Waiting times and patient satisfaction in the accident and emergency department

A survey of the waiting times and patients' opinions of these times was undertaken in a busy district general hospital A&E department. The various components of the overall waiting time are analysed and specific points of the patients' attendance, where waiting times were prolonged, are identified. Standards are derived which is hoped may result in 75% of patients being satisfied with the duration of their wait. The current levels of achievement are compared with these standards. Suggested and actual improvements to the department to improve our performance are described.

Prognostic significance of the balanced t(1;19) and unbalanced der(19)t(1;19) translocations in acute lymphoblastic leukemia

The recurring chromosomal 1;19 translocation in acute lymphoblastic leukemia (ALL) occurs in balanced t(1;19) (q23;p13) and unbalanced, -19, +der(19)t(1;19)(q23;p13) forms. The clinical features and outcome were compared for 30 patients with the t(1;19) and 36 patients with the der(19) forms. These were 45 children (less than 1-14 years) and 21 adults (15-54 years) (median age 9.0 years), 41 females, 25 males, with median white blood count (WBC) 20.9 x 10(9)/1. Patients were classified by karyotype thus: t(1;19) 11 cases; t(1;19) with additional change (+A) 19 cases; der(19) 17 cases; and der(19) +A, 19 cases. Non-random additional structural abnormalities included involvement of 1q, 6q, i(7q), i(9q), 9p, and 13q. The only significant difference in clinical or blast cell features between patients with the t(1;19) and the der(19) was the greater age of adults with t(1;19) (p less than 0.05). Projected median event-free survival and survival of all cases together was 22 months and greater than 112 months respectively. Neither age nor WBC contributed significantly to prognosis. For patients at all ages, prognosis of der(19) was better than t(1;19). This was statistically significant for event-free and overall survival in childhood (p = 0.02 and p = 0.01 respectively) and was independent of age (p = 0.04 and p = 0.008 respectively) and WBC (p = 0.03 and p = 0.04 respectively). Future studies should examine separately the outcome for patients with the balanced and unbalanced forms of the t(1;19).

Outcome of herpes simplex virus type 2 infection in guinea pigs

Factors that influence the outcome of genital herpes simplex virus (HSV) infection were explored in a guinea pig model. The viral inoculum required to establish infection in 50% of animals (ID50) was similar for inbred (strain 2) and outbred (Hartley) guinea pigs. However, the viral inoculum required to produce clinical disease in 50% of the animals (CD50) was 10 times greater for strain 2 compared to Hartley animals. HSV infection of both inbred and outbred animals was more likely to result in death of weanling than adult animals. The duration and severity of genital disease and the magnitude of vaginal viral replication were similar for strain 2 and Hartley animals in both young and adult animals. The lethal dose for 50% of animals (LD50) was 100-fold greater than the CD50 for Hartley animals, but the LD50 and the CD50 were equal in strain 2 guinea pigs. Viral cultures of homogenized neural tissues from infected animals revealed that HSV ascended to the level of the temporal cortex in strain 2 guinea pigs while virus was never recovered above the lumbar spinal cord in Hartley animals. Endogenous peripheral blood mononuclear cell-mediated cytolytic activity against HSV-infected targets was greater prior to HSV inoculation in survivors compared to animals that died. A fatal outcome of genital HSV-2 may relate to the failure to limit CNS viral replication. Death is more common among guinea pigs that have low endogenous HSV-directed natural killer activity, such as occurs among strain 2 and young animals whether inbred or outbred.

Postnatal encephaloclastic porencephaly--a new lesion?

A previously unrecognised and distinctive pattern of severe brain injury in extreme preterm neonates was observed recently. Fifteen neonates of birth weight 600-1270 g and gestation of 24-32 weeks showed relatively late development on cerebral ultrasound scan of extensive dense and cystic lesions involving the periphery of the brain. The extent of the changes was confirmed at postmortem examination in 11 babies. These changes have been called encephaloclastic porencephaly. The population of babies in whom this has occurred and their clinical outcome has been reviewed, with comparison between the evolution of the ultrasound changes and pathological findings at postmortem examination.

