Return to Contact Sports following Infectious Mononucleosis: The Role of Serial Ultrasonography

Splenic rupture is a rare but potentially fatal complication of infectious mononucleosis. Athletes returning to contact sports following infectious mononucleosis are at potential risk of splenic rupture secondary to abdominal trauma. No clear consensus exists as to when it is safe to allow these athletes return to contact sports. Suggested periods of abstinence have ranged from 2 weeks to 6 months. We outline our experiences with the use of abdominal ultrasonography at 1 month after the diagnosis of infectious mononucleosis as a means of determining when athletes can safely return to contact sports. Our study group was made up of 19 such patients (mean age: 16.7 yr). We found that 16 of these patients (84%) had normal splenic dimensions on ultrasonography 1 month after diagnosis, and they were therefore allowed return to contact sports. While the remaining 3 patients had an enlarged spleen at 1 month, their splenic dimensions had all returned to normal when ultrasonographic examination was repeated at 2 months postdiagnosis. We conclude that serial abdominal ultrasonography allows for informed decision making in determining when athletes can safely return to contact sports following infectious mononucleosis.

Pre-acclimation of a wastewater inoculum to cellulose in an aqueous-cathode MEC improves power generation in air-cathode MFCs

Cellulose has been used in two-chamber microbial fuel cells (MFCs), but power densities were low. Higher power densities can be achieved in air-cathode MFCs using an inoculum from a two-chamber, aqueous-cathode microbial electrolysis cell (MEC). Air-cathode MFCs with this inoculum produced maximum power densities of 1070 mW m(-2) (cathode surface area) in single-chamber and 880 mW m(-2) in two-chamber MFCs. Coulombic efficiencies ranged from 25% to 50%, and COD removals were 50-70% based on total cellulose removals of 60-80%. Decreasing the reactor volume from 26 to 14 mL (while maintaining constant electrode spacing) decreased power output by 66% (from 526 to 180 mW m(-2)) due to a reduction in total mass of cellulose added. These results demonstrate that air-cathode MFCs can produce high power densities with cellulose following proper acclimation of the inoculum, and that organic loading rates are important for maximizing power densities from particulate substrates.

Tumour necrosis factor antagonists and the risk of cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review

OBJECTIVES

RA is associated with early ischaemic heart disease. This appears to be driven largely by the presence of chronic inflammation. Studies suggest that treatment with disease-modifying drugs such as MTX may reduce the incidence of cardiovascular events in RA. Anti-TNF therapies significantly reduce inflammation in RA. However, the extent to which these agents also reduce cardiovascular disease (CVD) is uncertain. The purpose of this study was to explore the effect of anti-TNF agents on CVD in RA using a systematic literature review.

METHODS

We searched for studies of adults with RA treated with TNF antagonists where cardiovascular outcomes were recorded using MEDLINE, EMBASE, Cochrane Database, Database of Abstracts and Reviews of Effects, Health Technology Appraisal, Science Citation Index and Clinical Evidence from 1989 to 2010. Conference proceedings for the British Society of Rheumatology, ACR and EULAR between 2005 and 2009 were hand searched. Two reviewers assessed abstracts for inclusion and then quality of selected papers was assessed.

RESULTS

A total of 1840 abstracts were identified and 20 articles were suitable for inclusion. Information was obtained on the effect of TNF antagonists on overall CVD events, myocardial infarction, strokes and heart failure.

CONCLUSION

In many studies, TNF antagonists appear to reduce the likelihood of CVD in individuals with RA. Reassuringly, there does not appear to be an increased risk of cardiac failure. However, the reduction in CVD is not as consistently seen as with studies of MTX.

An evaluation of the strengths and weaknesses of a register of newly diagnosed rheumatoid arthritis, 1986-2010

OBJECTIVES

To evaluate the strengths and weaknesses of a register of management and outcomes of recently diagnosed RA, and allow comparisons between rheumatology centres on good clinical practice and guidelines.

METHODS

A register of newly diagnosed RA was initiated in 1986 in nine different regions of England, later expanded to UK-wide membership in 2002. Standardized data collection includes disease activity, function, radiological damage, therapy, hospitalizations, major comorbidity and mortality. A centralized database generates individual reports and comparative data for each centre yearly. Aims have been compared with actual achievements and any changes over 25 years.

