Breast magnetic resonance imaging: An essential role in malignant axillary lymphadenopathy of unknown origin

The aim of this retrospective case series was to assess the role of breast MRI in the investigation of "occult" malignancy, and the associated potential to influence patient management. Between January 2000 and March 2004, 18 patients, who presented with axillary lymphadenopathy, most likely due to "occult" breast cancer, were examined with MRI of the breast. The results showed 12 true positives, four true negatives, and two false positives. This gave an overall sensitivity of 85.7% and an overall accuracy of 86.7%. In those in whom malignancy was identified on MRI and subsequently proven histologically, 78% of these cancers were identified, and localized by preoperative MRI-guided sonography. In addition, 55% of these patients were eligible for conservative surgery. As such, MRI of the breast is highly sensitive for the detection of mammographically and clinically occult breast cancer. The use of MRI enables a preoperative diagnosis to be made in a high percentage of patients and may allow retrospective targeted ultrasound localization. Definitive surgical planning, including the option of breast conservation, is made possible with the result of the MRI examination.

Pallister-Hall syndrome: Unreported skeletal features of aGLI3mutation

We describe two patients with Pallister-Hall syndrome (PHS), both with evidence of a generalized skeletal dysplasia as typified by upper and lower acromesomelic limb shortening and the previously unreported fibular hypoplasia, radio-ulnar bowing, and proximal epiphyseal hypoplasia. Genomic DNA was only available for sequencing analysis in patient 2 and the mutation, c.3386_3387delTT was detected in exon 14 of the GL13 gene. It is also possible that the findings in patient 1 represent the phenotypic expression of a novel GLI3 mutation. This report further expands the PHS phenotype and raises the possibility of specific GLI3 mutations resulting in more severe skeletal features. It also suggests that PHS should be included in the differential diagnosis of antenatally ascertained acromesomelic limb shortening and bowing with fibular hypoplasia particularly in the presence of polysyndactyly.

A two-year prospective study of the health-related quality of life of children with chronic illness--the parents' perspective

The aim of this study was to assess prospectively changes in the health-related quality of life (HRQL) of children and adolescents with diabetes, asthma or cystic fibrosis (CF). One hundred and twenty-two parents of children aged 10-16 years with asthma, diabetes, or CF were recruited from specialist paediatric clinics. Parents described their children's HRQL using the Child Health Questionnaire (PF98) at baseline, 6, 12, 18 and 24 months post-baseline. They reported that the general health of children with CF was significantly worse than that of children with asthma and diabetes at baseline. In other domains there were few differences between the HRQL of children in the three groups. In several domains, the HRQL of children with asthma or diabetes improved over the 2 years of the study. This improvement was less evident for children with CF.

Pregnancy outcome following exposure to permethrin and use of teratogen information

NIX is a 1% permethrin creme rinse used for the treatment of head lice. There are no studies regarding human exposure during pregnancy. The primary objective of this study was to examine the safety of permethrin exposure during pregnancy. The secondary objective was to examine how teratogen information is perceived and used by women who requested information regarding this product. Women who had called the Motherisk and MotherSafe Programs to inquire about exposure to permethrin during pregnancy were followed-up to ascertain the outcome of their pregnancies. These women were compared with another group who had not been exposed to any known teratogenic drugs. Women who decided not to use permethrin were administered an additional questionnaire. We enrolled 147 women and completed outcomes on 113 pregnancies of women who had used permethrin some time during their pregnancy. There were 106 live births, six spontaneous abortions, one therapeutic abortion, and one major malformation in the women who used permethrin in the first trimester. The mean birthweight was 3540 +/- 492 g and the mean gestational age was 40 +/- 1 weeks. There were no statistically significant differences between the exposed and comparison groups in any of the pregnancy outcomes. Of the 34 women who chose not to use permethrin and who completed the additional questionnaire, 18 (52%) did not use permethrin because they did not feel the information was sufficiently reassuring. The results of this study suggest that the use of permethrin products during pregnancy appears to be relatively safe because there was no increase in the rates of major malformations. We also found that some women will not use a product during pregnancy unless they can receive a 100% guarantee that it will not harm their baby.

Cryptococcus neoformans var. gattii meningitis in an HIV-positive patient: first observation in the United Kingdom

We present a case of meningitis due to Cryptococcus neoformans var. gattii in an HIV-infected man recently returned from South Africa. We believe this is the first imported case of meningitis secondary to Cryptococcus neoformans var. gattii in an HIV-infected patient to be reported in the UK.

Cys-tRNACys formation and cysteine biosynthesis in methanogenic archaea: two faces of the same problem?

Aminoacyl-tRNA (transfer RNA) synthetases are essential components of the cellular translation machinery as they provide the ribosome with aminoacyl-tRNAs. Aminoacyl-tRNA synthesis is generally well understood. However, the mechanism of Cys-tRNACys formation in three methanogenic archaea ( Methanocaldococcus jannaschii, Methanothermobacter thermautotrophicus and Methanopyrus kandleri) is still unknown, since no recognizable gene for a canonical cysteinyl-tRNA synthetase could be identified in the genome sequences of these organisms. Here we review the different routes recently proposed for Cys-tRNACys formation and discuss its possible link with cysteine biosynthesis in these methanogenic archaea.