Atypical allergic colitis in preterm infants

Two atypical cases of colitis due to cow's milk protein intolerance (CMPI) are reported, affecting preterm infants. One developed a toxic dilatation of the colon and responded well to a casein hydrolysate based feed. The second presented insidiously and failed to tolerate a casein hydrolysate, but responded well to a chicken-based modular feed.

Antibiotic treatment failures in acute otitis media

When the clinician is presented with apparent treatment failure, noncompliance must be considered first. If this is the problem, the medication should be reinstituted after the parents are counseled. Next, the possibility of a superimposed viral illness also must be considered. When satisfied that these are not the problems, the clinician must consider whether the MEE has created so much positive pressure that antimicrobials cannot completely penetrate the middle ear space. If positive pressure is considered the problem, the same or another antimicrobial should be continued for a second 10-day course, allowing the pressure to decrease with time permitting more complete antibiotic penetration into the MEE. Alternately, clinicians with appropriate training may elect to relieve the pressure by tympanocentesis or myringotomy. If the clinician decides that it is more likely that the patient has a pathogen resistant to the initial choice of an antimicrobial agent, a second course of a more potent second-line antimicrobial is appropriate. Patients who fail a second course of antimicrobials should receive an alternate second-line antimicrobial or undergo drainage of the middle ear abscess. Those who fail a third course of antimicrobials should be referred to an otolaryngologist for evaluation or surgical intervention. Antimicrobials should be continued until the consultation occurs. This article has outlined potential clinical presentations for treatment failures as well as choices for second-line antibiotics. The relation of anatomic, environmental, microbial, and antimicrobial factors in persistent AOM must be considered in order to determine if the clinician should do more than merely prescribe second-line antibiotics.(ABSTRACT TRUNCATED AT 250 WORDS)

Near haploid acute lymphoblastic leukemia: seven new cases and a review of the literature

Seven new cases are described of near haploid acute lymphoblastic leukemia (ALL) and the findings reviewed together with updated complete remission duration and survival data for the 21 cases already published. The patients were four males and three females, with an age range 2-19 years; all had an immunophenotype consistent with common ALL. The poor prognostic outlook for patients with near haploid ALL is confirmed by the median remission duration of 14 months for these patients, which is comparable to that for the previously published cases. The pattern of chromosome loss was marked particularly by the presence of two copies of chromosomes 10, 14, 18, 21 and both sex chromosomes. Populations of hyperdiploid cells with double the near haploid number were observed in six of the patients, one of whom demonstrated further clonal evolution, and it is proposed that some cases classified as hyperdiploid ALL with greater than 50 chromosomes may also have arisen from a near haploid stem line.

Alveolar rhabdomyosarcoma with del(13q14)

We report a case of disseminated alveolar rhabdomyosarcoma, where chromosome analysis showed a deletion of chromosome 13(q14). This breakpoint is involved in the t(2;13)(q37;q14) previously reported in cases of rhabdomyosarcoma, but this is the first reported case in whom this deletion occurs without involvement of chromosome 2. The possible oncogenic role of the retinoblastoma (RB1) gene located at the breakpoint is discussed.

Low maternal CD4 count at inception of gestational cytomegalovirus (CMV) infection and impaired humoral response: effect on congenital CMV infection in the guinea pig

