Inhibin-Positive "Cholangioblastic" Variant of Intrahepatic Cholangiocarcinoma: Report of 3 New Patients With Review of the Literature

Cholangiocarcinoma is the second most common primary liver malignant neoplasm. It usually affects older individuals in their seventh decade of life with no gender predilection. Recently, a distinct subtype of cholangiocarcinoma has emerged with 2 proposed names: "cholangioblastic" and "solid tubulocystic." This variant predominantly occurs in younger women who lack the common risk factors for patients diagnosed with cholangiocarcinomas, such as older age and chronic liver disease or cirrhosis. We describe 3 new patients with a cholangioblastic variant of intrahepatic cholangiocarcinoma. At the time of diagnosis, the patients were aged 19-, 46-, and 28-year-old; 2 females and 1 male (the 46-year-old). None of our patients had a history of chronic liver disease or known predisposing factors for liver tumors. Tumor size ranged from 2.3 to 23 cm in greatest dimension. Histological examination of these tumors demonstrated reproducible morphology characterized by trabecular, nested, and multicystic patterns with micro and macro follicles filled with eosinophilic material. The immunohistochemical profile showed that the tumor cells were positive for keratin 7, inhibin, synaptophysin, and albumin in situ hybridization, while negative for HepPar1, arginase, and INSM1. All tumors lacked conventional intrahepatic cholangiocarcinoma/adenocarcinoma morphology. We also review the literature and emphasize that neuroendocrine tumors should be recognized as a major diagnostic pitfall of this variant.

Heterozygous midnolin knockout attenuates severity of nonalcoholic fatty liver disease in mice fed a Western-style diet high in fat, cholesterol, and fructose

Although midnolin has been studied for over 20 years, its biological roles in vivo remain largely unknown, especially due to the lack of a functional animal model. Indeed, given our recent discovery that the knockdown of midnolin suppresses liver cancer cell tumorigenicity and that this antitumorigenic effect is associated with modulation of lipid metabolism, we hypothesized that knockout of midnolin in vivo could potentially protect from nonalcoholic fatty liver disease (NAFLD) which has become the most common cause of chronic liver disease in the Western world. Accordingly, in the present study, we have developed and now report on the first functional global midnolin knockout mouse model. Although the overwhelming majority of global homozygous midnolin knockout mice demonstrated embryonic lethality, heterozygous knockout mice were observed to be similar to wild-type mice in their viability and were used to determine the effect of reduced midnolin expression on NAFLD. We found that global heterozygous midnolin knockout attenuated the severity of NAFLD in mice fed a Western-style diet, high in fat, cholesterol, and fructose, and this attenuation in disease was associated with significantly reduced levels of large lipid droplets, hepatic free cholesterol, and serum LDL, with significantly differential gene expression involved in cholesterol/lipid metabolism. Collectively, our results support a role for midnolin in regulating cholesterol/lipid metabolism in the liver. Thus, midnolin may represent a novel therapeutic target for NAFLD. Finally, our observation that midnolin was essential for survival underscores the broad importance of this gene beyond its role in liver biology.NEW & NOTEWORTHY We have developed and now report on the first functional global midnolin knockout mouse model. We found that global heterozygous midnolin knockout attenuated the severity of nonalcoholic fatty liver disease (NAFLD) in mice fed a Western-style diet, high in fat, cholesterol, and fructose, and this attenuation in disease was associated with significantly reduced levels of large lipid droplets, hepatic free cholesterol, and serum LDL, with significantly differential gene expression involved in cholesterol/lipid metabolism.

Gastrointestinal, Hepatic and Pancreatobiliary Involvement by Plasma Cell Neoplasms: Clinicopathologic Correlations in a Retrospective Cohort of 116 Cases

AIMS

Plasma cell neoplasms (PCNs) may involve the gastrointestinal (GI) tract in two forms: plasmacytoma (PC), an isolated lesion which lacks marrow involvement, and extramedullary myeloma (EMM). However, previous literature on PCNs involving the GI tract, liver and pancreas is limited. We evaluated the clinicopathologic features of the largest series of GI PCNs to date.

METHODS AND RESULTS

Six institutional archives were searched for GI, liver and pancreas cases involved by PCNs. Medical records were reviewed for clinical and imaging features. Histopathologic features evaluated included involved organ, tumor grade and marrow involvement. Overall, 116 cases from 102 patients were identified. Tumors most presented as incidental findings (29%). The liver was most involved (47%), and masses/polyps (29%) or ulcers (21%) were most common findings. Most cases had high-grade morphology (55%). The majority (74%) of GI PCNs were classified as EMM due to the presence of marrow involvement at some point during the disease course, occurring within a year of marrow diagnosis in 46% of patients. PC was classified in 26% of patients due to the lack of marrow involvement. Most (70%) patients died from disease within 10 years (median 14.1) of diagnosis and more than half (58%) died within 6 months.

CONCLUSION

PC and EMM involving the GI tract, liver and pancreas have a wide range of clinicopathologic presentations. Tumors may occur virtually anywhere in the GI tract or abdomen and may precede the diagnosis of marrow involvement. Both GI PC and EMM are associated with a poor prognosis.

Proteomic characterisations of ulcerative colitis endoscopic biopsies associate with clinically relevant histological measurements of disease severity

Aims and methods

Accurate protein measurements using formalin-fixed biopsies are needed to improve disease characterisation. This feasibility study used targeted and global mass spectrometry (MS) to interrogate a spectrum of disease severities using 19 ulcerative colitis (UC) biopsies.

Results

Targeted assays for CD8, CD19, CD132 (interleukin-2 receptor subunit gamma/common cytokine receptor gamma chain), FOXP3 (forkhead box P3) and IL17RA (interleukin 17 receptor A) were successful; however, assays for IL17A (interleukin 17A), IL23 (p19) (interleukin 23, alpha subunit p19) and IL23R (interleukin 23 receptor) did not permit target detection. Global proteome analysis (4200 total proteins) was performed to identify pathways associated with UC progression. Positive correlation was observed between histological scores indicating active colitis and neutrophil-related measurements (R²=0.42–0.72); inverse relationships were detected with cell junction targets (R²=0.49–0.71) and β-catenin (R²=0.51–0.55) attributed to crypt disruption. An exploratory accuracy assessment with Geboes Score and Robarts Histopathology Index cut-offs produced sensitivities/specificities of 72.7%/75.0% and 100.0%/81.8%, respectively.

Conclusions

Pathologist-guided MS assessments provide a complementary approach to histological scoring systems. Additional studies are indicated to verify the utility of this novel approach.