RESULTS

Thirty rheumatology centres have recruited 2866 patients. Study outputs have included peer-reviewed scientific publications and contributions to the recent National Audit Office report on RA. Referral times into secondary care have changed little over 25 years, but time to initiation of drug therapies has decreased. Delays between publication of clinical trial evidence and management guidelines and their implementation in normal clinical practice are illustrated by relatively infrequent use of combination therapies at diagnosis. Consecutive case recruitment, centre participation and follow-up were reportedly compromised by local funding issues. Centre participants report a benefit from feedback of actual clinical practice compared with recommended standards of care.

CONCLUSIONS

Most of the original objectives have been achieved. Cohort studies based predominantly in District General Hospitals provide unique insights into the natural history and impact of RA, its management, the translation of research findings into clinical practice and provide participating centres with important clinical governance and professional development opportunities.

The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review

OBJECTIVES

Patients with RA have an increased prevalence of cardiovascular disease (CVD). This is due to traditional risk factors and the effects of chronic inflammation. MTX is the first-choice DMARD in RA. We performed a systematic literature review to determine whether MTX affects the risk of CVD in patients with RA.

METHODS

We searched Medline, Embase, Cochrane database, database of abstracts of reviews of effects, health technology assessment and Science Citation Index from 1980 to 2008. Conference proceedings (British Society of Rheumatology, ACR and EULAR) were searched from 2005 to 2008. Papers were included if they assessed the relationship between MTX use and CVD in patients with RA. Two reviewers independently assessed each title and abstract for relevance and quality.

RESULTS

A total of 2420 abstracts were identified, of which 18 fulfilled the inclusion criteria. Two studies assessed the relationship between MTX use and CVD mortality, one demonstrated a significant reduction in CVD mortality and the second a trend towards reduction. Five studies considered all-cause CVD morbidity. Four demonstrated a significant reduction in CVD morbidity and the fifth a trend towards reduction. MTX use in the year prior to the development of RA decreased the risk of CVD for 3-4 years. Four studies considered myocardial infarction, one demonstrated a decreased risk and three a trend towards decreased risk with MTX use.

CONCLUSION

The current evidence suggests that MTX use is associated with a reduced risk of CVD events in patients with RA. This suggests that reducing the inflammation in RA using MTX not only improves disease-specific outcomes but may also reduce collateral damage such as atherosclerosis.

Bisphosphonate-laden acrylic bone cement: mechanical properties, elution performance, and in vivo activity

Cemented total hip replacements generally fail after 10-20 years, often due to implant loosening from bone resorption. Bisphosphonates such as zoledronic acid (ZA) and pamidronate (PAM) are potent inhibitors of bone resorption. The local delivery of bisphosphonates via acrylic bone cement could decrease osteolysis and prolong implant lifespan. Conflicting studies suggest that bisphosphonate loading may or may not reduce the mechanical properties of acrylic bone cement. We assayed acrylic bone cement laden with ZA or PAM at different concentrations and diluent volumes. Four-point bend testing and compressive testing indicated that high volumes of diluent (with or without bisphosphonate) significantly reduced bending modulus and compressive strength. Radiography and electron microscopy indicated that high diluent volumes generated abnormal acrylic bone cement structure. After 6 weeks of incubation in saline, only 0.9% w/w of the total bisphosphonate incorporated in acrylic bone cement eluted in vitro, indicating a slow elution rate. In vivo testing was performed using a rat model. Cement cylinders were inserted into incisions in rat distal femora and ZA delivered locally (via elution from acrylic bone cement) or systemically (via injection). At 4 weeks postoperatively, dual energy X-ray absorptiometry demonstrated no significant increase in local bone mineral density (BMD) adjacent to ZA-laden implants. In contrast, systemic ZA delivery (0.1 mg/kg) led to a large (48.6%) and significant increase in BMD. Thus, systemic delivery appears more effective than local delivery.

Reliability and validity of the myositis disease activity assessment tool

OBJECTIVE

To test the interrater reliability and validity of the Myositis Disease Activity Assessment Tool, which consists of the Myositis Intention-to-Treat Activity Index and the Myositis Disease Activity Assessment Visual Analog Scales.

