Prevalence of respiratory viruses and Mycoplasma pneumoniae in sputum samples from unselected adult patients

Sputum samples from adult patients are routinely used for bacteriological tests, but not for the diagnosis of viral/mycoplasmal infections. We examined 511 sputum samples submitted for bacterial tests from patients at the Royal Adelaide Hospital. Each specimen was tested directly (and after six days of cell culture amplification) for antigens to influenza A and B, parainfluenza 1, 2 and 3, adenovirus, respiratory syncytial virus (RSV) and Mycoplasma pneumoniae. Respiratory viruses or M. pneumoniae were found in 11% of all specimens but were most common (14%) in sputa reported as containing only "oral flora". Respiratory virus or M. pneumoniae infection was significantly more common in medical patients (12%) than in surgical patients (5%), and was most common in oncology (hematology/radiotherapy) patients (25%). Influenza A and RSV were equally common in medical patients, while RSV was the most frequent isolate in oncology patients. Respiratory viral infection is an underdiagnosed condition in adults, particularly the immunocompromised, which can be successfully diagnosed by virological examination of sputum.

Changes in portal hemodynamics and acute rejection in the first 2 weeks after orthotopic liver transplantation. A prospective Doppler ultrasound study

RATIONALE AND OBJECTIVES

To analyze changes in Doppler ultrasound variables of the portal vein in relation to liver biopsy findings, the authors performed a prospective study of 316 Doppler ultrasound examinations in the first 2 weeks after orthotopic liver transplantation on 23 patients.

METHODS

Recordings were obtained daily from the portal vein (diameter, maximum velocity, and flow). Correlations were explored between the Doppler ultrasound findings and histologic data. The chi-square test was used to analyze differences in Doppler ultrasound variables in patients with and without acute rejection.

RESULTS

In our series of 23 patients, acute rejection was diagnosed by liver biopsy in nine of them (39%). Changes in portal vein diameter, maximum velocity, and flow did not correlate consistently with liver biopsy findings, due to a multifactorial origin. Changes in portal hemodynamics were observed in patients with hepatic artery thrombosis, portal vein stenosis, acute rejection, and sepsis.

CONCLUSIONS

Although routine screening using Doppler ultrasound proved to be useful for the determination of rapid changes in portal hemodynamics within a short time, serial Doppler ultrasound examinations were not helpful in predicting acute rejection.

Preoperative assessment of the portal vein and hepatic artery in children with end-stage liver disease: is selective angiography still necessary?

BACKGROUND

Selective angiography involves increased risk for children and may cause vascular complications. The aim of this study was to determine whether selective angiography is still necessary for viewing the portal vein and hepatic artery.

METHODS

Doppler ultrasound, abdominal aortography, and selective angiography were performed and interpreted independently in 62 children (median age = 1 year 3 months), with end-stage liver disease, who were candidates for orthotopic liver transplantation.

RESULTS

Selective angiography agreed with the Doppler ultrasound findings of patency, flow direction, and diameter of the extrahepatic portal vein in 84%, 73%, and 79% of the children, respectively. Important additional information was obtained from selective angiography in only five of the 62 children (8%). Selective angiography showed an anomaly of the hepatic artery in 21 of the 62 children (33%). In 18 out of these 21 children (85%), an anomaly of the hepatic artery was already visible on the abdominal aortogram.

CONCLUSION

Selective angiography did not play any significant role in the detection of an anomaly of the hepatic artery and should only be done if the Doppler ultrasound findings of the portal vein are inconclusive or if abdominal aortography cannot provide reliable information about the hepatic artery. For the evaluation of the portal vein and hepatic artery, we recommend Doppler ultrasound and abdominal aortography, a less invasive angiographic procedure.

Analysis of growth in children after orthotopic liver transplantation

Growth after pediatric liver transplantation is an important factor in determining the quality of life. We collected data on height, skeletal age, and liver function of 45 consecutive pediatric transplant recipients and assessed the influence of primary diagnosis, liver function, and immunosuppressive regimen on their growth. Height and skeletal age were plotted as median standard deviation scores versus years post-transplantation. Growth, in terms of both height and skeletal age, were continuous without catch-up growth. Primary diagnosis was found to have no influence on height and poor liver function had a negative effect on both height and skeletal growth. A higher alternate day prednisolone maintenance dose also had negative effect on skeletal growth. Thus, it can be concluded that a pretransplant lack of growth will not be restored and is an indication for early transplantation in end-stage liver disease, especially in younger children.

