1251 FRAILTY PREVALENCE AND RISK OF SARCOPENIA IN OLDER HEART FAILURE (HF) INPATIENTS

Introduction

Both frailty and HF are common in the elderly population. Elderly HF patients have an increased risk of frailty and elderly frail patients are at a higher risk of developing HF. Frailty is an independent predictor of mortality in cardiovascular disease. Sarcopenia (defined as decreased muscle mass and muscle strength and/or performance) is also prevalent in HF patients and may progress to cardiac cachexia. HF may induce sarcopenia and sarcopenia may contribute to the poor prognosis of HF.

Aims

Methods

A cross-sectional, retrospective analysis of consecutive patients, 60 years and over, admitted with HF to a UK hospital. Data was manually extracted from anonymized electronic records. The Rockwood Clinical Frailty Scale (CFS) was used for assessment for frailty and the SARC-F tool was used for screening for sarcopenia. Patients with medical history of HF but did not present with decompensated HF were excluded. Also, patients with incomplete data were excluded. The IBM SPSS 28 statistical package was used for statistical analysis. Descriptive statistics and risk estimates were calculated.

Results

163 patients were analysed; 82 males and 81 females. The mean age was 81.4 years (SD 9.69). 71.5 % of patients were frail while 28.5 % were non-frail. The risk of sarcopenia was 10.9 times greater in the frail than in the non-frail patients (OR = 10.9; 95% C.I 4.85 – 24.67). There was a lower risk of sarcopenia in male patients than in the female patients (OR =0.45; 95% C.I 0.22 – 0.94).

Conclusions

Frailty is prevalent in older heart failure inpatients. It significantly increases the risk of sarcopenia in these patients. Women are at higher risk of sarcopenia than men. More research is needed into frailty and sarcopenia in.

1242 CO-MORBIDITY, FRAILTY AND EJECTION FRACTION IN OLDER HEART FAILURE INPATIENTS

Introduction

Co-morbidities and frailty are common in older heart failure patients. The aim of this study is to explore the relationship between co-morbidity, frailty and ejection fraction (EF) in older heart failure inpatients

Methods

A cross-sectional, observational, retrospective analysis of consecutive patients aged 60 years and over who were admitted with heart failure in a UK hospital. Patients with incomplete data were excluded. The Carlson’s comorbidity index (CCI) was used to compute comorbidity and the Rockwood Clinical Frailty Scale (CFS) was used to measure frailty. The EF was calculated as the midpoint of the ranges measured by echocardiography. IBM SPSS 28 software was used for statistical analysis. Descriptive statistics were used to measure baseline characteristics and Pearson’s correlation coefficient and linear regression were used to calculate correlation.

Results and discussion

101 patients were analysed; 48 males and 53 females. Mean age was 81.2 years(SD 9.98). Mean CCI was 6.97(SD 1.63) and mean CFS was 5.09(SD 1.14). There was statistically significant positive correlation between CCI and CFS (r= 0.232; p= .01). There was statistically significant inverse correlation between CCI and EF (r= -.277; p=. 005). When taking into account the level of frailty the correlation between CCI and EF was much stronger in non-frail than in frail patients (r= -.612; p=. 035 and r= -.216; p= .047 respectively). There was no correlation between CFS and EF (r= .095; p=.26). This was not surprising as HFpEF is the most common type of HF in the elderly. HFpEF patients are more likely to have more comorbidities and to be more frail compared to HFrEF patients.

Conclusion

There was a positive correlation between multi-morbidity and frailty in older inpatients admitted with heart failure. There was statistically significant inverse correlation between CCI and ejection fraction but there was no correlation between frailty and ejection.

Prevalence, predictors and outcomes of thyroid dysfunction in patients with acute myocardial infarction: the ThyrAMI-1 study

PURPOSE

Thyroid dysfunction in patients with cardiac disease is associated with worse outcomes. This study aimed to evaluate the prevalence and analyse predictors and outcomes of thyroid dysfunction in patients presenting with an acute myocardial infarction (AMI).

METHODS

A prospective multicentre observational study of patients recruited from six acute hospitals within the North of England. Consecutive patients without previous thyroid disease presenting with both ST-elevation AMI (STEMI) and non-ST-elevation AMI (NSTEMI) were recruited to the Thyroxine in Acute Myocardial Infarction 1 (ThyrAMI-1) cohort study between December 2014 and 2016. Thyroid profile, standard biochemistry measurements and demographic information were obtained within 12 h of admission to hospital. Multivariable logistic regression analyses were performed to assess the predictors of thyroid dysfunction and Cox proportional hazards analyses were utilised to compare all-cause mortality by categories of thyroid dysfunction up to June 2019.

RESULTS

Of the 1802 participants analysed, 1440 (79.9%) were euthyroid, 312 (17.3%) had subclinical hypothyroidism (SCH), 22 (1.2%) had subclinical hyperthyroidism (SHyper) and 25 (1.3%) had low T3 syndrome (LT3S). Predictors for SCH were increasing age, female sex, higher thyroid peroxidase antibody (TPOAb) levels, higher serum creatinine levels and early morning sampling time (between 00:01-06:00 h). The predictors of SHyper were lower body mass index and afternoon sampling time (between 12:01 and 18:00 h). Predictors of LT3S were increasing age, higher creatinine levels and presence of previous ischaemic heart disease. Compared to the euthyroid group, patients with LT3S had higher all-cause mortality; adjusted hazard ratio (95% CI) of 2.02 (1.03-3.95), p = 0.04, whereas those with SCH and SHyper did not exhibit significantly increased mortality; adjusted hazard ratios (95% CI) of 1.05 (0.74-1.49), p = 0.79 and 0.27 (0.04-1.95), p = 0.19, respectively.

