Psychosocial Health Among Young Adults With Kidney Failure: A Longitudinal Follow-up of the SPEAK (Surveying Patients Experiencing Young Adult Kidney Failure) Study

Rationale & Objective

There have been no longitudinal studies examining the evolution of psychosocial health of young adults with kidney failure as they age. We aimed to address this in the Surveying Patients Experiencing Young Adult Kidney Failure-2 (SPEAK-2) study.

Study Design

5-year follow-up longitudinal survey of the original SPEAK cohort.

Setting & Participants

16- to 30-year-olds in the UK receiving kidney replacement therapy (KRT) between 2015 and 2017 who participated in the SPEAK study.

Exposure

Kidney failure and KRT modality.

Outcomes

Psychosocial health and lifestyle behaviors.

Analytical Approach

Within-cohort changes in psychosocial health were analyzed using the paired t test, Wilcoxon signed-rank test and McNemar's test. We compared responses to the age-matched population and examined the impact of changes in KRT modality on psychological health using linear regression for continuous outcome variables as well as logistic, ordered logistic and multinomial logistic regression for binary, ordered categorical and unordered categorical variables, respectively.

Results

We obtained 158 survey responses; 129 had previously responded to SPEAK. Of these, 90% had a kidney transplant. Compared to the general population, respondents were less likely to be married or have children and were more likely to be living with their parents. Respondents had nearly 15 times greater odds of being unable to work due to health (odds ratio [OR] = 14.41; 95% confidence interval [CI], 8.0-26.01; P < 0.001). Respondents had poorer quality of life and mental wellbeing and were more likely to report psychological problems (OR = 5.37; 95% CI, 3.45-8.35; P < 0.001). A negative association between remaining on or moving to dialysis and psychosocial health was observed, although this was attenuated when controlling for the psychosocial state in SPEAK.

Limitations

Low response rate resulting in imprecise and potentially biased estimates and impact of COVID-19 pandemic while survey was active on psychosocial health.

Conclusions

Young adults with kidney failure have persistent poorer psychosocial health compared to their healthy peers as they age. Our findings also suggest a potential causal relationship between KRT modality and psychosocial health.

COVID-19 Vaccination and New Onset Glomerular Disease: Results from the IRocGN2 International Registry

Key Points

IgAN and MCD are the most common de novo glomerular diseases reported after COVID-19 vaccination, particularly after mRNA vaccination. Membranous nephropathy, pauci-immune GN, and collapsing GN have also been attributed to COVID-19 vaccination, some with dual histologies. Recovery of kidney function and proteinuria remission is more likely in IgAN and MCD by 4–6 months compared with the other glomerular diseases.

Background

Patients with de novo glomerular disease (GD) with various renal histologies have been reported after vaccination against SARS-CoV-2. Causality has not been established, and the long-term outcomes are not known. To better characterize the GDs and clinical courses/outcomes, we created the International Registry of COVID-19 vaccination and Glomerulonephritis to study in aggregate patients with de novo GN suspected after COVID-19 vaccine exposure.

Methods

A REDCap survey was used for anonymized data collection. Detailed information on vaccination type and timing and GD histology were recorded in the registry. We collected serial information on laboratory values (before and after vaccination and during follow-up), treatments, and kidney-related outcomes.

Results

Ninety-eight patients with GD were entered into the registry over 11 months from 44 centers throughout the world. Median follow-up was 89 days after diagnosis. IgA nephropathy (IgAN) and minimal change disease (MCD) were the most common kidney diseases reported. Recovery of kidney function and remission of proteinuria were more likely in IgAN and MCD at 4–6 months than with pauci-immune GN/vasculitis and membranous nephropathy.

Conclusions

The development of GD after vaccination against SARS-CoV-2 may be a very rare adverse event. Temporal association is present for IgAN and MCD, but causality is not firmly established. Kidney outcomes for IgAN and MCD are favorable. No changes in vaccination risk-benefit assessment are recommended based on these findings.