Fotemustine in patients with advanced gastric cancer, a phase II trial from the EORTC-GITCCG (European Organization for Research and Treatment of Cancer, Gastrointestinal Tract Cancer Cooperative Group)

Fotemustine activity was evaluated in 26 patients, mostly pretreated, with advanced gastric cancer. Its main toxicity was haematological with grade 3-4 neutropenia in 32% and grade 3-4 thrombocytopenia in 50% of the patients, complicated by 2 toxicity-related deaths due to haemorrhage. No complete or partial responses were observed in the 26 eligible patients and median survival was only 11 weeks. Fotemustine therefore has no activity in advanced gastric cancer.

Doppler ultrasound of the hepatic artery and vein performed daily in the first two weeks after orthotopic liver transplantation. Useful for the diagnosis of acute rejection?

RATIONALE AND OBJECTIVES

To analyze changes in Doppler ultrasound variables in relation to liver biopsy findings for the diagnosis of acute rejection after orthotopic liver transplantation (OLT), the authors performed in a prospective study 316 Doppler ultrasound examinations in the first 2 weeks after OLT on 23 patients.

METHODS

Recordings were obtained daily from the hepatic artery (resistive index [RI]) and hepatic vein (damping index [DI]). Correlations were explored between the Doppler ultrasound findings and histologic data. The chi-square test was used to analyze differences in Doppler ultrasound variables in patients with and without acute rejection.

RESULTS

Serial Doppler ultrasound examinations showed a significant increase in the RI in 11 of 22 patients (50%); the 23rd patient was excluded because of hepatic artery thrombosis. Despite an agreement in 15 of 22 patients (68%) no statistically significant correlation could be found (positive predictive value 6/11 = 55%; negative predictive value 9/11 = 82%; chi-square = 3.14; P > 0.05). A significant increase in the DI was observed in 14 of 23 patients (61%). However, no statistically significant correlation could be found as well with this parameter (positive predictive value 6/14 = 43%; negative predictive value 6/9 = 67%; chi-square = 0.00; P > 0.05).

CONCLUSION

Serial Doppler ultrasound examinations were not helpful in predicting acute rejection.

Ultrasound and cholangiography for the diagnosis of biliary complications after orthotopic liver transplantation: a comparative study

The ability of ultrasound to detect biliary obstruction, bile leakage and generalized ductal changes after orthotopic liver transplantation (OLT) was compared to cholangiography. Cholangiography was considered to be the gold standard. Adequate opacification of the biliary tree was achieved in 139 cholangiograms. Biliary obstruction, intermediate or large bile leakage, and generalized ductal changes were diagnosed with cholangiography in 15% (21/139), 14% (20/139), and 16% (22/139), respectively. Normal ultrasound findings could not exclude biliary stricture, generalized ductal changes, or bile leakage, and fluid collections were not correlated with bile leakage. Abnormal ultrasound findings were highly predictive of the cholangiographic diagnosis of biliary obstruction or generalized ductal changes (specificity of 98% and 100%, respectively). An irregular appearance of the bile ducts and increased periductal echogenicity proved to be characteristic features for generalized ductal changes.

Absence of human papillomavirus DNA from esophageal carcinoma as determined by multiple broad spectrum polymerase chain reactions

Strong evidence has implicated human papillomaviruses (HPV) in the pathogenesis of anogenital cancers and a number of other mucosal and cutaneous lesions. Data concerning the involvement of HPV in esophageal cancers are controversial. Different investigators have detected HPV types (mainly types 16 and 18) in biopsy specimens of esophageal cancers. A study was undertaken to determine whether responses to chemotherapy of advanced squamous cell carcinomas could be correlated with the HPV status. Polymerase chain reaction (PCR) amplification was used for the detection of HPV DNA in biopsies of esophageal squamous cell carcinomas treated with either surgical resection alone (n = 42) or chemotherapy followed by surgical resection (n = 21). Different general and consensus PCR primer sets, which allow the detection of most of the known as well as a number of not yet characterized HPV types, were used. HPV DNA was not detected in any of the 61 esophageal squamous cell carcinomas, suggesting that HPV infections are not likely to play a major role in the etiology of this neoplasm.

Familial occurrence of membranous obstruction of the inferior vena cava: arguments in favor of a congenital etiology

Membranous obstruction of the inferior vena cava is a rare disease. The etiology of the membrane is believed to be thrombotic or congenital. In three of 11 siblings from a single family, symptoms of membranous obstruction of the inferior vena cava developed during early adult life. All had signs of more long-standing disease, as judged by the presence of collaterals, cirrhosis and, in one case, hepatocellular carcinoma. On family screening no further cases of membranous obstruction of the inferior vena cava were found. There was also no evidence of inherited defects in the natural coagulation inhibitors (protein C, protein S and antithrombin III) and plasminogen deficiency. This familial occurrence of membranous obstruction of the inferior vena cava supports a congenital etiology, although a thrombotic etiology cannot be totally excluded.

