Management of suspected Lyme borreliosis: experience from an outpatient parenteral antibiotic therapy service

OBJECTIVES

Lyme borreliosis (LB) is the most common human tick-borne infection in Europe and the USA. In this study we set out to analyse the outcome of patients treated for Lyme disease via outpatient parenteral antibiotic therapy (OPAT) and the appropriateness of this treatment using current guidelines.

METHODS

This was a retrospective review of all patients with suspected LB managed via OPAT in Glasgow in 2000-11.

RESULTS

Of 72 patients treated for suspected LB, 35 patients (49%) were treated in accordance with guidelines and 36 (50%) were treated with no specific guidelines. A definite improvement was seen in 20 patients (28%). Adverse reactions were documented in 29 (40%) patients with neutropenia, and mild liver function derangement was most commonly observed.

CONCLUSION

These results show the complexity of translating well-substantiated regimens from clinical trials to actual clinical practice. OPAT was an effective way of administering parenteral therapy for Lyme disease but should not be undertaken lightly due to the rate of adverse events and low rates of success in certain patient groups seen in this study. In view of this, stricter criteria for inclusion to OPAT in line with published guidance should be applied to minimize patient harm and optimize success.

Q fever in military and paramilitary personnel in conflict zones: case report and review

We present the case of a 44-year-old civilian security officer medically evacuated from Iraq with acalculous cholecystitis and Guillain-Barré syndrome and subsequently found to have acute Q fever. The presenting features of Q fever in military and related personnel deployed to Iraq and Afghanistan are reviewed and the use of PCR in early diagnosis of Q fever is discussed. The atypical presentation in this case encourages clinicians to have a low threshold for considering Q fever as part of the differential diagnosis in soldiers and related personnel returning from these areas of high endemicity.

The thoracic anterior spinal cord adhesion syndrome

OBJECTIVES

This study included a series of middle-aged male and female patients who presented with chronic anterior hemicord dysfunction progressing to paraplegia. Imaging of anterior thoracic cord displacement by either a dural adhesion or a dural defect with associated cord herniation is presented.

METHODS

This is a retrospective review of cases referred to a tertiary neuroscience centre over a 19-year period. Imaging series were classified by two experienced neuroradiologists against several criteria and correlated with clinical examination and/or findings at surgery.

RESULTS

16 cases were available for full review. Nine were considered to represent adhesions (four confirmed surgically) and four to represent true herniation (three confirmed surgically). In the three remaining cases the diagnosis was radiologically uncertain.

CONCLUSION

The authors propose "thoracic anterior spinal cord adhesion syndrome" as a novel term to describe this patient cohort and suggest appropriate clinicoradiological features for diagnosis. Several possible aetiologies are also suggested, with disc rupture and inflammation followed by disc resorption and dural pocket formation being a possible mechanism predisposing to herniation at the extreme end of a clinicopathological spectrum.

SU-E-J-169: 4D-PET for Abdominal Tumor Target Volume Generation

PURPOSE

To examine the impact of 4D-PET on target volume delineation of upper-abdominal tumors, versus conventional un-gated PET.

METHODS

Four patients with upper-abdominal tumors underwent respiratory-correlated FDG PET/CT scanning (4D-PET) as part of a continuing IRB-approved research protocol. Internal target volumes of FDG-avid tumors were contoured on the 4D-PET and conventional un-gated PET by a radiation oncologist who is a specialist in gastro-intestinal tumors. To create the 4D-PET ITV, the end-inhale and end-exhale 4D-PET phases were used. The relative volumes and volumetric overlaps of the 4D and un-gated target volumes were examined. Additionally, 4D-PET was used to measure the motion of the tumors.

RESULTS

Of the four patients who were imaged, one showed minimal motion (〈 3 mm in any direction) and one showed minimal FDG avidity; these were removed from further analysis. Of the two tumors which showed significant motion and FDG uptake, 4D-PET volumes were 28% and 21% larger than un-gated PET volumes. The un-gated PET volumes were almost entirely contained within the 4D-PET volumes (95% and 93% for the two tumors). Tumors appeared to deform as well as translate with breathing, although this could be due to varying intra-gate motion rather than actual physiological deformation. The superior-inferior borders of the tumors exhibited the most motion, with displacements of 5.6 mm and 6.4 mm.