In humans, the rate and clinical expression of disease in congenitally cytomegalovirus (CMV)-infected infants is modified by maternal immunity to CMV. We used the guinea pig model of congenital CMV infection to compare maternal CD4+ T-cell numbers in nonpregnant animals to those in pregnant dams just before and 7-14 days after inoculation with guinea pig CMV (gpCMV) very early, early, or late in gestation. We also examined ELISA antibody responses to gpCMV in the inoculated nonpregnant and pregnant animals. When compared to nonpregnant uninfected animals, CD4 counts were lower in very early and in late uninfected gestation. CD4 counts also dropped further in the postinoculation period. Compared to nonpregnant gpCMV-inoculated animals, initial antibody responses to gpCMV were also decreased in gpCMV-infected pregnant dams. The group of dams inoculated very early in pregnancy experienced delays in seroconversion to gpCMV, persisting low titers throughout gestation, in utero fetal resorptions, and CNS-infected pups. The group of dams inoculated late in gestation had the lowest geometric mean titers at delivery (almost 50% with no detectable antibody) and a high rate of vertical gpCMV transmission and postnatal pup death. Significantly lower rates of both congenital infection and postnatal pup deaths were observed in litters of late gestation-infected dams that had gpCMV antibody at delivery. Thus, decreased circulating maternal CD4+ T cells very early and late in gestation were further decreased after gpCMV inoculation and were associated with delayed and depressed maternal antibody responses, all of which were associated with poor outcome after primary maternal gpCMV infection, the expression of which varied by time in pregnancy when gpCMV was acquired.

Cell-mediated immunologic responses and recurrent genital herpes in the guinea pig. Effects of glycoprotein immunotherapy

The specific immune alterations associated with HSV recurrences are ill defined although it appears that alterations in cell-mediated immune mechanisms are more likely associated with recurrent disease than humoral immunity. Immunization with HSV glycoproteins B and D (gBgD) after primary HSV infection has reportedly reduced the frequency of recurrences but the mechanisms remain unidentified. We therefore evaluated the effects of immunization with cloned gBgD on selected cell-mediated immune responses and their relationship to recurrent disease by using the guinea pig model of genital HSV-2 infection. In two experiments, immunization with gBgD + CFA on days 21 and 42 after HSV-2 inoculation significantly decreased the number of subsequent recurrent lesion days observed whereas CFA alone had no effect. Immunization with gBgD + CFA increased the lymphoproliferative and in vitro IL-2 response to gBgD more than to whole HSV-2 Ag preparations. Peak responses were observed 2 wk after the second immunization. The HSV-specific cytolytic response was also persistently increased beginning 1 wk after the first immunization. Analysis including both untreated and gBgD-immunized animals revealed that recurrent lesion days were inversely correlated to the IL-2 response to whole HSV-2 Ag (p less than 0.0001), the IL-2 response to gBgD (p = 0.0004), and the HSV-specific cytolytic response (p = 0.005 and 0.003 in two experiments, respectively). When the untreated group was analyzed separately, only the IL-2 response to whole HSV-2 Ag correlated to recurrences (p = 0.007). HSV glycoprotein immunization may increase IL-2 or other cytokines secreted by HSV-sensitized T cells increasing critical immune responses, such as NK- or lymphokine-activated killer-mediated cytolysis, that could eliminate the reactivated virus before the development of clinically apparent lesions.

Cell-mediated immunologic responses and recurrent genital herpes in the guinea pig. Effects of glycoprotein immunotherapy

The specific immune alterations associated with HSV recurrences are ill defined although it appears that alterations in cell-mediated immune mechanisms are more likely associated with recurrent disease than humoral immunity. Immunization with HSV glycoproteins B and D (gBgD) after primary HSV infection has reportedly reduced the frequency of recurrences but the mechanisms remain unidentified. We therefore evaluated the effects of immunization with cloned gBgD on selected cell-mediated immune responses and their relationship to recurrent disease by using the guinea pig model of genital HSV-2 infection. In two experiments, immunization with gBgD + CFA on days 21 and 42 after HSV-2 inoculation significantly decreased the number of subsequent recurrent lesion days observed whereas CFA alone had no effect. Immunization with gBgD + CFA increased the lymphoproliferative and in vitro IL-2 response to gBgD more than to whole HSV-2 Ag preparations. Peak responses were observed 2 wk after the second immunization. The HSV-specific cytolytic response was also persistently increased beginning 1 wk after the first immunization. Analysis including both untreated and gBgD-immunized animals revealed that recurrent lesion days were inversely correlated to the IL-2 response to whole HSV-2 Ag (p less than 0.0001), the IL-2 response to gBgD (p = 0.0004), and the HSV-specific cytolytic response (p = 0.005 and 0.003 in two experiments, respectively). When the untreated group was analyzed separately, only the IL-2 response to whole HSV-2 Ag correlated to recurrences (p = 0.007). HSV glycoprotein immunization may increase IL-2 or other cytokines secreted by HSV-sensitized T cells increasing critical immune responses, such as NK- or lymphokine-activated killer-mediated cytolysis, that could eliminate the reactivated virus before the development of clinically apparent lesions.