Rapid diagnosis of chlamydial respiratory infection in children

A study was undertaken to determine the incidence of chlamydial respiratory infection in paediatric patients during a 12-month period by antigen detection. Nasopharyngeal aspirates (NPA) from 514 patients were screened for genus-specific chlamydia antigen using the Pharmacia Chlamydia enzyme immunoassay (EIA) and Kallestad immunofluorescence (IF) assays. EIA screen-positive samples were confirmed by specific blocking antibody. Specimens which were EIA positive or IF positive were cultured for chlamydia. The NPAs from 7 patients were positive in the EIA and IF assays. Four of these patients were culture positive for chlamydia. Our results showed that the incidence of chlamydia respiratory infection by antigen detection was 1.4% or 0.8% if confirmed by culture.

Doppler ultrasound and angiography of the vasculature of the liver in children after orthotopic liver transplantation: a prospective study

Despite the availability of Doppler ultrasound, angiography still forms part of the protocol for evaluating children after orthotopic liver transplantation (OLT) at our department. To investigate whether Doppler ultrasound is a reliable method for evaluating the patency of the hepatic artery, portal vein, inferior vena cava, and the anastomotic site of the portal vein in children after OLT, we performed a prospective study in which Doppler ultrasound was compared with angiography in 38 children with 40 transplants (ten examinations on clinical demand and 49 examinations according to protocol). Good correlation was found in relation to demonstrating a patent hepatic artery (sensitivity 96% and specificity 100%). Two false-negative Doppler ultrasound results were attributable to technical difficulties and rejection. For evaluating the patency of the portal vein, Doppler ultrasound agreed with angiography in 58 of the 59 examinations (98%). The one and only false-positive angiography result was explained by inadequate opacification. Doppler ultrasound visualized stenosis of the portal vein three times more often than angiography. In seven children, Doppler ultrasound findings suspicious of pathology of the inferior vena cava were confirmed using cavography or surgery. Doppler ultrasound proved to be a reliable technique for evaluating the patency of the hepatic artery, inferior vena cava, and portal vein and the anastomotic site of the portal vein.

Routine diagnosis of seven respiratory viruses and Mycoplasma pneumoniae by enzyme immunoassay

A composite EIA, using 8-well microstrips, was used for the rapid detection of seven respiratory viruses and M. pneumoniae. The viruses included influenza A and B, parainfluenza 1, 2 and 3, adenovirus and respiratory syncytial virus. During the 61 month period--June 1988 to June 1993--17326 respiratory specimens, submitted from three states, were tested by this EIA. The specimens were mainly from a paediatric population (hospitals and private physicians). RSV was the predominant virus detected, followed by adenovirus, parainfluenza 3, M. pneumoniae, influenza A, parainfluenza 2, influenza B and parainfluenza 1. The use of blocking antibodies confirmed the identification of the agents, in particular with samples showing absorbance values greater than the cutoff with more than one infectious agent. Different methods for processing specimens in order to obtain a uniform suspension, and interpretation of non-specific reactions, are discussed. The assays showed an average sensitivity of 85% and specificity of 99%, compared to virus culture. This EIA system provided an efficient method for the rapid diagnosis of viral and mycoplasmal infections in a busy diagnostic laboratory.

Initiation of reverse transcription during cell-to-cell transmission of human immunodeficiency virus infection uses pre-existing reverse transcriptase

H3B cells, a laboratory clone of H9 cells persistently infected with the HTLV-IIIB strain of human immunodeficiency virus (HIV), contained significant levels of cell-associated reverse transcriptase (RT) activity measured by in vitro assays using either exogenous or endogenous templates. The cell-associated RT activity detected using exogenous template was almost wholly in a soluble (non-sedimentable) form whereas endogenous activity sedimented as a particulate structure associated with viral RNA. Despite this, H3B cells did not contain episomal HIV DNA detectable by Southern blot, indicating that in vivo reverse transcription was not occurring to any significant extent in these cells. However, when susceptible HUT 78 cells were infected by co-cultivation with H3B cells, dramatic synthesis of episomal HIV DNA occurred. Concurrently with this de novo initiation of reverse transcription, however, we found no detectable change in intracellular levels or cleavage profiles of immunoprecipitable RT polypeptides. Finally, actinomycin D pre-treatment of H3B cells to prevent de novo transcription from donor cell proviral DNA after co-cultivation did not affect the initiation of in vivo reverse transcription following cell-to-cell HIV infection. These results demonstrated that cells persistently infected with HIV contained significant fully cleaved cell-associated RT in a form that was active in vitro but not in vivo and that following cell-to-cell transmission of HIV infection to susceptible cells, de novo reverse transcription was initiated without detectable evidence of further synthesis or proteolytic processing of HIV RT. The nature of this initiation process requires further study.

