Fatal Campylobacter jejuni infection in a patient splenectomised for thalassaemia

A 35 year old man with a fatal Campylobacter jejuni infection is described. He had HbE/beta zero thalassaemia and had undergone splenectomy nine months previously for hypersplenism; he also had chronic hepatitis C infection. He presented with high grade fever but no gastrointestinal symptoms and rapidly progressed to septicaemic shock and hepatic encephalopathy despite treatment with penicillin, gentamicin, and, later, chloramphenicol and ceftazidime. Only one case of Campylobacter jejuni septicaemia occurring post-splenectomy has been reported previously, also in an iron overloaded thalassaemia patient. Unusual Gram negative bacilli must be covered by the chosen antibiotic regimen when splenectomised thalassaemic patients present with high grade fever.

Mycorrhizal fungi associated with three species of turfgrass

Small plots of highly maintained turfs of creeping bentgrass (Agrostis palustris cv. Penncross) and velvet bentgrass (Agrostis canina cv. Kingstown) and a marginally maintained stand of annual bluegrass (Poa annua) were sampled intensively over a 15-month period to measure the populations of spores of arbuscular mycorrhizal fungi (AMF) associated with their root systems. Direct isolation of spores and trap cultures were used to assess the AMF communities. Spores of more than 18 species of AMF were isolated. The six dominant species (as measured by the abundance and frequency of occurrence of spores) were Acaulospora mellea, an undescribed species of Acaulospora, Scutellospora calospora, Glomus occultum, Glomus etunicatum, and Entrophospora infrequens. Spores of 17 species of AMF were recovered from the root zones of velvet bentgrass, 15 species from creeping bentgrass, and 14 from annual bluegrass. Soil fertility differed among the three sites, and it was not possible to ascribe differences in the AMF communities in each plot to any particular variable (e.g., host, pH, soil P). Average spore abundance was greatest in the creeping bentgrass plot (191.0 spores/100 mL), next in the velvet bentgrass plot (82.4 spores/100 mL), and least in the bluegrass plot (28.4 spores/100 mL). Spores were recovered from a significantly greater percentage of the samples from the bentgrass plots (88.5 – 96.8%) than from the bluegrass plot (76.6%). Spores of an average of 4.5 species of AMF were isolated monthly from creeping bentgrass, 3.3 from velvet bentgrass and 2.0 from bluegrass. Average species richness and spore abundance were positively correlated in the creeping bentgrass and bluegrass plots (r = 0.77, p = 0.001, and r = 0.68, p = 0.006), but not in the velvet bentgrass plot. Spore abundance showed strong seasonal trends in all three plots (p = 0.03 – 0.001), with numbers increasing from spring until November. Richness and abundance declined from December until the following spring. In the bluegrass area, which experienced summer drought, spore populations and richness also showed a precipitous decline in July and August in the 1st year of the study (1990), but not in the 2nd year (1991). No such summer decline occurred in the bentgrass plots that received irrigation. The AMF community that was circumscribed by direct spore counts from the field usually was highly dissimilar to the community that was estimated by trap cultures initiated using soil from the turf areas. Key words: annual bluegrass, arbuscular mycorrhizal fungi, creeping bentgrass, putting greens, turfgrass, velvet bentgrass.

Sideroblastic anemia recurring during two pregnancies

A 25-year-old lady presented with a severe normocytic anemia (Hb 5.3 g/dl) and a sideroblastic marrow at the end of her first pregnancy. Six months into the puerperium, after the transfusion of a total of 8 units of red cells, there was apparent spontaneous improvement and then she was lost to follow-up. After a second pregnancy without clinical problems, she presented during a third pregnancy, at the age of 30 years, with similar hematological findings. Twenty-two months later she was well with a normal blood count. One possible reason for relapse in pregnancy is the increased demand for pyridoxine that occurs, but only one other case of sideroblastic anemia relapsing during pregnancies has been reported.

