Panton-Valentine leukocidin associated staphylococcal disease: a cross-sectional study at a London hospital, England

Recently, there has been international concern at the rapid emergence of highly pathogenic strains of Staphylococcus aureus associated with a toxin called Panton-Valentine leukocidin (PVL). In the UK, these strains are considered to be rare and mainly severe. We estimate the proportion of staphylococcal infections that are caused by strains containing the PVL genes, and describe risk factors for these infections. Three hundred and ninety consecutive S. aureus clinical isolates, submitted for routine diagnostic purposes were screened for PVL genes. Risk factors for infection were identified from the patient medical record. 9.7% (95% CI 7.0-13.1%) of clinical isolates and 20.8% of skin and soft tissue specimens contained the genes for PVL. Methicillin-resistant S. aureus with PVL was rare (0.8% of all isolates) but PVL with methicillin-sensitive S. aureus was common (9.0% of all specimens). PVL infection was more frequent in males (OR 3.0, 95% CI 1.3-7.0), and in young adults aged 20-39 years (OR 3.7, 95% CI 1.3-10.4). Over half of PVL positive S. aureus infections originated in patients based in the community. Community-onset PVL-associated disease is common in the UK and mainly causes skin and soft tissue infections that do not require admission to hospital. Consideration should be given to current infection control strategy, which advocates household contact screening and decolonization on the assumption that PVL-associated disease is rare.

Baseline predictors of ninety percent or higher antiretroviral therapy adherence in a diverse urban sample: the role of patient autonomy and fatalistic religious beliefs

The role of patient autonomy and influence of religious/spiritual beliefs on antiretroviral therapy (ART) adherence is to date not fully understood. This study assessed baseline predictors of high ART adherence (≥90%) measured by electronic drug monitors (EDM) at 12 and 24 weeks after enrollment in a randomized controlled trial testing behavioral interventions to improve ART adherence. Baseline data were collected with audio computer-assisted self interviews (ACASI) surveys among a diverse urban sample of HIV-infected participants (n = 204) recruited from community clinics in a large midwestern city. Baseline variables included a range of established ART adherence predictors as well as several less frequently studied variables related to patient autonomy and religious/spiritual beliefs. Statistically significant (p < 0.05) variables identified in univariate analyses were included in subsequent multivariate analyses predicting higher than 90% adherence at 12 and 24 weeks. Several baseline predictors retained statistical significance in multivariate analysis at 24 weeks. Baseline levels of autonomous support from friends and family, motivation to adhere, and having an active coping style were all positively associated with adherence, while the belief that God is in control of one's health was negatively associated with adherence. Results indicate that effective interventions should include a focus on promoting patients' autonomous regulation and religious/spiritual beliefs regarding ART adherence.

Evaluating adherence to medication in children and adolescents with HIV

OBJECTIVE

The study was aimed to evaluate the relationship between pharmacy supply, self-reported treatment adherence and HIV viral load in HIV-infected children.

METHODS

A retrospective (52 weeks) cohort study was conducted through the review of the existing databases. Pharmacy supply was classified as "home delivery" when the medications were delivered home and as "in pharmacy pick-up" when they were picked up at the pharmacy. Adherence was assessed through retrospective (3 days recall) self-report. Fisher's exact model, univariate and multivariate logistic regression analyses were used.

SETTINGS

The study collected data on 140 HIV-infected children (<18 years). Adherence, pharmacy supply information and HIV viral loads were obtained from clinical and research databases.

PATIENTS

The data from 127 HIV-infected children (60 boys and 67 girls; mean age 9.9 years) were collected.

MAIN OUTCOME MEASURES

Complete adherence (100%) was reported in only 24% of patients. With 40% of patients being rarely or never completely adherent, 64% of children achieved undetectable viral loads during the study period.

RESULTS

No association between pharmacy supply and self-reported adherence was found (p = 0.605). Self-reported adherence (p = 0.0328) and age (p = 0.025) were the significant predictors of reaching undetectable viral loads. Adolescents (>13 years) were significantly less likely to reach undetectable viral loads than children under 13 years (odds ratio 0.38; 95% CI 0.16 to 0.89).

CONCLUSION

In our study, pharmacy supply was not associated with self-reported adherence. Most importantly, adherence and age were significant predictors of reaching undetectable viral loads.