Effects of cytokines and R-837, a cytokine inducer, on UV-irradiation augmented recurrent genital herpes in guinea pigs

We have recently reported that latently HSV-2-infected guinea pigs exhibit a three- to four-fold increase in recurrent lesions after exposure to ultraviolet radiation (UV), allowing rapid evaluation of antiviral drugs in treating recurrent HSV disease. In this report we examine the effect of alpha interferon (IFN-alpha), interleukin-2 (IL-2), and a cytokine inducer (R-837) on UV-induced recurrent genital herpes. We have previously shown that topical R-837 is a biologic response modifier with no in vitro anti-HSV activity, but with potent anti-HSV activity in vivo due to cytokine induction and enhancement of cell-mediated immune responses. Three-day regimens of intravaginal R-837, or five-day intraperitoneal (i.p.) administration of IFN-alpha or of IL-2 each significantly reduced recurrent genital HSV-2 disease that occurred within 7 days of UV exposure, suggesting that cytokines or cytokine inducers may be useful in the treatment of recurrent HSV disease. This model using ultraviolet radiation to induce recurrent herpes simplex virus infection proved useful in the evaluation of immunoactive agents as putative antiviral drugs.

Antigenic and genetic variation in influenza A (H1N1) virus isolates recovered from a persistently infected immunodeficient child

Antigenic and genetic variations have been analyzed in eight consecutive isolates recovered from a child with severe combined immunodeficiency syndrome persistently infected with naturally acquired type A (H1N1) influenza virus over a 10-month period. Hemagglutination inhibition reactions and T1 oligonucleotide fingerprinting demonstrated that these viruses were related to strains causing outbreaks in the United States at that time (1983 to 1984) but that antigenic and genetic differences between consecutive isolates could be detected. This variation between isolates was examined further by sequencing the RNAs encoding the HA1 region of the hemagglutinin (HA) and the nucleoprotein (NP) in five of the consecutive isolates. Multiple point mutations were detected in both genes, and a deletion of one amino acid was detected in the HA. Depending on the isolates compared, 5.8 x 10(-3) to 17 x 10(-3) substitutions per nucleotide site per year were detected in the RNAs encoding the HA1, and 3.5 x 10(-3) to 24 x 10(-3) substitutions per nucleotide site per year were detected in the NP gene. Fifty-four percent of the base changes in the HA1 and 73% in the NP led to amino acid substitutions. A progressive accumulation of mutations over time was not observed, suggesting that the genetic diversity of these viruses may best be interpreted as the result of shifts in the population equilibrium (quasi-species) of replicating variant genomes.

Tracheal granulation tissue. A study of bacteriology

We prospectively examined 19 patients (21 laryngotracheal reconstructions) over a 6-month period to evaluate the bacteriology of granulation tissue present at the time of Teflon stent removal and at the first laryngoscopy several weeks later. The most frequently recovered isolates were viridans streptococci, Pseudomonas aeruginosa, nonhemolytic Streptococcus, and Staphylococcus aureus. All but one positive culture were polymicrobial. The amount of tissue did not correlate with the duration of stenting and the amount of granulation tissue and number of organisms decreased after stent removal. Further prospective study of the most appropriate antimicrobial therapy is needed.

Monocytoid B cell lymphoma

The clinical, light microscopic, ultrastructural, immunocytochemical and cytogenetic features of a case of monocytoid B cell lymphoma were investigated. The tumour initially affected the cervical and supraclavicular nodes, but 33 months later affected the left parotid salivary gland. The patient had subclinical Sjögren's syndrome. The neoplastic cells showed characteristic morphological features and had peri- and interfollicular distribution in the node. Immunocytochemically the tumour cells were L26, 4KB5, MB2, CD19, CD20, CD22 and IgM/kappa positive. Prominent plasmablastic plasmacytoid differentiation was present in the recurrent tumour, suggesting an origin from post-follicular B cells. The lymphoma cells showed unusual cytogenetic abnormalities.

