Limitations of Multigene Next-Generation Sequencing Panel for "Cerebral Palsy" Phenotype and Other Complex Movement Disorders

In the past couple of decades, literature in pediatric neurology and clinical genetics has identified hundreds of monogenic disorders that can masquerade as infantile cerebral palsy (CP). Accurate and prompt diagnosis in such cases may be challenging due to several reasons. There are commercial multigene CP panels, but their diagnostic yield is often limited compared with exome sequencing because of diverse etiologies that may mimic CP. We report one such case where a patient with spastic hemiplegia underwent a long diagnostic journey before genetic diagnosis was established with exome sequencing and appropriate management was started. TTC19-related mitochondrial complex III deficiency is an ultrarare disorder of energy metabolism that presents with bilateral lesions in the basal ganglia and a degenerative neuropsychiatric phenotype.

AB1089 PSYCHOSOCIAL IMPACTS OF THE COVID-19 PANDEMIC ON ETHIOPIAN AND CANADIAN RHEUMATOLOGY PATIENTS

Background

The Coronavirus-2019 (COVID-19) pandemic increased psychosocial distress in the general population and in patients with rheumatic disease. Limited data exists on the impact of COVID-19 in rheumatology patients living in Africa.

Objectives

To describe COVID-19 related illness and psychosocial impact in Ethiopian (ET) rheumatology patients attending the only public rheumatology clinic in Ethiopia (Tikur Anbessa Specialized Hospital (TAH) in Addis Ababa). To compare findings in ET with findings in Canadian (CA) rheumatology patients.

Methods

Between May 1 and Oct 31 2021, 130 patients attending the TAH rheumatology clinic answered questions related to COVID-19 infection, symptoms and testing, and psychosocial impacts of the COVID-19 pandemic. We assessed depression (Patient Health Questionnaire- 9), anxiety (General Anxiety Disorder-7; GAD7), COVID-19 stress factors and coping measures, Resilience (Brief Resilience Scale-BRS) and medication compliance (Morisky medication adherence scale – 4 item; MAS4). Rheumatic disease severity was assessed with the Routine Assessment of Patient Index Data-3 (RAPID-3). Questionnaires were translated to Amharic. Descriptive statistics are reported [mean (standard deviation), median (25%, 75%) number and percent.)] and compared to data of 97 CA patients with rheumatoid arthritis (RA) and lupus patients from Quebec1.

Results

ET patients were mainly female (71%) with a mean (SD) age of 47 (16), and resided in the capital city (Addis Ababa) (72%). Half had RA or lupus. A quarter of patients had moderate to severe rheumatic disease severity desite good medication adherence [MAS4 score of 3(2,4)]. Most (89%) reported no COVID-19 symptoms since the beginning of the pandemic, were not tested for COVID-19 and reported few risk factors for COVID-19 exposure. Eight (6%) ETs were diagnosed with COVID-19; 2 required hospitalization. Diagnosed patients reported a median of 2 COVID-19 symptoms (range 0-8; mainly cough, fever and malaise). Within the entire cohort, depression (PHQ9= 10 or above) and anxiety (GAD7=10 or above) were more frequent in ETs than CAs (depression 30% vs 3%; anxiety 16% vs 1%) yet nearly half (47%) of ETs had normal or high resilience levels. The most common COVID-19 stressors were risk of contracting COVID illness personally [ETs vs CAs risk ratio(95% confidence limits- CL); 0.67 (0.5, 0.99)] or of loved one [0.56 (0.36, 0.86)]. More ETs reported COVID-19 related stress related to difficulty obtaining food, medicine or other essentials [1.74, (1.00-3.0)], and getting needed supports [1.97 (1.03, 3.77)] (Table 1). CAs and ETs used similar levels of problem solving [median (25%,75%) CA 3.3 (2.8, 3.3), ET 3.5 (3.0, 3.7)] and emotion-focus [CA 2.5 (2.2, 3.1); ET 3.3 (2.8, 3.7)] coping strategies.

Table 1.

COVID-19 related stressors reported by Ethiopian and Canadian rheumatology patients

Common stressors from the coronavirus pandemic reported as severe †ET % reportedCA % reportedRR (95% CI) ET vs CAGetting sick28410.67 (0.5, 0.99)Having a loved one who becomes ill23410.56 (0.36, 0.86)Difficulty getting food, medicine and other essentials29161.74 (1.0-3.0)Difficulty getting support or help24121.97 (1.03-3.77)Postponement or cancellation of tests8200.42 (0.18, 0.95)Losing a job or experiencing a drop in income19100.185 (0.90, 3.81)Having more responsibilities at home21201.06 (0.59, 1.87)Having to work in a place likely to expose you to the coronavirus20270.73 (0.42, 1.24)Postponement or cancellation of medical visits19151.2 (0.63, 2.28)Changes in treatments7150.43 (0.17, 1.06)

†Severe stress = score 2 (moderately) to 5 (extremely)

Conclusion

During the COVID-19 pandemic, depression was more common in ETs compared to CAs with rheumatic disease. COVID-19-related stressors due to insecurity in obtaining the basic essentials and support were more pronounced in ETs. Differences between ETs and CA in these stressors may reflect local public health and economic supports. There were no differences in coping strategies.