COVID-19 in Patients with Glomerular Disease: Follow-Up Results from the IRoc-GN International Registry

Background

The acute and long-term effects of severe acute respiratory syndrome coronavirus 2 infection in individuals with GN are still unclear. To address this relevant issue, we created the International Registry of COVID-19 infection in GN.

Methods

We collected serial information on kidney-related and -unrelated outcomes from 125 GN patients (63 hospitalized and 62 outpatients) and 83 non-GN hospitalized patients with coronavirus disease 2019 (COVID-19) and a median follow-up period of 6.4 (interquartile range 2.3-9.6) months after diagnosis. We used logistic regression for the analyses of clinical outcomes and linear mixed models for the longitudinal analyses of eGFR. All multiple regression models were adjusted for age, sex, ethnicity, and renin-angiotensin-aldosterone system inhibitor use.

Results

After adjustment for pre-COVID-19 eGFR and other confounders, mortality and AKI did not differ between GN patients and controls (adjusted odds ratio for AKI=1.28; 95% confidence interval [CI], 0.46 to 3.60; P=0.64). The main predictor of AKI was pre-COVID-19 eGFR (adjusted odds ratio per 1 SD unit decrease in eGFR=3.04; 95% CI, 1.76 to 5.28; P<0.001). GN patients developing AKI were less likely to recover pre-COVID-19 eGFR compared with controls (adjusted 6-month post-COVID-19 eGFR=0.41; 95% CI, 0.25 to 0.56; times pre-COVID-19 eGFR). Shorter duration of GN diagnosis, higher pre-COVID-19 proteinuria, and diagnosis of focal segmental glomerulosclerosis or minimal change disease were associated with a lower post-COVID-19 eGFR.

Conclusions

Pre-COVID-19 eGFR is the main risk factor for AKI regardless of GN diagnosis. However, GN patients are at higher risk of impaired eGFR recovery after COVID-19-associated AKI. These patients (especially those with high baseline proteinuria or a diagnosis of focal segmental glomerulosclerosis or minimal change disease) should be closely monitored not only during the acute phases of COVID-19 but also after its resolution.

Imaging Cannabinoid Receptors: A Brief Collection of Covalent and Fluorescent Probes for CB1 and CB2 Receptors

There has been an expanding public interest towards the notion that modulation of the sophisticated endocannabinoid system can lead to various therapeutic benefits that are yet to be fully explored. In recent years, the drug discovery paradigm in this field has been largely based on the development of selective CB2 receptor agonists, avoiding the unwanted CB1 receptor-mediated psychoactive side effects. Mechanistically, target engagement studies are crucial for confirming the ligand–receptor interaction and the subsequent biological cascades that lead to the observed therapeutic effects. Concurrently, imaging techniques for visualisation of cannabinoid receptors are increasingly reported in the literature. Small molecule imaging tools ranging from phytocannabinoids such as tetrahydrocannabinol (THC) and cannabidiol (CBD) to the endocannabinoids as well as the purely synthetic cannabimimetics, have been explored to date with varying degrees of success. This Review will cover currently known photoactivatable, electrophilic, and fluorescent ligands for both the CB1 and CB2 receptors. Structural insights from techniques such as ligand-assisted protein structure (LAPS) and the discovery of novel allosteric modulators are significant additions for better understanding of the endocannabinoid system. There has also been a plethora of fluorescent conjugates that have been assessed for their binding to cannabinoid receptors as well as their potential for cellular imaging. More recently, bifunctional probes containing either fluorophores or electrophilic tags are becoming more prevalent in the literature. Collectively, these molecular tools are invaluable in demonstrating target engagement within the human endocannabinoid system.

Associations with kidney transplant survival and eGFR decline in children and young adults in the United Kingdom: a retrospective cohort study

Background

Although young adulthood is associated with transplant loss, many studies do not examine eGFR decline. We aimed to establish clinical risk factors to identify where early intervention might prevent subsequent adverse transplant outcomes.