Thioacetamide-induced norepinephrine production by hepatocytes is associated with hepatic stellate cell activation and liver fibrosis

BACKGROUND

Collagen production by activated hepatic stellate cells (HSCs) to encapsulate injury is part of the natural wound-healing response in injured liver. However, persistent activation of HSCs can lead to pathological fibrogenesis. Such persistent HSC activation could be mediated by norepinephrine (NE), a reaction product of dopamine beta-hydroxylase (DBH).

OBJECTIVE

To investigate the potential paracrine role of NE in hepatotoxin thioacetamide (TAA)-induced liver fibrosis.

METHODS/RESULTS

In TAA-treated mice, fibrotic liver tissue showed significant increases in the mRNA expression of DBH up to 14-fold and collagen up to 7-fold. Immunohistochemical staining showed increased DBH protein expression in fibrotic liver tissue. Parenchymal hepatocyte cell line HepG2 expressed DBH and secreted NE, and the conditioned medium of HepG2 cells promoted collagenesis in nonparenchymal HSC cell line LX-2. TAA treatment increased DBH expression by 170% in HepG2 cells, as well as increased NE by 120% in the conditioned medium of HepG2 cells. The conditioned medium of TAA-treated HepG2 cells was used to culture LX-2 cells, and was found to increase collagen expression by 80% in LX-2 cells. Collagen expression was reduced by pre-treating HepG2 cells with siRNA targeting DBH or by adding NE antagonists to the conditioned medium. Finally, TAA-induced oxidative stress in HepG2 cells was associated with induction of DBH expression.

CONCLUSION

Collectively, our results suggest a potential role for DBH/NE-mediated crosstalk between hepatocytes and HSCs in fibrogenesis. From a therapeutic standpoint, antagonism of DBH/NE induction in hepatocytes might be a useful strategy to suppress pathological fibrogenesis.

p300 Serine 89: A Critical Signaling Integrator and Its Effects on Intestinal Homeostasis and Repair

Simple Summary

Given their high degree of identity and even greater similarity at the amino acid level, Kat3 coactivators, CBP (Kat3A) and p300 (Kat3B), have long been considered redundant. We describe the generation of novel p300 S89A knock-in mice carrying a single site directed amino acid mutation in p300, changing the highly evolutionarily conserved serine 89 to alanine, thus enhancing Wnt/CBP/catenin signaling (at the expense of Wnt/p300/catenin signaling). p300 S89A knock-in mice exhibit multiple organ system, immunologic and metabolic differences, compared with their wild type counterparts. In particular, these p300 S89A knock-in mice are highly sensitive to intestinal injury resulting in colitis which is known to significantly predispose to colorectal cancer. Our results highlight the critical role of this region in p300 as a signaling nexus and provide further evidence that p300 and CBP are non-redundant, playing definite and distinctive roles in development and disease.

Abstract

Differential usage of Kat3 coactivators, CBP and p300, by β-catenin is a fundamental regulatory mechanism in stem cell maintenance and initiation of differentiation and repair. Based upon our earlier pharmacologic studies, p300 serine 89 (S89) is critical for controlling differential coactivator usage by β-catenin via post-translational phosphorylation in stem/progenitor populations, and appears to be a target for a number of kinase cascades. To further investigate mechanisms of signal integration effected by this domain, we generated p300 S89A knock-in mice. We show that S89A mice are extremely sensitive to intestinal insult resulting in colitis, which is known to significantly increase the risk of developing colorectal cancer. We demonstrate cell intrinsic differences, and microbiome compositional differences and differential immune responses, in intestine of S89A versus wild type mice. Genomic and proteomic analyses reveal pathway differences, including lipid metabolism, oxidative stress response, mitochondrial function and oxidative phosphorylation. The diverse effects on fundamental processes including epithelial differentiation, metabolism, immune response and microbiome colonization, all brought about by a single amino acid modification S89A, highlights the critical role of this region in p300 as a signaling nexus and the rationale for conservation of this residue and surrounding region for hundreds of million years of vertebrate evolution.

Allaying uncertainty in diagnosing buried Barrett's esophagus

Subsquamous intestinal metaplasia (SSIM) in the setting of Barrett's esophagus (BE) is a technically challenging diagnosis. While the risk for progression of BE involving the surface mucosa is well documented, the potential risk for development of advanced neoplasia associated with SSIM has been controversial. This study aimed to determine the effects of specimen adequacy, presence of dysplasia, and interobserver agreement for SSIM interpretation. Adult patients (n = 28) who underwent endoscopic therapy for BE with high-grade dysplasia or intramucosal carcinoma (HGD/IMC) between October 2005 and June 2013 were included. Initial evaluation (n = 140 slides) by an experienced gastrointestinal pathologist was followed by an interobserver study by 8 pathologists. Forty-seven (34%) slides had insufficient subsquamous tissue to assess for SSIM. SSIM was found in 19% of all slides and 29% of slides with sufficient subsquamous tissue. At least one slide had SSIM in 54% to 64% of patients. Subsquamous low grade dysplasia (LGD) was found in 4 (15%) slides with SSIM and subsquamous HGD/IMC was found in 5 (19%) slides with SSIM. At the patient level, 8 (53%) had no dysplasia, 4 (27%) had LGD and 3 (20%) had HGD/IMC. Overall agreement for SSIM by slide was 92% to 94% (κ = 0.73 to κ = 0.82, moderate to strong agreement), and by patient was 82% to 94% (κ = 0.65 to κ = 0.87, moderate to strong agreement). This study confirms the need for assessing specimen adequacy and assessing the prevalence of SSIM and is the first to assess interobserver agreement for SSIM and dysplasia within SSIM.

Concurrent Adult-Onset Diffuse β-Cell Nesidioblastosis and Pancreatic Neuroendocrine Tumor: A Case Report and Review of the Literature

Nesidioblastosis is an uncommon cause of organic persistent hyperinsulinemic hypoglycemia in adults. We report a case of adult-onset diffuse β-cell nesidioblastosis in a 49-year-old woman who was status-post Roux-en-Y gastric bypass and distal pancreatectomy for a well-differentiated pancreatic neuroendocrine tumor. While the neuroendocrine tumor was suspected to be an insulinoma, persistent hypoglycemia postoperatively suggested either incomplete resection or a second pancreatic neoplasm. Completion pancreatectomy revealed islet β-cell hyperplasia and nuclear pleomorphism consistent with β-cell nesidioblastosis. The patient's blood glucose levels normalized after completion pancreatectomy. While β-cell nesidioblastosis and insulinomas can coexist in the same patient, pathologists should be aware of β-cell nesidioblastosis as a potential cause for hyperinsulinemic hypoglycemia and should exclude it in patients who have not shown definitive clinical response after surgical excision of a pancreatic neuroendocrine tumor.