Outbreak of adenovirus type 4 conjunctivitis in South Australia

An outbreak of adenovirus type 4 conjunctivitis occurred in South Australia between April and November 1992. Eye swabs were submitted by general practitioners and ophthalmologists who had seen patients with clinical conjunctivitis or keratitis. Apart from interfamilial spread, there were no other common epidemiological factors. Adenovirus was isolated from the eye swabs of 38 patients. Isolates were typed by neutralisation tests and restriction endonuclease cleavage patterns and found to be adenovirus type 4. This report serves to illustrate an infrequent cause of epidemic conjunctivitis, namely adenovirus type 4. There was no demonstrable focus of the outbreak.

[Different evaluations of the staging of Hodgkin's and non-Hodgkin's lymphomas (NHL) with computer tomography and lymphography by different observers]

In this report, the differences in the evaluation of CT and lymphography findings by different observers is discussed. The study included 132 men and 79 women (146 NHL and 65 Hodgkin lymphomas). A total of 185 CT examinations and 78 lymphographies were available for reevaluation. In the lymphographies, discongruent findings were reported twice as frequently as in the CT scans (15% and 9%). An optimized examination protocol for CT and consistent criteria for the interpretation of lymphographic findings could possible lead to a better diagnostic evaluation.

The use of MDCK, MEK and LLC-MK2 cell lines with enzyme immunoassay for the isolation of influenza and parainfluenza viruses from clinical specimens

Primary Monkey Kidney (PMK) epithelial cells or egg inoculation have been traditionally used for the culture of influenza and parainfluenza viruses. The high cost and variability of obtaining high quality PMK cells prompted us to investigate the use of other cell strains for the growth of these viruses. For this study we investigated three cell lines viz. MDCK, MEK and LLC-MK2 for the culture of influenza A and B and parainfluenza 1, 2 and 3 viruses. Clinical specimens were spun onto cell monolayers in microtitre wells. The growth of these viruses was then identified by specific antibodies in an enzyme immunoassay (EIA). The LLC-MK2 and MDCK cell lines were found to provide optimal growth of parainfluenza and influenza viruses respectively. During the period from November, 1990 to July, 1992, 6501 respiratory specimens were tested. There were 100 influenza A, 36 influenza B and 261 parainfluenza virus isolates. The influenza isolates were further subtyped by the WHO Influenza Reference Centre. The use of these cell lines and the EIA provided an effective method for the routine culture of these viruses.

Successful treatment of veno-occlusive disease of the liver with urokinase in a patient with non-Hodgkin's lymphoma

A 38-year-old man with a non-Hodgkin's lymphoma of intermediate grade malignancy attained partial remission after three courses of CHOP (cyclophosphamide+hydroxydaunorubicin+vincristine+prednisolone). He was assigned to undergo autologous bone marrow transplantation (ABMT). The conditioning regimen consisted of cyclophosphamide and whole body irradiation. Two weeks later he developed veno-occlusive disease (VOD) of the liver. Doppler sonography confirmed the diagnosis showing a reversal of the blood flow in the portal vein. In addition a large thrombus was present in the inferior caval vein. Protein C level was strongly reduced (28%). Because of clinical deterioration intravenous urokinase was started. The transaminases normalised rapidly and the patient showed a dramatic clinical improvement. There were no major bleeding complications. Repeat Doppler sonography showed a normal antegrade flow in the portal vein. This case suggests that a coagulopathy in the hepatic vascular bed might contribute to the development of VOD and that patients with VOD are at risk for other thrombotic complications. Furthermore it shows that urokinase with platelet support can be given safely and effectively to a patient with VOD and severe thrombocytopenia.

