Carriage of serogroup W-135, ET-37 meningococci in The Gambia: implications for immunisation policy?

We found high levels of symptomless carriage of a hyperinvasive Neisseria meningitidis strain (electrophoretic type 37 [ET-37], serogroup W-135) during a vaccine trial in Gambian children in 1996. Serogroup C, ET-37 complex meningococci cause 30-40% of meningococcal disease in countries such as the UK, and have a point prevalence of 0.5-1.0%. The recent Haj-associated spread of serogroup W-135, ET-37 complex meningococci, which has been accompanied by numerous secondary cases, might be explained by the apparently raised carriage rates reported here.

Outcome of invasive pneumococcal disease: a UK based study. Oxford Pneumococcal Surveillance Group

METHODS

The records of 106 children aged less than 5 years with invasive disease caused by Streptococcus pneumoniae were reviewed.

RESULTS

The clinical manifestations were meningitis (37%), upper respiratory tract infection (24%), pneumonia (19%), and occult bacteraemia (18%). One child died and seven had persisting neurological impairment. Five serotypes caused 83% of disease and 92% of the serotypes are included in the seven valent conjugate vaccines which are undergoing trials.

CONCLUSIONS

These data suggest that S pneumoniae infection is associated with a low case fatality rate but substantial morbidity in the UK.

Clinical aspects of detrusor instability and the value of urodynamics: a review of the evidence

The term unstable bladder was introduced as a description of an observation not implying pathology. In some patients, special provocative maneuvers may be needed to demonstrate it. It is variable from one test to another. It is observed in some healthy volunteers. Therefore, detrusor instability observed during urodynamic testing is not a medical condition and may not necessarily be clinically relevant. In an individual patient the clinical relevance of the observation must be judged in relation to symptoms and signs of bladder dysfunction. In the field of female incontinence there is general agreement that, statistically, the pre-operative observation of detrusor instability implies poorer results of anti-incontinence surgery. However, some incontinent patients with detrusor instability are improved by surgery. Consequently, different authors draw different conclusions about the clinical relevance of detrusor instability, but no author considers that detrusor instability is an absolute contraindication to surgery for stress incontinence.

Molecular typing of bacteria directly from cerebrospinal fluid

Using Streptococcus pneumoniae as an example, the ability of multilocus sequence typing (MLST) to characterise isolates directly from cerebrospinal fluid (CSF) was investigated. A nested multiplex polymerase chain reaction method that amplifies the seven housekeeping gene fragments used for pneumococcal MLST was applied to 30 CSF samples from suspected cases of bacterial meningitis. The fragments were amplified from all 14 samples from which Streptococcus pneumoniae was cultured, and, after direct sequencing, the allelic profiles obtained from ten of the samples corresponded to those of clones previously associated with invasive pneumococcal disease. MLST could also predict the penicillin susceptibility and serotype of the CSF isolates.

A novel mutant allele of the chromatin-bound fission yeast checkpoint protein Rad17 separates the DNA structure checkpoints

To further dissect the genetic differences between the checkpoint pathway following S-phase cdc arrest versus DNA damage, a genetic screen was performed for checkpoint mutants that were unable to arrest mitosis following cell-cycle arrest with a temperature-sensitive DNA polymerase delta mutant, cdc20-M10. One such checkpoint mutant, rad17-d14, was found to display the cut phenotype following S-phase arrest by cdc20-M10, but not by the DNA synthesis inhibitor hydroxyurea, reminiscent of the chk1 mutant. Unlike chk1, rad17-d14 was not sensitive to UV irradiation. Interestingly, the ionising radiation sensitivity of rad17-d14 was only at higher doses, and cells were found to be defective in properly arresting cell division following irradiation in S phase, but not G(2) phase. Biochemical analysis attributes the checkpoint defects of rad17-d14 to the failure to phosphorylate the checkpoint effector Chk1p. To investigate if Rad17p monitors the genome for abnormal DNA structures specifically during DNA synthesis, chromatin association of Rad17p was analysed. Rad17p was found to be chromatin associated throughout the cell cycle, not just during S phase. This interaction occurred irrespective of the arrest with cdc20-M10 and, surprisingly, was also independent of the other checkpoint Rad proteins, and the cell-cycle effectors Chk1p and Cds1p.

