Love matters. A profile of Connecticut Hospice

After 25 years, America's first hospice looks back at its past challenges and successes, and looks forward to continuing its mission into the 21st century.

Haemolytic disease of the newborn due to anti-Ce

A baby was readmitted to the hospital 3 days after delivery when she developed jaundice. At admission, the direct antiglobulin test was also found to be positive. The baby required emergency exchange transfusion. A strongly reacting IgG anti-Ce (Rh7) was found in the serum of the mother. Severe haemolytic disease of the newborn due to anti-Ce is very rare. The mother's serum had been screened and found negative for red cell antibodies at 16 weeks gestation but the test was not repeated later in pregnancy when this antibody might have been detected.

Ratings of profile attractiveness after functional appliance treatment

The aim of this study was to determine the change in profile attractiveness in children with Class II Division 1 malocclusion after 18 months' treatment with functional appliances. Changes in profile attractiveness were assessed by panels of art students, dental students, and parents of orthodontic patients. Each panel consisted of an equal number of male and female raters. The raters first decided whether the initial or 18-month profile silhouette was more attractive, and then scored the degree to which it was more attractive on an unmarked visual analog scale. There were no significant differences between either male and female raters or among panels in their assessments of the change in profile attractiveness in the whole sample. Neither were there significant differences between the change in profile attractiveness of the untreated subjects and the subjects treated with either Fränkel function regulators or Harvold activators. It is concluded that treatment with functional appliances does not lead to more attractive profiles than nontreatment.

Mechanical transport and transmission of Cryptosporidium parvum oocysts by wild filth flies

Over the course of six months wild filth flies were collected from traps left for 7-10 days in a barn with or without a calf shedding Cryptosporidium parvum Genotype 2 oocysts in diarrheic feces. The oocysts of C. parvum transported on the flies' exoskeletons and eluted from their droplets left on visited surfaces were infectious for mice. The mean number of oocysts carried by a fly varied from 4 to 131, and the total oocyst number per collection varied from 56 to approximately 4.56 x 10(3). Fly abundance and intensity of mechanical transmission of infectious C. parvum oocysts were positively correlated, and both increased significantly when an infected calf was in the barn. Molecular data showed that the oocysts shed by infected calves were carried by flies for at least 3 weeks. Filth flies can acquire infectious C. parvum oocysts from unsanitary sites, deposit them on visited surfaces, and therefore may be involved in human or animal cryptosporidiosis.

The pulvinar sign on magnetic resonance imaging in variant Creutzfeldt-Jakob disease

BACKGROUND

There is a need for an accurate non-invasive diagnostic test for variant Creutzfeldt-Jakob disease (vCJD). We investigated the sensitivity and specificity of bilateral pulvinar high signal on magnetic resonance imaging (MRI) for the diagnosis of vCJD.

METHODS

MRI from patients with vCJD and controls (patients with suspected CJD) were analysed. Scans were reviewed on two separate occasions by two neuroradiologists and scored for the distribution of changes, and likely final diagnosis. Scans from vCJD cases were reassessed to reach a consensus on all abnormalities.

FINDINGS

We analysed 36 patients and 57 controls. vCJD patients were correctly identified based on bilateral pulvinar high signal in 29 of 36 and 32 of 36 cases on the first assessment by the two radiologists, and 32 of 36 and 31 of 36 on their second assessment. Bilateral increased pulvinar signal was identified in one of 57 and one of 57 controls on the first assessment and two of 57 and three of 57 controls on the second assessment. These reported changes in controls were graded as minimal/equivocal in six of seven patients and moderate in one (<0.5% of all control assessments). 80% of the assessments in vCJD cases were graded as moderate or substantial. On consensus review, 28 of 36 cases and none of 57 controls had prominent bilateral pulvinar signal-sensitivity 78% (95% CI 60-90%) and specificity 100% (95% CI 94-100%). Other common MRI features of vCJD were medial thalamic and periaqueductal grey matter high signal, and the notable absence of cerebral atrophy. Pulvinar high signal correlated with histological gliosis.

INTERPRETATION

In the appropriate clinical context the MRI identification of bilaterally increased pulvinar signal is a useful non-invasive test for the diagnosis of vCJD.

The diagnosis of prion diseases

Prion diseases of humans and other animals have clinical, economic and political significance. Pre-mortem diagnosis is therefore of great importance. Clinical diagnostic criteria and the current status of the available diagnostic tests are reviewed and possible future developments discussed. Presently, most diagnostic tests are indirect, relying on findings that may not be confined to prion diseases rather than on their particular intrinsic nature. They are therefore not absolutely specific nor are they 100% sensitive. The electroencephalogram (EEG), cerebral imaging and cerebrospinal fluid (CSF) analysis are the main techniques employed. However, there is hope that useful blood tests could be developed which would be simpler and less invasive. Also, there is hope that more specific tests will become available.

A glutamine insertion in the 1A alpha helical domain of the keratin 4 gene in a familial case of white sponge nevus

White Sponge Nevus (WSN) is a rare, autosomal dominant disorder that predominantly affects noncornified stratified squamous epithelia. Clinically, it is characterized by the presence of soft, white, and "spongy" plaques in the oral mucosa. The characteristic histopathologic features are epithelial thickening, parakeratosis, and vacuolization of the suprabasal layer of oral epithelial keratinocytes. Mutations in keratin 4 (K4) and keratin 13 (K13) genes have already been demonstrated to be responsible for WSN; the identification of new keratin mutations in a stratified squamous epithelia closely related to epidermis is of relevance for the understanding of the biochemistry of intermediate filaments, and for genotype phenotype correlations. In this study we investigated a 27-y-old, female Italian patient, affected by white asymptomatic oral plaques. Sequence analysis revealed a 3 bp (ACA) heterozygous insertion localized in the helix initiation motif of the 1A alpha helical domain of K4. We report this new K4 gene mutation and describe an amino acid insertion, in the 1A domain, responsible for a keratin disease.

