PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

BACKGROUND

Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment.

METHODS

All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals.

RESULTS

A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death.

CONCLUSION

Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

SP9.1.4 Management of Small Bowel Obstruction: A Comparison to NASBO

Aim

Prompt diagnosis and proactive decisions in management of small bowel obstruction (SBO) can reduce the associated morbidity, in-hospital stay and mortality. Following recommendations of National Audit of Small Bowel Obstruction (NASBO) and Bologna (2017), the “agreed pathway” of The Association of Surgeons of Great Britain and Ireland (ASGBI, 2018) sets clear guidelines to aid timely management of SBO. We aimed to audit our practice to these guidelines and compared outcomes to NASBO.

Methods

Data was collected retrospectively on patients admitted with SBO from July 2019 - December 2019 and presented as percentage, median or interquartile range (IQR).

Results

Median age of 76 included patients was 62.0 years, 53.9% were female. Aetiologies were; adhesions (59.2%), hernia (27.6%), malignancy (10.5%) and others (2.6%). Admission CTs were performed in 92.1% vs. 80.0% (NASBO), with a median time of 3.3 hours vs. 2.2 days (NASBO). Median time to surgery in those managed operatively (n = 35) was 10 hours vs. 1 day (NASBO), while in 72.0% vs. 21.0% (NASBO) of non-settling SBO, water soluble contrast study (WSCS) was performed in a median (IQR) time of 39.0 (20.0-45.4) hours. Adhesional SBO resolved in 85.7% of cases suitable for non-operative approach. Objective nutritional assessment was performed in 94.7% vs. 90.0% (NASBO). In-hospital stay, 30-day morbidity and mortality compared to NASBO were 5.0 vs. 10.7 days, 31.6% vs. 23.0% and 5.3% vs. 8.0% respectively.

Conclusion

ASGBI guidelines provide multi-faceted proactive approach in managing SBO; including early cross-sectional imaging, prompt WSCS use and timely nutritional interventions, promoting improved outcomes.

Acute management of cellulitis: A review

Cellulitis is an acute localised skin infection, usually accompanied by symptoms such as fever and rigors, nausea, and vomiting. It most commonly affects the lower limbs, although it can involve any part of the skin. It presents as area of redness and inflammation of the skin, with associated pain and swelling.

Zur Struktur von Hydroxy-5-phenyl-furanonen: Lösungs-NMR, Festkörper-13C-NMR und Röntgenstruktur im Vergleich / On the Structure of Hydroxy-5-phenyl-furanone Derivatives: NMR Spectroscopy in Solution and High Resolution Solid State 13C NMR Spectroscopy in Relation to X-Ray Crystallography

The structure of (5H)-2-Amino-3-hydroxy-5-phenyl-furan-4-one (lb) was determined by NMR-spectroscopy in solution and in the solid state. The structure of its oxidation product, 3,4-Dihydro-3,3,4,4-tetrahydroxy-5-phenyl-furan-2(5H)-one (7), given in the literature as 5-Phenyl-2,3,4-(5H)-furan-trione, was determined by NMR spectroscopy and crystal structure analysis. The solid state NMR spectrum of 7 was compared to the spectrum of dehydroascorbic acid

Oral health in Hlabisa, KwaZulu/Natal--a rural school and community based survey

AIMS

To investigate rates of dental caries and periodontal disease, available dental services and resources and perceived needs in a rural South African community.

DESIGN

A cross-sectional field study including situational analysis and focus group discussions.

SETTING

KwaZulu/Natal, South Africa.

PARTICIPANTS

A total of 520 children, adolescents and adults.

METHODS

WHO caries scores and periodontal CPI score were determined through clinical examinations in five age groups, 5-6 years, 12 y, 15 y, 35-54 y, 55 y+. Focus groups included ten 15-year-old children and ten adults.