Platform-independent gene expression signature differentiates sessile serrated adenomas/polyps and hyperplastic polyps of the colon

Background

Sessile serrated adenomas/polyps are distinguished from hyperplastic colonic polyps subjectively by their endoscopic appearance and histological morphology. However, hyperplastic and sessile serrated polyps can have overlapping morphological features resulting in sessile serrated polyps diagnosed as hyperplastic. While sessile serrated polyps can progress into colon cancer, hyperplastic polyps have virtually no risk for colon cancer. Objective measures, differentiating these types of polyps would improve cancer prevention and treatment outcome.

Methods

RNA-seq training data set and Affimetrix, Illumina testing data sets were obtained from Gene Expression Omnibus (GEO). RNA-seq single-end reads were filtered with FastX toolkit. Read mapping to the human genome, gene abundance estimation, and differential expression analysis were performed with Tophat-Cufflinks pipeline. Background correction, normalization, and probe summarization steps for Affimetrix arrays were performed using the robust multi-array method (RMA). For Illumina arrays, log₂-scale expression data was obtained from GEO. Pathway analysis was implemented using Bioconductor package GSAR. To build a platform-independent molecular classifier that accurately differentiates sessile serrated and hyperplastic polyps we developed a new feature selection step. We also developed a simple procedure to classify new samples as either sessile serrated or hyperplastic with a class probability assigned to the decision, estimated using Cantelli’s inequality.

Results

The classifier trained on RNA-seq data and tested on two independent microarray data sets resulted in zero and three errors. The classifier was further tested using quantitative real-time PCR expression levels of 45 blinded independent formalin-fixed paraffin-embedded specimens and was highly accurate. Pathway analyses have shown that sessile serrated polyps are distinguished from hyperplastic polyps and normal controls by: up-regulation of pathways implicated in proliferation, inflammation, cell-cell adhesion and down-regulation of serine threonine kinase signaling pathway; differential co-expression of pathways regulating cell division, protein trafficking and kinase activities.

Conclusions

Most of the differentially expressed pathways are known as hallmarks of cancer and likely to explain why sessile serrated polyps are more prone to neoplastic transformation than hyperplastic. The new molecular classifier includes 13 genes and may facilitate objective differentiation between two polyps.

Electronic supplementary material

The online version of this article (10.1186/s12920-017-0317-7) contains supplementary material, which is available to authorized users.

Meeting the Media: Friend or Foe?

For various reasons, the emergency department is an area of interest for the media. As a result, emergency physicians have to prepare for the occasions of being interviewed by the media some day in their career. It is natural to have some anxiety and fear in meeting the media, especially for the inexperienced. However, developing a good relationship with the media would not only benefit the organisation and the specialty, but also the general public as well. This is a review of the preparation, techniques, tricks and pitfalls in dealing with the media, especially in regard to television interviews.

Management of Body Packers in the Emergency Department

Body packing of illicit drugs is one of the means of drug trafficking. Asymptomatic suspects may be brought in by law-enforcement officers for body search of possible drug packing inside the body. Symptomatic body packers may present with gastrointestinal obstruction or toxicity of the leaking drugs inside the packets. Management strategies are largely determined by the modes of presentation. Asymptomatic persons must be persuaded with every effort for consent to the body cavity search as well as treatment for the safe passage of any packed drugs to avoid possible complications and medico-legal sequelae. Abdominal X-rays and computed tomography can be helpful in confirming the presence of drug packets and in identifying possible packet leakage. Gastrointestinal decontamination, whole bowel irrigation, use of specific antidote as well as operative intervention may be indicated. Emergency physicians must be conversant with the medical and legal aspects of the management of these body packers.

Emergency Management North of the Shenzhen River

A study was carried out in a district hospital located close to the Hong Kong - Shenzhen border, in order to get a picture of the epidemiology of diseases and injuries sustained by Hong Kong residents in China. The emergency medical treatment provided and the degree of patient satisfaction were also analysed. The majority of the patients were adult males. Trauma constituted more than 50% of the attendance, with traffic accident and common assault being the leading causes. This group of Hong Kong residents preferred to be treated in Hong Kong hospitals because of perceived better quality of care. There was a high demand on the local ambulance service and this might have financial and resource implications.

A Rare Cause of Necrotizing Fasciitis: Psoas Abscess

Necrotizing fasciitis always carries very high mortality and morbidity rates. It can be due to group A beta-haemolytic streptococci, which are traditionally described as the flesh-eating bacteria. More commonly, it is related to a mixed growth of bacteria that can be secondary to trauma or surgery. Secondary necrotizing fasciitis due to concomitant soft tissue infection is uncommon. We reported a fatal case of necrotizing fasciitis which was caused by a coexisting psoas abscess. A search for concomitant soft tissue infection is warranted in patients presenting with necrotizing fasciitis. This article also reviewed the clinical tools that may help to make an early diagnosis of the disease.

Beware of the Migrating Chest Pain and Widened Mediastinum: Case Series on Aortic Dissection

Objective

Aortic dissection is not a rare life-threatening emergency. Undiagnosed and untreated aortic dissection is associated with a high mortality. A review of cases in the hospital may provide a baseline picture to guide clinical decisions.

Design

Retrospective case review for a period of 3 years and 4 months.

Setting

District general hospital near the Hong Kong – Shenzhen ‘border’ with 24-hour Accident & Emergency service but without cardiothoracic surgical capability.

Population

All cases coded as ‘aortic dissection’ in the computerized ‘Clinical Management System’ of the hospital.

Main outcome measures

Date, sex, age, history of hypertension, presenting symptoms, pulse deficit, chest X-ray findings, pericardial effusion, A&E diagnosis, type of dissection and patient outcome.

Results

From August 1998 to November 2001, 26 cases of aortic dissection were identified. There were 19 males and 7 females. Age range was 26 to 90 years (mean 65.04 ± SD 15.04, median 66.50, mode 65). In the plain chest X-rays, widened superior mediastinum (>8 cm) was present in 19 patients (73.1%) and pleural effusion in three (11.5%). Pericardial effusion was found in six patients (23.1%). As regard to outcome, 11 were discharged home (42.3%), 14 were transferred to cardiothoracic surgical unit (where two subsequently died) and one died in the hospital.

Conclusion

The prevalence of aortic dissection may be more common than is generally appreciated by emergency physicians. Owing to its variable clinical presentations mimicking other diseases, the diagnosis of aortic dissection is easily missed. Higher clinical vigilance should be exercised for this potentially deadly condition.

Sexually transmitted infections of the lower gastrointestinal tract

The World Health Organization estimates that there is greater than one million new cases of sexually transmitted infections (STIs) every day. In many countries, STIs are at an unprecedented high, including the USA, where nearly 20 million new cases were reported in 2016. Although morbidity associated with STIs is usually seen in the context of genitourinary disease, these pathogens may also affect the gastrointestinal tract and cause anal pain, abdominal pain, or diarrhea. It is important to recognize patterns of injury associated with these pathogens, especially those that may mimic other gastrointestinal diseases, such as idiopathic inflammatory bowel disease (IBD). This review focuses upon STIs of the lower gastrointestinal tract, organized by the most common site of involvement: the anus, rectum, and colon.

