Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in adults characterized by high viral genome load within circulating natural killer cells

Epstein-Barr virus (EBV)-associated hemophagocytic lymphohistiocytosis (HLH) is a rare and aggressive disease usually encountered in the context of primary EBV infection. In most analyzed cases, EBV has been found predominantly in T cells. We describe the novel finding of high EBV genome numbers within circulating natural killer cells in adult patients with EBV-HLH.

Molecular characterisation of a recurrent, semi-cryptic RUNX1 translocation t(7;21) in myelodysplastic syndrome and acute myeloid leukaemia

A proportion of cytogenetic abnormalities in myelodysplastic syndromes (MDS) and acute myeloid leukaemia (AML) may escape detection by high-resolution genomic technologies, but can be identified by conventional cytogenetic and molecular analysis. Here, we report the detection of a reciprocal translocation t(7;21)(p22;q22) in the marrow of two adults with MDS and AML, using conventional cytogenetic analysis and fluorescence-in situ-hybridization (FISH). Reverse-transcription polymerase chain reaction (RT-PCR) and sequence analysis identified a fusion between RUNX1 and the gene encoding ubiquitin specific peptidase-42 (USP42), with splice-variants and variable break-points within RUNX1. Combined cytomorphology and FISH studies in MDS marrow revealed abnormal RUNX1 signals within megakaryocytes, suggesting that the acquisition of t(7;21)(p22;q22) does not confer complete differentiation arrest and may represent an early genetic event in leukaemogenesis. Single nucleotide polymorphism-arrays failed to detect additional sub-microscopic genomic changes predisposing to or associated with t(7;21). Molecular analysis of 100 MDS and AML marrow specimens by RT-PCR did not reveal new cases with the RUNX1-USP42 fusion. Thus, our studies have identified t(7;21)(p22;q22) as a rare but recurrent abnormality in MDS/AML, with the existence of alternative spliced forms of the RUNX1-USP42 transcript in different patients. Further studies are required to identify the potential contribution of these splice-variants to disease heterogeneity.

Clinical practice recommendations for bipolar disorder

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation.

Clinical practice recommendations for depression

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

Prospective audit of the effectiveness of hydrocortisone premedication on drug delivery reactions following amphotericin B lipid complex *

OBJECTIVE

Amphotericin B lipid complex (ABLC), a lipid-based formulation of amphotericin B, is an effective treatment for fungal infections, but is associated with mild to moderate drug delivery reactions (DDRs), such as fever, rigors and chills, in some patients. Although clinical studies have indicated that premedication with hydrocortisone may reduce the incidence of DDRs, there are currently limited confirmatory data from clinical practice. The aim of the audit was to assess prospectively a hydrocortisone premedication strategy with ABLC to reduce the rate of DDRs.

METHODS

Over an 18-month period, all cancer patients treated with ABLC at The Royal Shrewsbury Hospital were audited prospectively. Each patient received 100 mg of intravenous hydrocortisone 15-30 minutes prior to each ABLC infusion. The primary outcome was to determine the DDR rate per cycle of ABLC.

RESULTS

A total of 275 cycles of ABLC (mean dosage 930.6 mg) were administered during the course of the study period, and 16.0% were associated with DDRs. The majority of reactions occurred following the first infusion of a cycle (15.3%; subsequent infusions: 2.9%). The most common DDRs were rigor (15.3%) and fever (12.7%). There was no significant difference in the DDR rate (17.2 vs. 15.5%) or types of reactions between ABLC-naïve and previously treated patients. The dosage of ABLC administered had no effect on the DDR rate. Female gender, being neutropenic and younger age were found to be predictive of having a DDR.

CONCLUSIONS

The audit demonstrates that premedication with hydrocortisone results in a low incidence of DDRs following ABLC. The main limitation of this study is the lack of a randomised control group.