RESULTS

Caries prevalences and (mean scores) were 5-6 y 64% (dmft 3.0), 12 y 24% (DMFT 0.4), 15 y 27% (DMFT 0.8), 35-54 69% (DFT 2.6) and 55 y+ 80% (DFT 2.7). Most caries was untreated and where present, treatment had been extraction. Dental caries rates were low and except for 5-6 y were within WHO targets for the year 2000. Periodontal disease prevalence was high but would respond to improved oral hygiene. Knowledge of oral health was rudimentary.

CONCLUSIONS

A district-wide oral health promotion programme is required preceded by research to define effective health education messages. Access to simple but effective preventive and curative services would seem reasonable. In view of the lack of resources ART is suggested as caries treatment.

Role for tumor necrosis factor alpha receptor 1 and interleukin-1 receptor in the suppression of mouse hepatocyte apoptosis by the peroxisome proliferator nafenopin

Peroxisome proliferators (PPs) cause rodent liver enlargement and tumors. In vitro, PPs induce rat and mouse hepatocyte DNA synthesis and suppress apoptosis, a response mimicked by exogenous tumor necrosis factor alpha (TNFalpha). Here, we determine the role of TNF receptor 1 (TNFR1), TNF receptor 2 (TNFR2), and nuclear factor kappa beta (NFkappaB) in the response of mouse hepatocytes to the PP, nafenopin. Nafenopin (50 micromol/L) induced DNA synthesis as measured by bromodeoxyuridine (BrdU) incorporation, suppressed cell death as measured by Hoechst 33258 staining, induced peroxisomal beta-oxidation as measured by cyanide insensitive palmitoyl CoA oxidation (PCO) and caused activation of nuclear factor kappa beta (NFkappaB) as determined by electrophoretic mobility gel shift assay (EMSA). The induction of DNA synthesis and the suppression of apoptosis in response to nafenopin was abrogated completely by blocking antibodies to TNFR1 but not to TNFR2. In contrast, the induction of peroxisomal beta-oxidation by nafenopin was not blocked by the anti-TNFR1 antibody. Next, we evaluated the response of hepatocytes to interleukin-1 (IL-1), another proinflammatory cytokine. IL-1alpha (2.5 ng/mL) and, to a lesser extent, IL-1beta (5 ng/mL), shared the ability of TNFalpha to induce DNA synthesis and suppress apoptosis. In addition, anti-IL-1 receptor, type 1/p80 (IL-1R) antibodies were able to abrogate the response to nafenopin. IL-1alpha was still able to perturb hepatocyte growth in the presence of the anti-TNFR1 antibody suggesting that IL-1alpha acts independently rather than by elaborating TNFalpha. In summary, these data provide additional evidence for a role for hepatic cytokines in the perturbation of hepatocyte growth by PPs such as nafenopin.

n-Alkyl fluorenyl phases in chromatography. II. Dynamic behavior and high-performance liquid chromatography applications

The dynamic behavior of two n-hexyl fluorenyl phases (fluorene-6A [3a(Tn)(Qm)y], fluorene-6B [3b(Tn)(Qm)y]) and three n-decyl fluorenyl phases (fluorene-10A [4a(Tn)(Qm)y], fluorene-10B [4b(Tn)(Qm)y], and fluorene-10C [4c(M1)(Qm)y]) is investigated by solid-state nuclear magnetic resonance (NMR) spectroscopy using the dipolar filter technique with both 13C and 1H detection. These results are compared with those from other dynamic measurements, like the relaxation times in the rotating frame (T1pH) and the variation of the contact time (T(CH)). Additionally, another type of a fluorenyl phase [5a(Tn)(Qm)y], which has an aromatic moiety connected to the silica gel by amido couplings, was also investigated by the dipolar filter method. The solid-state NMR dynamic measurements indicate an increased mobility of the n-alkyl fluorenyl phases compared to the amido coupled fluorenyl phase. The lower the ligand density of the studied n-alkyl fluorenyl phases, the higher their mobility. The separation behavior of the respective phases in high-performance liquid chromatography was investigated with samples containing polycyclic aromatic hydrocarbons and nitro explosives. Depending on the amount of the chemically bound aromatic moiety and the length of their n-alkyl spacer groups, pi-pi interactions with the solute molecules are involved in the separation process and cause it to proceed at a different rate. Therefore, n-alkyl fluorenyl phases can be classified as mixed-mode phases.

