Variable degree of liver involvement in siblings with PiZZ alpha-1-antitrypsin deficiency-related liver disease

PiZZ alpha-1-antitrypsin deficiency is the commonest genetic cause of chronic liver disease, but only 10-15% of PiZZ individuals develop liver disease in childhood. Studies have demonstrated varying patterns of disease progression within siblings with the PiZZ phenotype. We retrospectively analysed the case-notes of all patients diagnosed with PiZZ A1ATD between 1978-2002 and compared the pattern of liver disease between affected siblings. We identified 29 families with more than 1 child with the PiZZ phenotype. Twenty-one (72%) PiZZ siblings of the 29 probands had liver disease, which was concordant for severity in 6 (29%), while 8 (28%) had no liver involvement. Five of 7 children requiring liver transplantation had siblings with no persistent liver dysfunction. This study suggests that there is a variable degree of liver involvement in siblings with PiZZ A1ATD-related liver disease and environmental and/or other genetic factors must be involved in determining disease severity.

Intra-abdominal lymphatic malformation

Intra-abdominal lymphangioma is a rare congenital lymphatic vascular malformation. It is found, most commonly, in adult patients who present with abdominal pain, and whom medical imaging (ultrasound, endoscopy and tomography) reveals a cystic intra-abdominal mass. Such masses may be on the mesentery, in contact with abdominal viscera or may be part of the visceral wall. Diagnosis of intra-abdominal lymphangioma is difficult because of its rarity, and because other pathologies may have the same radiological signs. The diagnosis is confirmed by anatomopathological examination with immunohistochemistry. The treatment is complete surgical excision, in order to prevent recurrence.

An assessment of renal failure in an SLE cohort with special reference to ethnicity, over a 25-year period

OBJECTIVES

Although the prognosis for patients with renal lupus has improved, a small number still progress to renal failure. Studies from the USA have found it difficult to distinguish whether the higher rate of renal failure in African-Americans is due to genetic or socio-economic factors. Our aim was to identify ethnic and other factors in a UK lupus cohort that contribute to renal failure.

METHODS

The University College London (UCL) Hospitals lupus cohort of 401 patients (Whites 64%, Blacks 19%), followed since 1978, has 127 patients with renal disease, of whom 21 have gone into renal failure. We determined the characteristics and possible causes of renal failure in this group. Black patients were disproportionately represented in the renal failure group (62% vs 19% for Whites).

RESULTS

Those in the renal failure group had persistently low C3 compared with the renal disease cohort. A high proportion of patients in the renal failure group were felt to be non-adherent to treatment.

CONCLUSIONS

Given that health-care for patients in the UK is free at the point of delivery, we postulate that in our cohort genetic factors rather than socio-economic status are likely to be more significant in causing renal failure. However, there may be cultural and other reasons for this, which requires further study.

Diagnosis and management of Staphylococcus aureus infections of the skin and soft tissue

Infections involving the skin and soft tissue are common and range from superficial, localized and sometimes self-limiting infections to deep, rapidly spreading and potentially life-threatening infections. Skin infections caused by Staphylococcus aureus include primary pyodermas, while those involving the soft tissues include cellulitis and pyomyositis. Surgical site infections and infections in intravenous drug users are also commonly caused by S. aureus. The severity of the infection determines the choice of treatment. There are few studies that have critically appraised the use of antibiotics in skin and soft tissue infections, and most guidelines are based on expert opinion. The beta-lactam group of antibiotics are the mainstay of treatment for methicillin-susceptible S. aureus infections. For methicillin-resistant S. aureus (MRSA) infections, both with community-acquired and hospital-acquired strains--which are becoming an increasing problem--the antibiotic choice is determined by local susceptibility patterns. Macrolides, clindamycin and cotrimoxazole are options for community-acquired MRSA, while vancomycin is reserved for treatment of infections caused by multiresistant MRSA strains and for patients with suspected endocarditis or severe sepsis. Although a number of the newer antibiotics such as linezolid and quinopristin/dalfopristin have been shown to have good activity against MRSA, these agents should only be used with specialist advice.

Community-acquired pneumonia: influence of management practices on length of hospital stay

AIMS

To identify variation in the management of -community-acquired pneumonia between two New Zealand hospitals and the factors that may account for any differences.

METHODS

A 12-month, prospective two-centre study was conducted. Between July 1999 and July 2000, 474 adult patients with community-acquired pneumonia were enrolled: 304 in Christchurch Hospital and 170 in Waikato Hospital. The patients were similar in age, sex, prior antibiotic use and comorbidity. There was no significant difference in the clinical outcomes for the patients at the two centres.