Methods

Retrospective cohort study using UK Renal Registry and UK Transplant Registry data, including patients aged < 30 years transplanted 1998–2014. Associations with death-censored graft failure were investigated with multivariable Cox proportional hazards. Multivariable linear regression was used to establish associations with eGFR slope gradients calculated over the last 5 years of observation per individual.

Results

The cohort (n = 5121, of whom n = 371 received another transplant) was 61% male, 80% White and 36% had structural disease. Live donation occurred in 48%. There were 1371 graft failures and 145 deaths with a functioning graft over a 39,541-year risk period. Median follow-up was 7 years. Fifteen-year graft survival was 60.2% (95% CI 58.1, 62.3).

Risk associations observed in both graft loss and eGFR decline analyses included female sex, glomerular diseases, Black ethnicity and young adulthood (15–19-year and 20–24-year age groups, compared to 25–29 years). A higher initial eGFR was associated with less risk of graft loss but faster eGFR decline. For each additional 10 mL/min/1.73m² initial eGFR, the hazard ratio for graft loss was 0.82 (95% CI 0.79, 0.86), p < 0.0001. However, compared to < 60 mL/min/1.73m², higher initial eGFR was associated with faster eGFR decline (> 90 mL/min/1.73m²; − 3.55 mL/min/1.73m²/year (95% CI -4.37, − 2.72), p < 0.0001).

Conclusions

In conclusion, young adulthood is a key risk factor for transplant loss and eGFR decline for UK children and young adults. This study has an extended follow-up period and confirms common risk associations for graft loss and eGFR decline, including female sex, Black ethnicity and glomerular diseases. A higher initial eGFR was associated with less risk of graft loss but faster rate of eGFR decline. Identification of children at risk of faster rate of eGFR decline may enable early intervention to prolong graft survival.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02156-2.

The clinical epidemiology of young adults starting renal replacement therapy in the UK: presentation, management and survival using 15 years of UK Renal Registry data

Background

Clinical epidemiology data for young adults on renal replacement therapy (RRT) are lacking. While mostly transplanted, they have an increased risk of graft loss during young adulthood.

Methods

We combined the UK Renal Registry paediatric and adult databases to describe patient characteristics, transplantation and survival for young adults. We grouped patients 11–30 years of age starting RRT from 1999 to 2008 by age band and examined their course during 5 years of follow-up.

Results

The cohort (n = 3370) was 58% male, 79% white and 29% had glomerulonephritis. Half (52%) started RRT on haemodialysis (HD). Most (78%) were transplanted (18% pre-emptive, 61% as second modality); 11% were not listed for transplant. Transplant timing varied by age group. The deceased:living donor kidney transplant ratio was 2:1 for 11–<16 year olds and 1:1 otherwise. Median deceased donor transplant waiting times ranged from 6 months if <16 years of age to 17 months if ≥21 years. Overall 8% died, with being on dialysis and not transplant listed versus transplanted {hazard ratio [HR] 16.6 [95% confidence interval (CI) 10.8–25.4], P < 0.0001} and diabetes versus glomerulonephritis [HR 4.03 (95% CI 2.71–6.01), P < 0.0001] increasing mortality risk.

Conclusions

This study highlights the frequent use of HD and the importance of transplant listing and diabetes for young adults. More than half the young adults in our cohort started renal replacement therapy on HD. One in 10 young adults were not listed for transplant by 5 years and were ∼20 times more likely to die than those who were transplanted. Diabetes as a primary renal disease was common among young adults and associated with increased mortality. Overall, almost 1 in 10 young adults had died by 5 years from the start of RRT.