References

[1]DaCosta et al presented at 21stCentury Lupus Conference, Sept. 2021

Acknowledgements

Study supported by the Global Rheumatology Alliance-International League of Associations for Rheumatology “ COVID-19 illness in Ethiopian rheumatology patients” and the Arthritis Society: “The impact of antimalarial drugs in arthritis patients exposed to SARS-CoV-2-the CoVIRAL project. The Arthritis Society. COVID-20-001.”

Disclosure of Interests

None declared

Variants in GNAI1 cause a syndrome associated with variable features including developmental delay, seizures, and hypotonia

PURPOSE

Neurodevelopmental disorders (NDDs) encompass a spectrum of genetically heterogeneous disorders with features that commonly include developmental delay, intellectual disability, and autism spectrum disorders. We sought to delineate the molecular and phenotypic spectrum of a novel neurodevelopmental disorder caused by variants in the GNAI1 gene.

METHODS

Through large cohort trio-based exome sequencing and international data-sharing, we identified 24 unrelated individuals with NDD phenotypes and a variant in GNAI1, which encodes the inhibitory Gαi1 subunit of heterotrimeric G-proteins. We collected detailed genotype and phenotype information for each affected individual.

RESULTS

We identified 16 unique variants in GNAI1 in 24 affected individuals; 23 occurred de novo and 1 was inherited from a mosaic parent. Most affected individuals have a severe neurodevelopmental disorder. Core features include global developmental delay, intellectual disability, hypotonia, and epilepsy.

CONCLUSION

This collaboration establishes GNAI1 variants as a cause of NDDs. GNAI1-related NDD is most often characterized by severe to profound delays, hypotonia, epilepsy that ranges from self-limiting to intractable, behavior problems, and variable mild dysmorphic features.

FRI0064 SAFETY OF LOW DOSE METHOTREXATE (MTX) AND TUBERCULOSIS (TB)

Background:

Increased awareness of the importance of MTX in rheumatic disease is leading to more MTX use in patients from TB-endemic areas. Current management guidelines for rheumatic disease address TB in the context of biologics but not MTX use.

Objectives:

To systematically review the published literature on TB rates with MTX ≤30 mg per week.

Methods:

We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘tuberculosis’. We also searched citations from review articles. Titles, abstracts or full manuscripts of the 4707 reports identified were screened independently by 2 reviewers to identify studies reporting TB in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on TB incidence (new TB diagnosis vs reactivation of latent TB), and outcomes (pulmonary, dissemination, death) and safety of isoniazid, INH. Descriptive summaries are presented on studies providing outcomes in patients taking MTX ≤30 mg per week.

Results:

After removing duplicates and studies not meeting criteria or providing sufficient information, 31 studies were included (8 cohort, 7 case-control, 1 clinical trial, 15 case reports/case series). Only 27% of articles reported data from low to moderate human development index countries. Studies were of moderate quality. Seven case control studies were heterogeneous but most demonstrated a modest increased risk of TB with MTX (Table). Five cohort studies reported TB incidence rates in rheumatic disease (treated with MTX +/- biologics) ranging from 102-367.9/100,000 patient-years. These rates were generally higher than comparator general population rates. Two cohort studies of MTX in RA (without biologic) reported cumulative TB incidence in Maldova (12 TB cases in 44 RA patients, 27%) and in China (9/114, 7.9%). Other cohort studies generated rates of overt infection (143/100,000 patient years in Spain, higher if co-prescribed with corticosteroids and other immunosuppressants in South Africa), and latent TB rates detection (16/922 RA screened, 1.7%, in Canada). When reported, rates of extra-pulmonary TB were higher than comparator general population rates. One clinical trial (China), 2 cohorts (Japan, USA) and 2 case-series (Belgium, USA) evaluated safety of INH and MTX. Isoniazid-related hepatotoxicity and neutropenia were generally more common when taken with MTX, but were usually reversible.

Conclusion:

Despite a paucity of high-quality data, this review confirms that TB screening and clinical surveillance are needed in patients from TB-endemic areas who are prescribed MTX, particularly with co-administration of corticosteroids or other immunosuppressants. Isoniazid, if monitored, appears safe and prevents TB reactivation.

References:

Table .

Case control studies

Region (Year)DiagnosisTB with MTXTB without MTXOdds RatioMexico(1999)Mixed (4 RA)1/65/752.76Japan(2004)RA3/4717/1540.56Canada(2009)RA29/48321/10463.12Brazil(2010)Lupus2/31/57112Taiwan(2012)Psoriasis33/144464/23411.2Taiwan(2015)JIA4/3574/10262.90South Africa (2017)RA0/1340/18NA

JIA=juvenile idiopathic arthritis

Acknowledgments:

Funded by the International League Against Rheumatism and McGill University Global Health Scholar Awards

Disclosure of Interests:

Anna Davidson: None declared, Alize Gunay: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Rosie Scuccimarri: None declared, Yewondwossen Mengistu: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

SAT0078 SAFETY OF LOW DOSE METHOTREXATE (MTX) IN HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION

Background:

Increased awareness of the efficacy of MTX in rheumatic disease is leading to more MTX use in patients from HIV endemic areas. While HIV related immunosuppression may contribute to improvement of some rheumatic diseases, immune reconstitution from highly active antiretroviral therapy (HAART) may lead to exacerbation or presentation of autoimmune disorders for which MTX therapy may be warranted. Most management guidelines for rheumatic disease do not address MTX use in the context of HIV.

Objectives:

To systematically review the published literature on the safety of using MTX ≤30 mg per week in HIV.

