hydatid aetiology of cystic lesions. However, we present 23 cases which demonstrate that these modalities in isolation are not adequate in diagnosing hydatid cysts, as claimed from this geographic area. Simple, congenital, choledochal and pancreatic pseudocysts were cystic lesions misinterpreted as hydatid cysts, as were infective disorders such as amoebiasis and tuberculosis. The appearance of a lipoma and an ovarian intra-abdominal cystadenoma and an intra-hepatic haematoma were among other conditions that were labelled as hydatid cysts on US/CT. However, in all the cyst/mass lesions that were misdiagnosed, counter-immunoelectrophoresis (CIEP), with an antigen that elicits an arc-5 in immunoelectrophoresis on cellulose acetate membranes as a substrate, did not detect any anti-Echinococcus antibodies in patients' sera. This was in contrast to the classic indirect haemagglutination test which was equivocal in some cases. The CIEP was specific and excluded hydatidosis though such a diagnosis was ventured on US and/or CT. We therefore conclude that a specific and sensitive serological test is mandatory for confirming a preoperative diagnosis of CHD. When surgery is not immediate, a negative serological test such as the CIEP would in addition indicate US or CT-guided aspiration of cyst fluid for cytological evaluation and/or enzyme immunoassay, thereby avoiding the cost and morbidity of laparotomy. Furthermore, chemotherapy is now a viable alternative provided the diagnosis is unequivocal. This may be a prudent protocol before a further decision on management is envisaged.