Predicting status along the continuum of suicidal thoughts and behavior among those with a history of nonsuicidal self-injury

Nonsuicidal self-injury (NSSI) and suicidal thoughts and behavior often co-occur, representing a growing public health concern. Despite extensive research examining suicidal thoughts and behavior among those who engage in NSSI, there is a lack of research investigating factors that, when considered together, can differentiate individuals along the continuum of suicidal thoughts and behavior (no history, suicidal ideation, suicide plan, suicide attempt). This study sought to address this question using a sample of 1178 college students with NSSI history (68.70% female). Discriminant function analysis was conducted including the following predictors: NSSI characteristics, negative affect difficulties, and behavioral and demographic risk factors for suicidal thoughts and behavior. Results suggest that self-disclosure of suicidal ideation, number of lifetime NSSI methods, NSSI frequency, depressive symptoms, and age most parsimoniously differentiate study groups. Those who use a greater number of NSSI methods and acts, paired with higher depressive symptoms and repeated self-disclosure of suicidal ideation are most likely to have a suicide attempt history; decreases in these variables suggest membership within less severe groups. Furthermore, older age may be related to greater suicidality. Findings suggest that the evaluation and co-occurrence of these variables may contribute to a more accurate suicide risk assessment.

Psychosocial Health and Lifestyle Behaviors in Young Adults Receiving Renal Replacement Therapy Compared to the General Population: Findings From the SPEAK Study

RATIONALE & OBJECTIVE

Patients in late adolescence and early adulthood receiving renal replacement therapy (RRT) face disruption to normal activities, which affects well-being. We aimed to define psychosocial and lifestyle outcomes for young adults on RRT compared to the general population.

STUDY DESIGN

We undertook a cross-sectional survey (the SPEAK [Surveying Patients Experiencing Young Adult Kidney Failure] Study) using validated measures and general population comparator data from the Health Survey for England and Avon Longitudinal Study of Parents and Children. Additional clinical information was obtained from the UK Renal Registry.

SETTING & PARTICIPANTS

16- to 30-year-olds receiving RRT.

OUTCOMES

Psychosocial health and lifestyle behaviors.

ANALYTICAL APPROACH

We compared outcomes between populations using age- and sex-adjusted regression models, weighted to account for response bias by sex, ethnicity, and socioeconomic status. Our findings were used to update recent meta-analyses.

RESULTS

We recruited 976 young adults and 64% responded to the survey: 417 (71%) with kidney transplants and 173 (29%) on dialysis therapy. Compared to the general population, young adults on RRT were less likely to be in a relationship and have children and more likely to live in the family home, receive no income, and be unable to work due to health. They had poorer quality of life, worse well-being, and twice the likelihood of a psychological disturbance (OR, 2.7; 95% CI, 2.0-3.7; P<0.001). They reported less smoking, alcohol and drug abuse, and crime. In a meta-analysis, our study showed the greatest differences in quality of life compared to the general population.

LIMITATIONS

Cross-sectional study design, meaning that we could not track the impact of treatment changes on the outcomes.

CONCLUSIONS

This study involving a large cohort of young adult transplant recipients and dialysis patients provides evidence of worse psychosocial outcomes but more positive lifestyle behaviors in young adults on RRT compared to the age-matched general population.

Continually improving standards of care: The UK Renal Registry as a translational public health tool

A disease registry uses observational study methods to collect defined data on patients with a particular condition for a predetermined purpose. By providing comprehensive standardised data on patients with kidney disease, renal registries aim to provide a 'real world' representation of practice patterns, treatment and patient outcomes that may not be captured accurately by other methods, including randomised controlled trials. Additionally, using registries to measure variations in outcomes and audit care against standards is crucial to understanding how to improve quality of care for patients in an efficacious and cost-effective manner. Registries also have the potential to be a powerful scientific tool that can monitor and support the translational process between research and routine clinical practice, although their limitations must be borne in mind. In this review, we describe the role of the UK Renal Registry as a tool to support translational research. We describe its involvement across each stage of the translational pathway: from hypothesis generation, study design and data collection, to reporting of long-term outcomes and quality improvement initiatives. Furthermore we explore how this role may bring about improvements in care for adults and children with kidney disease.