Effects of an oral health promotion program in people with mental illness

More knowledge is needed regarding what works to prevent oral health problems and reduce disparities in oral health. Motivational interviewing (MI) has demonstrated utility for improving health behavior, including among those with severe mental illness. This study tests whether MI enhances the efficacy of an oral health education intervention in individuals with severe mental illness. Sixty individuals were randomly assigned to MI plus oral health education or oral health education alone. Plaque scores, oral health knowledge, and self-regulation were assessed at baseline and at 4 and 8 weeks. Repeated-measures ANOVA showed improvement (p < 0.05) in plaque, autonomous regulation, and oral health knowledge across time for both groups; however, individuals receiving MI improved significantly more when compared with those receiving oral health education alone. Results suggest that MI is effective for enhancing short-term oral health behavior change for people with severe mental illness and may be useful for the general population.

Changes in MRS neuronal markers and T cell phenotypes observed during early HIV infection

OBJECTIVE

To determine if changes in brain metabolites are observed during early HIV infection and correlate these changes with immunologic alterations.

METHODS

Eight subjects with early HIV infection, 9 HIV-seronegative controls, and 10 chronically HIV-infected subjects without neurologic impairment underwent 1H magnetic resonance spectroscopy. Subjects with early stage infection were identified near the time of HIV seroconversion and imaged within 60 days of an evolving Western blot, while still having detectable plasma virus. Subjects had blood drawn for viral RNA and T cell quantification.

RESULTS

Both N-acetylaspartate (NAA) and Glx (glutamate + glutamine) were decreased in the frontal cortical gray matter of seropositive subjects. NAA levels were found to be decreased in the centrum semiovale white matter of chronically HIV-infected subjects, but not in those with early infection. Both HIV-infected cohorts demonstrated a lower number of CD4+ T lymphocytes and a higher number of CD8+ T lymphocytes in their blood. Lower NAA levels in the frontal cortex of subjects with early infection were associated with an expansion of CD8+ T cells, especially effector CD8+ T cells.

CONCLUSIONS

These results verify metabolism changes occurring in the brain early during HIV infection. Lower NAA and Glx levels in the cortical gray matter suggests that HIV causes neuronal dysfunction soon after infection, which correlates to the expansion of CD8+ T cells, specifically to an activated phenotype. Utilizing magnetic resonance spectroscopy to track NAA levels may provide important information on brain metabolic health while allowing better understanding of the virus-host interactions involved in CNS functional deficits.

An international comparison of barriers in opening oncology clinical trials

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Background: Well designed clinical trials are critical to improve the outcomes of patients with cancer. There are significant barriers to accrue patients to clinical trials beginning with processes required to “open” a trial. This study aims to compare the procedures and time required to open thoracic oncology trials at a United States academic center to a similar center in Europe. Methods: A retrospective review was performed of all thoracic oncology therapeutic trials submitted for regulatory review between 2001–2008 at Washington University School of Medicine (WUSM) and the University of Torino, Italy (UT). A process map was drafted by both institutions to establish the order of required events. The timing data for each step was collected and analyzed for comparison. Results: A total of 137 therapeutic thoracic oncology trials were reviewed, 83 from WUSM and 54 from UT. Five major regulatory steps are required to open a trial in WUSM compared to three at UT. The median times to open a trial are 163 days (with inter-quartile range of 91 to 257 days) for WUSM and 122 days for UT (with inter-quartile range of 96 to 159 days) (p = 0.048). The median times for regulatory approval are 75 days (inter-quartile range, 26 to 131 days) for WUSC and 31 days (inter-quartile range, 10 to 67 days) for UT (p<0.0001), attributed to the additional requirement of Scientific Review Committee approval at WUSM prior to consideration by the Institutional Review Board (IRB), while regulatory approval is a single process at UT. However, the median time for contact approval process identified as the limiting step requiring a median of 115.1 (WUSM, inter-quartile range of 78 to 187) or 84 (UT, inter-quartile range of 44 to 124) days (p = 0.011). Conclusions: It takes additional steps and significantly longer time to open a therapeutic thoracic clinical trial at a representative U.S. site (WUSM) compared with a site in Europe (UT). As global trial collaboration increases, uniform strategies must be developed to shorten the administrative process, encouraging the creation of streamlined systems that enable centers to increase the number of agents under investigation.

No significant financial relationships to disclose.