The three major Spanish clones of penicillin-resistant Streptococcus pneumoniae are the most common clones recovered in recent cases of meningitis in Spain

One hundred six isolates of Streptococcus pneumoniae recovered in Spain from patients with meningitis in 1997 and 1998 were characterized by multilocus sequence typing. A heterogeneous collection of genotypes was associated with meningitis in Spain: 65 different sequence types were resolved and, even at a genetic distance of 0.43, there were 37 distinct lineages. Thirty-eight percent of the isolates, including all isolates of serotypes 6B, 9V, 14, and 23F, were resistant to penicillin, and 24% of the isolates were members of the three major Spanish penicillin-resistant or multidrug-resistant clones of serotypes 6B, 9V, and 23F or serotype variants of these clones. These three clones (MICs, 1 to 2 microg of penicillin/ml) were the most common clones associated with pneumococcal meningitis in Spain during 1997 and 1998. Only two of the other clones associated with meningitis were penicillin resistant (MICs, 0.12 to 0.5 microg/ml). One of the two most prevalent penicillin-susceptible clones causing meningitis (serotype 3) has not been detected outside of Spain, whereas the other (serotype 18C) has been recovered from patients with meningitis in the United Kingdom, The Netherlands, and Denmark. The prevalence of meningitis caused by isolates of the three major Spanish penicillin-resistant or multiply antibiotic-resistant clones, which are now globally distributed, is disturbing and clearly establishes their ability to cause life-threatening disease.

Retroviruses: ancient and modern

Retroviruses are transmitted in two distinct ways: as infectious virions and as 'endogenous' proviral DNA integrated in the germ line of their hosts. Modern infectious viruses such as HIV recently infected mankind from simian hosts, whereas human endogenous retroviral genomes have been present throughout old world primate evolution. Recently we have characterised novel retroviruses in humans and pigs. Human retrovirus 5 (HRV-5) is detected as an exogenous genome in association with arthritis and systemic lupus erythematosus. Porcine endogenous retroviruses (PERV) are carried in swine DNA but can be activated to produce virions that are infectious for human cells, which has implications for xenotransplantation. A brief account of HRV-5 and PERV is given here.

Smokers and haemodynamic responses to desflurane

Changes in basic haemodynamic variables following a sudden increase in the concentration of inspired desflurane administered during anaesthesia were compared in 30 female smokers and 30 nonsmokers. Smokers had significantly greater percentage increases in heart rate (p = 0.02), systolic and diastolic blood pressure (p < 0.005 and = 0.01, respectively) and rate-pressure product (p < 0.005). Such increases were reached faster by smokers for both systolic and diastolic blood pressures (p < 0.01) and for rate-pressure product (p = 0.02). The peak values of rate pressure product reached were sufficient to warrant caution when using desflurane for anaesthesia in smokers.

A survey of biomedical scientists and consultant pathologists involved in the cervical screening programme

The past decade has seen a transformation in the National Health Service Cervical Screening Programme (NHSCSP) largely driven by responses to various screening scandals. Independent inquiries into these laboratory failures have identified a number of contributing factors. The aim of this postal survey was to determine how widespread these factors are throughout screening laboratories in England. The results indicate that issues around recruitment and retention of staff, the training of pathologists and low morale appear to be widespread. However, the results do not indicate a widespread breakdown in working relationships between consultants and biomedical scientists, although there is room for improvement in their relationships with hospital management. Finally, there seem to be mixed messages about the commitment of consultants to the screening programme.

A psychiatric trainee's guide to the criminal courts

This article provides a guide on the criminal justice system in England and Wales to assist psychiatrists who are asked to prepare reports on people subject to criminal proceedings. It describes which sections of the Mental Health Act 1983 are relevant at different stages of the criminal justice process.

Quinuclidine inhibitors of 2,3-oxidosqualene cyclase-lanosterol synthase: optimization from lipid profiles

Novel 3-substituted quinuclidine inhibitors of cholesterol biosynthesis are reported. Compounds were optimized against oxidosqualene cyclase-lanosterol synthase (OSC) inhibition in vivo, rather than by the conventional optimization of structure-activity relationship information based on in vitro OSC inhibition. Thus, examination of HPLC lipid profiles from orally dosed rats showed cholesterol biosynthetic intermediates and whether cholesterol levels were reduced. A new substituted quinuclidine pharmacophore 18a-c was rapidly found for the inhibition of OSC, and the most promising inhibitors were validated by the confirmation of potent OSC inhibition. Compound 16 gave an IC50 value of 83 +/- 11 nM for human and an IC50 value of 124 +/- 14 nM, for rat, coupled with oral and selective inhibition of cholesterol biosynthesis derived from OSC inhibition (rat, ED50 = 1.3 +/- 0.7 mg/kg, n = 5; marmoset, 15 mg/kg dose, n = 3, caused complete inhibition). These 3-substituted quinuclidines, which were derived from a quinuclidine series previously known to inhibit cholesterol biosynthesis at the squalene synthase step, may afford a novel series of hypocholesterolemic agents acting by the inhibition of OSC.