Young adults' perspectives on living with kidney failure: a systematic review and thematic synthesis of qualitative studies

INTRODUCTION

Young adults fare worse than younger adolescents or older adults on a broad range of health indicators. Those with a chronic illness such as renal failure are a particularly vulnerable group, who experience poor outcomes compared with both children and older adults. Understanding how being in receipt of renal replacement therapy (RRT) affects the lives of young adults might help us to better prepare and support these individuals for and on RRT, and improve outcomes. This study aimed to synthesise research describing young adults' experiences of the psychosocial impact of kidney failure and RRT.

DESIGN

A systematic literature review identified qualitative research reporting the perspectives of people aged 16-30 years receiving RRT on the psychosocial impact of renal failure. Electronic databases (including Medline/EMBASE/PsycINFO/ASSIA) were searched to November 2017 for full-text papers. The transparency of reporting of each study was assessed using the Consolidated Criteria for Reporting Qualitative Health Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. An inductive thematic synthesis was undertaken.

PARTICIPANTS

Seven studies from five different countries were included, comprising 123 young adults receiving RRT.

RESULTS

Comprehensiveness of reporting was variable: studies reported 9-22 of the 32 COREQ-checklist items.Three global themes about the impact of kidney failure on young adults were identified: (1) difference desiring normality, (2) thwarted or moderated dreams and ambitions, and (3) uncertainty and liminality. These reflected five organising themes: (1) physical appearance and body image, (2) activity and participation, (3) educational disruption and underachievement, (4) career ambitions and employment difficulties, and (5) social isolation and intimate relationships.

CONCLUSIONS

Across different countries and different healthcare settings, young adults on RRT experience difference and liminality, even after transplantation. Tailored social and psychological support is required to allow young adults to experience wellness while in receipt of RRT, and not have life on hold.

Sociodemographic, Psychologic Health, and Lifestyle Outcomes in Young Adults on Renal Replacement Therapy

BACKGROUND AND OBJECTIVES

Young adults receiving RRT face additional challenges in life. The effect of established kidney failure on young adulthood is uncertain. We aimed to establish the psychosocial and lifestyle status of young adults receiving RRT.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Our study was a systematic review and meta-analysis of 16-30-year olds receiving RRT compared with the general population. We selected randomized, controlled trials; cohort studies; or cross-sectional studies without language restriction and extracted proportions of sociodemographic and lifestyle outcomes or validated psychologic health tests producing quality of life, wellbeing, and self-esteem scores. We undertook random effects meta-analysis.

RESULTS

There were 60 studies with a total of 15,575 participants. Studies were largely single-center cross-sectional studies of those transplanted in childhood. Compared with healthy peers, young adults on RRT had lower quality of life, which was worse for patients on dialysis (seven studies: standardized mean difference, -1.01; 95% confidence interval [95% CI], -1.32 to -0.70) compared with patients with transplants (nine studies: standardized mean difference, -0.42; 95% CI, -0.64 to -0.20). They were more likely to be unemployed (seven studies: relative risk, 1.89; 95% CI, 1.47 to 2.44) and live in the family home (two studies: relative risk, 1.84; 95% CI, 1.40 to 2.43). They were less likely to be married or have a partner (four studies: relative risk, 0.71; 95% CI, 0.53 to 0.95). Higher education (three studies: relative risk, 1.05; 95% CI, 0.73 to 1.51), alcohol abstinence (three studies: relative risk, 1.96; 95% CI, 0.84 to 4.67), and smoking status (two studies: relative risk, 0.72; 95% CI, 0.36 to 1.44) did not differ. Results were limited by high heterogeneity and a small evidence base, biased toward surviving patients.

CONCLUSIONS

Established kidney failure is associated with lower quality of life in young people and limited employment, independence, and relationships compared with healthy peers.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_10_19_CJASNPodcast_17_12_.mp3.