Immune response to guinea pig cytomegalovirus polypeptides and cross reactivity with human cytomegalovirus

The immune response to guinea pig cytomegalovirus (gpCMV) was evaluated by immunoblotting. Preinoculation guinea pig plasma did not react with gpCMV antigen, whereas convalescent plasma reacted to at least 18 gpCMV-specific polypeptides. The initial immune response was primarily directed at polypeptides with MWs of 100, 75, and 56 kDa. Over 80% of plasma collected more than 29 days after viral inoculation reacted to these polypeptides and also to those with MW of 54, 52, and 38 kDa. In this report, we also demonstrate cross reactivity between gpCMV and human CMV (HCMV). Human immunoglobulin (IVIG) reacted to at least 20 HCMV polypeptides and cross reacted with six gpCMV polypeptides. GpCMV convalescent plasma also reacted with HCMV polypeptides.

T cell non-Hodgkin's lymphoma with uveitis, pancreatitis, digital gangrene and multiple chromosomal abnormalities

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Relation of maternal CMV viremia and antibody response to the rate of congenital infection and intrauterine growth retardation

Pregnancy outcome after maternal primary CMV infection initiated at different times during gestation was investigated by using the inbred Strain-2 guinea pig model of congenital CMV infection. The highest vertical transmission rates occurred in pups from dams that were initially viremic in late gestation presumably because delivery occurred prior to detectable maternal CMV-specific immune response. In contrast, conceptus loss was highest with maternal CMV infection initiated at conception. Intrauterine resorptions, intrauterine growth retardation, and disseminated neonatal CMV infection with CNS involvement were more frequent in pups born to mothers that were initially viremic prior to rather than after midgestation. Maternal viremia was prolonged and antibody responses were delayed after CMV inoculation in early gestation compared to late gestation. Prolonged maternal viremia plus early gestational virus exposure/infection of the fetus appeared to be associated with the most severe outcome. These findings suggest that the timing of initial maternal viremia and immune responses, the stage of fetal development, and the length of in utero exposure to CMV are important factors in subsequent disease expression and rates of congenital infection.

Cartilaginous pseudocyst of the external auricle in children with atopic eczema

Four children with severe atopic eczema developed painless endochondral pseudocysts of the external auricle. The lesions were bilateral in two cases. In one case the lesion spontaneously resolved; of the remaining five lesions, one contained haematoma and the other four contained serous fluid. The aetiology of these lesions and their association with atopic eczema are unclear, but repeated minor trauma from rubbing may play a part.

Recurrent genital herpes in the guinea pig augmented by ultraviolet irradiation: effects of treatment with acyclovir

The guinea pig model of genital herpes simplex virus infection has proven useful in the evaluation of antiviral drugs. We have recently demonstrated that recurrent herpetic infections can be induced in latently infected guinea pigs by ultraviolet irradiation. In this report we have examined the effect of acyclovir on ultraviolet radiation-induced recurrent genital herpes. Prophylactic topical acyclovir decreased the severity but not the incidence of ultraviolet radiation-induced recurrences while intraperitoneal acyclovir initiated before ultraviolet irradiation reduced both the incidence and severity of induced recurrences. When treatment was begun after ultraviolet exposure, neither topical nor intraperitoneal acyclovir were effective in reducing the incidence or severity of induced recurrent disease. The effectiveness of acyclovir in the control of induced recurrent genital infections in the guinea pig is similar to what has been observed in human trials. This model of ultraviolet radiation-induced recurrent herpes simplex virus infection should prove useful in the evaluation on new putative antiviral drugs.