Peroxisome proliferator-activated receptor (PPAR) alpha-regulated growth responses and their importance to hepatocarcinogenesis

Peroxisome proliferators (PPs) are a class of non-genotoxic rodent hepatocarcinogens that act by perturbing liver growth regulation. We have demonstrated previously that PPs suppress both spontaneous rat hepatocyte apoptosis and that induced by exogenous stimuli such as transforming growth factor-beta1 (TGF beta1). More recently, we have demonstrated that PPs can suppress apoptosis induced by more diverse stimuli such as DNA damage or ligation of Fas, a receptor related to the tumour necrosis factor alpha (TNF alpha) family of cell surface receptors. PPs transcriptionally activate the peroxisome proliferator activated receptor-alpha, PPAR alpha, a member of the nuclear hormone receptor superfamily. We investigated whether activation of PPAR alpha mediates the suppression of rat hepatocyte apoptosis induced by PPs. We isolated a naturally occurring variant form of PPAR alpha (hPPAR alpha-6/29) from human liver by PCR cloning. hPPAR alpha-6/29 shared the ability of mPPAR alpha to bind to DNA but, unlike mPPAR alpha, could not be activated by PPs. Furthermore, hPPAR alpha-6/29 could act as a dominant negative regulator of PPAR-mediated gene transcription. When introduced into primary rat liver cell cultures by transient transfection, hPPAR alpha-6/29 prevented the suppression of hepatocyte apoptosis by the PP nafenopin, but not that seen in response to phenobarbitone (PB), a non-genotoxic carcinogen whose action does not involve PPAR alpha. The suppression of hepatocyte apoptosis was abrogated completely even though only 30% of hepatocytes were transfected, suggesting the involvement of a soluble factor. Recent data have suggested that TNF alpha, perhaps released by liver Kupffer cells in response to PPs, may play a key role in mediating the effects of PPs on hepatocyte growth regulation.

Stationary interphases with extended alkyl chains: a comparative study on chain order by solid-state NMR spectroscopy

Stationary interphases with long n-alkyl chains (n = 18, 22, 30, 34) have been examined by solid-state NMR spectroscopy. The determination of the silane functionality and the degree of cross-linking of silane ligands on the silica surface was performed by 29Si CP/MAS NMR spectroscopy. High-speed 1H MAS and 13C CP/MAS NMR spectroscopy were utilized to assess alkyl chain order and mobility of the different bonded phases. For this purpose, 1H NMR line widths and 13C chemical shifts have been evaluated. It is shown that stationary phase order and rigidity increase with alkyl chain length. In addition, the temperature-dependent trans/gauche conformational change occurs at higher temperatures for a polymeric C34 phase compared with a C30 sorbent. This behaviour is discussed in the context of previously reported chromatographic (HPLC) shape selectivity differences.

1H MAS NMR spectroscopy of chemically modified silica gels: a fast method to characterize stationary interphases for chromatography

Chemically modified silica gels used as stationary phases in chromatography have been investigated by means of solid-state 1H magic angle spinning (MAS) NMR spectroscopy. Since the organosilanes are bonded to the surface of the silica gel, their protons are diluted and possess a higher mobility in comparison to protons in pure organic solids. Thereby the usually strong homonuclear dipole-dipole interactions among the protons are reduced and it is possible to obtain well-resolved 1H NMR spectra of the organic interphases with MAS-only techniques. Effects of temperature and magnetic field strength on the resolution of the spectra are examined as well as the dependence of T1 and T1pH relaxation times on temperature and spinning speed.