Intratumoural lymphatics in benign and malignant soft tissue tumours

Soft tissue sarcomas do not generally metastasise via lymphatics, and the presence or absence of lymphatic vessels within sarcomas and benign soft tissue tumours is not known. In this study, we determined whether lymphatic vessels were present in a wide range of benign and malignant soft tissue lesions by examining intratumoural expression of the lymphatic endothelial cell markers, Lyve-1 and podoplanin. Intratumoural Lyve-1+/podoplanin+ lymphatics were not identified in sarcomas apart from all cases of epithelioid sarcoma (a tumour which is known to metastasise to lymph nodes) and a few cases of leiomyosarcoma, rhabdomyosarcoma and synovial sarcoma. Intratumoural lymphatics were also absent in most benign soft tissue tumours. Reparative and inflammatory soft tissue lesions contained lymphatics, as did all (pseudosarcomatous) proliferative myofibroblastic lesions including nodular, proliferative and ischaemic fasciitis, elastofibroma, nuchal fibroma and deep fibromatosis. Our results show that most soft tissue sarcomas do not contain intratumoural lymphatics, a finding which is consistent with the infrequent finding of sarcoma metastasis to lymph nodes. In contrast to fibrosarcoma and a number of other malignant spindle cell tumours, proliferative fibroblastic/myofibroblastic lesions of soft tissue contain intralesional lymphatic vessels.

Body fat distribution, serum glucose, lipid and insulin response to meals in Alström syndrome

BACKGROUND

Alström syndrome is an autosomal recessive condition characterized by obesity, insulin resistance and hypertriglyceridaemia. Responses to fat and carbohydrate ingestion are important in planning dietetic advice and may help to explain the mechanism of metabolic disorder in the syndrome.

METHODS

After a 12-h fast, five Alström subjects received a 3.1 MJ (742 kcal), 75.8% fat breakfast on day 1, and a 3.3 MJ (794 kcal), 77.5% carbohydrate breakfast on day 2. Serum glucose, triglyceride and insulin levels were measured at baseline, and 2 and 3.5 h post-meal. Abdominal computerized tomography in three subjects and magnetic resonance imaging in one demonstrated distribution of abdominal fat.

RESULTS

Body fat was distributed subcutaneously, as well as viscerally. There were no changes in serum glucose, insulin or triglycerides after the high fat meal. Triglycerides remained stable after the high carbohydrate meal but glucose and log insulin levels increased [8.4 +/- 4.1 to 13.4 +/- 6.9 mmol L(-1) (P < 0.05) and 2.6 +/- 0.27 to 3.15 +/- 0.42 pmol L(-1) (P < 0.05), respectively].

CONCLUSIONS

Dietetic advice in Alström syndrome must include calorie restriction to reduce obesity, which is predominantly subcutaneous. This study has shown that low carbohydrate advice may prove more effective than fat restriction in control of hyperglycaemia and hyperinsulinism. A single high energy meal does not exacerbate hypertriglyceridaemia.

Platelet associated IgG and immune thrombocytopenia in lymphoproliferative and autoimmune disorders

Thrombocytopenia is frequently encountered in patients with lymphoproliferative disorders (LPD) and systemic erythromatosus (SLE) and to a lesser extent in association with other diseases such as rheumatoid arthritis (RA), pernicious anaemia (PA) and autoimmune haemolytic anaemia (AIHA). This report attempts to document the incidence of thrombocytopenia in these disorders, other than that overtly due to malignant infiltration or marrow suppression by drugs and to demonstrate, that in a significant proportion antibody mediated immune destruction of platelets can be confirmed by positive platelet antibody tests. Platelet associated IgG (PAIgG) was measured in all patients by a quantitative enzyme linked assay. Platelet antibodies were found in 11 of 24 (46%) thrombocytopenic patients with LPD, 10 of 16 (62%) patients with SLE and thrombocytopenia, and in all patients with RA and PA who had low platelet counts at the time of study. In addition, elevated PAIgG levels were found in the following non-thrombocytopenic patients: 9 of 43 (21%) patients with LPD, 2 of 12 (17%) with SLE, 2 of 12 (17%) with AIHA, 2 of 39 (5%) with PA and 5 of 61 (8%) patients with RA. The nature and the role of raised PAIgG levels in diseases other than autoimmune thrombocytopenia is controversial. Our reasons for interpreting these as true platelet autoantibodies in this selected group of disorders and the clinical implications of our results are discussed.