METHODS

Two phases of the study were conducted to assess the reliability and validity of the tool, which was modified following the first phase. In the first phase of the reliability study, 123 adult myositis patients were evaluated in 7 centers, and in the second phase 40 patients were evaluated in 2 centers. The validity study included 294 patients in 5 centers in the first phase and 65 patients in 3 centers in the second phase. The interrater reliability was assessed using intraclass correlation coefficients. The criterion validity was calculated using sensitivity, specificity, and positive predictive value (PPV) of a grade of A in any system. Spearman's rank correlation coefficient was used to measure the convergent validity of cross-sectional scores between the 2 instruments.

RESULTS

There was a 2:1 ratio of female to male patients. There was no significant difference in mean age at diagnosis (46.3 versus 46.8 years) and mean disease duration (7.7 versus 10 years) between the 2 groups recruited for the different phases of the study. There was an improvement in interrater reliability in the second phase of the study. There was a significant improvement in the validity of the assessment tool following modification of the tool. The sensitivity, specificity, and PPV of a grade of A in any system improved from 86%, 92%, and 67% in the first phase to 96%, 94%, and 83%, respectively, in the second phase. Convergent validity between the 2 activity tools showed good correlation, ranging from 0.8 to 0.94, for the individual organ systems.

CONCLUSION

This is the first major attempt to assess the reliability and validity of a disease activity index in myositis. Our findings indicate that, following within-study modification, the tool appears to be a reliable and valid instrument to assess myositis disease activity.

Contemporary patterns of care and disease activity outcome in early rheumatoid arthritis: the ERAN cohort

OBJECTIVES

To report from the Early Rheumatoid Arthritis Network (ERAN), time from symptom onset to start of therapy, treatment choices and disease outcome in early RA.

METHODS

Patients with newly diagnosed RA were prospectively enrolled from 19 centres in the UK and Eire. Standardized information was collected on case report forms at first presentation, 3-6 months, 1 yr and annually thereafter. The choice and intensity of drug treatment was left to the discretion of individual centres.

RESULTS

A total of 808 patients were recruited between 2002 and 2007, with a mean follow-up of 16 (0-60) months. Of them, 62% fulfilled four or more ACR criteria for RA at first visit. The median time from onset of symptoms to referral to secondary care was 4 months [interquartile range (IQR) 2-9, n = 655] and to start of first DMARD 8 months (IQR 4-13, n = 638). DMARDs were prescribed in 97% of the patients, initially as monotherapy in 91%, and as combination therapy in 9%. The second DMARD (n = 220) was a switch to another as monotherapy in 52% and step-up to combination therapy in 48%. The proportions with a 28-joint disease activity score >5.1 at baseline and 3 yrs were 46 and 19%, >3.2 were 84 and 54% and <2.6 were 6 and 33%, respectively.

CONCLUSIONS

Patients presenting with RA in ERAN do not receive DMARDs promptly, largely due to delays in referral to secondary care. Contemporary treatment practice is to start with DMARD monotherapy, and to use combination DMARDs as second-line therapy in approximately half of them. Over 3 yrs the proportion of patients continuing to have active disease remains high.

Bowel associated dermatosis - arthritis syndrome: a case report

We report a rare case of Bowel Associated Dermatosis – Arthritis Syndrome in a young patient with complex Crohn's disease who presented with fever, arthritis, rash and worsening of diarrhea with abdominal pain, who promptly responded to a short course of steroids.

Ex vivo monitoring of human cytomegalovirus-specific CD8+ T-cell responses using QuantiFERON�-CMV

We have developed a novel diagnostic technology to monitor the human cytomegalovirus (HCMV)-specific CD8+ T-cell responses that is based on the detection of secreted interferon-gamma (IFN-gamma) in the whole blood (referred to as QuantiFERON -CMV). Evaluation of QuantiFERON -CMV in healthy individuals revealed that this technology was at least as sensitive and with some HCMV epitopes more sensitive than the ELISPOT for detecting ex vivo IFN-gamma. Results from QuantiFERON -CMV assays showed 97% (36/37 individuals) agreement with the anti-HCMV serology test in healthy individuals. Furthermore, we also show that this technology can be used to assess HCMV-specific T-cell responses in transplant patients. This study shows that QuantiFERON -CMV is a simple, reproducible, and reliable test for the detection of IFN-gamma in response to HCMV CD8+ T-cell epitopes, and may be a valuable diagnostic test for the detection of HCMV infection and a useful clinical tool for monitoring the immune response in immunosuppressed patients during therapy.