Solid state NMR and extraction studies on "phenyl"-bonded stationary phases used for solid phase extraction

The solid phase extraction (SPE) and elution of [14C]-propranolol from aqueous buffer has been studied for a range of phenyl-bonded SPE materials. Differences were noted in the recovery of the analyte using methanol-water eluents depending upon the manufacturer and whether or not phase had been endcapped. Efficient recoveries of [14C]-propranolol were only achieved when triethylamine was added to the eluting solvent as a competing base. Solid state cross polarisation/magic angle spinning (CP/MAS) NMR spectroscopy was used to characterise the phases further, which revealed differences in endcapping between materials as well as differences in the type and extent of cross-linking.

Recurrence of HIV-related tuberculosis in an endemic area may be due to relapse or reinfection

SETTING

Two Research Clinics within Nairobi, Kenya, one in the Infectious Diseases Hospital, the national referral centre for tuberculosis, and one in a community based project in Pumwani district, and the Bacterial Molecular Genetics Unit at the London School of Hygiene and Tropical Medicine.

OBJECTIVE

To determine whether recurrence of tuberculosis after 'adequate' treatment was due to reinfection with a different isolate of Mycobacterium tuberculosis or to relapse of the original infection.

DESIGN

A retrospective comparison by DNA fingerprinting of sets of isolates of M. tuberculosis from patients with recurrence of tuberculosis and in whom isolates from the original episode had been stored was made. Five patients with recurrence of tuberculosis two to nineteen months after adequate treatment and documented clearance of disease were studied.

RESULTS

In one patient, fingerprints of the isolates of M. tuberculosis from the recurrence were quite different to those from the original episode; in the other four, the fingerprints were identical.

CONCLUSION

Reinfection rather than relapse was the cause of recurrence in at least one patient. The high 'relapse' rates seen in HIV-related tuberculosis in Africa may in part be due to increased susceptibility to reinfection and not to treatment failure.

Antimicrobial susceptibility and presence of extrachromosomal deoxyribonucleic acid in Salmonella and Shigella isolates from patients with AIDS

The development of multi-drug resistance by enteric bacteria is an increasing problem in the developing countries. There is need to monitor antimicrobial susceptibility of these organisms in order to ensure appropriate treatment and control of infections. Antimicrobial susceptibility patterns, plasmid DNA content and restriction enzyme digests of plasmid deoxyribonucleic acid (DNA) were used to study 175 Salmonella and Shigella species isolated from predominantly HIV-seropositive adult patients in Nairobi, Kenya. All the isolates were sensitive to ciprofloxacin. A significantly higher proportion of Shigella species were resistant to chloramphenicol, cotrimoxazole, streptomycin and tetracycline compared to Salmonella species (p-value < 0.001). Multi-resistant Salmonella typhimurium isolates had 60, 40 and 5 MDa plasmids, the 5 MDa plasmid was absent in gentamicin sensitive isolates. In addition to 2-10 MDa range of plasmids, multi-resistant Shigella species had a heavy 100-105 MDa plasmid. Restriction enzyme digests were similar for the 60 and 40 MDa plasmid DNA bands from Salmonella typhimurium isolates but did not show any consistency among Shigella spp. Plasmid-encoded multi-drug resistance plays a major role in the spread of resistance among enteric bacteria. It is vital to use drugs rationally in order to control the emergence and spread of multi-drug resistance.