Extent of misclassification of death from Creutzfeldt-Jakob disease in England 1979-96: retrospective examination of clinical records

OBJECTIVE

To investigate the extent to which deaths from Creutzfeldt-Jakob disease were misclassified during 1979-96.

DESIGN

Structured review of clinical records based on predetermined criteria to determine whether death could have been due to sporadic or variant Creutzfeldt-Jakob disease.

SETTING

100 health authorities and 275 NHS trusts in England.

SUBJECTS

1485 people who died aged 15-44 years from selected neurological disorders in England during 1979-96.

MAIN OUTCOME MEASURE

Cause of death.

RESULTS

The clinical records of 705 (48%) subjects were successfully traced. Tracing of clinical records was highest in subjects who died during 1990-6. There was sufficient information in the records of 640 (91%) of the 705 subjects to exclude Creutzfeldt-Jakob disease as a cause of death. In 61 (9%) subjects, there was insufficient information to reach any conclusion about the validity of the cause of death recorded on the death certificate. The clinical records of four subjects were examined further by the National Creutzfeldt-Jakob Disease Surveillance Unit; none was thought to have died from Creutzfeldt-Jakob disease.

CONCLUSIONS

No new cases of sporadic or variant Creutzfeldt-Jakob disease were detected in a sample of deaths most likely to have included misclassified cases. This suggests that the surveillance system is unlikely to have missed a significant number of cases among people aged 15-44 years. Hence, any rapid increase in the number of cases of variant Creutzfeldt-Jakob disease in this age group is likely to be real not artefactual.

Evaluating faba beans for resistance to ascochyta blight using detached organs

Detached-organ techniques were developed, using either individual leaves or stem segments with attached leaves, for use in genetic studies on resistance to ascochyta blight in faba beans. A single isolate of Ascochyta fabae, A26, was used to infect the highly resistant population ILB 752, moderately resistant cultivar Fiord and highly susceptible population NEB 463. Cultural conditions were established that maintained the detached organs in good condition for more than the 10 days required for disease symptoms to be expressed. Detached organs were scored for presence, number and size of lesions and also for number of lesions bearing pycnidia. Spore suspensions of 5 x 102 to 2 x 106 per mL were used, with 5 x 104 providing as much infection as greater concentrations. Leaves and stems were taken from 3-, 5- or 7-week-old plants. Younger plant parts were more susceptible than older ones and plants aged 3–5 weeks provided adequate material for the tests. The susceptibility of the 3 accessions in these experimental conditions followed the order expected from field trials.

Successful transplantation of pediatric en bloc kidneys with bilateral double ureters

We report a case in which en bloc kidneys with bilateral double ureters from a 5-month-old donor were successfully transplanted into a 25-year-old recipient. No stents were used. There were no complications after the transplant. The patient remains well at more than 1.5 years post-transplantation with serum creatinine 1.2 mg/dl.

Vertebrate genome evolution: a slow shuffle or a big bang?

In vertebrates it is often found that if one considers a group of genes clustered on a certain chromosome, then the homologues of those genes often form another cluster on a different chromosome. There are four explanations, not necessarily mutually exclusive, to explain how such homologous clusters appeared. Homologous clusters are expected at a low probability even if genes are distributed at random. The duplication of a subset of the genome might create homologous clusters, as would a duplication of the entire genome. Alternatively, it may be adaptive for certain combinations of genes to cluster, although clearly the genes must have duplicated prior to rearrangement into clusters. Molecular phylogenetics provides a means to examine the origins of homologous clusters, although it is difficult to discriminate between the different explanations using current data. However, with more extensive sequencing and mapping of vertebrate genomes, especially those of the early diverging chordates, it should soon become possible to resolve the origins of homologous clusters.

The relationship between new variant Creutzfeldt-Jakob disease and bovine spongiform encephalopathy

Creutzfeldt-Jakob disease (CJD) has been transmitted in the laboratory and also by iatrogenic accident. However, research has failed to find evidence that its most common form (sporadic CJD) is a natural infection and, in particular, that there is a causal link with scrapie. Bovine spongiform encephalopathy (BSE) probably resulted from scrapie infection in cattle food. In the wake of the BSE epidemic, a novel clinico-pathological form of CJD has been recognized: new variant CJD (nvCJD). This paper reviews the relationship between nvCJD and BSE and presents the accumulated evidence supporting the view that nvCJD resulted from BSE contamination of human food.

Female genital mutilation--experience of The Royal Women's Hospital, Melbourne

This study was performed to improve our knowledge and understanding of the needs of women affected by female genital mutilation. We looked at the types of complications of these practices which present to a large metropolitan women's hospital in order to determine how we can appropriately treat and support affected women. This was an observational study of women from countries with a high prevalence of female genital mutilation who presented to the Royal Women's Hospital between October, 1995 and January, 1997. Fifty-one patients with a past history of female genital mutilation who were attending the hospital for antenatal or gynaecological care consented to participate in the study. We found that 77.6% of women identified as having had female genital mutilation had undergone infibulation. More than 85% of the women in our study reported a complication of the procedure. The major complications were dyspareunia, apareunia and urinary tract infections; 29.4% of these women required surgery to facilitate intercourse. In our study group there was no difference in Caesarean section rates between the women who had previously delivered in Australia compared with those who had delivered in Africa. Women who have had a female genital mutilation procedure have specific needs for their care which present challenges to both their general practitioners and obstetrician/gynaecologists. These women have significant complications related to their procedure including social and psychosexual problems which require sympathetic management.