Methods:

We searched CINAHL, Embase, Global, MEDLINE and World of Science databases (Jan 1990 to May 2018) for terms including ‘methotrexate’ and ‘human immunodeficiency virus’. We also searched citations from review articles. Titles, abstracts or full manuscripts were screened independently by 2 reviewers to identify studies reporting HIV in patients taking MTX. Study quality was assessed using the McGill Mixed Methods Appraisal Tool (MMAT). Data was extracted on MTX and HIV adverse events (MTX toxicity, HIV viral load, CD4 count). Descriptive summaries are presented for studies providing outcomes in patients taking MTX ≤30 mg per week.

Results:

After removing duplicates and studies not meeting criteria or not providing sufficient information, 42 of the 2714 identified reports were included (1 clinical trial, 2 cohort, 1 cross-sectional study, 38 case reports/case series). Most reports (81%) originated from USA or Europe. Study quality was generally good with most studies fulfilling 50-100% of MMAT criteria. The randomized controlled trial (USA) assessing MTX on atherosclerotic disease in HIV showed that adverse events were more common in MTX versus placebo (12.8% vs 5.6%, p non-inferiority <0.05) and included infection, transient CD4 and CD8 drop, pulmonary toxicity, and death (1 attributed to MTX/HIV, 1 unrelated). One cohort study (South Africa) reported 43 RA patients on MTX who acquired HIV. In this cohort, RA generally improved despite only 5 individuals continuing MTX. No data on MTX adverse event rates was reported. One cohort study (USA) reported 13 HIV patients with myositis. One received MTX (with other immunosuppression) without MTX adverse effects but died due to AIDS. A cross-sectional study (France) of 43 HIV pts with autoimmune disease reported one patient on MTX (and other immunosuppression) developed an adverse event (cytopenia) compared to 5/33 patients not on MTX (cytopenia). The 38 case reports/series described 54 individuals with HIV receiving MTX. Of these studies, 27 (describing 42 subjects) reported on MTX adverse events and 35 (describing 46 subjects) reported on HIV adverse events. MTX adverse events developed in 29 subjects (hematologic 13, renal/hepatic 1, opportunistic infections 10, other events 2). HIV adverse events were noted in 23 subjects (Kaposi’s sarcoma 4, CD4 decrease 16, HIV viral titer increase 4). Five deaths were reported (2 infection, 1 infection and wasting, 2 HIV related deaths). Most subjects also received corticosteroids or other immunosuppressants including biologics.

Conclusion:

There remains limited data on the safety of low dose MTX in HIV. Surveillance for HIV is warranted for individuals on MTX who are at risk for acquiring HIV. Caution and careful monitoring for MTX toxicity, opportunistic infections and HIV state is suggested if MTX is used in the setting of HIV particularly if combined with other immunosuppression.

References:

[1] Clin Infectious Disease 2019:68

[2] J Rheumatology 2014:41

[3] Arthritis and Rheumatism 2003:49

[4] Medicine 2017:96

Acknowledgments :

Funding from International League Against Rheumatism

McGill University Global Health Scholar Awards

Disclosure of Interests:

Alize Gunay: None declared, Anna Davidson: None declared, Ines Colmegna: None declared, Diane Lacaille: None declared, Hal Loewen: None declared, Michele Meltzer: None declared, Yewondwossen Mengistu: None declared, Rosie Scuccimarri: None declared, Zenebe Yirsaw: None declared, Sasha Bernatsky: None declared, Carol Hitchon Grant/research support from: UCB Canada; Pfizer Canada

Carbon monoxide from neighbouring restaurants: the need for an integrated multi-agency response

BACKGROUND

Carbon monoxide (CO) is a colourless, odourless toxic gas produced during incomplete combustion of carbon-based fuels. Most CO incidents reported to the UK Health Protection Agency (HPA) are due to faulty gas appliances, and legislation exists to ensure gas appliances are properly installed.

METHODS

We present three CO poisoning incidents of unusual origin reported to the HPA. In each, residents living above restaurants were poisoned after workers left charcoal smouldering overnight in specialist or traditional ovens whilst ventilation systems were turned off. This led to production of CO, which travelled through floorboards and built up to dangerous concentrations in the flats.

RESULTS

Working with local authorities, these incidents were investigated and resolved, and work was conducted to prevent further occurrences.

CONCLUSIONS

The novel nature of these CO incidents led to delays in recognition and subsequent remedial action. Although previously undescribed, it is likely that due to the number of residences built above restaurants and the rising popularity of traditional cooking methods, similar incidents may be occurring and could increase in frequency. Multi-agency response and reporting mechanisms could be strengthened. Awareness raising in professional groups and the public on the importance of correct ventilation of such appliances is vital.

Abnormal cone structure in foveal schisis cavities in X-linked retinoschisis from mutations in exon 6 of the RS1 gene

PURPOSE

To evaluate macular cone structure in patients with X-linked retinoschisis (XLRS) caused by mutations in exon 6 of the RS1 gene.

METHODS

High-resolution macular images were obtained with adaptive optics scanning laser ophthalmoscopy (AOSLO) and spectral domain optical coherence tomography (SD-OCT) in two patients with XLRS and 27 age-similar healthy subjects. Retinal structure was correlated with best-corrected visual acuity, kinetic and static perimetry, fundus-guided microperimetry, full-field electroretinography (ERG), and multifocal ERG. The six coding exons and the flanking intronic regions of the RS1 gene were sequenced in each patient.