RESULTS

The mean duration of i.v. antibiotic therapy was 1.7 versus 3.0 days (P < 0.001) and length of stay (LOS) was 3.0 versus 5.9 days (P < 0.001) for Waikato and Christchurch Hospitals, respectively. Using multivariate analysis, we could account for 61% of the observed variation in LOS. Duration of i.v. antibiotic therapy independently accounted for 16% of variation in LOS compared with age (2%), chronic obstructive pulmonary disease, duration of fever, intensive care unit admission and centre of admission (all <1%). For the duration of i.v. antibiotics, centre of admission, largely reflecting clinician practice at each centre, independently accounted for 13% of variation, compared with duration of fever (5%), admission to the Intensive Care Unit (4%), Pneumonia Severity Index score (3%) and bacteraemia (3%).

CONCLUSION

Of the identifiable factors, variations in clinician behaviour outweighed the influence of patient factors on the duration of i.v. antibiotic therapy, which in turn was the major determinant of LOS for patients hospitalised with community-acquired pneumonia. An early switch from i.v. to oral antibiotic therapy in conjunction with early discharge planning may significantly reduce LOS without compromising patient outcomes.

Autotransplantation for advanced lymphoma and Hodgkin's disease followed by post-transplant rituxan/GM-CSF or radiotherapy and consolidation chemotherapy

Disease relapse occurs in 50% or more of patients who are autografted for relapsed or refractory lymphoma (NHL) or Hodgkin's disease (HD). The administration of non-cross-resistant therapies during the post-transplant phase could possibly control residual disease and delay or prevent its progression. To test this approach, 55 patients with relapsed/refractory or high-risk NHL or relapsed/refractory HD were enrolled in the following protocol: stem cell mobilization: cyclophosphamide (4.5 g/m(2)) + etoposide (2.0 g/m(2)) followed by GM-CSF or G-CSF; high-dose therapy: gemcitabine (1.0 g/m(2)) on day -5, BCNU (300 mg/m(2)) + gemcitabine (1.0 g/m(2)) on day -2, melphalan (140 mg/m(2)) on day -1, blood stem cell infusion on day 0; post-transplant immunotherapy (B cell NHL): rituxan (375 mg/m(2)) weekly for 4 weeks + GM-CSF (250 microg thrice weekly) (weeks 4-8); post-transplant involved-field radiotherapy (HD): 30-40 Gy to pre-transplant areas of disease (weeks 4-8); post-transplant consolidation chemotherapy (all patients): dexamethasone (40 mg daily)/cyclophosphamide (300 mg/m(2)/day)/etoposide (30 mg/m(2)/day)/cisplatin (15 mg/m(2)/day) by continuous intravenous infusion for 4 days + gemcitabine (1.0 g/m(2), day 3) (months 3 + 9) alternating with dexamethasone/paclitaxel (135 mg/m(2))/cisplatin (75 mg/m(2)) (months 6 + 12). Of the 33 patients with B cell lymphoma, 14 had primary refractory disease (42%), 12 had relapsed disease (36%) and seven had high-risk disease in first CR (21%). For the entire group, the 2-year Kaplan-Meier event-free survival (EFS) and overall survival (OS) were 30% and 35%, respectively, while six of 33 patients (18%) died before day 100 from transplant-related complications. The rituxan/GM-CSF phase was well-tolerated by the 26 patients who were treated and led to radiographic responses in seven patients; an eighth patient with a blastic variant of mantle-cell lymphoma had clearance of marrow involvement after rituxan/GM-CSF. Of the 22 patients with relapsed/refractory HD (21 patients) or high-risk T cell lymphoblastic lymphoma (one patient), the 2-year Kaplan-Meier EFS and OS were 70% and 85%, respectively, while two of 22 patients (9%) died before day 100 from transplant-related complications. Eight patients received involved field radiation and seven had radiographic responses within the treatment fields. A total of 72 courses of post-transplant consolidation chemotherapy were administered to 26 of the 55 total patients. Transient grade 3-4 myelosuppression was common and one patient died from neutropenic sepsis, but no patients required an infusion of backup stem cells. After adjustment for known prognostic factors, the EFS for the cohort of HD patients was significantly better than the EFS for an historical cohort of HD patients autografted after BEAC (BCNU/etoposide/cytarabine/cyclophosphamide) without consolidation chemotherapy (P = 0.015). In conclusion, post-transplant consolidation therapy is feasible and well-tolerated for patients autografted for aggressive NHL and HD and may be associated with improved progression-free survival particularly for patients with HD.