CONCLUSIONS

Thyroid dysfunction is common in AMI patients on admission to hospital and our data provide an understanding regarding which factors might influence thyroid dysfunction in these patients. Furthermore, the negative association between LT3S and increased mortality post-AMI has once again been highlighted by this study. More research is required to assess if treatment of thyroid dysfunction improves clinical outcomes.

Remote and rapid pathological diagnosis in a resource challenged unit

Malawi is one of the world's poorest countries, but despite this, has a dedicated paediatric oncology service. The service has been hampered by the inability to make a timely cytological diagnosis in the majority of patients. A telemedicine programme was commenced to help overcome this problem, and the results for the first 197 consecutive patients are described. The results are compared with the local reports where available. Most samples were fine needle aspirates (104/197-53%), but others included bone marrow aspirates, peripheral blood films and other fluid collections. A diagnosis was arrived at in 52% of the samples; there were 46 discordant results, 38 were when one or other of the local or distant teams were unable to make a diagnosis, and only 8 where the diagnoses of the 2 teams differed. Diagnoses were made and reports were compiled by the 'distant' team within 24 h and sent to the centre in Malawi. This simple telepathology initiative has had a positive impact on clinical management, and could be used in other less resourced centres twinned with better resourced ones.

Human neutrophil antibodies in a blood donor population: a lookback study

BACKGROUND AND OBJECTIVES

Human neutrophil antibodies (HNA) have been associated with severe transfusion-related acute lung injury (TRALI). We identified HNA antibodies in a blood donor population and performed an observational lookback on patients who received products from these donors to determine whether TRALI was associated with these transfusions.

MATERIALS AND METHODS

  Human neutrophil antibodies were determined in 1171 blood donors (388 non-transfused males, 390 human leucocyte antigen (HLA) antibody-negative females and 393 HLA antibody-positive females) for IgG and IgM antibodies using a flow cytometric assay. Selected positive samples had a monoclonal antibody immobilization of granulocyte antigen (MAIGA) and neutrophil genotyping performed to confirm specificity. Lookback was performed on patients receiving blood from donors with positive samples by extracting recipient data from hospital medical records. An expert panel of three pulmonary critical care physicians reviewed the summarized data and assigned a diagnosis of TRALI, possible TRALI, cannot distinguish between TRALI and TACO, TACO and other.

RESULTS

Eight donors had HNA antibodies of which five contributed to this lookback (3-HNA-specific antibodies, 2-HNA non-specific antibodies). Seventy-six blood products were transfused from these donors into individual patients. One patient developed TRALI that was associated with a donor with a non-specific HNA antibody as well as class-I and class-II HLA antibodies.

CONCLUSION

The incidence of TRALI in this lookback was low and combined with low frequency of HNA antibodies in the donor population suggests not screening donors for HNA antibodies at this time is acceptable.

Increased dopaminergic neurotransmission in therapy-naïve asymptomatic HIV patients is not associated with adaptive changes at the dopaminergic synapses

Central dopaminergic (DA) systems are affected during human immunodeficiency virus (HIV) infection. So far, it is believed that they degenerate with progression of HIV disease because deterioration of DA systems is evident in advanced stages of infection. In this manuscript we found that (a) DA levels are increased and DA turnover is decreased in CSF of therapy-naïve HIV patients in asymptomatic infection, (b) DA increase does not modulate the availability of DA transporters and D2-receptors, (c) DA correlates inversely with CD4+ numbers in blood. These findings show activation of central DA systems without development of adaptive responses at DA synapses in asymptomatic HIV infection. It is probable that DA deterioration in advanced stages of HIV infection may derive from increased DA availability in early infection, resulting in DA neurotoxicity. Our findings provide a clue to the synergism between DA medication or drugs of abuse and HIV infection to exacerbate and accelerate HIV neuropsychiatric disease, a central issue in the neurobiology of HIV.

British Society for Haematology, slide session, annual scientific meeting, Glasgow, 2008

A morphology session is held each year at the Annual Scientific Meeting of the British Society of Haematology. Prior to the meeting this year, eight morphology cases were made available to BSH members as glass slides and also digitally as 'virtual slides'. A panel of invited commentators who had no prior knowledge of the diagnosis discussed the eight cases. An initial limited history and blood count are given with representative images from the case material; this is followed by the discussants' comments and suggested diagnosis. The actual clinical diagnosis is then given with other relevant information.

Immobilisation of heavy metal in cement-based solidification/stabilisation: a review

Heavy metal-bearing waste usually needs solidification/stabilization (s/s) prior to landfill to lower the leaching rate. Cement is the most adaptable binder currently available for the immobilisation of heavy metals. The selection of cements and operating parameters depends upon an understanding of chemistry of the system. This paper discusses interactions of heavy metals and cement phases in the solidification/stabilisation process. It provides a clarification of heavy metal effects on cement hydration. According to the decomposition rate of minerals, heavy metals accelerate the hydration of tricalcium silicate (C3S) and Portland cement, although they retard the precipitation of portlandite due to the reduction of pH resulted from hydrolyses of heavy metal ions. The chemical mechanism relevant to the accelerating effect of heavy metals is considered to be H+ attacks on cement phases and the precipitation of calcium heavy metal double hydroxides, which consumes calcium ions and then promotes the decomposition of C3S. In this work, molecular models of calcium silicate hydrate gel are presented based on the examination of 29Si solid-state magic angle spinning/nuclear magnetic resonance (MAS/NMR). This paper also reviews immobilisation mechanisms of heavy metals in hydrated cement matrices, focusing on the sorption, precipitation and chemical incorporation of cement hydration products. It is concluded that further research on the phase development during cement hydration in the presence of heavy metals and thermodynamic modelling is needed to improve effectiveness of cement-based s/s and extend this waste management technique.