Handheld Flyback driven coaxial dielectric barrier discharge: Development and characterization

The development of a handheld single and triple chamber atmospheric pressure coaxial dielectric barrier discharge driven by Flyback circuitry for helium and argon discharges is described. The Flyback uses external metal-oxide-semiconductor field-effect transistor power switching technology and the transformer operates in the continuous current mode to convert a continuous dc power of 10-33 W to generate a 1.2-1.6 kV 3.5 micros pulse. An argon discharge breakdown voltage of approximately 768 V is measured. With a 50 kHz, pulse repetition rate and an argon flow rate of 0.5-10 argon slm (slm denotes standard liters per minute), the electrical power density deposited in the volume discharge increases linearly at a rate of 75+/-20% mW/cm(3) per 1 slm of gas. Electrical power transfer efficiency between the secondary Flyback coil and the discharge volume increases from 0.1% to 0.65%. Neutral argon gas forced convection analysis yields a similar energy loss rate to the electrical discharge process. Optical emission spectroscopy studies of the expanding discharge plume into ambient air reveal that the air climatically controls the plume chemistry to produce an abundance of neutral argon atoms and molecular nitrogen.

Alcohol--how much is too much?

The aims of this study were to examine perceptions of what a sample of students and graduates consider an excessive alcohol intake to be and it's effect on their health. 115 University College Cork (UCC) students and 133 UCC graduates were questioned about their opinions of an acceptable weekly intake of alcohol. The results reveal dramatic changes in drinking habits over recent decades. Students began drinking earlier than graduates and are far more accepting of greater amounts of alcohol being consumed. The student's average opinion of what constituted an excessive weekly alcohol intake was 26.5 units of alcohol/week whereas the graduates felt over 18 units/week was too much. We concluded that even amongst these highly educated cohorts there is a low level of awareness of safe limits of alcohol consumption.

Inhibition of Testosterone-Induced Hyperplasia of the Prostate of Sprague-Dawley Rats by Pumpkin Seed Oil

The oil from the pumpkin (Cucurbita pepo) seed is claimed to be useful in the management of benign prostatic hyperplasia. This investigation seeks to examine the effect of pumpkin seed oil on testosterone-induced hyperplasia of the prostate of rats. Hyperplasia was induced by subcutaneous administration of testosterone (0.3 mg/100 g of body weight) for 20 days. Simultaneous oral administration of either pumpkin seed oil (2.0 and 4.0 mg/100 g of body weight) or corn oil (vehicle) was also given for 20 days. The weights of the rats were recorded weekly, and the influence of testosterone and pumpkin seed oil on the weight gain of the rats was examined. On day 21, rats were sacrificed, and the prostate was removed, cleaned, and weighed. The prostate size ratio (prostate weight/rat body weight) was then calculated. Neither testosterone nor pumpkin seed oil had any significant influence on the weight gain of the rats. Testosterone significantly increased prostate size ratio (P < .05), and this induced increase was inhibited in rats fed with pumpkin seed oil at 2.0 mg/100 g of body weight. The protective effect of pumpkin seed oil was significant at the higher pumpkin seed oil dose (P < .02). We conclude pumpkin seed oil can inhibit testosterone-induced hyperplasia of the prostate and therefore may be beneficial in the management of benign prostatic hyperplasia.

Prehospital activated charcoal: the way forward

OBJECTIVES

Single dose activated charcoal (SDAC) may be an effective method of gastric decontamination when administered to patients within an hour of drug overdose. However, few patients who may benefit from this treatment attend an emergency department within this timeframe. The authors sought to determine the current attitudes of ambulance NHS trusts to recent recommendations that the administration of SDAC should be considered as a prehospital therapy.

METHODS

A postal questionnaire was used to determine the current level of use of prehospital activated charcoal by ambulance NHS trusts, the incidence of associated complications, and barriers preventing the routine use of prehospital SDAC.

RESULTS

A completed questionnaire was returned by 36 of the 39 ambulance NHS trusts in the UK (response rate 92%). Currently none of the trusts that responded to the questionnaire provides prehospital SDAC as an intervention. The most common barriers to the provision of prehospital SDAC are the current lack of evidence in the medical literature proving it is effective in improving patient outcome and the lack of a recognised protocol for its administration. Other issues included concerns regarding potential complications, ambulance turnaround times, lack of availability of SDAC, and lack of funding.

CONCLUSIONS

A lack of published evidence proving efficacy remains the most important factor in preventing the routine administration of SDAC to appropriate patients in the prehospital environment. Further research in this setting is required to determine the usefulness of this therapy.

Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage

OBJECTIVES

To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be seen as an indirect measure of waiting time throughout the emergency department (ED).