Community-acquired pneumonia in Christchurch and Waikato 1999-2000: microbiology and epidemiology

AIMS

To prospectively record current epidemiology and microbiology of community-acquired pneumonia in two New Zealand centres.

METHODS

Between July 1999 and 2000 all adults admitted to Christchurch and Waikato Hospitals with community-acquired pneumonia were screened for study inclusion. All those enrolled had their medical history, clinical variables, inpatient management and clinical outcomes recorded and standardised microbial diagnostic testing carried out.

RESULTS

474 participants were enrolled with a mean age of 64 years and a microbial diagnosis was made in 197 cases (42%). Streptococcus pneumoniae (14%), Haemophilus influenzae (10%) and Influenza A virus (7%), Legionella spp (4%) and Mycoplasma pneumoniae (3%) were the most commonly isolated organisms. An 'atypical' organism was diagnosed in 8% of cases compared to 30% and 23% in previous Christchurch and Waikato studies respectively. Fourteen of the 67 S pneumoniae isolates (21%) had reduced susceptibility to penicillin, all with a MIC < or = 2 microg/mL, a level of reduced susceptibility not associated with worse patient outcomes. Clinical outcome included a mean hospital stay of 6.7 days and a 6 week mortality of 6%.

CONCLUSION

Although S pneumoniae was the most commonly isolated organism in this study there have been significant changes in the prevalence of atypical organisms since previous surveys. Ongoing surveillance of antibiotic resistance and variations in the prevalence of organisms causing community-acquired pneumonia is required to guide clinicians' empiric antibiotic use.

Comparison of transvaginal ultrasound, saline infusion sonography and hysteroscopy to investigate postmenopausal bleeding and unscheduled bleeding on HRT

A study was conducted to compare transvaginal ultrasound (TVS), saline infusion sonography (SIS) and outpatient hysteroscopy for examining the uterine cavity in women with postmenopausal bleeding and unscheduled bleeding on hormone replacement therapy (HRT). Fourty Subjects agreed to undergo TVS, SIS and hysteroscopy in addition to endometrial sampling. The abnormalities detected by each imaging method were recorded together with the discomfort (visual analogue scale). Thirty women completed all three imaging procedures. In 18 cases TVS suggested an abnormal cavity. SIS and hysteroscopy were of similar efficacy in clarifying the nature of this, and confirmed an abnormality in 12 cases (40%). TVS was significantly less painful than the other procedures (p < 0.001). SIS and hysteroscopy were associated with pain scores similar to endometrial sampling. These findings justify the need for a large randomised trial of TVS, SIS, hysteroscopy and endometrial sampling, in order to develop the most appropriate strategy for investigating postmenopausal bleeding and unscheduled bleeding on HRT.

Urinary free cortisol in chronic fatigue syndrome

OBJECTIVE

The authors measured 24-hour urinary free cortisol in a group of well-characterized patients with chronic fatigue syndrome.

METHOD

They obtained 24-hour urine collections from 121 consecutive clinic patients with chronic fatigue syndrome and 64 comparison subjects without the syndrome.

RESULTS

Urinary free cortisol was significantly lower in the subjects with chronic fatigue syndrome regardless of the presence or absence of current or past comorbid psychiatric illness. Lower levels of urinary free cortisol were not related to medication use, sleep disturbance, or disability levels.

CONCLUSIONS

There is mild hypocortisolism in chronic fatigue syndrome. Whether a primary feature or secondary to other factors, hypocortisolism may be one factor contributing to the symptoms of chronic fatigue syndrome.

Urinary tract infection in adults: research priorities and strategies

Waning interest in urinary tract infection (UTI) research has limited clinical advances during the past two decades. Although care has improved for some specific UTI syndromes, there is limited evidence for most of the decisions made each day in the management of these infections. Additional clinical research is necessary to improve UTI prevention and care strategies.

Prospective study of 424 cases of Staphylococcus aureus bacteraemia: determination of factors affecting incidence and mortality

BACKGROUND

Staphylococcus aureus bacteraemia (SAB) is a common complication of S. aureus infection and is associated with a high mortality.

AIMS

To document prospectively the pattern of illness associated with SAB in New Zealand and, by recording patient demographic factors and clinical features, to identify risk factors associated with a poor outcome.