Resting brain perfusion in social anxiety disorder: a voxel-wise whole brain comparison with healthy control subjects

INTRODUCTION

Social anxiety disorder (SAD) is a condition characterised by fears of social interaction and performance situations. SAD may be related to a dysregulation or hyperactivity of cortico-limbic circuitry. This is the first voxel-based whole brain study comparing resting function in SAD to a normal control group.

METHODS

Resting perfusion in adult subjects with generalised SAD was compared with healthy adult volunteers using Statistical Parametric Mapping (SPM). In subjects with SAD, correlations were also sought between resting perfusion and clinical severity measured using the total Liebowitz Social Anxiety Scale (LSAS).

RESULTS

Twenty-eight subjects with SAD were compared with 19 healthy volunteers. SAD subjects had increased resting perfusion in the frontal cortex and right cerebellum, and decreased perfusion in the pons, left cerebellum, and right precuneus. Total LSAS correlated positively with left frontal cortex resting perfusion, and negatively with right fusiform and right lingual perfusion.

CONCLUSION

This study demonstrated increased resting frontal function in social anxiety disorder that is consistent with its hypothesised role in the modulation of excessive limbic activity in anxiety disorders. The correlation of posterior cortical resting function with the severity of SAD symptoms may point to defective perception of self and others.

Pharmacotherapy augmentation strategies in treatment-resistant anxiety disorders

BACKGROUND

A large proportion of patients with anxiety disorders fail to respond to first-line medication interventions, despite evidence of the effectiveness of these agents.

OBJECTIVES

To assess the effects of medication versus placebo augmentation in the treatment of patients with anxiety disorders who have failed to respond adequately to first-line drug therapies.

SEARCH STRATEGY

The Cochrane Depression, Anxiety & Neurosis Group (CCDAN) specialised registers (CCDANCTR-Studies and CCDANCTR-References) were searched on 3/8/2005, MEDLINE (January 1966 to July 2005) and PsycINFO (1966 to 2005, Part A). Unpublished trials were identified through the Controlled Trials database and the National Institute of Health's Computer Retrieval of Information on Scientific Projects (CRISP) service (1972 to 2005). Additional studies in any language were sought in reference lists of retrieved articles.

SELECTION CRITERIA

All randomised controlled trials (RCTs) of the medication augmentation of pharmacotherapy for treatment resistant anxiety disorders.

DATA COLLECTION AND ANALYSIS

Two raters independently assessed RCTs for inclusion in the review, collated trial data, and assessed trial quality. Investigators were contacted to obtain missing data. Summary statistics were stratified by class of augmentation agent and anxiety disorder. Overall effect estimates were calculated using a random-effects model, heterogeneity was assessed and subgroup/sensitivity analyses were undertaken.

MAIN RESULTS

Twenty eight short-term (average of seven weeks) randomised controlled trials (740 participants) were included in the review, 20 of which investigated augmentation of medication for treatment-resistant obsessive compulsive disorder (OCD). Summary statistics for responder status from nine trials demonstrate overall superiority of a variety of medication agents to placebo (relative risk of non-response (RR) 3.16, 95% CI 1.08 to 9.23). Similarly, symptom severity was significantly reduced in the medication groups, relative to placebo (number of trials (N) = 14, standardised mean difference (SMD) -0.87, 95% CI -1.37 to -0.36). There is no evidence of a difference between medication and placebo in total dropout rate, or in the number of dropouts due to adverse events.

AUTHORS' CONCLUSIONS

Medication augmentation can be an effective and well-tolerated short-term treatment strategy for non-responders to first-line pharmacotherapy of anxiety disorders. However, any conclusions must be tentative in view of methodological and clinical heterogeneity, and the fact that much of the relevant database is based on antipsychotic augmentation trials in OCD patients resistant to serotonin reuptake inhibitors (SRIs). Additional data are needed to address several areas, including the efficacy of augmentation over the longer-term, and the value of medication augmentation in comparison to other strategies (e.g. switching medication, adding psychotherapy).

A comparison of the effects of citalopram and moclobemide on resting brain perfusion in social anxiety disorder

INTRODUCTION

The serotonin specific reuptake inhibitor (SSRI) citalopram and the reversible mono-amine oxidase-A inhibitor (RIMA) moclobemide have both been used successfully for the treatment of social anxiety disorder (SAD). In this study we investigate the effects of these compounds on resting brain function using single photon emission computed tomography (SPECT).

METHODS

Subjects meeting DSM-IV criteria for SAD underwent regional cerebral blood flow (rCBF) SPECT using Tc-HMPAO at baseline and after 8 weeks of treatment with either citalopram or moclobemide. Using statistical parametric mapping brain SPECT studies were analysed to determine the effects of treatment on rCBF, to compare the effects of citalopram and moclobemide, and to detect correlations between changes in rCBF and clinical response.

RESULTS

Subjects received citalopram (n=17) or moclobemide (n=14) as therapy. Subjects in both treatment groups demonstrated a significant improvement of SAD symptoms as measured by the Liebowitz Social Anxiety Scale total score. All subjects demonstrated a decrease in rCBF in the insulae post therapy. Subjects receiving citalopram had decreased superior cingulate rCBF after therapy compared to those receiving moclobemide.