Bisphosphonate rescue in distraction osteogenesis: a case series

Distraction osteogenesis is a powerful stimulus for new bone (and tissue) generation (anabolism). Biomechanical stimulation by distraction of the regenerate region results in a high rate of tissue and bone production. However, catabolism (bone resorption) can also occur, the process potentially accentuated in a stress-shielded environment of an external fixator. Regenerate insufficiency can result in regenerate bending or fracture after frame removal. Experimental evidence has demonstrated that bisphosphonates may mediate improved local limb bone mineral density (BMD) and regenerate strength in animal models. Seven patients who had undergone limb lengthening using an Ilizarov device were found to have regenerate insufficiency. Poor regenerate quality led to consideration for intervention. With informed consent, patients received a therapeutic regime of intravenous pamidronate (n = 3) or zoledronic acid (n = 4).The mean age was 13.8 years (SD, +/-3.6 years), with a minimum follow-up period of 4 months after fixator removal. The sites of regenerate insufficiency were the proximal tibia (n = 6) and the distal femur (n = 1). The mean time interval in the fixator before bisphosphonate treatment was 170 days (range, 124-252 days), with an average length increase of 4.8 cm (SD, +/-1.1 cm). At time of intravenous bisphosphonate treatment, dual-energy x-ray absorptiometry measurements demonstrated a reduced BMD (mean, 62.1%; SD, +/-12.6%) in the bone adjacent to the lengthening site of the nonoperated side. Mean healing index was high at 79.6 days/cm (range, 64.4-108.0 days/cm), reflecting the observed regenerate insufficiency. No significant systemic complications were encountered. Six of the patient's fixators were removed without requirement for other intervention, demonstrating a rapid and sustained improvement in local BMD, increasing to a mean of 85.6% (SD, +/-13.3%) of the healthy side. One patient did not respond and subsequently healed after percutaneous osteogenic protein 1 (bone morphogenetic protein 7) and bone marrow injection. Most failed regenerate cases maintain some underlying anabolic activity and can be treated successfully with bisphosphonate therapy, which reduces catabolism. Only 1 case required percutaneous administration of an anabolic therapy to achieve union. These minimally invasive approaches may lessen the need for surgery in a group where significant surgical reintervention could otherwise be required.

Residual risk of transfusion transmitted human immunodeficiency virus, hepatitis B virus, hepatitis C virus and human T lymphotrophic virus

BACKGROUND

The risk of transfusion transmitted viral infection is now so low that mathematical modelling is required to estimate the residual risk. The first national viral risk estimates for hepatitis B virus (HBV), human immunodeficiency virus (HIV) and hepatitis C virus (HCV) were recently published by the Australian Red Cross Blood Service. Using several refinements to the original methodology, as well as an additional 2 years of data, new risk estimates have been derived.

METHODS

Viral screening data for Australian donors for 2000/2003 were retrospectively analysed. The data were applied to three published models to estimate the residual risk of transmitting HIV, HBV, HCV or human T lymphotrophic virus (HTLV) by blood transfusion in Australia.

RESULTS

Applying the three models to HBV, HIV and HCV, three point estimates of the residual risk per unit were calculated for each virus. The median point estimates were 1 in 1,339,000 for HBV, 1 in 1 in 7,299,000 for HIV, and 1 in 3,636,000 for HCV. Although the HTLV risk could not be equivalently calculated because of the lack of incident infection it was estimated to be considerably less than 1 in 1,000,000 using a separate method.

CONCLUSIONS

The most current and accurate estimate of residual risk of viral transmission in Australia has been provided in the present study. The residual risk in Australia is exceptionally small, continuing to decrease and is generally less than European or US risk estimates. These new estimates demonstrate that for viral transmission the Australian blood supply is amongst the safest in the world, and provide a basis for evaluating the cost benefit of future viral testing methodologies.

Play-wrestlers and their injuries

Television (TV) broadcast wrestling series have become very popular amongst Irish children in recent years. Over a four-month study period, 2.3% of injuries seen at a busy paediatric fracture clinic were attributable to play-wrestling. The mean age was 9.5 years (range 4-15 years). All of the children had been role-playing wrestlers and imitating wrestling "moves" seen on TV. None had formal training in wrestling or martial arts. The commonest injury was fracture of the distal radius (7/13). One child required general anaesthetic for manipulation of a dorsally displaced fracture of radius. All other injuries were treated conservatively and resolved without sequelae.