Retinal findings in adult leukaemia: correlation with leukocytosis

The associations between retinal findings and haematological parameters in acute leukaemia are controversial. Sixty-three newly-diagnosed acute leukaemia patients, aged 12-77 years, were studied prospectively for the presence of intra-retinal haemorrhages (IRH), white-centred haemorrhages (WCH), cotton wool spots (CWS) and macular haemorrhages (MH), Thirty-three patients (52.4%) showed at least one retinal abnormality. The prevalence of individual findings was: IRH (30 cases), WCH (20 cases), CWS (5 cases), MH (11 cases). In contrast to previous studies, there was no association between any of these retinal findings and the haemoglobin level or the platelet count. There was a higher median WBC in patients with IRH (68 x 10(9)/l) than in those without IRH (15.4 x 10(9)/l), P = 0.037. When the acute myeloblastic leukaemia cases were considered separately, an association was also found between higher WBC and the presence of WCH and CWS. There was no association between retinal findings and FAB type in the AML cases. We conclude that a high WBC may be at least as important as anaemia and thrombocytopenia in the pathogenesis of the retinopathy of acute leukaemia.

Development and density of wool follicles in Merino sheep selected for single fibre characteristics

Wool follicles are classified into 3 major types: primary (P), original secondary (SO), and derived secondary (SD). They are formed during fetal life as successive waves of initiation pass through the skin. P follicles are the first to be initiated. SO follicles develop between the primaries and are separated from them at non-randomly distributed sites. SD follicles are the last to be initiated and branch from SO and other SD follicles. We have measured the densities of these follicles in 4 lines of sheep selected for different fleece characters. Primary follicle and total follicle densities (NP and NP + NS) were estimated by conventional procedures. The densities of pilary canals were also obtained to provide a measure of Np + NSO. Follicle counts in both adult and fetal animals showed that NP and NP + NSO were relatively constant across the lines. Predominantly, density differences were due to variations in the numbers of follicles initiated during the last wave, forming the derived secondary population. Changes in follicle densities were therefore effected by developmental mechanisms that increase or decrease the extent of branching rather than by altering the numbers of P and SO follicles. The results suggest firstly that the numbers of initiation sites for P or SO follicle formation in the fetus, corresponding to the pilary canals of adult skin, are limited. Secondly, the skin has the capacity to continue to initiate follicles after most or all of the sites have been occupied. It is concluded that the mechanisms controlling follicle initiation site densities and total follicle densities are independently regulated in the sheep. The observations are discussed in relation to factors that influence the densities of the different follicle types. The results have practical implications for changing fleece weight and fibre diameter through selective breeding.

Autosomal dominant thrombocytopenia with microthrombocytes: a family study

A family demonstrating autosomal dominant thrombocytopenia is described. A 28-year-old Malay housewife was found to have a platelet count of 40 x 10(9)/l with a low mean platelet volume (6.8 fl) while being investigated prior to ovarian cystectomy. The bone marrow was consistent with immune thrombocytopenia but she failed to respond to appropriate therapy. Five siblings, one parent and one nephew have easy bruising and platelet counts of 39-82 x 10(9)/l. Platelet aggregation studies excluded a major functional defect. Survival of homologous platelets in the circulation was normal. Familial thrombocytopenias are rare but important to differentiate from the common acquired thrombocytopenias in order to spare the patient unnecessary treatments.

Adult idiopathic thrombocytopenic purpura without the option of splenectomy

In this part of Malaysia, consent of splenectomy is virtually unobtainable, so we studied the outcome of ITP without this treatment option. Thirty-two adult patients were seen, but 7 defaulted before therapy evaluation. Of the remaining 25, 17 achieved a complete remission with prednisolone, but in only 8 was this prolonged. Twelve patients, who failed to respond to prednisolone or who required > 15 mg/day as maintenance, were offered splenectomy, but all fused. Of these 12: one has died from an intracranial haemorrhage; three others have defaulted while on no treatment with platelet counts of < 16 x 10(9)/1; one has had a baby who died from intracranial bleeding. The other seven patients have platelet counts ranging from 4 - 202 x 10(9)/1 with moderate bleeding on doses of prednisolone of 0-60 mg/day: long-term corticosteroid side-effect are evident in all but one of them. This study demonstrates that ITP patients who refuse splenectomy have a high morbidity.