CONCLUSION

Both SSRI's and RIMA's decreased rCBF in the insulae during treatment of SAD; an effect that may be consistent with the role of these regions in processing internal somatic cues evoked by emotional stimuli. Citalopram had a greater effect on superior cingulate perfusion, an effect that is consistent with evidence of high levels of 5-HT transporters in this region.

Dehydrated hereditary stomatocytosis with transient perinatal ascites

The case is reported of a mother and baby with dehydrated hereditary stomatocytosis and perinatal ascites, an autosomal dominant condition not previously reported in Britain. Recognition is important for the management of pregnancy and for avoidance of splenectomy which, if performed, can predispose the patient to fatal thromboembolic events.

Epstein-Barr virus (types 1 and 2) in the tear film in Sjogren's syndrome and HIV infection

Evidence of Epstein-Barr virus (EBV) shedding in the saliva and tear film has been sought to explain the pathogenesis of the oral and ocular features of Sjogren's syndrome. Patients with human immunodeficiency virus (HIV) infection are purported to have a higher incidence of keratoconjunctivitis sicca. Twenty patients with definite Sjogren's syndrome (primary and secondary), 19 with HIV infection, and 15 normal controls were recruited and studied. Human herpes viruses (EBV 1 and 2, CMV, HZV, and HSV-1) in tear film were detected by polymerase chain reaction of DNA extracted from Schirmer strips. HSV-1, VZV, and CMV were not detected in any tear samples. EBV-1 DNA was found in the tear film of 4 patients with Sjogren's syndrome, which was not significantly different from the control group (P = 0.18). Twelve patients with HIV infection had evidence of EBV-1 in their tears, which was significantly different from controls (P = 0.0002) and patients with Sjogren's syndrome (P = 0.014). EBV-2 was found in 3 patients with HIV and in 1 patient with secondary Sjogren's syndrome, and was always found as a co-infection with EBV-1 (P = 0.01). This represents the first report examining EBV types 1 and 2 in the tear film and also EBV in the tear film of patients with HIV. Shedding of EBV in the tear film was not related to the presence of keratoconjunctivitis sicca in Sjogren's syndrome. EBV-2 co-infection with EBV-1 has not been previously reported in the tear film. EBV infection is abnormally regulated in Sjogren's syndrome and HIV, and it is likely that the presence of EBV in the tear film is related to the patients' altered immune status.

Takayasu arteritis and atherosclerosis: illustrating the consequences of endothelial damage

The excess of cardiovascular morbidity associated with chronic vasculitic disease has become a focus of considerable research, particularly regarding the link between endothelial damage and the development of atherosclerosis. We describe a case of Takayasu arteritis treated sub-optimally by today's standards, giving rise to an 11 year history of progressive, stepwise decline associated with cerebrovascular events and leading to early death. Postmortem findings presented a picture of chronic atherosclerotic disease but in a distribution consistent with lesions of Takayasu arteritis.

Intravenous apomorphine therapy in Parkinson's disease: clinical and pharmacokinetic observations

Six patients with Parkinson's disease and refractory motor fluctuations, with severe subcutaneous (s.c.) nodule formation as a result of long-term s.c. apomorphine infusions, were switched to intravenous (i.v.) therapy via a long-term in-dwelling venous catheter. Five patients were followed-up for a mean of 7 months (range 0.5-18 months). All patients had plasma apomorphine concentrations measured at baseline during s.c. infusions and three had follow-up measurements when stabilized on i.v. therapy, to test the hypothesis that motor fluctuations in these patients are largely due to impaired absorption of apomorphine. The mean i.v. rate of 9.0 mg/h (range 5-14 mg) and 24-h dose of 256.7 mg (range 90-456 mg) of apomorphine were not significantly reduced compared with the s.c. route (9.24 mg/h and 243.4 mg). However, additional oral anti-parkinsonian medication was reduced by a mean of 59%, and 'off' time was virtually eliminated (mean reduction from 5.4 to 0.5 h per day, P< 0.05). There was also a significant reduction in dyskinesias and markedly improved quality of life. Pharmacokinetic analysis demonstrated more reliable and smoother delivery of apomorphine via the i.v. route, although 'off' periods were not always explained by low plasma apomorphine concentrations. Complication rates were high and included three unforeseen hazardous intravascular thrombotic complications, secondary to apomorphine crystal accumulation, necessitating cardiothoracic surgery. We conclude that i.v. apomorphine therapy holds promise as a more effective way of controlling motor fluctuations than the s.c. route. However, further preclinical research is required before i.v. Britaject apomorphine can be recommended for routine clinical practice. Even when stable plasma apomorphine concentrations were achieved, motor fluctuations could not be totally eradicated, suggesting that postsynaptic receptor changes may also play a role in the refractory 'off' periods in these patients.