Leflunomide in rheumatoid arthritis: recommendations through a process of consensus

OBJECTIVES

To determine, by consensus, the optimal use of leflunomide in rheumatoid arthritis (RA), using a multidisciplinary panel of experts and performing meta-analyses of available data.

METHODS

A multidisciplinary panel of experts in RA was convened. Important questions, pertinent to the use of leflunomide in the treatment of RA, were defined by consensus at an initial meeting. Each question was allocated to subgroups of two or three members, who worked separately to prepare a balanced opinion, based on published literature, data from individual patients taking part in phase II and phase III clinical trials provided by Aventis, and data from a USA-based medical claims database (AETNA). The full group then reconvened to agree on an overall consensus statement. Recommendations concerning efficacy and tolerability versus comparator drugs and placebo were derived from two new meta-analyses.

RESULTS

Leflunomide was at least as effective as sulphasalazine and methotrexate, and equally well tolerated on meta-analysis of trial data. Overall withdrawal rates for all adverse events were similar for all three drugs. Avoidance of the loading dose reduces 'nuisance' side-effects (e.g. nausea), but probably delays the onset of action. Adverse events could usually be managed by dose reduction and/or symptomatic therapy.

CONCLUSIONS

On the basis of efficacy, safety and cost, leflunomide should be considered in patients with RA who have failed first-line DMARD drug therapy. In refractory cases, leflunomide may be used in combination with, for example, methotrexate before biological agents. Therapy should be initiated by a specialist, but repeat prescribing in general practice on a shared care basis is acceptable using agreed protocols. Clear mechanisms are required to monitor toxicity, with good communication between the patient and rheumatologist to manage nuisance side-effects and avoid unnecessary discontinuation of leflunomide.

Follow-up of six blood donors highlights the complementary role and limitations of hepatitis C virus antibody and nucleic acid amplification tests

BACKGROUND AND OBJECTIVES

The purpose of this study was to analyse the follow-up results for six blood donors who screened positive for hepatitis C virus (HCV) by nucleic acid amplification technology (NAT) but were non-reactive in the primary antibody immunoassay (HCV NAT yield).

MATERIALS AND METHODS

Volunteer blood donations were screened, in parallel, for antibodies to hepatitis C virus (anti-HCV) and for human immunodeficiency virus (HIV)/HCV RNA using the Abbott PRISM HCV Chemiluminescent immunoassay (ChLIA) and the Chiron Procleix HIV-1/HCV RNA assays, respectively. NAT yield donor samples were further tested using supplemental assays, including an alternate HCV antibody enzyme immunoassay (EIA) (Abbott Murex anti-HCV Version 4), an immunoblot (Ortho RIBA-3 or Genelabs Diagnostics HCV Blot 3.0) and two alternative HCV NAT assays [Roche HCV Amplicor and an assembled HCV polymerase chain reaction (PCR)]. Five of the six donors were available for follow-up testing.

RESULTS

The six NAT yield donations were identified as constituents of 24-member minipools among 2,212,695 donations screened over the 28-month study period. All samples were positive when tested, undiluted, using the Roche Amplicor and assembled reverse transcription-polymerase chain reaction (RT-PCR) alternate NAT assays. One of the donors, subsequent to seroconversion, showed RNA levels that fluctuated above and below the limit of detection of the NAT screening assay. Three of the six were reactive on the secondary EIA and showed reactivity to the core c22(p) antigen by immunoblot at the index donation. Two others subsequently became reactive in the ChLIA prior to the EIA, showing reactivity against c100 and/or c33c antigens by immunoblot. The remaining donor became reactive in the ChLIA and EIA at the same time, showing RIBA reactivity against all of the following three peptides: c100; c33c; and c22(p).

CONCLUSIONS

This study demonstrated that at least five of six HCV NAT yield donors were in the pre- or early antibody seroconversion phase of infection. The observation that one yield donor demonstrated HCV RNA that fluctuated above and below the limit of detection of the primary NAT-screening assay supports the maintenance of both NAT and antibody screening for HCV. Follow-up testing of suspected yield donors revealed that the primary and alternate anti-HCV immunoassays had different performance characteristics, depending on the specificity of the donor's early anti-HCV response.