UK Renal Registry 18th Annual Report: Chapter 10 Clinical, Haematological and Biochemical Parameters in Patients Receiving Renal Replacement Therapy in Paediatric Centres in the UK in 2014: National and Centre-specific Analyses

The median height z-score for paediatric patients on dialysis was −2.1 and for those with a functioning transplant −1.3. Children transplanted before the age of 12 years improved their height z-score over the subsequent five years, whereas those older than 12 maintained their height z-score, with all transplanted patients having a similar median height z-score after five years of starting renal replacement therapy (RRT). The median weight z-score for children on dialysis was −1.4 whereas children with a functioning transplant had a near normal weight for age and sex with a median z-score of −0.3. Of those with data, 75% of the prevalent paediatric RRT population had one or more ‘traditional’ risk factors for cardiovascular disease, with 1 in 10 having all three risk factors present. For the 10 centres reporting quarterly laboratory data, the average creatinine in transplant patients was 79 mmol/L; dialysis patients had normal average anaemia and acidosis markers and evidence of secondary hyperparathyroidism with an average PTH of 17.3 pmol/L. For transplant patients, 80% achieved the systolic blood pressure (SBP) standard and 93% achieved the haemoglobin standard. For haemodialysis patients, 57% achieved the SBP standard, 62% achieved the haemoglobin standard, 82% achieved the calcium standard, 51% achieved the phosphate standard and 39% achieved the parathyroid hormone (PTH) standard. For peritoneal dialysis patients, 70% achieved the SBP standard, 77% achieved the haemoglobin standard, 72% achieved the calcium standard, 54% achieved the phosphate standard and 33% achieved the PTH standard.

UK Renal Registry 18th Annual Report: Chapter 4 Demography of Patients Receiving Renal Replacement Therapy in Paediatric Centres in the UK in 2014

A total of 917 children and young people under 18 years with established renal failure (ERF) were receiving treatment at paediatric nephrology centres in 2014.At the census date (31st December 2014), 79.3% of prevalent paediatric patients aged ,18 years had a functioning kidney transplant, 11.2% were receiving haemodialysis (HD) and 9.5% were receiving peritoneal dialysis (PD). In patients aged ,16 years, prevalence of ERF was 60.4 per million age related population (pmarp) and the incidence 9.4 pmarp. The most common primary renal diagnosis was renal dysplasia+reflux, present in 32.6% of prevalent paediatric patients aged ,16 years. About a third of patients had one or more reported comorbidity at onset of renal replacement therapy (RRT). The improvement in rates of pre-emptive transplantation for those referred early has been maintained over the last 10 years at 37.5%, compared to 27.4% in 2000–2004. At transfer to adult services, 90.3% of patients had a functioning kidney transplant. Survival during childhood amongst children commencing RRT was the lowest in those aged less than two years compared to those aged 12 to less than 16 years with a hazard ratio of 4.1 (confidence interval 2.2–8.0), and in those receiving dialysis compared to having a functioning transplant with a hazard ratio of 6.3 (confidence interval 3.9–10.2).

Autoimmune haemolytic anaemia associated with Epstein Barr virus infection as a severe late complication after kidney transplantation and successful treatment with rituximab: case report

BACKGROUND

Autoimmune haemolytic anaemia (AIHA) is a rare complication following kidney transplantation and usually occurs early in its course. It is characterised by autoantibodies or alloantibodies directed against red blood cells (RBCs).

CASE PRESENTATION

We describe a 44 year old woman who presented 5 years after kidney transplantation with profound transfusion dependent warm AIHA. Investigations confirmed an IgG autoantibody against RBCs and high titre Epstein-Barr virus (EBV) viraemia. The patient was at higher risk for EBV disease being seronegative at the time of transplantation but had detectable EBV capsid IgG antibody at the time of presentation. The haemolysis was refractory to high dose steroid and intravenous immunoglobulin. There was a rapid and complete resolution of both the anaemia and the viraemia following rituximab therapy, with no adverse events. Twenty-six units of blood were required during the course of treatment.