Fluorescein as a topical fluorescent contrast agent for quantitative microendoscopic inspection of colorectal epithelium

Fiber bundle microendoscopic imaging of colorectal tissue has shown promising results, for both qualitative and quantitative analysis. A quantitative image quality control and image feature extraction algorithm was previously designed for quantitative image feature analysis of proflavine-stained ex vivo colorectal tissue. We investigated fluorescein as an alternative topical stain. Images of ex vivo porcine, caprine, and human colorectal tissue were used to compare microendoscopic images of tissue topically stained with fluorescein and proflavine solutions. Fluorescein was shown to be comparable for automated crypt detection, with an average crypt detection sensitivity exceeding 90% using a combination of three contrast limit pairs.

Gastric Proteins MUC5AC and TFF1 as Potential Diagnostic Markers of Colonic Sessile Serrated Adenomas/Polyps

OBJECTIVES

A subset of colon cancers originates from sessile serrated adenomas/polyps (SSA/Ps). Our goal was to identify markers for SSA/Ps that could aid in distinguishing them from hyperplastic polyps (HPs).

METHODS

We performed immunostaining for gastric proteins MUC5AC and TFF1 in formalin-fixed, paraffin-embedded (FFPE) samples of HPs (n = 47), SSA/Ps (n = 37), and normal colon (n = 30).

RESULTS

Control mucosa expressed only trace amounts of MUC5AC and TFF1. HPs exhibited an 11.3- and 11.4-fold increase in MUC5AC and TFF1 expression confined to the upper segments of the crypts near the luminal surface of the polyps. SSA/Ps displayed on average 1.6-fold (MUC5AC, P  < .008) and 1.4-fold (TFF1, P  < .03) higher signal intensity for these markers than HPs, with a dramatic coexpression of MUC5AC and TFF1 typically occupying the entire length of the crypt. Immunoperoxidase results were similar to immunofluorescence staining for both MUC5AC and TFF1.

CONCLUSIONS

Our results suggest that the analysis of expression of MUC5AC and TFF1 may be useful for differentiating SSA/Ps from HPs. We also suggest the possibility that crypt morphology may be at least partly due to overproduction of highly viscous gastric mucins and that these proteins may play a role in the serrated pathway to colon carcinogenesis.

Quantitative analysis of ex vivo colorectal epithelium using an automated feature extraction algorithm for microendoscopy image data

Qualitative screening for colorectal polyps via fiber bundle microendoscopy imaging has shown promising results, with studies reporting high rates of sensitivity and specificity, as well as low interobserver variability with trained clinicians. A quantitative image quality control and image feature extraction algorithm (QFEA) was designed to lessen the burden of training and provide objective data for improved clinical efficacy of this method. After a quantitative image quality control step, QFEA extracts field-of-view area, crypt area, crypt circularity, and crypt number per image. To develop and validate this QFEA, a training set of microendoscopy images was collected from freshly resected porcine colon epithelium. The algorithm was then further validated on ex vivo image data collected from eight human subjects, selected from clinically normal appearing regions distant from grossly visible tumor in surgically resected colorectal tissue. QFEA has proven flexible in application to both mosaics and individual images, and its automated crypt detection sensitivity ranges from 71 to 94% despite intensity and contrast variation within the field of view. It also demonstrates the ability to detect and quantify differences in grossly normal regions among different subjects, suggesting the potential efficacy of this approach in detecting occult regions of dysplasia.

Quantitative structural markers of colorectal dysplasia in a cross sectional study of ex vivo murine tissue using label-free multiphoton microscopy

Two-photon excitation of label-free tissue is of increasing interest, as advances have been made in endoscopic clinical application of multiphoton microscopy, such as second harmonic generation (SHG) scanning endoscopy used to monitor cervical collagen in mice¹. We used C57BL mice as a model to investigate the progression of gastrointestinal structures, specifically glandular area and circularity. We used multiphoton microscopy to image ex-vivo label-free murine colon, focusing on the collagen structure changes over time, in mice ranging from 10 to 20 weeks of age. Series of images were acquired within the colonic and intestinal tissue at depth intervals of 20 microns from muscularis to the epithelium, up to a maximum depth of 180 microns. The imaging system comprised a two-photon laser tuned to 800nm wavelength excitation, and the SHG emission was filtered with a 400/40 bandpass filter before reaching the photomultiplier tube. Images were acquired at 15 frames per second, for 200 to 300 cumulative frames, with a field of view of 261um by 261um, and 40mW at sample. Image series were compared to histopathology H&E slides taken from adjacent locations. Quantitative metrics for determining differences between murine glandular structures were applied, specifically glandular area and circularity.

Overexpression of p53 predicts colorectal neoplasia risk in patients with inflammatory bowel disease and mucosa changes indefinite for dysplasia

Background and aims: We previously demonstrated a significant colorectal neoplasia risk in inflammatory bowel disease (IBD) patients with mucosal changes indefinite for dysplasia (IND) and the potential diagnostic utility of p53 and cytokeratin 7 immunohistochemistry in IBD-associated neoplasia. The primary aim of this exploratory study was to determine the predictive value of the two markers for neoplasia risk in the IBD-IND population.

Methods: We identified 44 eligible cases with IBD and IND in colon biopsy from our pathology database. We semi-quantified the expression of p53 and cytokeratin 7 in the colon biopsies by immunohistochemistry and correlated their expression, demographic information, and clinical features with colorectal neoplasia outcome.

Results: The mean age of the cohort was 46.6 ± 15.1 years, with 25 (56.8%) being male. The median follow-up was 101 months (range: 6–247) after IND diagnosis. Among these 44 patients, 11 (25%) progressed to neoplasia (low-grade dysplasia = 6; high-grade dysplasia = 2; cancer 3) at a median follow-up of 66 months (range: 19–145). Univariate analysis demonstrated that age and p53 overexpression were associated with progression to neoplasia.

Conclusions: Twenty-five percent of patients with IBD and IND developed colorectal dysplasia or cancer. Overexpression of p53 and age are associated with neoplastic progression.