Influence of prior exposure to zidovudine on stavudine phosphorylation in vivo and ex vivo

Intracellular phosphorylation of stavudine (d4T) and zidovudine (ZDV) was investigated in peripheral blood mononuclear cells (PBMCs) isolated from ZDV-naive and ZDV-experienced human immunodeficiency virus (HIV)-positive patients. An in vivo study measured the amount of d4T triphosphate (d4TTP), while an ex vivo study assessed the capacity of cells to phosphorylate added d4T. Endogenous dTTP was also measured. d4TTP and dTTP were determined in vivo using a reverse transcriptase chain termination assay. In ex vivo studies, d4T (1 microM) was incubated in resting and phytohemagglutinin-stimulated (10 microg ml(-1); 72 h) PBMCs for 24 h. After washing and methanol extraction, radiolabeled anabolites were detected by high-performance liquid chromatography. d4TTP reached its highest level 2 to 4 h after dosing (0.21 +/- 0.14 pmol/10(6) cells; n = 27 [mean +/- standard deviation]). Comparison of ZDV-naive and ZDV-experienced individuals showed no significant difference in levels of d4TTP (ZDV naive, 0.23 +/- 0.17 pmol/10(6) cells [n = 7] versus ZDV experienced, 0.20 +/- 0.14 pmol/10(6) cells [n = 20]; P = 0.473) or the d4TTP/dTTP ratio (0.14 +/- 0.12 [n = 7] and 0.10 +/- 0.08 [n = 20], respectively; p = 0.391). Ex vivo data demonstrated no significant difference in the formation of d4TTP or total d4T phosphates in naive and experienced patients (0.086 +/- 0.055 pmol/10(6) cells in ZDV-naive patients [n = 17] versus 0.081 +/- 0.038 pmol/10(6) cells in ZDV-experienced patients [n = 22]; P = 0.767). The ability of HIV-infected patients to phosphorylate d4T in vivo and ex vivo was unchanged with increasing exposure to ZDV.

A multicentre, open, non-comparative phase II study of a combination of fludarabine phosphate, cytarabine and granulocyte colony-stimulating factor in relapsed and refractory acute myeloid leukaemia and de novo refractory anaemia with excess of blasts in transformation

The primary objective of this study was to determine the complete remission (CR) rate achieved with the FLAG (fludarabine phosphate, cytarabine and granulocyte colony-stimulating factor) regimen in patients with relapsed or refractory acute myeloid leukaemia (AML) or de novo refractory anaemia with excess of blasts in transformation (RAEB-t). Secondary objectives were to evaluate survival and toxicity. Induction treatment consisted of between one and two courses of FLAG. Patients achieving CR received between one and two courses of consolidation treatment. Eighty-three of the 89 patients entering the study were eligible for assessment. CR rates were: 17 out of 21 (81%) in late relapse AML (Group 1), 13 out of 44 (30%) in early relapse/refractory AML (Group 2), and 10 out of 18 (56%) in de novo RAEB-t (Group 3). Thirty-four of the 40 responders (85%) achieved CR after one induction course. Median survival times were 1.4 years, 3 months and 1.6 years in Groups 1, 2 and 3 respectively. Other than myelosuppression, the FLAG regimen was not generally associated with clinically significant toxicity and was well tolerated by most patients including the elderly. The FLAG regimen offers a very effective alternative treatment for CR induction in poor prognosis adult patients with either relapsed or refractory AML or de novo RAEB-t. FLAG delivers high-dose treatment without increasing overall toxicity, an approach which is of particular value in older patients, who constitute the majority in these diseases. It is therefore an important advance in developing new treatment options for these patients.

Peripheral neuropathy: zalcitabine reassessed

Given that the long-term medical management of HIV infection necessitates making best use of all available antiretrovirals, it is somewhat surprising that the nucleoside analogue reverse transcriptase inhibitor (NRTI) zalcitabine is less commonly used. This may be due to the potential for peripheral neuropathy (PN) which has been associated with the use of this drug. The perception that zalcitabine is poorly tolerated appears to have arisen largely from the results of early monotherapy trials in patients with AIDS and low CD4 cell counts. In contrast, results of more recent studies show that PN is relatively infrequent when zalcitabine is used in combination with other antiretrovirals in current treatment settings.

A simple sore throat?

Apreviously healthy 26-year-old man presented with a 3-day history of sore throat, fever, rigors, loin pain and vomiting. He was pyrexial (40°C) and tachycardic (104 beats/minute), but had a normal blood pressure. Clinical examination revealed erythematous fauces without any exudates, and bilateral submandibular Iymph node enlargement. There was no meningism or para-spinal tenderness. The platelet count was decreased (108 × 109/litre, normal range (NR) 150–400x109/litre) and white cell count was elevated (16.1×109/litre, NR 4–11x109/litre) with a neutrophilia. Markers of inflammation (erythrocyte sedimentation rate 61mm/h and C-reactive protein 226mg/litre) and urea (11.1 mmol/litre, NR 3–7 mmol/litre) were also elevated.

Chest X-ray and glandular fever slide test were both normal. The patient was started on intravenous ceftriaxone after blood, urine and throat swabs were sent off for culture.

The patient's temperature settled over the next 4 days, and he was converted to oral antibiotics. Gram-negative anaerobes were cultured from the blood; these were identified as Fusobacterium nucleatum, suggesting that the patient had necrobacillosis. Throat swabs failed to grow the organism. In order to exclude an abdominal source for the organism, the patient also had an abdominal ultrasound and a radiolabelled white cell scan, both of which were normal. The patient's inflammatory markers and renal function returned to normal with antibiotic treatment, and he remains well 1 year after his illness.

Post-transfusion HIV infection despite donor screening: a report of three cases

In August 1996, a blood donation was collected which subsequently infected three patients post-transfusion with HIV 1. The donation itself was originally screened as negative for anti-HIV 1/2 using a sensitive EIA method, but subsequently was shown to contain p24 Ag and HIV RNA by an amplification technique. The proposed introduction of nucleic acid testing of all blood donations in the UK for hepatitis C, hepatitis B and HIV may further reduce the remote risk of further episodes of post-transfusion infection. The infection in the index recipient was detected on routine pre-transplant virological screening but proved difficult to confirm, at a time when she had recently received myeloablative treatment for a haematological malignancy which impaired the immune response. There is a need for continued vigilance in such patients to exclude post-transfusion infection, at a time when natural immunological responses have been impaired by their disease or treatment.