Increased recurrence of tuberculosis in HIV-1-infected patients in Kenya

There is evidence that in human immunodeficiency virus 1 (HIV-1) infected patients with tuberculosis the rate of recurrence of tuberculosis is increased in those patients treated with a standard thiacetazone-containing regimen. To assess the impact of HIV-1 on tuberculosis in Kenya, patients with tuberculosis were studied prospectively. After treatment with either a standard thiacetazone plus isoniazid regimen or a short-course thiacetazone-containing regimen, overall recurrence rate of tuberculosis was 34 times greater in 58 HIV-1-positive patients than in 138 HIV-1-negative patients (adjusted rate ratio 33.8, 95% CI 4.3-264). Recurrence in the HIV-1-positive group was strongly associated with a cutaneous hypersensitivity reaction due to thiacetazone during initial treatment (rate ratio 13.2, 95% CI 3.1-56.2). In all patients with a cutaneous hypersensitivity reaction ethambutol was substituted for thiacetazone. No significant association was found between recurrence among HIV-1-positive patients and initial resistance, initial treatment regimen, a diagnosis of AIDS (WHO definition), or poor compliance. DNA fingerprinting suggested that both relapse and new infection may have produced recurrence of tuberculosis. In patients who had a cutaneous hypersensitivity reaction, increased recurrence rate may have been related to interruption of treatment, subsequent poor compliance, or more advanced immunosuppression. Alternatively, a change to the combination of ethambutol and isoniazid in the continuation phase for 11 months only may not be adequate.

The impact of HIV on resource utilization by patients with tuberculosis in a tertiary referral hospital, Nairobi, Kenya

By using routinely collected data and results from research studies at the Infectious Diseases Hospital (IDH), Nairobi, we have begun to determine the scale of the increase in resource utilisation and treatment costs for tuberculosis control services caused by the HIV epidemic. New cases of tuberculosis registered annually at the IDH rose 61%, from 447 in 1985 to 720 in 1990. HIV seroprevalence among patients with tuberculosis rose from 7.5% in 1986 to 42% in 1990. The inpatient mortality rate rose from 8.4% in 1985 to 16.8% in 1989, but fell to 13.5% in 1990. HIV-positive patients were admitted to hospital on 2 or more occasions more often than HIV-negative patients (Relative risk (RR) = 2.46, 95% confidence intervals (CI), 1.1-5.7), but average duration of admission was similar for the 2 groups. Significantly more HIV-positive patients were prescribed antibiotics, antifungal agents, antidiarrhoeal agents, analgesics and corticosteroids than HIV-negative patients. Microbiological investigations, apart from those for tuberculosis, were performed more commonly among HIV-positive patients (RR = 2.0, 95% CI 1.0-4.2). Using this data, the average cost of ideal drug therapy, including antituberculosis drugs and treatment for intercurrent infections and other complications, was estimated using 1992 prices (ECHO, Coulsdon Surrey, UK). The costs were US$16.62 and US$32.94 for HIV-negative patients using 'standard' therapy (2STH/10TH) and short course therapy (2SHRZ/6TH) respectively, and US$41.18 for HIV-positive patients using a short-course regimen without thiacetazone (2EHRZ/6EH). The HIV epidemic is causing both an increase in the numbers of patients requiring treatment and an increase in the average cost of treatment per patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Brucellosis: imported and laboratory-acquired cases, and an overview of treatment trials

Following the successful eradication of Brucella abortus infection in cattle, human brucellosis in England and Wales has become an uncommon imported disease. Culture of the organism presents a major laboratory hazard, and difficulties in identification may occur using a biochemical test-strip method. An overview of recent treatment trials of brucellosis indicates that regimens combining streptomycin and doxycycline are associated with a higher success rate (judged by the frequency of treatment failure and relapse following therapy) than combinations of rifampicin and doxycycline.

Cohort study of human immunodeficiency virus infection in patients with tuberculosis in Nairobi, Kenya. Analysis of early (6-month) mortality

Retrospective studies suggest that the mortality rate from HIV-1-associated tuberculosis is greater than that from tuberculosis alone, but it is not clear if this is due to failure of antituberculosis treatment or to the complications of HIV-1 infection. We have carried out a prospective cohort study of patients with tuberculosis in Nairobi, Kenya, to compare mortality rates, risk factors, and causes of death in HIV-1 positive and HIV-1 negative patients. One hundred seven HIV-1 positive and 174 HIV-1 negative patients with tuberculosis attending two tuberculosis treatment centers in Nairobi were enrolled and followed monthly. Mortality was significantly higher in HIV-1 positive than in HIV-1 negative patients within 6 months of the start of antituberculosis treatment after adjustment for age, sex, and education (rate ratio = 3.8; 95% confidence interval, 1.7 to 8.1; p less than 0.001). Most of the excess mortality occurred after the first month of treatment and was due to nontuberculous infections. Predictors for mortality differed greatly between HIV-1 positive and HIV-1 negative patients. Mortality was greater in HIV-1 positive patients treated with a "standard" regimen for tuberculosis than in HIV-1 positive patients receiving a "short-course" regimen (p = 0.08 when adjusted for all independent risk factors). Tuberculosis control programs in developing countries need to implement "short-course" regimens and train health workers to recognize and treat nontuberculous infections to maintain their effectiveness in the face of the HIV epidemic.