CONCLUSIONS

4D-PET can be used to estimate the motion of FDG-avid upper-abdominal tumors. Use of 4D-PET increases the size of target volumes compared to un-gated PET in a subset of upper-abdominal cancer patients. Direct measurement of tumor motion and deformation by 4D-PET imaging could allow the use of patient-specific margins rather than population-based margins, potentially leading to increased target coverage and reduced normal tissue irradiation.

Indication of reactor ν(e) disappearance in the Double Chooz experiment

The Double Chooz experiment presents an indication of reactor electron antineutrino disappearance consistent with neutrino oscillations. An observed-to-predicted ratio of events of 0.944±0.016(stat)±0.040(syst) was obtained in 101 days of running at the Chooz nuclear power plant in France, with two 4.25 GW(th) reactors. The results were obtained from a single 10 m(3) fiducial volume detector located 1050 m from the two reactor cores. The reactor antineutrino flux prediction used the Bugey4 flux measurement after correction for differences in core composition. The deficit can be interpreted as an indication of a nonzero value of the still unmeasured neutrino mixing parameter sin(2)2θ(13). Analyzing both the rate of the prompt positrons and their energy spectrum, we find sin(2)2θ(13)=0.086±0.041(stat)±0.030(syst), or, at 90% C.L., 0.017<sin(2)2θ(13)<0.16.

A novel pneumococcus with a new association

A case of severe invasive pneumococcal disease in a 68 year old female is described. She presented following a holiday in Turkey with an uncommon but well documented complication of Streptococcus pneumoniae bacteraemia; Austrian's triad of meningitis, pneumonia and endocarditis. She then progressed to develop an atypical variant of Guillain Barre syndrome, never previously documented in association with pneumococcal disease. The pneumococcus was identified as serotype 6A and genetic typing by multi-locus sequence typing showed it to be a unique genetic profile (ST4533). We hypothesise that ST4533 may have resulted from genetic re-assortment from streptococci which had colonised the patient in the United Kingdom and bacteria encountered in Turkey. The ability to associate uncommon genotypes with uncommon clinical presentations may improve understanding of the pathogenesis of this organism, and this highlights the need for international invasive pneumococcal disease surveillance.

Low risk of inhibitor formation in haemophilia A patients following en masse switch in treatment to a third generation full length plasma and albumin-free recombinant factor VIII product (ADVATE®)

Previous studies have suggested that development of inhibitors in previously treated patients (PTPs) may be attributable to a switch in factor VIII (FVIII) therapeutic product. Consequently, it is widely recognized that inhibitor development must be assessed in PTPs following the introduction of any new FVIII product. Following a national tender process in 2006, all patients with haemophilia A in Ireland changed their FVIII treatment product en masse to a plasma and albumin-free recombinant full-length FVIII product (ADVATE(®)). In this study, we retrospectively reviewed the case records of Irish PTPs to evaluate risk of inhibitor formation following this treatment switch. One hundred and thirteen patients participated in the study. Most patients (89%) had severe haemophilia. Only one of 96 patients with no inhibitor history developed an inhibitor. Prior to the switch in his recombinant FVIII (rFVIII) treatment of choice, this child had only experienced three exposure days (EDs). Consequently, in total he had only received 6 EDs when his inhibitor was first diagnosed. In keeping with this lack of de novo inhibitor development, we observed no evidence of any recurrent inhibitor formation in any of 16 patients with previously documented inhibitors. Similarly, following a previous en masse switch, we have previously reported that changing from a Chinese hamster ovary cell-produced to a baby hamster kidney cell-produced rFVIII was also associated with a low risk of inhibitor formation in PTPs. Our cumulative findings from these two studies clearly emphasizes that the risk of inhibitor development for PTPs following changes in commercial rFVIII product is low, at least in the Irish population.