Patterns of respite use by aging mothers of adults with mental retardation

Use of respite services by 275 aging families of adults with mental retardation was examined over a 4.5-year period. Although more than twice as many families used respite in 1993 compared to 1988, over half never used respite during this period. Most families using respite received in-home services, in moderate amounts, and with high levels of satisfaction. In an analysis of predictors of respite use, the only significant predictor in 1988 was poorer functional abilities of the adult with mental retardation. By 1993, respite use was predicted by three characteristics: poorer functional abilities, better health in the adult with mental retardation, and greater maternal caregiving burden. These findings reflect variability in aging families' needs for support and changing respite policies.

Urinary incontinence after radical prostatectomy: a randomized controlled trial comparing pelvic muscle exercises with or without electrical stimulation

OBJECTIVES

To assess the effectiveness of intensive conservative treatment on and the impact of urinary incontinence after radical retropubic prostatectomy.

PATIENTS AND METHODS

Sixty-three men with urinary incontinence >/= 8 weeks after radical prostatectomy were randomized to one of three groups; group 1, standard treatment (control); group 2, intensive pelvic muscle exercises (PME); or group 3, PME plus electrical stimulation (PME+ES). Group 1 received verbal and written instructions about postoperative PME from their urologist and from the nurses at the pre-admission clinic. Groups 2 and 3 were treated by a physiotherapist for 30 min twice a week for 12 weeks and carried out home exercises three times a day on the days when they were not treated. Outcome was assessed using the 24-h pad test, two validated quality-of-life questionnaires and a urine symptom inventory, all obtained at baseline, 12, 16 and 24 weeks after enrolment. The final pad test was carried out approximately 8 months after surgery.

RESULTS

Fifty-eight patients completed the study, 21 in group 1, 18 in group 2 and 19 in group 3; five discontinued, three with bladder neck contractures requiring dilatation, one with rectal pain when doing the exercises and one unable to complete therapy while on vacation. The mean (median) time elapsed from surgery to entry into the study was 19 (8) weeks. At 12 weeks from baseline, the mean overall urine loss had decreased from 463 g to 115 g but there were no differences among groups, nor were there significant differences in urine loss at 16 and 24 weeks (F=0. 16, P=0.69). There was a significant impact on quality of life during the early recovery. Despite preoperative instructions, many patients revealed little or no knowledge about catheter care, bladder spasms, rectal pain, incontinence and erectile dysfunction. Little of the preoperative education was retained because of the overwhelming nature of the diagnosis.

CONCLUSIONS

From the initial assessment to the final pad-test at approximately 8 months after surgery, incontinence improved greatly in all three groups. This rapid improvement may have masked any treatment benefit. Further research should address incontinence in men whose urine loss has stabilized and who underwent surgery >8 months previously. Moreover, a telephone-based follow-up soon after discharge may alleviate many of the concerns expressed.

Identification of three major clones of multiply antibiotic-resistant Streptococcus pneumoniae in Taiwanese hospitals by multilocus sequence typing

In this paper we demonstrate the advantages of a new molecular typing procedure, multilocus sequence typing, for the unambiguous characterization of penicillin-resistant pneumococci. The sequences of approximately 450-bp fragments of seven housekeeping genes were determined for 74 penicillin-resistant Taiwanese isolates of Streptococcus pneumoniae (MIC of penicillin > 0.5 microgram/ml). The combination of alleles at the seven loci defined an allelic profile for each strain, and a dendrogram, based on the pairwise mismatches in allelic profiles, grouped 86% of the isolates into one of three penicillin-resistant clones for which the MICs of penicillin were 1 to 2 microgram/ml. Isolates within each clone had identical alleles at all seven loci or differed at only a single locus, and the fingerprints of their pbp1A, pbp2B, and pbp2X genes were uniform. Isolates of the Taiwan-19F clone and the Taiwan-23F clone were resistant to penicillin, tetracycline, and erythromycin but were susceptible to chloramphenicol. A second serotype 23F clone and serotype 19F variants of this clone were resistant to penicillin, tetracycline, chloramphenicol, and, in some cases, erythromycin. Comparisons of the allelic profiles of the three major clones with those of reference isolates of the known penicillin-resistant clones showed that the Taiwan-19F and Taiwan-23F clones were previously undescribed, whereas the second serotype 23F clone was indistinguishable from the Spanish multidrug-resistant serotype 23F clone. Single isolates of the Spanish penicillin-resistant serotype 9V clone and the Spanish multidrug-resistant serotype 6B clone were also identified in the collection.