RESULTS

Two unrelated males, ages 14 and 29, with visual acuity ranging from 20/32 to 20/63, had macular schisis with small relative central scotomas in each eye. The mixed scotopic ERG b-wave was reduced more than the a-wave. SD-OCT showed schisis cavities in the outer and inner nuclear and plexiform layers. Cone spacing was increased within the largest foveal schisis cavities but was normal elsewhere. In each patient, a mutation in exon 6 of the RS1 gene was identified and was predicted to change the amino acid sequence in the discoidin domain of the retinoschisin protein.

CONCLUSIONS

AOSLO images of two patients with molecularly characterized XLRS revealed increased cone spacing and abnormal packing in the macula of each patient, but cone coverage and function were near normal outside the central foveal schisis cavities. Although cone density is reduced, the preservation of wave-guiding cones at the fovea and eccentric macular regions has prognostic and therapeutic implications for XLRS patients with foveal schisis. (Clinical Trials.gov number, NCT00254605.).

Molecular testing for hereditary retinal disease as part of clinical care

OBJECTIVE

To describe clinical molecular testing for hereditary retinal degenerations, highlighting results, interpretation, and patient education.

METHODS

Mutation analysis of 8 retinal genes was performed by dideoxy sequencing. Pretest and posttest genetic counseling was offered to patients. The laboratory report listed results and provided individualized interpretation.

RESULTS

A total of 350 tests were performed. The molecular basis of disease was determined in 133 of 266 diagnostic tests; the disease-causing mutations were not identified in the remaining 133 diagnostic tests. Predictive and carrier tests were requested for 9 and 75 nonsymptomatic patients with known familial mutations, respectively.

CONCLUSIONS

Molecular testing can confirm a clinical diagnosis, identify carrier status, and confirm or rule out the presence of a familial mutation in nonsymptomatic at-risk relatives. Because causative mutations cannot be identified in all patients with retinal diseases, it is essential that patients are counseled before testing regarding the benefits and limitations of this emerging diagnostic tool.

CLINICAL RELEVANCE

The molecular definition of the genetic basis of disease provides a unique adjunct to the clinical care of patients with hereditary retinal degenerations.

Validity and reproducibility of resting metabolic rate measurements in rural Bangladeshi women: comparison of measurements obtained by Medgem™ and by Deltatrac™ device

OBJECTIVE

To assess reproducibility and validity of resting metabolic rate (RMR) of Bangladeshi women as measured with the MedGem device and using the Deltatrac metabolic monitor as a reference; and (2) to evaluate the FAO/WHO/UNU basal metabolic rate (BMR)-prediction equations.

DESIGN

In each of two sessions, resting oxygen consumption was measured in triplicate by MedGem and in triplicate by Deltatrac device.

SETTING

Matlab area, the rural field research area of the Centre for Health and Population Research, Bangladesh (ICDDR,B).

SUBJECTS

A total of 37 nonpregnant, nonlactating women, aged 27.6 +/- 4.5 y, BMI 20.8 +/- 3.1 kg/m(2) participated.

RESULTS

The difference in oxygen consumption by MedGem and Deltatrac device was significantly level dependent. Within-subject within-session variations (expressed as CV) were 9.0 and 3.0% (P < 0.01) and within-subject between-session variations were 8.2 and 4.5% (P < 0.01) for MedGem and Deltatrac, respectively. Mean RMR measured by Deltatrac (5.17 +/- 0.51 MJ/day) was not significantly different from the BMR predicted by the FAO/WHO/UNU equations (5.16 +/- 0.42 MJ/day) in the second session and only 0.19 MJ/day higher than predicted in the first session (P < 0.05).

CONCLUSION

Reproducibility and validity of the MedGem device was poor compared to the Deltatrac reference method. The FAO/WHO/UNU BMR-prediction equations give a good estimation of the BMR of rural, nonpregnant, nonlactating Bangladeshi women of 18-35 y.

SPONSORSHIP

Wageningen University (The Netherlands) and ICDDR,B (Bangladesh).

The public health response to a case of Lassa fever in London in 2000

OBJECTIVES

Evaluation of the Department of Health 1996 guidance, the Memorandum on the Management and Control of Viral Haemorrhagic Fevers.

METHODS

Description of the public health management in 2000 of the fifth UK patient confirmed to have Lassa fever.

RESULTS

Delayed risk categorisation of the patient occurred for a variety of reasons. DH Guidance was followed once infection control advice was sought. Active surveillance of 125 contacts was extremely resource intense, involving over 3000 communications. Self-monitoring by healthcare workers should be considered in future. Advice on use of ribavirin prophylaxis is not included in the Memorandum, nor advice or templates for information sheets for contacts. Information sheets are now available from the Health Protection Agency in the event of future cases. International aspects not adequately addressed include the need for reliable risk assessment to be carried out before patients are medically evacuated from the country of origin, and the steps required to repatriate UK nationals. Effective and efficient communication is required between national and international organisations involved in such incidents.

CONCLUSIONS

If guidelines are unclear or impracticable they will not be followed. It is important that lessons are learned and documented and that national guidance be regularly reviewed.