METHODS

From 1 July 1996 to 31 December 1997, adults with SAB were prospectively studied in six tertiary care hospitals. All information obtained from patients' records was recorded on worksheets and transferred to a computerized spreadsheet for analysis.

RESULTS

There were 424 patients with SAB. Maori (relative risk (RR)= 1.8, 95% confidence interval (CI) = 1.3-2.6) and Pacific Island people (RR = 4.0, 95% CI = 3.1-5.3) were significantly more likely than people of European descent to acquire SAB, but not to die from the infection. Fifty per cent of cases were community acquired. A source was identified for 85%: intravenous catheter (31%), primarily hospital acquired, and skin/soft tissue (22%), primarily community acquired, were the most common foci. The 30-day mortality was 19%, 83% of whom died within 2 weeks. Risk factors for a poor outcome were: increasing age above 60, female sex (RR = 1.4, 95% CI = 1.0-2.1), diabetes mellitus (RR = 1.5, 95% CI = 1.0-2.4), immunosuppression (RR = 1.5, 95% CI = 1.0-2.4), pre-existing renal impairment (RR = 1.8, 95% CI = 1.2-2.7), malignancy (RR= 2.2, 95% CI = 1.4-3.5), lung as a source (RR = 2.8, 95% CI = 1.9-4.2) and unknown source (RR = 2.3, 95% CI = 1.5-3.3). Mortality was also accurately predicted by two multifactor scoring systems. There was a low rate of methicillin resistance (5%).

CONCLUSIONS

Staphylococcus aureus bacteraemia is more likely to occur in certain ethnic groups, while mortality is associated with other identifiable risk factors and continues to be high. Intravenous catheters remain the most common and most preventable cause of SAB.

An unusual case of recurrent septicaemia

A52-year-old farmer presented with a 1-week history of fever, rigors and myalgia. Three days before admission he had developed pleuritic left-sided chest pain. Clinical examination revealed a temperature of 38.4°C and bibasal pulmonary crepitations. Chest radiograph showed an area of patchy pulmonary opacity at the left lung base and a few small areas of opacity in the right lung. A presumptive diagnosis of pneumonia was made. Blood cultures subsequently grew Staphylococcus aureus and treatment with intravenous flucloxacillin was commenced. No other focus of infection was found, investigations included normal transthoracic echocardiogram and abdominal ultrasound scan.

The patient rapidly improved; however, 2weeks later he again became febrile. Further blood cultures grew Klebsiella pneumoniae. An abdominal computed tomography scan showed a high density linear structure straddling the second part of the duodenum and the inferior vena cava, representing a foreign body (Figure 1). Clot could be seen in the vena cava where it had been penetrated. Multiple ill-defined opacities seen in the lung base were consistent with embolization of the lungs. A plain abdominal radiograph showed the foreign body was a 4cm sewing needle (Figure 2). The needle and clot were removed surgically through an incision in the inferior vena cava and culture of specimens yielded both Staphylococcus aureus and Klebsiella pneumoniae (Figure 3) . The patient was treated with cefuroxime and made an uneventful recovery but had no recollection of having swallowed the needle.

Hospital outbreak of Salmonella virchow possibly associated with a food handler

A foodborne outbreak of salmonella infection at a private hospital in London in 1994 was found to be associated with eating turkey sandwiches prepared by a food handler. One patient, nine staff, and a foodhandler's baby were confirmed to have Salmonella enterica serotype virchow, phage type 26 infection. The attack rate was estimated to be 5% among the approximately 200 patients and staff at risk. A food handler reportedly became ill days after, but her baby days before, the first hospital case. Although it appeared to be a single outbreak, antibiogram analysis, supplemented by plasmid profile typing, demonstrated that there were two strains of S. virchow involved, one with resistance to sulphonamides and trimethoprim and a second sensitive to these antimicrobial drugs. Mother and child had different strains. The investigation demonstrated the importance of full phenotypic characterization of putative outbreak strains including antimicrobial susceptibility testing. Outbreaks of foodborne infection in hospitals are preventable and are associated with high attack rates and disruption of services. There is a need for good infection control policies and training of all staff involved in patient care as well as in catering services. Consultants in Communicable Disease (CCDCs) should include private hospitals in their outbreak control plans. Good working relations between Infection Control Doctors (ICDs) in the private health sector and their local CCDCs are important if outbreaks are to be properly investigated.