Serotype distribution and prevalence of resistance to benzylpenicillin in three representative populations of Streptococcus pneumoniae isolates from the coast of Kenya

As surveillance data from sub-Saharan Africa are few, three representative populations of Streptococcus pneumoniae isolates were examined in Kenya for serotype distribution and Etest minimum inhibitory concentrations (MICs) of benzylpenicillin: (1) 75 lung aspirate or blood culture isolates from 301 consecutive adult patients with pneumonia, (2) 112 invasive isolates from continuous pediatric inpatient surveillance over 4 years, and (3) 97 nasopharyngeal isolates from systematically selected sick children. The proportions with benzylpenicillin MICs of > or = 0.1 microgram/mL were 0.27, 0.29, and 0.47, respectively. Vaccine-related serotypes accounted for 96% of invasive isolates from children and 90% of those from human immunodeficiency virus (HIV)-seropositive adults. Serotype 1 accounted for 44% of pneumococci from HIV-seronegative patients but only 5% of those from HIV-seropositive patients (P = .0002). Of serotype 1 isolates, 98% were susceptible to benzylpenicillin, but serogroups 13, 14, 19, and 23 were strongly associated with an MIC of > or = 0.1 microgram/mL.

Osteogenic protein-1 (bone morphogenetic protein-7) reduces severity of injury after ischemic acute renal failure in rat

We have shown that osteogenic protein-1 (OP-1) (bone morphogenetic protein-7) is responsible for the induction of nephrogenic mesenchyme during embryonic kidney development. Gene knock-out studies showed that OP-1 null mutant mice die of renal failure within the first day of postnatal life. In the present study, we evaluated the effect of recombinant human OP-1 for the treatment of acute renal failure after 60 min bilateral renal artery occlusion in rats. Bioavailability studies in normal rats indicate that approximately 1.4 microg OP-1/ml is available in the circulation 1 min after intravenous administration of 250 microg/kg, which then declines steadily with a half life of 30 min. About 0.5% of the administered OP-1 dose/g tissue is targeted for OP-1 receptors in the kidney. We show that OP-1 preserves kidney function, as determined by reduced blood urea nitrogen and serum creatinine, and increased survival rate when administered 10 min before or 1 or 16 h after ischemia, and then at 24-h intervals up to 72 h after reperfusion. Histochemical and molecular analyses demonstrate that OP-1: (a) minimizes infarction and cell necrosis, and decreases the number of plugged tubules; (b) suppresses inflammation by downregulating the expression of intercellular adhesive molecule, and prevents the accumulation and activity of neutrophils; (c) maintains the expression of the vascular smooth muscle cell phenotype in pericellular capillaries; and (d) reduces programmed cell death during the recovery. Collectively, these data suggest that OP-1 prevents the loss of kidney function associated with ischemic injury and may provide a basis for the treatment of acute renal failure.

Clinical studies of cerebral and urinary tract function in elderly people with urinary incontinence

Brain and urinary tract function have been studied in a group of 128 geriatric patients with established urinary incontinence. Median age was 79 years. About half suffered from dementia. A group of 27 continent patients of similar age and cognitive status was used in some comparisons. It was expected that impaired voluntary control of voiding (urge incontinence) would be associated with particular aspects of cognitive impairment and dysfunction of specific regions of the brain. Comprehensive investigations, including 24 h monitoring of incontinence, videourodynamic testing, cognitive testing and SPECT brain scanning, demonstrated that genuine urge incontinence could be proven in half of the patients and was frequently accompanied by reduced sensation of bladder filling, especially in males. Genuine urge incontinence with reduced bladder filling sensation led to greater urine loss than other types of incontinence. Overall, cognitive function was slightly more impaired in patients with genuine urge incontinence, but the strongest and most specific association was with impaired temporal orientation. Genuine urge incontinence with reduced bladder filling sensation was associated with global underperfusion of the cerebral cortex and more specifically, with underperfusion of the frontal areas of the brain, especially on the right. These results are consistent with PET scan observations of Blok et al. (Brain 1997;20:112-121), which show that areas in the right anterior cingulate gyrus and right inferior frontal gyrus are involved in voluntary voiding of normal males.

Antibody persistence and Haemophilus influenzae type b carriage after infant immunisation with PRP-T

OBJECTIVES

To assess the persistence of serum Haemophilus influenzae type b antibodies and the prevalence of H influenzae type b carriage in a group of preschool age children previously vaccinated in infancy.

DESIGN

Names were randomly selected from immunisation records. Families were visited on five occasions over a period of 12 months and throat swabs were taken from all family members present, with blood obtained from children at the first and last visits.

RESULTS

One hundred and fifty three children at a median age of 3.6 years had a geometric mean titre (GMT) of 1.06 micrograms/ml (95% CI 0.80 to 1.38). Eight per cent had an undetectable antibody concentration, received a booster dose of plain PRP vaccine, and responded with concentrations > 2 micrograms/ml. GMT at 4.5 years of age was 0.89 microgram/ml (0.69 to 1.16). Twelve children who had been exposed to H influenzae had a GMT of 4.7 v 0.8 micrograms/ml for those without exposure.

CONCLUSIONS

Accelerated immunisation against H influenzae without a second year booster results in persistence of satisfactory serum concentrations of antibody to 4.5 years of age. In those with undetectable antibody, immunological memory may still be present.