Specialist vaccination advice and pockets of resistance to MMR vaccination: lessons from an outbreak of measles

An outbreak of measles was associated with a private nursery school in north west London. Sixteen cases were identified of whom 13 were laboratory confirmed. The majority of cases were aged three years or younger. Older cases were siblings of younger cases. None of the cases had been vaccinated against measles. In the nursery school 33% of the children had not received MMR vaccination. Based on specialist advice from the Health Protection Agency the outbreak control team recommended that children with no history of MMR vaccination should have a first MMR dose as soon as possible and that children with one MMR dose should receive the second dose as soon as possible (minimum of one month between doses). Some parents had strong negative views about MMR and represented 'pockets of resistance' to vaccination advice. The specialist vaccination advice, which was different to national immunisation guidelines, also caused some confusion amongst other health professionals. With a decrease in MMR vaccination uptake and resulting increased potential for future measles outbreaks, clinicians should be aware of and understand specialist vaccination advice intended to deal with outbreaks.

Limited genetic susceptibility to severe Graves' ophthalmopathy: no role for CTLA-4 but evidence for an environmental etiology

Graves' disease (GD) is an autoimmune thyroid disease (AITD) characterized by hyperthyroidism and by the occurrence of a distinctive ophthalmopathy (orbitopathy), which presents with varying degrees of severity. Graves' disease clusters in families but the importance of heredity in the pathogenesis of the associated ophthalmopathy is unclear. We have studied the family history of 114 consecutive, ethnically mixed patients with severe Graves' ophthalmopathy (GO). Patients were selected by unambiguous single ascertainment. Seventy-seven percent of patients were female and 59% smoked. The mean age at onset of their GD was 43 years (range 17-78 years). Forty-one patients (36%) had a family history of AITD, defined as a first- and/or a second-degree relative affected with either Graves' disease (GD) or Hashimoto's thyroiditis (HT). The segregation ratio for AITD in nuclear families in our ascertained Graves' ophthalmopathy families was 0.07 (0.12 in Caucasians only). Hence, the higher prevalence of AITD among relatives of Graves' ophthalmopathy patients agreed with the known genetic predisposition to AITD and this predisposition was stronger in women than in men. However, only 3 of the 114 patients had a family history of severe Graves' ophthalmopathy (all second-degree relatives) and the segregation ratio for GO was 0. These data did not support a major role for familial factors in the development of severe Graves' ophthalmopathy distinct from Graves' disease itself. In addition, we tested 4 candidate genes, human leukocyte antigen (HLA), tumor necrosis factor-beta (TNF-beta), CTLA-4 and the thyrotropin receptor (TSHR), for association with Graves' ophthalmopathy. These were negative except for the HLA and CTLA-4 genes, which were found to be weakly associated with GO giving similar relative risk (RR) as in GD patients without ophthalmopathy. These data suggested that environmental factors, rather than major genes, were likely to predispose certain individuals with AITD to severe Graves' ophthalmopathy. Smoking remains one example of such potential external insults.

Molecular epidemiology of a large outbreak of hepatitis B linked to autohaemotherapy

BACKGROUND

Unregulated skin-piercing procedures potentially facilitate the transmission of bloodborne pathogens. In February, 1998, a patient who had recently received autohaemotherapy at an alternative medicine clinic in the UK was diagnosed with acute hepatitis B. The autohaemotherapy procedure involved the drawing of 1 mL of the patient's blood, mixing with saline, and reinjection of the autologous blood mixture. We investigated the extent of hepatitis B virus (HBV) infection in patients and staff of the clinic.

METHODS

Patients who had attended the clinic between January, 1997, and February, 1998, were tested for serological markers of HBV, and for HBV DNA by PCR. HBV DNA was sequenced to assess the relatedness of the virus identified in the cases. We analysed the number and dates of visits with regard to HBV status.

FINDINGS

Serum samples were received from 352 patients and four staff members. Serological evidence of exposure to HBV was found in 57 (16%). Of the 33 patients and staff who were positive for hepatitis B surface antigen, 30 (91%) showed complete nucleotide identity in the DNA segments derived from the surface and core genes. Five patients with linked infection had markers of chronic hepatitis B, and one of these was regarded as the likely source of the outbreak. The attack rate was associated with the number of visits (p<0.0001) and the week of visit (p=0.011). Contaminated saline in a repeatedly used bottle was the probable vehicle of transmission.

INTERPRETATION

We have described a large community-based outbreak of hepatitis B due to transmission by a single HBV variant. Our findings emphasise the continuing risk of transmission of bloodborne viruses in all health-care settings where skin-piercing procedures are used.

Eyelid healing after carbon dioxide laser skin resurfacing: histological analysis

OBJECTIVE

To clarify in vivo healing of eyelid skin after carbon dioxide (CO2) laser resurfacing.

DESIGN

Patients requesting upper eyelid blepharoplasty consented to undergo previous CO2 laser skin resurfacing of the upper eyelid skin segments to be excised at various time intervals. After blepharoplasty, the skin specimens were analyzed histopathologically by 2 masked pathologists.

PATIENTS

Eight patients with Fitzpatrick skin types I and II.

INTERVENTION

Upper eyelid CO2 laser resurfacing 1,2, 4, or 12 weeks before planned upper eyelid blepharoplasty.

MAIN OUTCOME MEASURES

Epidermis: thickness, polarity, contour, and constituents. Dermis: repair zone thickness, vascular and inflammatory pattern, collagen deposition, and elastic fiber changes.

RESULTS

The epidermis regenerated within 7 to 10 days. By 3 months, the epidermis revealed flattening of the rete peg pattern with restoration of polarity, keratinocytes, and melanocytes. The 3-month dermis demonstrated a fibrotic repair zone (500-700 microm), new elastic fibers, and telangiectatic capillaries.