Thermal preconditioning prevents peritendinous adhesions and inflammation

Adhesion formation is one of the foremost obstacles to a reliably good outcome in tendon and joint surgery. Thermal preconditioning has been found to reduce the inflammatory response through the induction of molecular chaperone expression, a recently described family of cytoprotective intracellular proteins. The authors analyzed the effect of thermal preconditioning on the inflammatory response to surgery, on tendon healing, and on the formation of peritendinous adhesions in 16 New Zealand White rabbits. Very significant decreases in adhesion formation and in the gliding and dimensions of tendons in animals that had thermal preconditioning were found. Tendons from these animals also showed a decreased level of adhesion formation and a significantly diminished inflammatory response on histologic examination with no biomechanically significant deleterious effect on the strength of tendon healing on testing load to failure. These findings are consistent with induction of heat shock proteins by hyperthermic pretreatment. Such prevention of peritendinous adhesions and the inflammatory response to injury and surgery without compromising healing are findings that have significant implications for tendon surgery and all surgery involving joints and soft tissues.

Antibiotic prophylaxis for dental or urological procedures following hip or knee replacement

OBJECTIVES

Reports of prosthetic joint infection associated with urological or dental procedures have prompted suggestions that these patients require antibiotic prophylaxis, but no guidelines have been agreed. We have polled orthopaedic surgeons, urologists, and dentists on this issue.

METHODS

The questions asked were: could infection of a joint prosthesis result from a dental or urological procedure; does the risk of infection warrant patients informing their dentist or urologist about their joint replacement; should these patients have prophylactic antibiotics for (a) routine procedures and (b) lengthy procedures.

RESULTS

Urologists and orthopaedic surgeons agreed that infection could probably result from urological procedures and that patients should definitely inform their urologist about their prosthesis. Orthopaedic surgeons thought that antibiotics were definitely indicated for routine and lengthy urological procedures while urologists thought antibiotics were probably indicated. Orthopaedic surgeons thought that infection probably could result from dental procedures, while dentists answered "don't know". Both groups agreed that patients should definitely inform their dentist about their prosthesis. Orthopaedic surgeons thought that antibiotics probably were necessary for routine and lengthy dental procedures, whereas dentists answered "probably not" and "don't know", respectively.

CONCLUSIONS

These results could provide the basis for a consensus regarding prophylactic antibiotic use in this growing patient population.

The age-specific prevalence of human parvovirus immunity in Victoria, Australia compared with other parts of the world

The age-specific immunity to human parvovirus infection was estimated in Victoria, Australia using prospectively collected samples from the Royal Children's Hospital, the Royal Women's Hospital and the Australian Red Cross Blood Service and from sera stored at the Victorian Infectious Diseases Reference Laboratory (VIDRL). All testing was performed at VIDRL using a commercial enzyme-linked immunosorbent assay (Biotrin). Of the 824 sera tested, 28% of those drawn from people aged 0-9 years contained protective antibodies to human parvovirus. This rose to 51% in the next decade of life. There was then a slow rise to about 78% immunity over 50 years of age. An analysis of all requests for parvovirus serology at VIDRL from 1992 to 1998 suggested that parvovirus tended to occur in 4-year cycles, with 2 epidemic years followed by 2 endemic years. A review of published reports of parvovirus immunity suggested that parvovirus infection may be more common, with a correspondingly higher proportion of the community immune, in temperate as opposed to tropical countries.

Results of HCV screening of volunteer blood donors with a chemiluminescent immunoassay and a second- or third-generation EIA: overlap of false-positive reactivity and its impact on donor management

BACKGROUND

This study reports the results of adopting a strategy of anti-HCV testing of volunteer blood donors that uses a primary screening assay, two secondary EIAs (Anti-HCV Version III, Murex; Monolisa Anti-HCV New Antigens, Sanofi Pasteur), and a confirmatory immunoblot (HCV WB, Murex).

STUDY DESIGN AND METHODS

A comparison was made of HCV test results from volunteer donors tested in two periods when different primary HCV screening assays were in use. The same two secondary screening assays and the same confirmatory test were used for the whole study. The two different primary assays were semi-automated second- or third-generation HCV EIA (Abbott Diagnostics) and an HCV chemiluminescent immunoassay (ChLIA), performed on a fully automated analyzer (PRISM, Abbott).