Aspects of tuberculosis in Africa. 2. The value of microbiology in the management of tuberculosis in Nairobi, Kenya

A group of African patients with tuberculosis were followed over the first month of treatment to assess the bactericidal response to 2 treatment regimens (streptomycin/thiacetazone/isoniazid and streptomycin/rifampicin/isoniazid/pyrazinamide). Patients also infected with human immunodeficiency virus (HIV) had lower pre-treatment counts of viable Mycobacterium tuberculosis and a greater proportion became culture-negative by 28 d. The response to therapy in HIV positive and HIV negative patients was similar. Because of the combination of these findings and the higher early mortality in patients with HIV, the causes of acute infection in patients with tuberculosis were studied. It was found that HIV positive patients were frequently bacteraemic and that the principal pathogen was Salmonella typhimurium, but recurrent pneumococcal bacteraemia was also seen.

Cohort study of HIV-positive and HIV-negative tuberculosis, Nairobi, Kenya: comparison of bacteriological results

We have set up a cohort of human immunodeficiency virus (HIV) positive and negative patients with tuberculosis in order to address the problems associated with HIV-related tuberculosis. We present here the results of sputum smear microscopy, culture, mycobacterial identification tests and drug susceptibility assays from specimens taken at presentation. In this selected population of largely pulmonary tuberculosis cases, HIV infection is not associated with significant differences in sputum smear positivity rate, culture positivity rate or initial drug resistance. No atypical mycobacteria were found. Direct sputum smear examination remains specific for the diagnosis of tuberculosis in Kenya in spite of the presence of HIV. HIV infection was not associated with an increase in the proportion of pulmonary cases still culture-positive at 6 months. However a significant increase in the proportion of cases still culture-positive at 6 months was seen in those with initially resistant strains and also in those treated with standard regimen (streptomycin, thiacetazone and isoniazid for 1 month followed by thiacetazone and isoniazid for 11 months, 1STH/11TH) rather than a short-course, rifampicin-containing regimen (rifampicin, pyrazinamide and isoniazid for 2 months, together with streptomycin for the first month and followed by 6 months of thiacetazone and isoniazid, SHRZ/6TH).

Cross-sectional survey of HIV infection among patients with tuberculosis in Nairobi, Kenya

Evidence from many countries suggests an association of human immunodeficiency virus (HIV) infection and tuberculosis of major public health significance. In order to begin assessing the impact of HIV on tuberculosis in Kenya, we have determined the HIV-1 seroprevalence among tuberculosis patients and compared the clinical characteristics of tuberculosis in HIV-positive and HIV-negative patients in two cross-sectional studies at the Infectious Disease Hospital (IDH) and the Ngaira Avenue Chest Clinic (NACC), Nairobi, Kenya. The diagnosis in 92% of all patients with pulmonary tuberculosis was confirmed by culture. The remainder were diagnosed on histological, clinical or radiological grounds. HIV seroprevalence among tuberculosis patients at IDH was 26.5% (52/196) compared to 9.2% (18/195) at NACC (P less than 0.001). There was no association between numbers of streptomycin injections in the previous 5 years and HIV infection. Positive sputum smear rates in HIV-positive patients were slightly lower than in HIV-negative patients at both study sites (71% vs 83% at IDH and 73% vs 82% at NACC) but the difference was not significant. Only Mycobacterium tuberculosis was isolated. Miliary disease was not associated with HIV infection. Persistent diarrhoea, oral candidiasis, generalized itchy rash, herpes zoster and generalized lymphadenopathy were all associated with HIV infection, but 46% (95% CI:38-54%) of all HIV-positive patients had none of the clinical features listed in the WHO Clinical Criteria for the Diagnosis of AIDS, apart from fever, cough and weight loss. Stevens-Johnson Syndrome was reported in 7/52 (13%) patients with HIV infection, and in 4/144 (3%) patients without (RR 4.85, 95% CI: 1.45-15.88).(ABSTRACT TRUNCATED AT 250 WORDS)