CONCLUSIONS

Eyelids heal similarly to other skin regions treated by CO2 laser resurfacing. This cutaneous healing is analogous to that previously reported with use of chemical peels. Histological changes may explain the skin smoothing and wrinkle reduction seen clinically.

The cost of rabies postexposure prophylaxis: one state's experience

OBJECTIVE

This study was undertaken to evaluate trends in the use of rabies postexposure prophylaxis (PEP) before, during, and following an epidemic of raccoon rabies in Massachusetts.

METHODS

The authors reviewed initiation of PEP as reported to the Massachusetts Department of Public Health (MDPH) from August 1994 to December 1995 and surveyed hospital pharmacies to determine the number of vials of Human Rabies Immune Globulin (HRIG) dispensed from 1991 through 1995 and charges to patients per vial.

RESULTS

PEP use increased dramatically, from 1.7 per 100,000 population in 1991 (pre-epidemic) to 45 per 100,000 in 1995 (after the first stages of the epidemic). The median costs per patient for biologics was $1646 (range: $632-$3435). Including physician and emergency room charges, per-patient median costs were $2376 (range: $1038-$4447). Total health care charges for PEP in Massachusetts in 1995 were estimated at $2.4 million to $6.4 million.

CONCLUSIONS

Given the rapid increase in use of PEP, further studies should be undertaken to determine the appropriateness of use, and other alternatives, such as oral wildlife vaccines, should be considered.

Reduced virulence of rifampicin-resistant mutants of Francisella tularensis

Rifampicin-resistant mutants of a live vaccine strain (LVS) of Francisella tularensis were produced and screened for virulence in mice; 4 avirulent clones with intraperitoneal (ip) LD50s > 10(6) cfu, compared with 10(2) cfu for LVS, were characterized. Growth characteristics at 37 degrees C, surface envelope proteins, and lipopolysaccharide profiles of resistant mutants were identical to those of LVS. Polymerase activity of the mutants was more resistant than the enzyme from LVS to the inhibitory action of rifampicin. Growth rates for mutants and LVS were similar during the first 5 h at 42 degrees C, but viability of the mutants decreased to < 0.01% at 24 h. LVS and mutants differed in their ability to grow in vitro in host macrophages: LVS increased 580-fold over 72 h; mutants increased 33-fold. After ip inoculation of the organisms into mice, increasing numbers of LVS from peritoneal cells were isolated; mutants decreased over 4 days.

Phorbol ester reduces constitutive nuclear NF kappa B and inhibits HIV-1 production in mature human monocytic cells

NF kappa B is a potent mediator of specific gene expression in human monocytes and has been shown to play a role in transcription of the HIV-1 genome in promonocytic leukemias. There is little information available on the response of NF kappa B to cytokines in normal human monocytes. We have used a 32P-labeled oligonucleotide derived from human immunodeficiency virus (HIV-1) long terminal repeat, which contains a tandem repeat of the NF kappa B binding sequence, as a probe in a gel retardation assay to study this transcription factor. Using this assay, we have detected NF kappa B in extracts of nuclei from normal human monocytes. Treatment of normal monocytes with 12-0-tetradecanoyl phorbol-13-acetate (TPA) for 4-24 h caused the complete disappearance of NF kappa B from nuclear extracts of monocytes. A similar result was obtained with the mature monocytic leukemia cell line THP-1. The constitutive transcription factor SP1 was unaffected by addition of TPA. The disappearance of NF kappa B from the nucleus was concentration dependent between 10 and 50 ng/ml of phorbol ester. In THP-1 cells, TPA also induced a new, faster-migrating NF kappa B species not induced in monocytes. Protein kinase C inhibitor staurosporine, but not cyclic nucleotide-dependent protein kinase inhibitor HA-1004, also dramatically reduced constitutive levels of nuclear NF kappa B. Finally, TPA addition to monocytes infected with HIV-1 inhibited HIV-1 replication, as determined by reverse transcriptase assays, in a concentration-dependent manner. These results are in striking contrast to the increase in nuclear NF kappa B and HIV-1 replication induced by phorbol esters in promonocytic leukemia cells U937 and HL-60, and emphasize the importance of studying cytokine regulation of HIV-1 in normal monocytes.

Rabies control in the Republic of the Philippines: benefits and costs of elimination

We compared the benefits and costs of eliminating animal and human rabies in the Philippines. If rabies had been eliminated in 1988, economic benefits would total P52.8 (US$2.5) million in 1989. These benefits would largely arise from the abolition of expenses associated with rabies prevention: P29.7 (US$1.4) million for animal vaccination, P21.6 (US$1.0) million for human postexposure prophylaxis, and P0.3 (US$0.02) million for animal rabies examinations. Benefits also included P1.2 (US$0.06) million in additional earnings of humans whose death due to rabies would be prevented. Nationwide elimination was estimated to cost between P88.1 (US$4.2) million and P317.2 (US$15.0) million, assuming a canine-to-human ratio of 1:10, vaccine coverage of 60%, and a cost per vaccination of no less than P25 (US$1.19) and no more than P90 (US$4.27). These costs would be recouped 4.1-11.0 years after the initiation of a one-year elimination campaign. A sensitivity analysis showed that an elimination programme would be economically beneficial in all but the most extreme cases.