Gene expression profiling of serrated polyps identifies annexin A10 as a marker of a sessile serrated adenoma/polyp

Sessile serrated adenomas/polyps (SSA/Ps) are precursors of colon cancer, particularly those that exhibit microsatellite instability. Distinguishing SSA/Ps from the related, but innocuous, microvesicular hyperplastic polyp (MVHP) can be challenging. In this study seven gastrointestinal pathologists reviewed 109 serrated polyps and identified 60 polyps with histological consensus. Microarray analysis was performed on six distal consensus MVHPs < 9 mm, six proximal consensus SSA/Ps > 9 mm, and six normal colon biopsies (three proximal, three distal). Comparative gene expression analysis confirmed the close relationship between SSA/Ps and MVHPs as there was overlapping expression of many genes. However, the gene expression profile in SSA/Ps had stronger and more numerous associations with cancer-related genes compared with MVHPs. Three genes (TFF2, FABP6, and ANXA10) were identified as candidates whose expression can differentiate SSA/Ps from MVHPs, and the differences in expression were confirmed by quantitative RT-PCR. As ANXA10 showed the most promise in differentiating these polyps, the expression of ANXA10 was evaluated by immunohistochemistry in consensus SSA/Ps (n = 26), MVHPs (n = 21), and normal colon (n = 9). Immunohistochemical expression of ANXA10 was not identified in separate samples of normal colon or in the normal colonic epithelium adjacent to the serrated polyps. Consistent with the microarray and quantitative RT-PCR experiments, immunohistochemical expression of ANXA10 was markedly increased in SSA/Ps compared to MVHPs (p < 0.0001). An ANXA10 score ≥ 3 has a sensitivity of 73% and a specificity of 95% in the diagnosis of an SSA/P. In conclusion, we show that SSA/Ps and MVHPs have significant overlap in gene expression, but also important differences, particularly in cancer-related pathways. Expression of ANXA10 may be a potential marker of the serrated pathway to colon cancer.

Fatal parasitic meningoencephalomyelitis caused by Halicephalobus deletrix : a case report and review of the literature

Infection with the saprophagous nematode Halicephalobus species is uncommon but has been reported in horses worldwide. Only 3 human cases have been previously described, all of which have been fatal. We report a fourth fatal case, which occurred in a 39-year-old woman who presented with meningeal signs, altered mental status, and a prodromal pruritic rash. Diagnostic evaluation included an open brain biopsy, which was diagnosed as granulomatous vasculitis. The patient subsequently died after a course of steroids and cyclophosphamide. At autopsy, a robust perivascular mixed inflammatory infiltration of the brain parenchyma, meninges, and ventricular system was present with larval forms and mature nematodes morphologically consistent with Halicephalobus deletrix . Although extremely rare, this organism needs to be considered in the differential diagnosis of human helminthic infection of the central nervous system.

'Fracture' of the penis: a case series

OBJECTIVES

To examine the epidemiology of penile 'fracture' and its presenting characteristics in the local population.

DESIGN

Retrospective study.

SETTING

District hospital, Hong Kong.

PATIENTS

Patients with a discharge diagnosis of 'fractured' penis during a 7-year period from August 1998 to August 2005.

MAIN OUTCOME MEASURES

Age, time of attendance, cause, symptoms, signs, emergency department diagnosis, site of rupture, operative findings, and final outcome.

RESULTS

A total of 11 patients were identified. The mean age was 44 years (range, 30-63 years). The interval between time of injury and presentation ranged from 17 minutes to 7 days. Seven (64%) cases were attributed to sexual intercourse, three (27%) to penile manipulation, and one (9%) to rolling over the erect penis during sleep. Ten patients underwent surgery; all had primary suturing of the tunica tear, while two also required primary urethral repair. At follow-up, three (27%) patients had erectile dysfunction, one had mild penile deformity and one had a mild urethral stricture.

CONCLUSION

Emergency physicians and surgeons, as well as family physicians, should be familiar with the presentation of 'fractured' penis, as prompt diagnosis and early surgical repair are instrumental in ensuring a successful outcome with minimal complications. The public should also be educated to seek medical attention immediately, as delay or failure to report may result in permanent physical and psychological disabilities that could otherwise have been avoided.

Microarray analyses and molecular profiling of Stat3 signaling pathway induced by hepatitis C virus core protein in human hepatocytes

Hepatitis C virus (HCV) infection is a major contributor to the development of end-stage liver disease, including cirrhosis and hepatocellular carcinoma (HCC). We have previously shown that HCV core protein promotes immortalization of primary human hepatocytes. To identify molecular changes involved in core protein-mediated immortalization, we have investigated differential gene expression by microarray analyses in primary human hepatocytes and HCV core gene introduced hepatocytes after senescence (early passage), immortalization (middle passage), and anchor-independent growth (late passage). Out of 33,000 human genes screened, 1918 transcripts were differentially expressed (>2-fold) in immortalized human hepatocytes (IHH) as compared to negative controls. Our analyses provided a molecular portrait of changes in gene expression associated with three distinct stages of hepatocytes after introduction of HCV core gene. Many of the overall changes were involved with important cellular pathways, including cell growth regulation, immune regulation, oxidative stress, and apoptosis. We focused on the Stat3 signaling pathway by further verifying selected genes at the protein level relevant to hepatocyte growth regulation. Our data suggested that the introduction of HCV core protein results in an increase in expression of IL-6, gp130, leptin receptor, and Stat3. Upregulation of these genes in turn may regulate c-myc and cyclin D1, downstream of the Stat3 signaling pathway. Identification of these modulated genes with potential roles may help in the selection of targets for therapies against HCV-mediated liver disease progression.

Is public access defibrillation needed in Hong Kong?

The survival rate for non-traumatic out-of-hospital cardiac arrest in Hong Kong is low (1.25%-1.6%). Despite the reduced time interval between call receipt and first defibrillatory shock to 11.12 minutes during the past decade, the time interval between collapse/recognition and first defibrillatory shock, at 14.25 minutes, is too long. Studies of out-of-hospital cardiac arrest performed in Hong Kong were reviewed to ascertain whether a public access defibrillation programme can improve survival in Hong Kong. Three delays were found in the traditional response by emergency medical service, namely in the collapse/recognise-to-call receipt, call receipt-to-vehicle stops, and vehicle stops-to-first defibrillatory shock time intervals. The first delay is related to public education, while the second and third delays are intrinsic to a dispatched response. A public access defibrillation programme employing responders at scenes of cardiac arrests can eliminate the collapse/recognise-to-call receipt and call receipt-to-vehicle stops time intervals before defibrillation. Possible sites of public access defibrillation could include the airport and other immigration points, which have a high volume of people passing through, with projected figures for out-of-hospital cardiac arrest at these sites supporting this consideration. For successful implementation of public access defibrillation, a comprehensive educational programme and coordination with the emergency medical service are required.

Patient absconding behaviour in a public general hospital: retrospective study

OBJECTIVE

To identify characteristics of patients who abscond from general hospital wards, and to determine patient outcomes.

DESIGN

Retrospective study.

SETTING

In-patient wards of a public general hospital, Hong Kong.

SUBJECTS AND METHODS

Incident reports of 116 absconding episodes over a 20-month period from 1 November 1998 to 30 June 2000 were reviewed. Clinical characteristics, time and reason for absconding, destination of patient, outcomes, and adverse events were recorded.