CONCLUSIONS

To our knowledge this is the first reported case of EBV associated AIHA in a renal transplant recipient. It highlights a rare pathology associated with post-transplant EBV infection, of broad interest to transplant physicians, haematologists, and microbiologists, and the effective novel use of monoclonal anti-CD20 therapy.

UK Renal Registry 17th Annual Report: Chapter 9 Clinical, Haematological and Biochemical Parameters in Patients Receiving Renal Replacement Therapy in Paediatric Centres in the UK in 2013: National and Centre-specific Analyses

BACKGROUND

The Paediatric Registry analyses renal replacement therapy (RRT) data in children. All 13 UK paediatric nephrology centres submit electronic data.

AIMS

To provide centre specific data and to determine adherence to relevant audit standards.

METHODS

Data analysis to calculate summary statistics and achievement of an audit standard.

RESULTS

The median height z-score for children on dialysis was -2.0 and for children with a functioning transplant -1.3. Children transplanted before age 11 years improved their height z score subsequently, whereas those >11 maintained their height z-score, with all transplanted patients having a similar height z-score after 3 years of starting RRT.The median weight z-score for children on dialysis was -1.2, and for children with a functioning transplant -0.2.Of those with data, 75% of the prevalent paediatric RRT population had .1 risk factors for cardiovascular disease, with 1 in 10 having all three risk factors evaluated. For transplant patients, 76% achieved the systolic blood pressure (SBP)standard and 91% achieved the haemoglobin standard. For haemodialysis patients, 53% achieved the SBP standard,66% the haemoglobin standard, 84% the calcium standard,43% the phosphate standard and 43% achieved the parathyroid hormone (PTH) standard. For peritoneal dialysis patients, 61% achieved the SBP standard, 83% the haemoglobin standard, 71% the calcium standard, 56% the phosphate standard and 36% achieved the PTH standard.

CONCLUSIONS

Quarterly data collection will improve quality and reporting. Continued focus on improving height and avoiding obesity is needed. Awareness and management of cardiovascular risk is an important long term strategy.

UK Renal Registry 17th Annual Report: Chapter 4 Demography of the UK Paediatric Renal Replacement Therapy Population in 2013

AIMS

To describe the demographics of the paediatric renal replacement therapy (RRT) population under the age of 18 years in the UK and to analyse changes in demography over time.

METHODS

Data were collected electronically from all 13 paediatric renal centres within the UK. A series of cross-sectional and longitudinal analyses were performed to describe the demographics of paediatric RRT patients.

RESULTS

A total of 891 children and young people under 18 with established renal failure (ERF) were receiving treatment at paediatric nephrology centres in 2013. At the census date, 80.2% had a functioning transplant, 11.7%were receiving haemodialysis (HD) and 8.1% were receiving peritoneal dialysis (PD). In patients aged ,16 years the prevalence of ERF was 58.2 per million age related population(pmarp) and the incidence 9.3 pmarp. A third of the prevalent patients had one or more reported comorbidities.At transfer to adult services, 85.2% of patients had a functioning renal transplant. Pre-emptive transplantation was seen to occur in a third of children starting RRT under16 years, with lower rates seen in girls and ethnic minorities.Living donation as starting modality has continued to improve with an increase from 8.8% in 1999–2003 to 18.4% in 2009–2013. Survival in childhood amongst children starting RRT was the lowest in those aged less than two years.

CONCLUSIONS

We report continued improvement in data quality and electronic submission of data returns. The data provided in this report show relatively stable trends of incidence and prevalence in children with established renal failure.