Client attachment in learning disabilities nurse education

This paper describes the method by which the learning disabilities branch programme in Southampton has been adapted to reflect educational and practical changes. Emphasis is placed on integrating theory and practice through giving students extended contact with a caseload of patients with the support of a tutor and mentors. The authors report on the initial difficulties and benefits resulting from the new programme.

A comparison of the effects of IGF-I and insulin on glucose metabolism, fat metabolism and the cardiovascular system in normal human volunteers

The metabolic and cardiovascular effects of recombinant human IGF-I were compared to insulin in six normal subjects. Subjects were studied twice and intravenously received an infusion of [6,6-2H2]glucose (0-480 min) and in random order either IGF-I 20 micrograms kg-1 h-1 (43.7 pmol kg-1 min-1 or insulin 0.5 mU kg-1 min-1 (3.4 pmol kg-1 min-1) with an euglycaemic clamp. One subject was withdrawn following a serious adverse event. During the IGF-I infusion glucose appearance rate (Ra) decreased from 1.79 +/- 0.13 at baseline (150-180 min) to 0.35 +/- 0.26 mg kg-1 min-1 (P < 0.01) at 360 min, and glucose utilization rate (Rd) increased from 1.79 +/- 0.28 to 4.17 +/- 0.84 mg kg-1 min-1 (P < 0.01). There was no change in free fatty acids (FFA) and an increase (percentage change from pre-infusion mean) in cardiac output +l37.3% +/- 9% (P < 0.01), heart rate +13% +/- 2% (P < 0.01) and stroke volume +21% +/- 7% (P < 0.05). During the insulin infusion glucose Ra decreased from 1.89 +/- 0.13 to 0.34 +/- 0.33 mg kg-1 min-1 (P < 0.01) and FFA from 0.546 mmol l-1 to 0.198 mmol l-1 (P < 0.01), glucose Rd increased from 1.89 +/- 0.18 to 5.41 +/- 1.47 mg kg-1 min-1 (P < 0.01) and there were no significant changes in the cardiovascular variables.

Renal response to candoxatrilat in patients with heart failure

OBJECTIVES

Our primary objective was to compare the effects of three different doses of candoxatrilat with the effects of placebo on urinary volume in patients with moderately severe heart failure. The effects of candoxatrilat on urinary composition, neuroendocrine indexes and renal hemodynamic function were also studied.

BACKGROUND

Candoxatrilat, a neutral endopeptidase inhibitor, reduces degradation of atrial natriuretic peptide and provokes diuresis in patients with mild heart failure, but the renal effects have not been studied in patients with moderately severe heart failure in a placebo-controlled study.

METHODS

In a double-blind crossover trial, the effects of intravenous boluses of saline vehicle (placebo) and 50, 100 and 200 mg of candoxatrilat were compared on separate days in 12 patients with heart failure. Urinary output and composition were measured for 8 h. Renal blood flow and glomerular filtration rate were determined by radionuclide techniques. Blood was withdrawn for the measurement of hormones before and 3 h after dosing.

RESULTS

All doses of candoxatrilat increased urinary volume (e.g., [mean +/- SEM] 263 +/- 53 to 490 +/- 82 ml for saline solution and the 200-mg dose, respectively, p < 0.01) and sodium content (14 +/- 4 to 37 +/- 11 mmol, p < 0.001) in the 1st 4 h after dosing. Plasma atrial natriuretic peptide increased (140 +/- 26 to 279 +/- 37 pg/ml, p < 0.01), whereas aldosterone decreased (178 +/- 41 to 125 +/- 35 pg/ml, p < 0.01), and renin activity was unchanged (10 +/- 2 to 12 +/- 3 ng/ml per h).