Cell-to-cell transmission of human immunodeficiency virus infection induces two distinct phases of viral RNA expression under separate regulatory control

A cell clone persistently infected with human T cell-lymphotrophic virus type IIIB (H3B cells) contained mainly the multiply spliced (2 kb) and singly spliced (4.3 kb) species of human immunodeficiency virus (HIV) RNA. When H3B cells were co-cultured with susceptible HUT78 cells, cell fusion occurred within 4 h of cell mixing and was accompanied by a marked increase of the unspliced full-length (9.2 kb) HIV RNA. This first phase of viral RNA induction (4 to 12 h post-infection) was followed by a second phase of viral RNA synthesis from 24 h p.i. in which there were significant increases in all three species of HIV RNA. Reverse transcriptase (RT) inhibitors such as azidothymidine (AZT) at concentrations that abolished de novo HIV DNA synthesis, abolished the first phase but not the second phase of viral RNA synthesis in our model system. A comparable one-step cell-free virus infection showed a pattern of viral RNA synthesis similar to that of the cell-to-cell transmission of infection. However, viral RNA synthesis following cell-free virus infection was totally inhibited by RT inhibitors. The early phase (4 to 12 h) expression of 9.2 kb HIV RNA is likely to use newly synthesized HIV DNA as template; during this phase, HIV RNA and DNA syntheses occur simultaneously, with each process being dependent on the other for maximal yield. During the later (24 to 48 h) phase, all three HIV RNA species may be transcribed at least in part from proviral DNA from the original donor cells. This later phase may provide one of the mechanisms for natural spread of virus to new cells and for enhanced viral gene expression in vivo, despite the presence of AZT.

Phase II study of miltefosine (hexadecylphosphocholine) in advanced soft tissue sarcomas of the adult--an EORTC Soft Tissue and Bone Sarcoma Group Study

The EORTC Soft Tissue and Bone Sarcoma Group conducted a phase II study with oral miltefosine at a dose of 50 mg thrice daily in patients with metastatic soft tissue sarcomas. No responses were seen in 18 evaluable patients. Toxicity consisted mainly of nausea/vomiting. It is concluded that oral miltefosine has no activity in soft tissue sarcoma.

Activity of cisplatin in adenocarcinoma of the pancreas

The activity of cisplatin in metastatic adenocarcinoma of the pancreas was assessed in 33 patients. Cisplatin was administered in a dose of 100 mg/m2, every 4 weeks. There were 2 complete responses and 5 partial responses (a response rate of 21%). The median duration of response was 5 months (range, 2+ to 15 months). Cisplatin is a modestly active drug in advanced pancreatic cancer.

Treatment of patients with metastatic pancreatic and gastrointestinal tumours with the somatostatin analogue Sandostatin: a phase II study including endocrine effects

Somatostatin analogues can suppress the secretion of some gastrointestinal hormones and growth factors involved in the growth regulation of gastrointestinal cancers and can inhibit the growth of experimental pancreatic tumours. Therefore, in a phase II study 34 patients with metastatic pancreatic (n = 14), colorectal (n = 16) and gastric cancer (n = 4) were treated with three daily subcutaneous injections of 100-200 micrograms of the somatostatin analogue Sandostatin (SMS 201-995). All patients had an extensive tumour load and 13 were pretreated with chemotherapy. Before Sandostatin treatment the patients with pancreatic cancer showed a higher mean plasma concentration of GH (P less than 0.05) and a lower concentration of 'total' somatomedin-C (P less than 0.005) compared with patients with colorectal cancer; there was no significant difference between these two groups in plasma levels of directly assayable somatomedin-C, EGF/TGF-alpha, insulin and prolactin. Within 3 days after start of treatment, somatomedin-C levels initially decreased (without a change in basal plasma GH levels), but returned to pretreatment levels within 4-13 weeks. Plasma insulin levels also were suppressed but only during the first 3-5 days of treatment. Plasma EGF-TGF-alpha levels increased significantly at day 5 of treatment only in the pancreatic cancer patients. Twenty-seven per cent of the patients showed stable disease for 3-9 months, but most patients experienced subjective improvement in the absence of serious side-effects. However, the overall survival remained disappointing, emphasising the need for better treatment regimens.

Evaluation of the Becton Dickinson Directigen test for respiratory syncytial virus in nasopharyngeal aspirates

A premarket trial of the Becton Dickinson Directigen respiratory syncytial virus membrane-based enzyme immunoassay compared the test with virus isolation for the detection of respiratory syncytial virus in 583 nasopharyngeal aspirates. After modification, the Directigen test showed a sensitivity of 83% and a specificity of 90%. It offers the potential for an efficient bedside test--without the need for any equipment--for the diagnosis of respiratory syncytial virus infection and requires only a 0.25-ml sample volume. However, for optimum reliability, freezing-thawing of samples and access to a confirmatory test were shown to be necessary.