RESULTS

The majority of patients who absconded were middle-aged males admitted through the Accident and Emergency Department to the specialty of general medicine. Most incidences occurred within 24 hours of admission while in the emergency admission wards. Twelve percent of incidents were repeated episodes of absconding. The most common clinical diagnoses given to this patient group were drug overdose, intoxication, and soft tissue injury. Known drug addicts (29.3%) formed a substantial proportion of the patient group. Forty- seven patients returned to the ward within a few hours, while a further nine (7.8%) re-attended the Accident and Emergency Department of the hospital within 4 days. Several adverse outcomes were recorded: one patient died following a fall from height and two patients committed criminal offences.

CONCLUSION

Patient absconding incidents are an important issue in hospital risk management. They can delay the delivery of appropriate medical treatment and may lead to other adverse patient outcomes, in addition to potential medicolegal consequences.

A cluster of invasive aspergillosis in a bone marrow transplant unit related to construction and the utility of air sampling

BACKGROUND

An investigation was launched to identify the source of a cluster of invasive aspergillosis in the bone marrow transplant unit (BMTU) when construction was taking place on the floor directly below the unit. The utility of air sampling for Aspergillus was examined.

METHODS

Cases of Aspergillus colonization and infection were identified in the BMTU and in the wards adjacent to the construction site. Air sampling was performed in the BMTU before and after room and air duct cleaning and then randomly during a 6-month period, beginning 6 months after construction ended. The results were correlated with the incidence of Aspergillus infections.

RESULTS

The cluster of cases of invasive aspergillosis could not be directly linked to the construction. In the BMTU, the rate of Aspergillus colonization and infection during construction was 2.5 times higher than that for the 6 months before the construction and 2.9 times higher for the adjacent wards. After construction ended, the rates returned to pre-construction rates. Two cases of invasive aspergillosis were observed in the BMTU during random air sampling, but the results of air sampling could not be correlated to cases.

CONCLUSIONS

Although the cluster of cases of invasive aspergillosis could not be linked to the construction, the construction did increase the rates of Aspergillus colonization in the BMTU and adjacent wards. Periodic air samplings could not correlate conidia counts to invasive Aspergillus infection.

Enterobacter sakazakii infections among neonates, infants, children, and adults. Case reports and a review of the literature

Enterobacter sakazakii can cause serious infections especially among the very young and the elderly. It continues to be more common among neonates and infants than adults. Its tropism for the central nervous system in neonates and infants remains a mystery. Among neonates and infants, E. sakazakii has a propensity to cause meningitis resulting in ventriculitis, brain abscess or cyst formation, and development of hydrocephalus requiring ventricular-peritoneal shunt. Computed tomography of the head is therefore useful in following patients with E. sakazakii meningitis. Mortality and morbidity of E. sakazakii meningitis is high, and virtually all patients recovering from the central nervous system infection suffered mental and physical developmental delays. The case-fatality rate decreased among patients with meningitis treated with the third-generation cephalosporins. Most adults with E. sakazakii infection had serious underlying diseases and 50% of the adults with the infection had malignancies. However there has never been a known case of meningitis. Increasing antibiotic resistance among Enterobacter species should lead one to consider using the carbapenems or the newer cephalosporins in combination with a second agent such as an aminoglycoside. Limited data suggest that trimethoprim-sulfamethoxazole may be a useful agent in the treatment of infections caused by the Enterobacter species, especially in view of the production of extended-spectrum beta-lactamases capable of inactivating the cephalosporins and extended-spectrum penicillin.

Prehospital care in Hong Kong

A quick and efficient prehospital emergency response depends on immediate ambulance dispatch, patient assessment, triage, and transport to hospital. During 1999, the Ambulance Command of the Hong Kong Fire Services Department responded to 484,923 calls, which corresponds to 1329 calls each day. Cooperation between the Fire Services Department and the Hospital Authority exists at the levels of professional training of emergency medical personnel, quality assurance, and a coordinated disaster response. In response to the incident at the Hong Kong International Airport in the summer of 1999, when an aircraft overturned during landing, the pre-set quota system was implemented to send patients to designated accident and emergency departments. Furthermore, the 'first crew at the scene' model has been adopted, whereby the command is established and triage process started by the first ambulance crew members to reach the scene. The development of emergency protocols should be accompanied by good field-to-hospital and interhospital communication, the upgrading of decision-making skills, a good monitoring and auditing structure, and commitment to training and skills maintenance.

Delays by patients, emergency physicians, and surgeons in the management of acute appendicitis: retrospective study

OBJECTIVES

To compare the contributions of patients, emergency physicians, and surgeons in the delay of diagnosis and treatment of appendicitis, and the effects of delay on disease stage and complication rate.

DESIGN

Retrospective study.

SETTING

Accident and emergency department of a district public hospital, Hong Kong.

PATIENTS

All patients undergoing emergency appendectomy between August 1998 to September 1999.

MAIN OUTCOME MEASURES

Patient delay in presentation, emergency physician delay in hospital admission, and surgeon delay in performing the operation; operative findings; and postoperative complications.

RESULTS

Of 158 patients undergoing emergency operation, 14 had no pathological diagnosis and four had a diagnosis other than that of acute appendicitis. Of the 140 pathologically confirmed cases of appendicitis, the mean emergency patient delay was greater in advanced appendicitis than it was in simple appendicitis (42.0 hours versus 24.9 hours; P<0.005). The mean emergency physician delay in advanced appendicitis was also greater than it was in simple appendicitis (17.9 hours versus 5.8 hours; P<0.05). The difference in the mean surgeon delay in simple (10.9 hours) and advanced (16.3 hours) appendicitis, however, was not significant. The mean emergency physician delay showed a significant association with the postoperative complication rate (P=0.05). The delay was mainly because of a failure to diagnose the condition and admit the patient at the first visit to the accident and emergency department (22.1%). The diagnostic accuracy showed a significant association with the level of experience of the emergency physician involved (P<0.05).

CONCLUSION

There should be a higher index of suspicion, better surgical training, and better senior supervision at accident and emergency departments, to avoid preventable morbidity and mortality in acute appendicitis.

Influenza in human immunodeficiency virus-infected patients during the 1997-1998 influenza season

A cluster of cases of severe influenzal disease was recognized in HIV-infected individuals during the 1997-1998 influenza season. Both primary influenza pneumonia and concomitant viral and bacterial pneumonia were found.