CONCLUSIONS

Candoxatrilat given acutely causes diuresis, even in patients with moderately severe heart failure.

Puerperal acquired factor VIII inhibitor causing a von Willebrand-like syndrome in a patient with anti-DNA antibodies

A 30-year-old Malay lady, with no previous or family history of bleeding, presented with severe gum bleeding 25 days post-partum. The factor VIII:c was 0.03 iu/ml with evidence of a slow-acting factor VIII inhibitor. Von Willebrand factor antigen (VWF:age) varied from less that 0.05 to 0.17 iu/ml, and there was absent ristocetin-induced platelet aggregation. Anti-nuclear and anti-DNA antibodies were present, but there were no other features of systemic lupus erythematosus. There was some clinical response to cryoprecipitate and tranexamic acid, and slight improvement with corticosteroid. Fifteen months later, the patient has no active bleeding problem, and her VWF-ag is increasing spontaneously. However, factor VIII:c is less than 0.01 iu/ml and her factor VIII inhibitor titre is still > 20 Bethesda units/ml.

Randomized trial of intravenous immunoglobulin prophylaxis for patients with chronic lymphocytic leukaemia and secondary hypogammaglobulinaemia

Forty-two patients with chronic lymphocytic leukaemia (CLL), serum IgG levels < 5.5 milligrams and a history of two or more recent infections, were randomized to receive infusions of 18 g human intravenous immunoglobulin (IVIg) or human albumin placebo every three weeks. During the 12 month study 122 infections were documented but only four were associated with neutropenia. Ten patients (24%) with IgG levels < 3.0 milligrams experienced 65% of the infections. In response to IVIg there were immediate and accumulative increases in serum IgG levels and an associated decrease in total and serious infections. If three further infections occurred, placebo patients were commenced on 18 g IVIg, and IVIg patients were increased to 24 g IVIg. Approximately 50% of these cases subsequently remained infection free. The study shows the usefulness of prophylactic Sandoglobulin in CLL patients with hypogammaglobulinaemia, and suggests that this may be justified in those with recurrent infections and serum IgG levels < 3 milligrams.

M3-variant of acute promyelocytic leukaemia. A case report in a Malay boy

The variant form of acute promyelocytic leukaemia (AML-M3) possesses its own characteristic morphology, although usually a few of the cells may have cytoplasmic features of typical AML-M3. In contrast to typical AML-M3, this M3-variant form commonly presents with hyperleucocytosis. As in typical AML-M3, disseminated intravascular coagulopathy (DIVC) occurs in the M3-variant. A boy with this morphological variant of AML-M3 is described. Uncharacteristically, his presenting white blood count was low, and DIVC was present before treatment was started. Six days into intensive chemotherapy his coagulopathy worsened and he subsequently died of intracranial haemorrhage. An alternative approach to the treatment of AML-M3, with the use of retinoids, is discussed.

Hydroxyurea treatment for chronic myeloid leukaemia during pregnancy

A patient being treated for chronic myeloid leukaemia with hydroxyurea became pregnant. Despite an increase in the dose of hydroxyurea (to 3 g per day) during the pregnancy, her white blood cell count could only be controlled at about 150 x 10(9)/l. A healthy baby girl was born at 37 weeks with normal blood counts and no evidence of congenital abnormality. There are now five reports of the use of hydroxyurea in pregnancy, and where leukapheresis is not available it may be the treatment of choice.