GaIN (Georgia Interactive Network for Medical Information) study on health professionals' search requests and continuing education needs

Health sciences librarians are being called upon to be more proactive in their institutions' continuing education efforts. In an effort to identify whether search requests indicated CE needs, a study was conducted by a group of members of GaIN (Georgia Interactive Network for Medical Information). MEDLINE requests from health care professionals for subject specific clinical topics were collected during a six-month period via a standard search request form created for the study. Copies of all completed requests were collected and broad ICD-9 codes assigned to the search topics. Institutional reports were generated for each participating library to share with hospital CE coordinators. They were also compiled for the group as a whole, and reflected the "hottest" topics requested during the study period for physicians and for non-physicians (nurses, allied health, administrators). A survey to hospital librarians and CE educators showed some value in the reports, but greater potential for further collaboration between librarians and CE coordinators.

The effects of prescribed versus ad libitum feedings and formula caloric density on premature infant dietary intake and weight gain

BACKGROUND

Although feedings that are organized on an ad lib basis (i.e., in response to infant cues of hunger and of satiation) could enhance an infant's self-regulatory capacities for feeding, ad lib feeding of fully nipple-fed premature infants in a special care nursery has not been examined.

OBJECTIVE

To study whether the caloric and protein intake and weight change of fully nipple-fed preterm infants differed by the feeding regimen (prescribed or ad lib) and by the caloric density of the formula (20- or 24-kcalories per ounce).

METHOD

The 78 infants who participated in the study were randomized to prescribed or ad lib feeding regimens and, within each regimen, were further randomized to receive either 20-calorie or 24-kcalorie per ounce formula. Dietary intake (volume/kg, caloric intake/kg) and weight change (grams/kg gained or lost) were assessed for each of the 5 study days. Multivariate data analysis was used to examine the effects of feeding regimen and caloric density on dietary intake and weight change, controlling biologic variables (infant gender, race, lung disease diagnosis, treatment with supplemental oxygen, gestational age and weight at birth, and weight on the day prior to full nipple-feeding).

RESULTS

Overall, the ad lib feeding regimen had a negative effect on volume intake and caloric intake. Weight gain was influenced by caloric intake, but not by feeding regimen or the caloric density of the diet. With increased full nipple-feeding experience, caloric intake of ad lib feeders approached that of the infants fed on the prescribed regimen.

CONCLUSIONS

Development of self-regulatory capacities through ad lib feeding experience was indicated by infant regulation of the volume of intake by the caloric density of the formula, an unexpected finding. Furthermore, the approach of the caloric intake of infants on the ad lib regimen to that of infants on the prescribed regimen suggests they had gained skill in regulating intake with experience. Whether or not the trend for similar intakes would continue beyond 5 days is a question for further study.

Memory for conversation

Memory for conversation is treated as a source of coherence in social encounters and its connections with social competence are tested in a study of problem-solving conversations. As predicted, accurate recall is found to correlate positively with social competence and negatively with social anxiety. Partners have better memory for their own contributions than for each other's, and this difference is exacerbated by topic importance. Differences in recall are also found for differing amounts of involvement in the conversations. Results are explained in terms of resource allocation during conversation.

Toxoplasmosis masking non-Hodgkin's lymphoma: a case report

A 39-year-old female with persistent cervical lymphadenopathy is reported. Initial investigations resulted in a diagnosis of toxoplasmosis, but subsequently the patient proved to have high grade immunoblastic non-Hodgkin's lymphoma. This paper highlights the difficulties in accurately diagnosing some cases of either toxoplasmosis or lymphoma, and briefly mentions some of the ongoing technical advances which will increase diagnostic specificity and sensitivity by early detection of genetic mutations.

Effect of atrial natriuretic hormone on vasopressin and thirst response to osmotic stimulation in human subjects

To evaluate the effect of systemically administered atrial natriuretic hormone (ANH) on osmotically induced secretion of arginine vasopressin (AVP) and thirst sensation, 11 healthy men, aged 18 to 28 years, were studied on four occasions. The intravenous infusions of placebo (P) or one of three doses of ser-tyr28 human ANH (0.6 [LD], 1.8 [MD], and 5.4 [HD] pmol/kg/min) were given in random order over 2 hours. During the second hour, subjects also received a 5% saline (HS) infusion (0.1 ml/kg/min). The baseline parameters were similar on each of the study days. Plasma ANH levels increased approximately twofold, eightfold, and 25-fold during LD, MD, and HD infusions, respectively. HS infusion caused increases in serum sodium level (5 to 7 mEq/L) and osmolality (14 to 15 mOsm/L) (p < 0.001). During HS infusion on P day, ANH levels almost doubled (p < 0.001). AVP levels remained stable during the first hour of ANH infusions. An addition of HS caused a significant increase in AVP levels (p < 0.001). The magnitude of this increase was similar on each of the study days. Similarly, thirst perception increased significantly (p < 0.01) and to the same extent during HS infusion on all study days. Both AVP levels and thirst showed a very good correlation with serum osmolality on each of the study days, and there were no significant differences between any of the slopes or intercepts. We conclude that short-term elevation of plasma ANH levels up to 25-fold affects neither the osmotically stimulated secretion of AVP nor thirst perception.