METHODS

An emergency medicine consultant and a senior ED nurse (G or F grade), known as the IMPACT team, staffed the triage area for four periods of four hours per week, Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted. Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team. Data were collected prospectively on all patients seen by the IMPACT team. The number of patients waiting to be seen (for triage, in majors and in minors) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational.

RESULTS

There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 (p<0.0001) at formal two hourly assessments. The largest difference was seen in minors. Of the patients seen at triage by the IMPACT team, 48.9% were discharged home immediately after assessment and treatment. With the IMPACT team present, no patient waited more than four hours for initial clinical consult.

CONCLUSIONS

By using a senior clinical team for initial patient consultation, the numbers of patients waiting fell dramatically throughout the ED. Many patients can be effectively treated and discharged after initial consult by the IMPACT team.

Hepatocellular damage from non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the management of rheumatological disorders, and as analgesics and antipyretics. Hepatotoxicity is an uncommon, but potentially lethal complication, which usually occurs within 12 weeks of starting therapy. It can occur with all NSAIDs, but appears to be more common with diclofenac and particularly sulindac. Female patients aged >50 years, with autoimmune disease, and those on other potentially hepatotoxic drugs, appear to be particularly susceptible. Liver function test abnormalities generally settle within 4-6 weeks of stopping the causative drug. However, some patients may develop acute liver failure and successful orthotopic liver transplantation may be undertaken in such patients. Recent in vitro animal studies have shown that the mechanism of diclofenac toxicity relates both to impairment of ATP synthesis by mitochondria, and to production of active metabolites, particularly n,5-dihydroxydiclofenac, which causes direct cytotoxicity. Mitochondrial permeability transition (MPT) has also been shown to be important in diclofenac-induced liver injury, resulting in generation of reactive oxygen species, mitochondrial swelling and oxidation of NADP and protein thiols. Physicians and hepatologists must be vigilant to the hepatotoxic potential of any NSAID, as increased awareness, surveillance and reporting of these events will lead to a better understanding of the risk factors and the pathophysiology of NSAID-related hepatotoxicity.

Accident and emergency medicine--still a useful 'apprenticeship'?

The objective of this study was to compare the expressed confidence of senior house officers (SHOs) at performing practical medical procedures before and after working in an accident and emergency (A&E) post. The extent of formal teaching of these skills and opportunity for independent performance of them was also assessed. A postal questionnaire was sent to all SHOs completing an A&E post in the Trent region of the United Kingdom. Doctors were asked to grade their subjective confidence at performing listed practical skills before and after working in A&E. Eighty-four replies from 120 questionnaires were received (70% response rate). There was a significant improvement in confidence ( <0.0001) for all the skills studied after working in A&E. The proportion of doctors who received instruction varied for each of the skills. The expressed confidence of SHOs in performing practical procedures improved dramatically after working in A&E. Although remaining a valuable 'apprenticeship' for junior doctors, structured training is inadequate in the accident and emergency SHO post.

The efficacy and safety of nutritional supplement use in a representative sample of adults in the North/South Ireland Food Consumption Survey

OBJECTIVE

To describe the current use of nutritional supplements and their contribution to micronutrient intakes in a representative sample of Irish adults, to evaluate the impact of supplement use on the adequacy of micronutrient intakes and to assess the risk to supplement users of exceeding tolerable upper intake levels (UL).

STUDY DESIGN AND SUBJECTS

Food intake data were collected in 1379 (662 male and 717 female) randomly selected Irish adults aged 18 to 64 years using a 7-day food diary. The current use of nutritional supplements was assessed using a self-administered questionnaire and respondents entered each supplement as it was consumed into the food diary.