Are sleep problems under-recognised in general practice?

AIMS

To evaluate the frequency of sleep problems in Australian children aged 4.5-16.5 years, and to determine whether the frequency of sleep problems on questionnaire predicts the reporting of sleep problems at consultation.

METHODS

Parents of 361 children (aged 4.5-16.5 years) attending their general practitioner for "sick" visits were asked to assess their child's sleep over the previous six months using the Sleep Disturbance Scale for Children, from which six sleep "disorder" factors and a total sleep problem score were obtained.

RESULTS

The percentage of children with a total sleep problem score indicative of clinical significance (T score >70 or >95th centile) was 24.6% (89/361). Despite this high frequency, parents only addressed sleep problems in 4.1% (13/317) of cases and reported that GPs discussed sleep problems in 7.9% (25/317) of cases. Of the 79 children who reported total sleep problem T scores in the clinical range, only 13.9% (11/79) discussed sleep with their general practitioner within the previous 12 months. Regression analyses revealed an age related decrease in problems with sleep-wake transition and sleep related obstructive breathing; sleep hyperhydrosis, initiating and maintaining sleep, and excessive daytime sleepiness did not significantly decrease with age. No significant gender differences were observed.

CONCLUSIONS

Results suggest that chronic sleep problems in Australian children are significantly under-reported by parents during general practice consultations despite a relatively high frequency across all age groups. Given the impact on children and families, there is a need for increased awareness of children's sleep problems in the community and for these to be more actively addressed at consultation.

Quality use of medicines in the rural ambulant elderly: a pilot study

INTRODUCTION

Australia has a rapidly ageing population, especially in rural areas, and strategies to address medicines and the elderly are particularly relevant. The aims of this 18 month study, therefore, were to: (1) determine the influence of a medication review on the quality of life of elderly ambulatory patients managed by a general practitioner; and (2) assess the impact of the medication review process on health outcomes such as medication-related hospital admissions in ambulant elderly patients actively managed by their GP.

METHODS

The study was conducted within the area serviced by the rural Riverina Division of General Practice, New South Wales, Australia. Patients were identified by clinical audit, and recruited to the study if they met the inclusion criteria of being: older than 65 years, ambulant, living independently and on five or more medications. The study sample consisted of 402 participants (156 men, 38.8%; 246 women, 61.2%). Fifty-eight participants withdrew from the study for a variety of reasons. A two-group (intervention, control) pre- and post-intervention randomized study design was utilized. Quality of life was assessed using SF-36. The medication history and clinical details of the 202 study participants were reviewed by the project pharmacist and their GP. Medication changes were suggested to patients by their GP and follow-up SF36 and review of hospitalisation episodes were conducted after 6 months.

RESULTS

3382 medications were identified as being taken, an average of 8.4 medications per patient. After the initial medication review, the study pharmacist suggested an alteration in dose, form or frequency for 687 medications in the intervention group. The GPs recommended an alteration in 243 of patient medications. Of the entire study population (n = 402), only two participants' admission to hospital was specifically attributed to medication-related issues. There were no significant differences between the quality of life assessments for the combined groups; however, the intervention group recorded significantly higher scores in two of the nine dimensions measured: vitality (p 0.009) and mental health (p 0.0001), at the post-intervention assessment.

CONCLUSION

While the intervention did not reduce hospitalisation episodes and only led to a modest improvement in quality of life, the development of a mutually acceptable form of face-to-face pharmacist/GP medication review, identification of potentially serious adverse drug reactions, identification of previously unreported complementary medicine use, and enhanced GP awareness of the risks of polypharmacy were positive outcomes of the study.

Binge alcohol consumption by non-alcohol-dependent women during pregnancy affects child behaviour, but not general intellectual functioning; a prospective controlled study

Effects of binge ethanol consumption during early gestation on child neurodevelopment have not been elucidated. To study whether binge drinking affects cognitive abilities and behavior of exposed children, a prospective observational study comparing 51 children exposed to binge drinking during the first trimester of pregnancy to 51 children not exposed to any teratogens was conducted. The children's physical development, intelligence, language abilities and behavior were assessed. Temperament test results showed that children exposed in utero to maternal binge drinking displayed a greater degree of disinhibited behavior and that this behavior was associated with early drinking variables. Although binge alcohol drinking by non-alcohol-dependent women during the first trimester of pregnancy does not appear to affect intelligence or cognitive and language development of young children, binge drinking in pregnancy does increase the likelihood of certain behavioral characteristics that might predispose these children to later behavioral dysfunction.