Acute myocardial infarction survival rate and complications after streptokinase therapy in Hospital Universiti Sains Malaysia, Kelantan--a comparative study

Thrombolytic therapy is a well-established therapy in acute myocardial infarction (AMI), reducing mortality and infarct size. This study is a retrospective analysis of survival and complications after the use of streptokinase at Hospital Universiti Sains Malaysia. Streptokinase was first used here in March 1990. Between then and February 1992, 126 patients were admitted to the Coronary Care Unit. Thirty-two patients who fulfilled our criteria for thrombolytic treatment were given an hour intravenous infusion of 1.5 MU streptokinase, and started on aspirin. A control group of 64 patients selected from before March 1990, and matched for age, sex and site of infarct, was given standard therapy. The survival at 4 weeks post-AMI was 91% in the streptokinase therapy group and 91% in both groups (p > 0.05). The complications encountered were reperfusion arrhythmias (2 patients), hypotension(1), maculopapular rash(1) and gum bleeding(1). None of these complications were statistically increased when compared to the control group and none resulted in the death of a patient. We conclude that streptokinase therapy can be given safely in a rural Malaysian setting. Our survival and complication rates are comparable with other published series.

Reduction of plasma prolactin by acute administration of CB-154 in ovariectomized F344 and Holtzman rats treated with diethylstilbestrol: a comparison of RIA and Nb2 lymphoma bioassay

Fischer 344 (F344) and Holtzman Sprague-Dawley female rats were ovariectomized and implanted with a s.c. Silastic capsule of diethylstilbestrol (DES). At 1, 4 and 8 weeks of DES exposure, blood samples were obtained by infraorbital sinus puncture under light ether anesthesia before and 2 hours after s.c. administration of CB-154 (2.5 mg/rat). The plasma obtained was assayed for prolactin by radioimmunoassay (RIA) and Nb2 lymphoma cell bioassay (BA). At 1 week of DES treatment plasma prolactin in F344 rats measured by RIA was decreased by CB-154 (approximately 60%) whereas the level measured by BA was not changed and the BA:RIA ratio was increased from 2.4 +/- 0.2 to 4.8 +/- 0.9. CB-154 decreased plasma prolactin levels at 4 weeks but the effect seen by RIA (approximately 80%) was greater than that seen by BA (approximately 60%) and the BA:RIA ratio was increased (2.2 +/- 0.2 vs 3.4 +/- 0.5). By 8 weeks of DES exposure, CB-154 was as effective in reducing the levels measured by BA (approximately 89%) as those measured by RIA (approximately 85%) and the BA: RIA was not affected by the dopamine agonist. In Holtzman rats CB-154 decreased prolactin levels measured by RIA and BA to the same extent at both 1 and 4 weeks resulting in no change in the BA:RIA ratio, but at 8 weeks the BA:RIA was decreased by CB-154 (2.1 +/- 0.1 to 1.7 +/- 0.1). As was observed in F344 rats, the reduction in plasma prolactin induced by CB-154 increased as the duration of DES treatment increased (1 week approximately 45%; 4 weeks approximately 55-60%; 8 weeks approximately 80-85% inhibition) regardless of assay method. It is concluded that DES increases the BA:RIA ratio of plasma prolactin and that acute CB-154 treatment increases, decreases or does not change the BA:RIA ratio depending on the strain of rat used and the duration of DES treatment.

Genetic aspects of cold resistance and related characters in newborn Merino lambs

Resistance to body cooling and rate of recovery from induced hypothermia were measured in 287 single, newborn Merino lambs from 24 different sire families, using a water bath test in which partly immersed lambs were progressively cooled. Birth weight, birthcoat type (fine-hairy) and skin thickness were recorded at the time of test. There was an unexpected occurrence of congenital goitre, the incidence and severity of which was estimated by manual palpation of the thyroid gland. Heritability (� s.e.) of cold resistance (CR), estimated by paternal half-sib analysis, was 0.70 � 0.25. Sex of lamb, type of weather, time of test, Fecundin treatment and age of ewe were fitted in the model as fixed effects but none were significant. Other heritable traits (h2 � s.e.) included birthweight (0.50 � 0.22), birthcoat grade (0.61 � 0.24), coat depth (0.62 � 0.24), skin thickness (0.35 � 0.19) and the severity of goitre (0.21 � 0.16). Significant genetic correlations (r �s.e.) between cold resistance and other traits were: birthweight, +0.76 � 0.18; birthcoat grade, +0.56 � 0.24; birthcoat depth, +0.56 � 0.24; skin thickness, +0.51 � 0.27; goitre, -0.58 � 0.40. Most of the corresponding phenotypic correlations were small. Goitre did not affect CR significantly, despite the genetic correlation between them. Heritability of CR, further adjusted for the effects of birthweight, birthcoat grade and depth, and skin thickness as covariates, was 0.55 � 0.23. About 40% of the variation in CR was accounted for by fitting fixed effects and covariates, but significant sire effects remained. Rate of recovery from hypothermia was not heritable and it was unrelated to any other variable except goitre, which tended to be associated with slower recovery (rp = 0.18). It was concluded that genetic selection for increased CR would succeed but would promote birthcoat hairiness unless a corrective selection index was used. The relationship between birthcoat type and CR was considered to be mediated by genes affecting both coat type and CR, not primarily by a direct effect of coat insulation.