Is health locus of control related to health education activity

Analysis of responses of 1922 teachers indicated that Multidimensional Health Locus of Control scale was a suitable instrument for assessing their health beliefs. The results suggest that health belief is not linked to whether teachers teach about cancer and, by implication, health generally.

Cancer education and the primary school teacher in England and Wales

Many adult behaviors and attitudes develop in early childhood. There is a growing acceptance of the need for health education of children of primary school age. Cancer is an important topic within health education, and this study was designed to assess the level of cancer education in schools. Data were collected from a randomly selected sample of over 1,000 teachers of children in primary school years 3-6 (ages 7-11 years). Cancer had been taught about by 18% of the sample, and their pupils' ages had no significant effect on whether they had taught about cancer. Cancer was most often taught about in response to a real-life situation, and the majority of the teachers did not use cancer education resources to help them. The study sought to ascertain why so many teachers had taught about cancer. It appears that concerns over their own lack of personal knowledge, and a perceived lack of resources, were the most common reasons. The young age of the pupils was also a deterrent to cancer education, especially among the teachers of the younger pupils. The results indicate various interventions that may increase the level of primary-school-based cancer education. These include improving teachers' awareness of cancer education issues and providing appropriate cancer education resources.

Autologous bone marrow transplantation in poor-risk high-grade non-Hodgkin's lymphoma in first complete remission. Newcastle and Northern Lymphoma Group

We report the safety and efficacy of autologous bone marrow transplantation (ABMT) in 30 patients with high-grade non-Hodgkin's lymphoma (NHL) in first complete remission (CR1) following remission induction chemotherapy. Two patients relapsed prior to ABMT. All patients were conditioned with high-dose melphalan. In Addition, ten received fractionated total body irradiation, one hemi-body irradiation and four high-dose etoposide. Unmanipulated non-cryopreserved autologous marrow was reinfused within 56 h of harvesting. Engraftment occurred in all patients with a median of 11 days of neutropenia (< 0.5 x 10(9) l-1), a median requirement for platelet transfusion of 3 days and packed red cell transfusion of 2 units, with a median hospital stay of 18 days post transplant. There was no procedure-related mortality and only minor morbidity was observed. Two patients relapsed at 1 and 2 months post transplantation, and one patient died of carcinoma of the lung 33 months after transplantation. The remaining 25 patients remain alive, well and in CR1 with a median follow-up of 44 months. The event-free survival at 3 years for all patients considered for ABMT was 83%. We conclude that ABMT for high-grade NHL in CR1 with non-cryopreserved marrow results in rapid haematological recovery without growth factor support. It is safe and is associated with high survival when used as consolidation of CR in high-risk patients.

Zidovudine phosphorylation in HIV-infected patients and seronegative volunteers

OBJECTIVES AND DESIGN

Measurement of phosphorylated zidovudine (ZDV) inside infected cells is more likely to provide satisfactory dose response relationships than serum concentrations. This study provides information on ZDV phosphorylation in HIV-seronegative volunteers (n = 5) and in patients with HIV infection (n = 12).

METHODS

Intracellular ZDV phosphate metabolites were measured in peripheral blood mononuclear cells isolated from whole blood by density cushion centrifugation. Cells were washed and extracted overnight with 60% methanol prior to analysis by high performance liquid chromatography. Fractions eluted from the column corresponding to ZDV, ZDV monophosphate (ZDV-MP), ZDV diphosphate (ZDV-DP) and ZDV triphosphate (ZDV-TP) were collected, hydrolysed by acid phosphatase and ZDV levels quantified by radioimmunoassay.

RESULTS

The area under the plasma ZDV concentration-time curve (AUC0-6 h) was similar in seronegative volunteers and patients [mean +/- SD, 4.64 +/- 2.50 versus 5.56 +/- 2.67 mumoles/l h; 95% confidence interval (CI), -4.39-2.23; P = 0.646, Mann-Whitney U test]. However, ZDV phosphorylation was greater in patients, with the AUC0-6 h for total phosphate metabolites being 5.91 +/- 3.42 pmoles/10(6) cells h compared with seronegative volunteers (0.66 +/- 0.48 pmoles/10(6) cells h; 95% CI, -8.35 to -2.32; P = 0.0003). The concentration of ZDV-TP was similar in both groups, the increase in total phosphates in patients being due primarily to ZDV-MP. ZDV-MP AUC0-6 h and total ZDV phosphate AUC0-6 h were closely correlated (r2 = 0.94). The relationship between total ZDV phosphate AUC0-6 h and the CD4 count demonstrates that patients with a count < 100 x 10(6)/l have much higher ZDV phosphate levels, predominantly ZDV-MP.

CONCLUSION

ZDV is phosphorylated to a greater extent in patients than in healthy volunteers. The increased ZDV-MP in patients with low CD4 counts may explain the well known occurrence of increased ZDV toxicity in patients with more advanced disease. The ability to measure ZDV phosphorylated metabolites (without the administration of radiolabelled nucleoside) represents a significant advance in our understanding of the clinical pharmacology of the drug.

Laparoscopic varicocelectomy

We report our initial experience of laparoscopic ligation of varicocele in 13 patients with a mean age of 34 years (range 18-39). Eight patients were subfertile, and the rest complained of dragging pain and discomfort in the left scrotum. At laparoscopy the peritoneum overlying the spermatic vessels was divided, and the spermatic veins were mobilized, clipped, and divided. The spermatic artery was identified and preserved in 11 of the 13 cases. The patients were discharged within 24 h of hospital admission. Semen quality improved in seven of the eight subfertile patients studied with a mean follow-up of 8 months. Four patients who were operated on for pain and discomfort had symptomatic improvement by the time of their first outpatient visit at 3 months. One patient complained of paresthesia along the anterior aspect of his thigh, which resolved in 6 weeks. There were no other complications. Laparoscopic varicocelectomy is a safe and effective minimally invasive procedure for treatment of clinical varicocele.