Tc-99m hexamethylpropylene amine oxime scintigraphy in the diagnosis of brain death and its implications for the harvesting of organs used for transplantation

PURPOSE

Diagnosing brain death is important in managing the comatose patient for whom the continuation of life support is being questioned and when organ harvesting is being considered. The virtual immediate localization of Tc-99m HMPAO to cerebral and cerebellar tissue provides an index of blood perfusion, and its absence denotes brain death. Other methods for assessing brain death include cerebral angiography, MRI, CT imaging after inhalation of stable xenon, electroencephalography, and clinical examination. The contrast material used for angiography may damage harvested organs, and the other studies have significant errors. MRI, CT imaging, and angiography are unsuitable for bedside use.

METHODS

Twenty-three patients, who presented with head trauma, prolonged anoxia or intrinsic brain disease (e.g., glioblastoma multiforme) and who were brain-dead by clinical examination criteria, were referred to the nuclear medicine division for verification of brain death. For adults, approximately 25 mCi Tc-99m hexamethylpropylene amineoxime (HMPAO) was administered intravenously. All patients but one were imaged using a mobile scintillation camera at the bedside.

RESULTS

We demonstrated (1) both cerebral and cerebellar perfusion, (2) neither cerebral nor cerebellar perfusion, (3) cerebral without cerebellar perfusion, and (4) cerebellar without cerebral perfusion. Patients without cerebral perfusion were diagnosed as brain-dead. The significance of a viable cerebellum in the absence of cerebral viability was not fully appreciated, although organs were harvested from such patients. We determined how well the clinical examination criteria held up in the diagnosis of brain death against the new gold standard of Tc-99m HMPAO scintigraphy: Clinical examination criteria correctly predicted brain death only 83% of the time compared with HMPAO scintigraphy.

CONCLUSIONS

Brain death assessment by Tc-99m HM-PAO scintigraphy has proved to be a reliable, safe, and cost-effective bedside method and may have practical application in the assessment of brain death in potential cadaveric donors.

Persistence of episomal HIV-1 infection intermediates in patients on highly active anti-retroviral therapy

Treatment of HIV-1-infected individuals with a combination of anti-retroviral agents results in sustained suppression of HIV-1 replication, as evidenced by a reduction in plasma viral RNA to levels below the limit of detection of available assays. However, even in patients whose plasma viral RNA levels have been suppressed to below detectable levels for up to 30 months, replication-competent virus can routinely be recovered from patient peripheral blood mononuclear cells and from semen. A reservoir of latently infected cells established early in infection may be involved in the maintenance of viral persistence despite highly active anti-retroviral therapy. However, whether virus replication persists in such patients is unknown. HIV-1 cDNA episomes are labile products of virus infection and indicative of recent infection events. Using episome-specific PCR, we demonstrate here ongoing virus replication in a large percentage of infected individuals on highly active anti-retroviral therapy, despite sustained undetectable levels of plasma viral RNA. The presence of a reservoir of 'covert' virus replication in patients on highly active anti-retroviral therapy has important implications for the clinical management of HIV-1-infected individuals and for the development of virus eradication strategies.

Terrestrial gamma ray dose rates of Brunei Darussalam

GPS-indexed in-situ and car-borne survey of terrestrial gamma-ray dose rates were carried out in Brunei and adjacent areas using two portable NaI(Tl) counters. The mean and population weighted average dose rates for Brunei are 34 and 33 nGy/h, respectively. The car-borne data and the in-situ data when spectral analysed separately, were found to show fractal behaviour with D of 1.7 and 1.8, respectively. A contour map of the dose rates was also produced.

I-131 orthoiodohippurate assessment of renal function after heart transplantation

PURPOSE

The authors studied the relation between cardiac output (CO) and effective renal plasma flow (ERPF) and compared values from control patients with various cardiac problems with those in a group of study patients who had undergone heart transplantation.

METHODS

The experimental group was divided into three subgroups according to the interval between the time of surgery and the time of the CO-ERPF studies. Group 1 consisted of patients studied fewer than 10 days after surgery; group 2 consisted of patients studied 10 to 20 days after operation; and group 3 consisted of patients studied more than 20 days after operation. Effective renal plasma flow was determined by the single-injection, single plasma sample method, where 50 microCi I-131 orthoiodohippurate was injected intravenously in a single dose and plasma concentrations of radioactivity were determined. The quotient of injected dose radioactivity divided by plasma radioactivity is highly predictive of global ERPF. Cardiac output was measured by thermodilution.

RESULTS

In the control group, a positive linear correlation was found between CO and ERPF; however, the CO:ERPF ratio was elevated, and after heart transplantation, a lag time was observed for as long as 3 weeks in some patients before CO:ERPF ratios returned to control group levels. The regression equation and standard error for the control group was CO = 1.85 + 0.0065 ERPF (+/-0.62) l/min versus 1.433 + 0.0068 ERPF (+/-0.64) l/min for group 3. The correlation coefficients comparing CO with ERPF were r = 0.88, 0.23, 0.51, and 0.85, for the control group and groups 1, 2, and 3, respectively.

CONCLUSION

A localized release of catecholamines from the adrenal gland is proposed to cause ERPF damping after abrupt increases in CO.

Failure to eradicate vancomycin-resistant enterococci in a university hospital and the cost of barrier precautions

OBJECTIVE

To describe the effect of infection control interventions on the incidence of vancomycin-resistant enterococci (VRE), the utility of pharyngeal cultures for surveillance for VRE colonization, and the cost of barrier precautions.

DESIGN

Evaluation of the occurrence of VRE infection or colonization, rates of vancomycin use, results of surveillance cultures before and after interventions, and the cost of increased barrier precautions.

SETTING

University of Massachusetts Medical Center, a 347-bed tertiary-care teaching hospital with eight intensive-care units, one burn unit, and one bone marrow transplant unit.

PARTICIPANTS

Patients in the intensive-care units and staff who were involved with patients colonized or infected with VRE.

METHODS

Infection control interventions included placement of patients with VRE in private rooms, strict contact isolation, cohorting of patient and nursing staff, prohibiting of equipment sharing, and monitoring of compliance with the vancomycin restriction policy, with hand washing, and of the adequacy of environmental cleaning. Both rectal and pharyngeal cultures were obtained from patients at the beginning of the outbreak, and the utility of pharyngeal cultures was evaluated. The cost of barrier precautions was estimated by comparing the cost of glove and gown use before and after the outbreak began.

RESULTS

The interventions decreased the number of new cases of VRE, but total eradication of VRE was not achieved. Compliance with the room-cleaning protocol was 91% (141/155 observations). Hand washing following interaction with patients who were not in isolation was 51%, vs 100% for patients in isolation. Overall, handwashing compliance was 71% (319/449): 56% (130/231) for physicians and 86% (187/218) for nurses (P<.0001). The mean number of doses of vancomycin dispensed per 1,000 patient days decreased from 145 to 114 per 1,000 patient days (P<.001). Compliance with vancomycin-use guidelines was 85%. Forty-six (77%) of 60 surveillance rectal swabs yielded enterococci, as compared to only 4 (11%) of 36 pharyngeal cultures (P<.0001). Expenses on glove and gowns alone increased by over $11,000 per year since the epidemic began.