How does posture influence the haemodynamic assessment of a cardiovascular drug? Experience with nicardipine

The extent to which posture altered the haemodynamic response to slow calcium channel blocker nicardipine was evaluated in 22 male patients with angiographically confirmed coronary artery disease. Patients were randomly allocated to supine or upright posture and an otherwise identical protocol performed in each group. At rest, following a control saline period, four doses of the drug (log cumulative dosage: 1.25, 2.5, 5.0, and 10.0 mg) were administered by i.v. infusion over a total period of 40 min; haemodynamic indices were recorded during the 3-5 min following each 5 min infusion. The exercise effects of the drug, in each posture, were determined by comparison of a control predrug exercise with observations at the same workload following the maximal cumulative dose. Nicardipine reduced resting mean blood pressure (MBP) and systemic vascular resistance index (SVRI) in both postures, the decrease being more pronounced when upright (MBP, -12%, -18%; p less than 0.01: SVRI, -30%, -46%; p less than 0.01). The increases in cardiac index (CI) and stroke volume index (SVI) were higher when upright (29 and 54% vs. 10 and 27%; p less than 0.01). Pulmonary artery occluded pressure (PAOP) increased by 29% when upright, without change when supine. On exercise, the effects for HR, MBP, CI, SI, and SVRI responses were independent of posture; however, a qualitative difference was apparent for PAOP (-17% vs. +14%; p less than 0.05). Thus, although the actions of nicardipine were qualitatively similar, quantitative differences related to posture were confirmed. These differences appeared to relate to posture-related baseline haemodynamic differences between the groups but with similar postnicardipine absolute values.

Comparison of diet history interview and self completed questionnaire in assessment of diet in an elderly population

STUDY OBJECTIVE

The aim of the study was to determine the reliability of a diet history interview with a short self completed questionnaire of a basic design used in other studies in the United Kingdom.

DESIGN

The study used a cohort of elderly people randomly divided into two groups after stratification for sex. Members of one group completed the questionnaire first and were interviewed later; the procedure was reversed for the other group.

SETTING

Participants were drawn from registers of two general practitioners at a Nottingham health centre.

PARTICIPANTS

All non-Asian men aged 65-74 years and women aged 59-65 years registered with the practices were identified (n = 152); 20 could not be traced and two were too ill, leaving 130 possible participants. Of these, 80 took part in the study.

MEASUREMENTS AND RESULTS

Ranking of subjects in terms of estimated fat, fibre, and calcium intakes was compared in the history interview and in the self completed questionnaire. Agreement in tertile ranking was 58% for fibre, 53% for fat, and 49% for calcium. Corresponding correlation coefficients for estimated nutrient intakes were 0.49, 0.45, and 0.41 respectively. The differences in nutrient intakes estimated by the two methods were not affected by age, sex, marital status, or smoking patterns. Subjects in the group asked to complete the questionnaire before being interviewed showed greater percentage concordance for tertile ranking, but this reached significance only for fat intake.

CONCLUSIONS

The two methods provide estimates of intakes similar to those found in other studies in the United Kingdom, and the agreement between them in terms of tertile ranking is also similar to previous studies. The incidence of gross misclassification was low.