Determination of Ro 14-4767 (Loceryl) by LC using automated column switching with ultraviolet and electrochemical detection

Ro 14-4767, Loceryl is a member of a new class of antimycotics, and a number of dosage forms are being developed for its topical application. The active, impurities and its major oxidation products are amenable to ultraviolet detection at wavelengths of approximately 220 nm. As new delivery systems and lower strengths have been developed, it was recognized that a more sensitive detection method may be necessary to support product development. Ro 14-4767, Ro 14-3168 (impurity) and diastereomers are readily oxidized at potentials of 0.8 V (vs Ag/AgCl) at a glassy carbon electrode. Electrochemical detection substantially improved the sensitivity relative to UV detection. However, detection of impurities and oxidation products by either UV or electrochemical detection exhibited interference problems from the cream matrix. Employing column switching eliminated the interference problem from the cream matrix and adding tetrahydrofuran to the mobile phase (acetonitrile and pH 7.0 phosphate buffer) significantly increased the selectivity and sensitivity for both UV and electrochemical detection. The method requires the use of two pumps to continually deliver the mobile phase through both detectors before and after valve switching, preventing the baseline from shifting during a stop in the flow to the electrochemical detector. Quantitative recovery of the active, the potential degradation products, and Ro 14-3168 from a placebo cream using column switching and UV detection has been demonstrated. Utilizing this methodology it is possible to quantitate 0.1% of the formulation label claim for the potential degradation products and Ro 14-3168. Electrochemical detection provides greater selectivity in that only Ro 14-3168, Ro 14-4767 and its diastereomers are detected. However, the sensitivity of detection relative to UV is enhanced. The method is linear in the range of 50 to 150% of the working standard solution for 0.01% and 0.001% active concentration of the cream. The column switching technique can be automated for reproducible assay of a large number of samples.

Bone mineral density and fracture in postmenopausal women

This retrospective study examined bone mineral density (BMD) for discrimination of female patients with fractures. Bone densitometry was done in 146 patients over the age of 50 years at radius, lumbar spine, and proximal femur sites using single and dual photon absorptiometry. The patients were divided into three groups: (A) no osteoporotic fractures (n = 92); (B) mild spine fractures with greater than 15% compression (n = 38); and (C) hip fractures (n = 16). Groups B and C did not differ significantly from each other in BMD, but these groups differed significantly from group A for spine and femur BMD. No significant differences between groups were found for the radius. Receiver operating characteristic (ROC) analysis showed that the BMD of the proximal femur had the highest diagnostic sensitivity for both spine and femur fractures; the radius had the lowest overall sensitivity, and the spine was intermediate.

Serotonin uptake by platelets of suicidal and aggressive adolescent psychiatric inpatients

Thirty-four adolescent psychiatric inpatients were studied in order to find out whether there is a correlation between serotonin platelet uptake (SPU), suicidality and aggression. The patients were divided into four main diagnostic groups according to clinical data: borderline personality disorder, affective disorder (unipolar) including schizoaffective disorder, schizophrenia and 'others'. These patients were also characterized by the quantitative symptoms profile from K-SADS scale (Children's Version of the Schedule of Affective Disorders and Schizophrenia) and by their behavior: aggression, suicide attempts and violent suicide attempts. In the schizophrenic group, a correlation was found between low Vmax values of SPU and aggressive behavior (p less than 0.05). In addition, in the 'other' group a correlation was found between low Vmax values of SPU and conduct disorder (p less than 0.05). On the other hand, in 'other' patients a correlation was found between low Km values of SPU and violent suicide attempt (p less than 0.05). It is noteworthy that the lowest (20-35%) Vmax values of SPU were found in the patients of the affective group as compared to values of the three other diagnostic groups. These findings are similar to those concerning unipolar depressive adults. It is assumed that there are less binding sites for serotonin on platelets of depressive adolescents than was suggested for depressive adults.

Purification and sequencing of glycosylation variants of BSF-1, as a MAF, from the EL-4 leukaemia cell line

Macrophage activation activity was characterized from a PMA-induced subclone of the murine EL-4 leukaemic cell line. The MAF was purified from the cell line culture supernatant by concentration, CM-Sepharose and lentil lectin Sepharose chromatography, AcA 54 gel filtration, Mono Q FPLC and reverse phase HPLC. Four protein bands of different abundance were observed on SDS-PAGE with molecular weights of 17,500 to 21,000 Da. Three of the four proteins were sequenced from the N-terminal and shared homology with the published sequence of BSF-1. Variation of the molecular weight due to glycosylation was demonstrated by N-glycanase treatment, all four proteins gave a band of 14,200 Da after deglycosylation. Both glycosylated and deglycosylated forms of BSF-1 were equally active in the MAF assay. A monoclonal antibody to BSF-1 neutralized 80% of the activity from crude culture supernatants in the MAF assay. These studies have indicated that BSF-1 is the major, if not the only, MAF activity from this particular subline of the murine EL-4 leukaemic cell line.

Dermatologic findings and manifestations of acquired immunodeficiency syndrome (AIDS)

We present a review of the spectrum of human T-lymphotropic virus type III (HTLV-III) infection with particular emphasis on cutaneous manifestations in 217 patients. Correlations are made with immunodeficiency as measured by absolute T-helper cell number. A classification is presented of these dermatologic findings.