Fine-structural aspects of bromodeoxyuridine incorporation in sister chromatid differentiation and replication banding

The structure of harlequin-stained chromosomes following substitution with low levels of 5-bromodeoxyuridine (BrdUrd) over two cell cycles and high levels over the last part of one cycle (replication banding) was studied in Chinese hamster ovary (CHO) cells. By using correlative light (LM) and scanning electron microscopy (SEM), it was shown that the effects of both the ultraviolet light (u.v.) and hot SSC treatment steps of the harlequin staining procedure were necessary to obtain sister-chromatid differentiation (SCD) or replication banding. u.v. treatment alone resulted in dark Giemsa staining of both chromatids with SEM morphology of short compact protuberances and an overall flattened smooth appearance in both the unsubstituted and BrdUrd-substituted chromatids, a morphology essentially similar to that of untreated chromosomes. SSC alone on the other hand resulted in dark-staining chromatids with an SEM morphology of raised, loosely packed loops of fibres in both types of chromatids. u.v. and SSC treatment together resulted in differentiation, with dark-staining unifilarly (TB) chromatids in the LM corresponding to raised loosely packed loops in the SEM and pale bifilarly (BB) chromatids corresponding to the smooth compact flattened SEM appearance. Where the BrdUrd-substituted strand became the template (BT), or when the nascent strand TB contained high levels of BrdUrd substitution in replication banding, the chromatid stained pale and showed the compact smooth appearance in the SEM. The Giemsa staining ability and ultrastructural morphology of harlequin staining is discussed with respect to putative DNA loss and also in terms of preferential protein-protein, protein-DNA cross-linkage in BrdUrd-containing DNA. These changes are also compared with the ultrastructural morphology observed after other banding methods, where deterioration of protein and DNA-protein interaction resulting in aggregation of chromatin fibres appears to be the major mechanism.

Effects of the immunomodulating agent R837 on acute and latent herpes simplex virus type 2 infections

R837 is an immune modulator with no in vitro activity against herpes simplex virus (HSV). We evaluated topical R837 as therapy for genital HSV type 2 infection using the guinea pig model of this disease. Furthermore, we investigated the effect of R837 therapy on acute and latent neural HSV infections. Therapy initiated 12 h after viral inoculation and given twice a day significantly reduced the acute neural infection so that HSV was recovered from only 1 of 64 neural tissue specimens obtained from R837 recipients compared with 43 of 56 specimens obtained from placebo recipients (P less than 0.0001). R837 initiated 36 h after HSV inoculation and given once a day also significantly reduced the total mean lesion score of the acute disease from 14.1 +/- 4.3 to 2.6 +/- 5.3 (P less than 0.0001) and shortened the period of vaginal HSV shedding from 6.9 +/- 1.7 to 3.2 +/- 1.4 days (P less than 0.001). R837-treated animals also developed fewer HSV recurrences than did controls (2.0 +/- 1.7 versus 5.1 +/- 1.7; P less than 0.0002). Latent HSV was detected in 23 of 24 dorsal root ganglia explant cultures from placebo recipients but in only 2 of 30 cultures from R837-treated animals, and HSV in these 2 cultures was detectable only with the addition of a demethylating agent. Topical R837 exhibited in vivo anti-HSV activity, reducing both acute and latent neural infections as well as acute and recurrent genital disease.

Herpes simplex virus glycoprotein immunotherapy of recurrent genital herpes: factors influencing efficacy

Recombinant herpes simplex virus type 1 (HSV-1) glycoproteins B (gB) and D (gD) were used as immunotherapeutic agents for the treatment of recurrent genital herpes in guinea pigs. Administration of a gBgD vaccine eight to 21 days after intravaginal HSV-2 inoculation significantly increased the titer of anti-HSV antibodies (P less than 0.005) while significantly reducing the frequency of subsequent herpetic recurrences (P less than 0.05). The effectiveness of gBgD immunotherapy was influenced by both the co-administration of adjuvant, the type of adjuvant, and by the timing and route of administration. These data demonstrate that recurrent HSV disease in animals with established latent infection may be favorably altered by the administration of immunogenic viral proteins.