RESULTS

During the period of use of the EIAs as primary screening assays, there were 60 donors per year who were confirmed as anti-HCV-positive, 29 who were classed as having indeterminate HCV serologic results, and 236 who were assessed as having biologically false-positive anti-HCV results. These numbers compared with 57, 52, and 320 such donors, respectively, in the first year of routine use of the ChLIA. The significant increase (p<0.05) in the number of anti-HCV-indeterminate donors after the introduction of the ChLIA was primarily due to an increase in donors who reacted on Monolisa HCV, but not an HCV Murex (expected 18/year vs. the observed 31/year, p<0.01).

CONCLUSIONS

Compared to the second- or third-generation HCV EIA, the HCV ChLIA has a significantly greater overlap of false reactivity with the Monolisa HCV assay. This finding has implications for the selection of primary and secondary assays for anti-HCV screening of blood donors.

Characteristics of hepatitis C-positive blood donors in Victoria, Australia

Data from 3156 voluntary blood donors in Victoria, Australia, who were repeatedly reactive on anti-HCV screening test were analysed. It showed that between 1990 and 1997, 0.97% of routine blood donors were anti-HCV repeat reactive. Sixty-four (64) donors tested positive for HCV RNA. They were more likely to be male, had a mean age of 32.7 +/- 10.9 years and a mean serum ALT level of 70.9 +/- 46.5 i.u.L-1: the latter value being significantly different from donors with biological false reactivity (P < 0.0001). Among HCV antibody-positive donors there was a significantly increased rate of prior injecting drug use (34 vs. 1%), transfusion (25 vs. 10%) and tattooing (31 vs. 7%) than among donors with biological false reactivity (all P < 0.0001). The association of these risk factors is stronger with positivity for both immunoblot and HCV RNA than immunoblot alone. The data suggest that efforts should be made to increase the efficacy of donor questioning about prior drug use.

Exposure to hepatitis A virus among blood donors, injecting drug users and prison entrants in Victoria

To assess prevalence of exposure to hepatitis A virus (HAV) among injecting drug users (IDUs) and prison entrants in Victoria, and to compare this with prevalence of HAV among a reference population of blood donors, sera stored from two previous studies and from randomly selected blood donors were tested for total antibody to HAV. The first study was a longitudinal study of field-recruited IDUs from 1990 to 1992 and the second was a study of all prison entrants in 1991-92 (both studies were carried out in Victoria); blood donors were from the Australian Red Cross Blood Bank Victoria in 1995. Forty-five per cent of 2175 prison entrants and 51% of 293 IDUs were seropositive for HAV, compared with 30% of 2995 blood donors. When standardized for age against the blood donors, HAV seropositivity in IDUs was 44% and in prison entrants 60%. The strongest association of HAV seropositivity among the IDUs on multivariate analysis was a history of imprisonment. There are high rates of exposure to HAV among prison entrants, whether with a history of IDU or not, and among IDUs who have a prison history. The role of sharing contaminated injecting equipment in transmission of HAV seems to be less important than institutionalization per se. With adequate resourcing, both populations are appropriate targets for HAV vaccination, especially in a context of continuing decline of transmission of HAV in the general community.

HLA patterns in Australian patients with insulin dependent diabetes mellitus (IDDM)

HLA antigens were determined in 169 Australian patients with insulin dependent diabetes mellitus (IDDM). HLA-B8 (47.9% v. 23.8%) and B15 (18.9% v. 8.2%) were significantly more frequent in the IDDM patients than in 1460 controls. The relative risks for developing IDDM in people carrying these antigens were 2.94 and 2.59 respectively. Carriers of the B8/B15 genotype had a relative risk of 5.48. These HLA associations in Australian IDDM patients are similar to those reported in other predominantly Caucasian populations.

THE PROGNOSIS IN ZOSTER PARALYSIS

1. Forty-five cases of zoster paralysis, not involving the cranial nerves, are detailed. These include eighteen cases not previously published. Of these eighteen patients, one-third were referred for an orthopaedic opinion.

2. Complete or almost full recovery occurred within a year in two-thirds of the patients. Permanent paralysis occurred in one-sixth of the patients studied.

3. Muscles that failed to recover were mainly or wholly supplied from single segments of the spinal cord; so the prognosis must be guarded in those cases in which such muscles are completely paralysed.

4. Various phenomena occurring in zoster paralysis are discussed.