RESULTS

Twenty-three per cent of respondents regularly used nutritional supplements. Twice as many women used supplements as men. The intakes of micronutrients were significantly higher (P<0.001) in supplement users than in non-users. Micronutrient intakes from food sources were similar in male users and non-users of supplements, but were significantly higher (P<0.01) in female users, by 3 to 13%, for Fe, Mg, Mn, vitamins C and E and niacin than in non-users. The percentage of female users between 18 and 50 years who had mean Fe intakes below the average requirement (AR) (10 mg) decreased from 50 to 25 when the contribution from supplements was included. The use of supplements reduced the percentage of men who had mean intakes below the AR for Zn from 19 to 13, for riboflavin from 14 to 6 and for vitamin A from 20 to 5, and reduced the percentage of women with intakes below the AR for Ca from 23 to 16 and for riboflavin from 23 to 14. Twenty-one women out of 80 aged between 18 and 50 years, who consumed supplemental folate, achieved the intake of 600 microg recommended to prevent neural tube defects. Twenty-two per cent of the women who took iron and 15% of the women who took vitamin B6 in supplemental form had mean daily intakes that exceeded that UL for these nutrients. Supplement users did not exceed the UL for the other micronutrients.

CONCLUSIONS

Supplementation appears to be beneficial in promoting adequate intakes of some micronutrients, particularly Fe and folate in women aged 18-50 years and vitamin A in men. There appears to be little risk to supplement users of experiencing adverse side effects due to excessive intakes of micronutrients.

Low risk of central venous thrombosis with nontunnelled central venous catheters

142 noncuffed, nontunnelled, single lumen central venous catheters were inserted in 103 patients with haematological malignancy. Insertion related complications were minimal and no symptomatic catheter-related central venous thrombosis occurred. Nontunnelled central venous catheters are an excellent alternative to the more commonly used tunnelled devices in terms of convenience, cost-effectiveness and low incidence of side effects.

Alternative subcellular locations of keratinocyte basonuclin

Basonuclin is a zinc finger protein present in the basal cell layer of the epidermis and in hair follicles. Human basal epidermal cells are often heterogeneous with respect to a nuclear or cytoplasmic location of basonuclin and the protein may be concentrated in either compartment. In mouse and rat epidermis, although clusters of basonuclin may be seen in some basal cell nuclei, the protein is mainly concentrated in the cytoplasm. When epidermis whose basal cells contain predominantly cytoplasmic basonuclin is disaggregated and the cells are cultivated in the presence of supporting 3T3 cells, the basonuclin of the growing keratinocyte colonies is strongly concentrated in the cell nuclei. Transfer of the cells to culture medium without supporting 3T3 cells results in a predominantly cytoplasmic concentration of the basonuclin. This translocation is reversible, since addition of supporting 3T3 cells restores most basonuclin to the nucleus. The nuclear location is associated with more rapid cell growth. We conclude that different states of the keratinocyte require greater or less activity of basonuclin, and the subcellular location of the protein is probably related to the magnitude of its action on the cells.

Clinical evaluation or investigation?

For devices undergoing clinical investigation in the European Union, manufacturers must comply with the requirements of the Medical Device Directive. In certain Member States, the Competent Authority reserves the right to perform a pre-assessment of clinical information together with a technical review of the proposed device. Inadequacies in these submissions remain the single most common reason for rejection.

Prognostic factors for cutaneous squamous cell and basal cell carcinoma. Determinants of risk of recurrence, metastasis, and development of subsequent skin cancers

Squamous cell carcinoma and basal cell carcinoma are the most common cancers in humans. This article discusses general prognostic factors for these nonmelanocytic skin cancers. Anatomic and histologic considerations for both carcinomas are also presented.

Tissue necrosis and necrotizing fasciitis after intramuscular administration of diclofenac

OBJECTIVE

To report 6 cases of severe local reactions associated with intramuscular injection of diclofenac.

CASE SUMMARIES

Three patients developed extensive tissue necrosis at the injection site after intramuscular diclofenac. Necrotizing fasciitis in an additional 3 patients was associated with complications such as adult respiratory distress syndrome, renal failure, shock, and disseminated intravascular coagulation. Organisms were cultured from the necrotic site in 3 cases. Two patients died.

DISCUSSION

Tissue necrosis is a rare but serious complication of intramuscular administration of medicines, including nonsteroidal antiinflammatory drugs (NSAIDs). Pain often occurs at the time of the injection, but tissue necrosis typically becomes apparent a few days later. Necrotizing fasciitis is characterized by rapidly spreading infection with necrosis of fascia and subcutaneous fat.

CONCLUSIONS

Intramuscular administration of diclofenac may be associated with severe tissue necrosis or necrotizing fasciitis. Although rare, these serious complications should be considered when intramuscular injection of NSAIDs is contemplated.