CONCLUSIONS

Implementation of the various infection control measures did not eradicate VRE cases from the hospital. Rectal cultures were more useful than pharyngeal cultures for surveillance of VRE. Controlling VRE epidemics can be costly.

Infections associated with implantable cardioverter defibrillators placed transvenously and via thoracotomies: epidemiology, infection control, and management

In 1993, the incidence of infection associated with implantable cardioverter defibrillators (ICDs) excluding generator, lead, and patch placements was 16.7% at our institution. Eighty-eight percent of the ICD implantations were two-staged procedures: the cardiologists performed the electrophysiologic studies in their laboratories, and implantations were performed in the operating rooms a few hours to a few days later by cardiothoracic surgeons. In 1994, both the electrophysiologic studies and ICD implantations were performed in the operating rooms without waiting periods. From 1993 to 1995, the proportion of ICDs placed transvenously increased from 56% to 100%, whereas the proportion of two-staged ICD placements decreased from 88% to zero. From 1992 to 1993 the infection rate decreased concomitantly from 16.7% to zero. From 1992 through 1995, the infection rate for implantable ICDs alone was 4.8%, and the overall infection rate for implantable ICDs (including generator, lead, and patch placements) was 6.9%, comparable to the rate reported in the literature (2.2% to 7.2%). The elimination of the two-stage procedure and the increased proportion of transvenously placed ICDs has contributed to the decrease in infection rate.

Long-term laboratory contamination by Mycobacterium abscessus resulting in two pseudo-outbreaks: recognition with use of random amplified polymorphic DNA (RAPD) polymerase chain reaction

Beginning in 1993, an increase in clinical isolates of Mycobacterium abscessus was observed in a single hospital microbiology laboratory. This involved a cluster of four patients in June 1993 and five patients and a quality-control culture of distilled water in May 1994. Twenty-three M. abscessus isolates recovered between 1991 and 1996 were compared by random amplified polymorphic DNA polymerase chain reaction (RAPD-PCR). Sixteen of 21 clinical isolates recovered over a 6-year period and the distilled water isolate had identical RAPD-PCR patterns consistent with a single strain or clone. Only six of 15 patients had findings suggestive of clinical disease. Since the use of in-house-prepared distilled water was discontinued, no further laboratory contamination of clinical specimens has been observed. Molecular typing was the key to defining distilled water as the source of this pseudo-outbreak. Recognition of such outbreaks is important for prevention of unnecessary therapeutic and diagnostic interventions.

Safety of prolonging peripheral cannula and i.v. tubing use from 72 hours to 96 hours

OBJECTIVE

To compare the rates of phlebitis of peripheral intravenous lines left in place for 72 hours versus rates of those left in place 96 hours.

DESIGN

A prospective, nonrandomized study.

SETTING

A university teaching hospital with 375 beds.

PATIENTS

Consecutive adult patients who received peripheral intravenous lines and were admitted to the wards.

MEASUREMENTS

The phlebitis rates were monitored by the i.v. Team for 1 month according to a predetermined definition for phlebitis: palpable cord or at least two of the following: tenderness, warmth, erythema, and induration.

RESULTS

A total of 2503 peripheral lines were evaluable. The overall phlebitis rate was 6.8%. The phlebitis rates for lines left in for 72 and 96 hours were not significantly different (3.3% vs 2.6%, p = 1.000) by Fisher's Exact Test and survival analysis. It was estimated that in 1 month approximately 300 intravenous lines potentially could be prolonged beyond 72 hours; 215 lines were changed at 72 hours despite no signs of inflammation, 61 lines were kept till 96 hours, and 19 lines were kept beyond 96 hours.

CONCLUSIONS

Phlebitis rate for our peripheral intravenous catheters at 96 hours was not significantly different from that at 72 hours. If intravenous cannulas and lines were prolonged to 96 hours, a potential cost saving of $61,200 per year could be realized.

The epidemiology of fecal carriage of vancomycin-resistant enterococci

An outbreak of vancomycin-resistant enterococci (VRE) began at the University of Massachusetts Medical Center in May 1993. As of September 1995, we had a total of 253 patients infected or colonized with VRE, with consequent increasing demand for private rooms. We analyzed results of surveillance cultures for VRE of 49 patients known to be colonized or infected with VRE. Of these, 34 (70%) were classified as persistent carriers, defined as patients with at least three consecutively positive cultures from any site taken over at least a 2-week period. The length of carriage varied from 19 to 303 days (median, 41 days); 11 patients were converters, defined as patients with three consecutive negative cultures from all previously colonized sites taken over a 3-week period. These patients were free of VRE for 39 to 421 days (median, 142 days). Four were recolonizers after they were documented to be clear of VRE for 33 to 106 days. VRE carriage tends to be prolonged, and hospitalization of patients with VRE will require continued isolation and contact precautions for control of transmission.

Itraconazole maintenance treatment for histoplasmosis in AIDS: a prospective, multicenter trial

PURPOSE

To study the efficacy and safety of maintenance treatment with itraconazole for disseminated histoplasmosis in patients with AIDS.

PATIENTS AND METHODS

This was a prospective, multicenter, open-label study conducted at university-based hospitals participating in the AIDS Clinical Trial Group (ACTG). Forty-six AIDS patients with mild to moderate disseminated histoplasmosis who had successfully completed 12 weeks of induction treatment with itraconazole were treated with itraconazole, 200 mg once daily (42 patients) or 400 mg once daily (4 patients). Patients were followed at monthly intervals with clinical and laboratory assessment for relapse or toxicity. Primary outcome measures were relapse of histoplasmosis and survival. Secondary outcome measures included drug-limiting toxicity and changes in serum and urine Histoplasma polysaccharide antigen (HPA) levels.

RESULTS

Two patients relapsed during a median follow-up period of 87 weeks. The 1-year relapse-free rate was estimated to be 95.3% (95% CI, 85.3%-99.7%). One relapse may have been related to poor adherence to treatment and the second to concurrent administration of rifampin. From the start of maintenance treatment, the estimated 1-year survival rate was 73.0% (95% CI, 67.5%-77.9%). Five patients discontinued treatment because of suspected drug toxicity, three of whom had possible or probable hepatotoxicity. Median serum and urine HPA levels declined significantly during treatment. The only patient in whom antigen levels rose >2 U developed clinical relapse 1 week later; antigen levels were unavailable in the other relapsing patient.

CONCLUSIONS

Itraconazole, 200 mg daily, is effective in preventing relapse of disseminated histoplasmosis in patients with AIDS. It is generally well tolerated, but clinicians should be alert for drug interactions and possible hepatotoxicity.