Follow-up of abnormal Papanicolaou smears among women of different races

BACKGROUND

Current information about racial differences in the rate of cervical abnormalities is incomplete, and there are few data about racial differences in compliance with follow-up and treatment. The purpose of this study was to investigate the frequency and follow-up of abnormal Pap smear findings in white, black, and Southeast Asian women.

METHODS

The charts of women who attended a St Paul family practice residency clinic and who had abnormal Papanicolaou (Pap) smear results between January 1, 1989, and September 1, 1992, were reviewed, and information about age, race, insurance, Pap smear findings, diagnostic studies, and treatment procedures was recorded.

RESULTS

Of 1794 women who had Pap smears during this period, 190 (10.6%) had abnormal results, with a diagnosis of atypia, dysplasia, or carcinoma. The rate of abnormality was greater for black women (16.4%) than for Southeast Asian (6.1%) and white women (11.6%); however, the proportion of abnormal Pap smears that showed moderately severe or worse changes was greater for Southeast Asians than for whites (30.6% vs 14.3%, P < .05). Southeast Asian women with abnormal Pap smears were also less likely than whites and blacks to follow through with recommended diagnostic and treatment procedures.

CONCLUSIONS

Southeast Asian women in this study were less likely than white and black women to comply with recommended follow-up diagnostic and treatment procedures for cervical disease.

Serum inhibitors precede the development of SAIDS

Rhesus macaque monkeys infected with the simian immunodeficiency virus develop a syndrome mimicking AIDS in humans. We have demonstrated previously that sera from individuals infected with human immunodeficiency virus type 1 inhibit the proliferation of lymphocytes from healthy noninfected subjects and that this phenomenon is associated with the development of clinical AIDS. We have also shown that sera from monkeys infected with SIV also have such inhibitors. In this body of work, we attempted to document the onset of these inhibitors in relation to the time of SIV infection. Twenty rhesus macaques were injected with one of two tissue strains of SIV or media. Blood was drawn on a set schedule and the serum samples frozen at -70 degrees C. The animals were monitored and observed for up to 42 weeks. All test animals were autopsied. Sera from all the draws were assayed against the same populations of human peripheral blood mononuclear cells in the same experiment using suboptimal amounts of phytohemagglutinin (PHA). Sera from those animals that subsequently developed SAIDS were more likely to demonstrate serum inhibition. This inhibition could be seen as early as 8-10 weeks after infection. By week 14, the assay could differentiate animals into SAIDS or healthy groups with a sensitivity of 67% and a specificity of 89%.

Randomized phase I chemoprevention dose-seeking study of alpha-difluoromethylornithine

BACKGROUND

alpha-Difluoromethylornithine (DFMO) is an irreversible inhibitor of ornithine decarboxylase (ODC), the key enzyme in mammalian polyamine biosynthesis. Levels of ODC are closely related to tumor promotion, and inhibition of ODC is associated with suppression of tumor development in laboratory animals. DFMO has shown a dose-response effect in tumor inhibition in mice.

PURPOSE

A randomized phase I study of DFMO was conducted to determine the lowest daily oral dose that can achieve at least 50% inhibition of ODC activity induced by 12-O-tetradecanoylphorbol-13-acetate (TPA) in human skin, with minimal clinical toxicity (grade 1 or lower; Eastern Cooperative Oncology Group [ECOG]).

METHODS

Cancer patients entered in steps 1 and 2 of the study had been treated and had no clinical evidence of cancer. In step 1, 13 patients received 0.125, 0.25, 0.5, or 0.75 g/m2 DFMO four times a day. In step 2, 13 patients received 0.125 or 0.25 g/m2 four times a day or 0.5 or 1.0 g/m2 every day. The 26 patients treated in steps 1 and 2 (range, < 1-6 months) had colon, prostate, or bladder cancer. In step 3, six cancer-free subjects at risk for colorectal cancer received 0.5 g/m2 every day for 5-12 months. To evaluate the effectiveness of DFMO in reducing TPA-induced ODC activity, we calculated the percent change from pretreatment ODC levels in skin biopsy specimens and the percentage of subjects with at least a 50% reduction in ODC levels.

RESULTS

In step 1 of the study, treatment-limiting audiotoxicity was observed at the three highest doses. Because the only dose with no major toxic effects in step 2 was 0.5 g/m2 every day, that dose was administered in step 3, with no major toxic effects. Seven subjects treated with 0.5 g/m2 every day had pretreatment ODC levels in the normal range; five averaged a reduction in ODC activity of at least 50%. DFMO had linear pharmacokinetics over the entire dose range. When 0.5 g/m2 was given every day, the peak plasma concentration was 47.1 +/- 5.1 microM at 3-4 hours (monthly mean +/- SE, 14.5 +/- 5.2 microM); half-life was 3.5 hours; and area under the curve for plasma concentration x time for a single dose of DFMO was 311 +/- 39 microM x hour.

CONCLUSIONS

These data support phase II chemoprevention studies with DFMO given at a dose of 0.5 g/m2 every day.

IMPLICATIONS

Studies investigating prevention of cancers with DFMO are under consideration.