Dissociations of cerebral cortex, subcortical and cerebral white matter volumes in autistic boys

High-functioning autistic and normal school-age boys were compared using a whole-brain morphometric profile that includes both total brain volume and volumes of all major brain regions. We performed MRI-based morphometric analysis on the brains of 17 autistic and 15 control subjects, all male with normal intelligence, aged 7-11 years. Clinical neuroradiologists judged the brains of all subjects to be clinically normal. The entire brain was segmented into cerebrum, cerebellum, brainstem and ventricles. The cerebrum was subdivided into cerebral cortex, cerebral white matter, hippocampus-amygdala, caudate nucleus, globus pallidus plus putamen, and diencephalon (thalamus plus ventral diencephalon). Volumes were derived for each region and compared between groups both before and after adjustment for variation in total brain volume. Factor analysis was then used to group brain regions based on their intercorrelations. Volumes were significantly different between groups overall; and diencephalon, cerebral white matter, cerebellum and globus pallidus-putamen were significantly larger in the autistic group. Brain volumes were not significantly different overall after adjustment for total brain size, but this analysis approached significance and effect sizes and univariate comparisons remained notable for three regions, although not all in the same direction: cerebral white matter showed a trend towards being disproportionately larger in autistic boys, while cerebral cortex and hippocampus-amygdala showed trends toward being disproportionately smaller. Factor analysis of all brain region volumes yielded three factors, with central white matter grouping alone, and with cerebral cortex and hippocampus-amygdala grouping separately from other grey matter regions. This morphometric profile of the autistic brain suggests that there is an overall increase in brain volumes compared with controls. Additionally, results suggest that there may be differential effects driving white matter to be larger and cerebral cortex and hippocampus-amygdala to be relatively smaller in the autistic than in the typically developing brain. The cause of this apparent dissociation of cerebral cortical regions from subcortical regions and of cortical white from grey matter is unknown, and merits further investigation.

Moraxella catarrhalis bacteraemia associated with Mycoplasma pneumoniae infection and pneumonia

This report describes a case of severe pneumonia associated with Mycoplasma pneumoniae infection and Moraxella catarrhalis bacteraemia in a 44-y-old woman with undiagnosed breast carcinoma. M. pneumoniae is increasingly recognized as a co-pathogen but to the authors' knowledge this is the first reported case of M. catarrhalis bacteraemia associated with M. pneumoniae infection.

Characterization of G3BPs: tissue specific expression, chromosomal localisation and rasGAP(120) binding studies

The G3BP (ras-GTPase-Activating Protein SH3-Domain-Binding Protein) family of proteins has been implicated in both signal transduction and RNA-metabolism. We have previously identified human G3BP-1, G3BP-2, and mouse G3BP-2. Here, we report the cloning of mouse G3BP-1, the discovery of two alternatively spliced isoforms of mouse, and human G3BP-2 (G3BP-2a and G3BP-2b), and the chromosomal localisation of human G3BP-1 and G3BP-2, which map to 5q14.2-5q33.3 and 4q12-4q24 respectively. We mapped the rasGAP(120) interactive region of the G3BP-2 isoforms and show that both G3BP-2a and G3BP-2b use an N-terminal NTF2-like domain for rasGAP(120) binding rather than several available proline-rich (PxxP) motifs found in members of the G3BPs. Furthermore, we have characterized the protein expression of both G3BP-1 and G3BP-2a/b in adult mouse tissues, and show them to be both tissue and isoform specific.

Provider adherence to a clinical practice guideline for acute asthma in a pediatric emergency department

Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time-consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated.

OBJECTIVES

To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence.

METHODS

Prospective, cohort study of children aged 1-18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters.

RESULTS

Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty-eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence.

CONCLUSIONS

Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.

Cognitive and behavioural performance in children with sleep-related obstructive breathing disorders

Sleep-related obstructive breathing disorders (SROBD) are common in children. While the sequelae of cor pulmonae, and growth and developmental impairment have been well documented, neurocognitive deficits have been less well studied. There is emerging evidence that children with SROBD show reduced neurocognitive functioning especially in the inter-related areas of attentional capacity, memory and cognitive function. In addition, these children show increased problematic behaviour and reduced school performance. Early reports suggest that some of these deficits may be reversible with treatment. The genesis of the defects is unclear but may include hypoxaemia and subtle changes in sleep architecture. The natural history of SROBD and long-term effects on neurocognitive functioning and behaviour remain to be fully examined.

Physical examination findings in deep venous thrombosis

DVT is a potentially serious disease and can serve as a marker for PE, an entity with even higher morbidity. Thus, it is critically important that emergency physicians consider this diagnosis in patients who present with suspicious symptoms. Recognition of alternative conditions, such as compartment syndrome, septic arthritis, and cellulitis, is also important for optimal care. Because physical examination is only 30% accurate for DVT, it serves to increase clinical suspicion in patients at risk but cannot be used to eliminate the possibility of thromboembolic disease. Because of this limitation, the diagnosis of DVT should be pursued using adjunctive testing in any patient with unexplained limb pain or swelling. Duplex sonography is currently the initial diagnostic study of choice for evaluation of DVT and, if test results are negative, it should be repeated serially if the clinical suspicion is high.