Toxoplasma antibodies in HIV-positive patients from Nairobi

Sera from 94 patients infected with human immunodeficiency virus (HIV) 1, together with 86 controls, attending the Kenyatta National Hospital, Nairobi were examined for antibodies to Toxoplasma gondii using enzyme immunoassay and latex and dye tests. 54% had Toxoplasma-specific immunoglobulin G (IgG) by dye test. 22% of the HIV-positive group had IgG levels in excess of 180 units/ml (approximating to a dye test titre of 1:1300) compared to 1% of the HIV-negative group. There was no correlation between high levels of IgG and clinical stage of HIV disease or features indicative of active toxoplasmosis. It is proposed that the elevated serum IgG is a reflection of early Toxoplasma reactivation, not necessarily associated with disease.

Comparative humoral responses to HIV-1 p24gag and gp120env in subjects from East Africa and the UK

We compared 1616 sera from HIV-1-infected subjects and matched HIV-negative local controls in Uganda, Kenya and the UK. Sera were screened for specific antibody to HIV-1 p24 Gag and gp120 Env proteins and for p24 antigenaemia. In contrast to the UK, the majority of African HIV-1-infected subjects maintained detectable anti-p24 antibodies. However, lower reactivity of anti-p24 was observed in African AIDS patients, compared with those with asymptomatic HIV-1 infection. This reduction in anti-p24 reactivity with more advanced clinical stage was less marked in African HIV-1 infection than in the UK. Correspondingly, p24 antigenaemia was more common in patients with AIDS from the UK than in African patients (65 versus 4%). Reductions in anti-gp120 reactivity were observed in African AIDS patients, compared with the asymptomatic group. However, median reactivity of anti-gp120 in UK patients remained unchanged in both asymptomatic and AIDS subjects. The differences in humoral response to p24 and gp120 between Africa and the UK are semi-quantitative rather than qualitative and could be explained by initial higher antibody response to HIV-1 in African subjects.

Cutaneous hypersensitivity reactions due to thiacetazone in HIV-1 seropositive patients treated for tuberculosis

The effects of the human immunodeficiency virus (HIV) on tuberculosis management was investigated in 227 patients initially treated with a regimen containing streptomycin, isoniazid, and thiacetazone (STH). 93 of these 227 were HIV-seropositive. 60 patients, of whom 18 were HIV-seropositive, received a regimen consisting of streptomycin, isoniazid, rifampicin, and pyrazinamide (SHRZ) in the initial phase, and thiacetazone and isoniazid (TH) in the continuation phase. Cutaneous hypersensitivity reactions occurred in 22 of 111 (20%) HIV-seropositive patients, and in 2 of 176 (1%) HIV-seronegative patients (RR = 18, 95% CI 4.4-76, p less than 10(-7]. During the first 8 weeks of treatment 18 reactions occurred among the 93 HIV-seropositive patients on STH, whereas no reaction occurred in 17 HIV-seropositive patients during the initial phase of SHRZ/TH (p = 0.04). None of the 18 HIV-seropositive patients with cutaneous reactions who were subsequently challenged with isoniazid reacted, nor did any of the 10 tested with streptomycin, but 6 of the 7 challenged with thiacetazone reacted. 3 patients (all HIV-positive and with toxic epidermal necrolysis) died as a result of the cutaneous reaction. These results have major implications for tuberculosis control programmes in Africa.