Primary systemic amyloidosis with a retroperitoneal mass

A 73-year-old black woman presented with congestive heart failure, abdominal distension and ascites. A large retroperitoneal mass was demonstrated by gray-scale abdominal ultrasonography and confirmed by laparatomy and postmortem examination. This retroperitoneal mass consisted mainly of amyloid, as demonstrated by green birifringence with alkaline Congo red staining. Resistance of this staining pattern to permanganate treatment and the absence of inflammatory disease or malignancy at autopsy suggest the diagnosis of primary systemic amyloidosis. This is the first reported case of this disease manifesting as a retroperitoneal mass.

Molecular weight, isoelectric point, and stability of a murine lymphokine that induces macrophage tumoricidal activity

A factor in antigen- or mitogen-stimulated murine spleen cell culture supernatants that induces macrophage-mediated tumor cytotoxicity was characterized physicochemically. Although activity was eluted from Sephadex G-100 columns in a region corresponding to a MW of 55,000, rechromatography of the first and second halves of the eluted peak resulted in two separate peaks, corresponding in location to the first and second halves of the original peak. This shows that the original peak comprises two activation factors of slightly different MW. In contrast, electrofocusing experiments designed to assure that the isoelectric position had been reached by the end of the run showed a single isoelectric point of pH 5.8, with no sign of charge heterogeneity. Denaturation studies showed rapid loss of activity at 60 degrees C, stability over a pH range of 5 to 10, loss of activity at pH 4.0, and loss of two-thirds of the activity in 6 M urea. The number of criteria by which this lymphokine has now been characterized should suffice to distinguish it from other lymphokines evaluated by similar methods.

Mixed cryoglobulinemia: clinical aspects and long-term follow-up of 40 patients

The clinical course of 40 patients with significant quantities of mixed cryoglobulins, but without lymphoproliferative, collagen-vascular or chronic infectious diseases, is presented. These cases comprise 51.3 percent of all mixed and 31.7 percent of all types of cryoglobulins evaluated by us over the period 1960--1978. A characteristic clinical syndrome, consisting of recurrent palpable purpura (100 percent), polyarthralgias (72.5 percent) and renal disease (55 percent), was seen. Biopsy specimens of skin lesions showed cutaneous vasculitis, and half had immune reactants in vessel walls. Seventy percent of patients had evidence of hepatic dysfunction, often subclinical, and more than 60 percent of those tested had serologic evidence of prior infection with hepatitis B virus. Hepatic lesions ranged from minimal triaditis to chronic active hepatitis and/or cirrhosis. All 22 patients in whom clinical renal disease developed had significant proteinuria; 63.6 percent had diastolic hypertension, 77.3 percent edema, 45.5 percent renal failure and 22.7 percent were nephrotic. Glomerular disease associated with deposition of immunoglobulin G, immunoglobulin M and complement, often with coexistent renal arteritis, was confirmed pathologically in 15 cases. All cryoglobulins had rheumatoid factor activity and consisted of IgM and polyclonal IgG; five also contained IgA. Thirteen had a monoclonal IgM kappa component. Serum protein electrophoresis was unremarkable or showed diffuse hyperglobulinemia. Striking depression of early complement components was noted but did not correlate well with the cryoprotein concentration, renal involvement or clinical course. Follow-up for periods up to 21 years from onset of symptoms revealed that renal involvement has a deleterious effect on prognosis. Postmorten examinations of nine patients demonstrated widespread vasculitis in addition to renal involvement. Preterminal infection was found in eight.

Cerebral arteritis in scleroderma

Central nervous system (CNS) involvement is rare in scleroderma unless there are concomitant abnormalities in renal or lung function or malignant hypertension. A 43-year-old woman with typical scleroderma developed subacute encephalopathy despite absence of the above abnormalities. Cerebral angiography demonstrated a focal arteritis. The patient improved while being given corticosteroids. We believe this case indicates that cerebral arteritis can occur in scleroderma.

Haemolytic anaemia due to erythrocyte pyrimidine 5'-nucleotidase deficiency. Report of the first South African family

The first South African case of haemolytic anaemia due to erythrocyte pyrimidine 5'-nucleotidase deficiency is reported. The anaemia is characterized by the presence of high erythrocyte pyrimidine nucleotide levels and marked basophilic stippling. The enzyme levels in 20 family members confirm an autosomal recessive mode of inheritance and illustrate the difficulty of diagnosing the carrier state.

Leucocyte migration test in patients after corneal transplantation

Twenty-four patients with corneal homografts were repeatedly evaluated by the leucocyte migration test using pooled human corneal extract 0.2 mg/ml as antigen. All patients were treated with small doses of local or systemic steroids. If cloudiness of the graft developed, the doses were increased up to 40 mg methylprednisolone or 48 mg triamcinolone daily. Before transplantation, two patients showed inhibition of leucocyte migration. During the third postoperative week seventeen responded with migration inhibition. The grafts remained clear in all but one patient during this period of time. After the second postoperative month, leucocyte migration inhibition was found in none of sixteen patients whose grafts remained clear. Three of seven patients with late graft rejection exhibited migration inhibition and in two of them this response was demonstrated repeatedly several months prior to the clinical reaction. These findings suggest that the test may predict graft failure in some patients.

Serum complement levels in patients with mixed (IgM-IgG) cryoglobulinaemia

Serum complement levels were determined in seven patients with mixed (IgM–IgG) cryoglobulinaemia. All seven patients had either no measurable or very low levels of C'2. C'50 haemolytic units were determined in three patients and were also found low, although less striking. The mechanism by which the blood of these patients became depleted of C'2 could not be determined.