The HNF4A R76W mutation causes atypical dominant Fanconi syndrome in addition to a β cell phenotype

Background

Mutation specific effects in monogenic disorders are rare. We describe atypical Fanconi syndrome caused by a specific heterozygous mutation in HNF4A. Heterozygous HNF4A mutations cause a beta cell phenotype of neonatal hyperinsulinism with macrosomia and young onset diabetes. Autosomal dominant idiopathic Fanconi syndrome (a renal proximal tubulopathy) is described but no genetic cause has been defined.

Methods and Results

We report six patients heterozygous for the p.R76W HNF4A mutation who have Fanconi syndrome and nephrocalcinosis in addition to neonatal hyperinsulinism and macrosomia. All six displayed a novel phenotype of proximal tubulopathy, characterised by generalised aminoaciduria, low molecular weight proteinuria, glycosuria, hyperphosphaturia and hypouricaemia, and additional features not seen in Fanconi syndrome: nephrocalcinosis, renal impairment, hypercalciuria with relative hypocalcaemia, and hypermagnesaemia. This was mutation specific, with the renal phenotype not being seen in patients with other HNF4A mutations. In silico modelling shows the R76 residue is directly involved in DNA binding and the R76W mutation reduces DNA binding affinity. The target(s) selectively affected by altered DNA binding of R76W that results in Fanconi syndrome is not known.

Conclusions

The HNF4A R76W mutation is an unusual example of a mutation specific phenotype, with autosomal dominant atypical Fanconi syndrome in addition to the established beta cell phenotype.

Prevalence in the General Population of a CFH Sequence Variant Associated with Atypical Haemolytic Uraemic Syndrome in an Extensive Family from Southwest England

BACKGROUND/AIMS

Twenty-five members of a family from the county of Devon in England have been affected by atypical haemolytic uraemic syndrome (aHUS) associated with a CFH mutation (c.3643C>G; p.Arg1215Gly). A 65-year-old male was diagnosed with aHUS after losing a renal transplant to a thrombotic microangiopathy. Subsequent mutation screening revealed the same CFH mutation without him being knowingly related to the local kindred. We designed a study to investigate the prevalence of this mutation in the local area. In addition, we examined the diagnoses of pre-existing haemodialysis patients to determine whether other patients might unknowingly be at risk of carrying the same CFH mutation.

METHODS

The Exeter Ten Thousand (EXTEND) study aims to recruit 10,000 healthy volunteers over the age of 18 years living within 25 miles of Exeter in Devon. We genotyped DNA from 4,000 EXTEND subjects for CFH c.3643C>G; p.Arg1215Gly. We reviewed the diagnoses of 294 haemodialysis patients in the Devon area and genotyped 7 patients with either end-stage renal disease of unknown aetiology, malignant hypertension or renovascular disease.

RESULTS

CFH c.3643C>G; p.Arg1215Gly was not detected in any of the 7 haemodialysis patients or the 4,000 individuals within the EXTEND study.

CONCLUSIONS

We conclude that CFH c.3643C>G; p.Arg1215Gly is not endemic in Devon. This reinforces our existing practice of genotyping only patients with kidney disease and evidence of a thrombotic microangiopathy for this mutation. This is the first study looking at the prevalence of CFH mutations in the general population.

Can deuterium stable isotope values be used to assign the geographic origin of an auxiliary hoverfly in south-western France?

Deuterium δD isotopic analysis is increasingly being used to trace wildlife movement, and undoubtedly has much to offer in this respect, but questions still remain as to the feasibility and practicality of the method in ecology. Here we report our attempt to determine the geographic origin of an auxiliary hoverfly, Episyrphus balteatus, in south-western France. We used quantile regression to calculate the minimum separation distance, based on the International Atomic Energy Agency/World Meteorological Organization (IAEA/WMO) data, at which two insects could be said to originate from different latitudes with a given degree of confidence. We collected larvae in spring 2007 and 2009 to obtain the δD signal of indigenous hoverflies and we trapped adults during one complete year (from Dec. 2006 to Nov. 2007). The smallest separation distance calculated was about 1400 km in western Europe. Our results revealed greater variability in δD of adults in autumn than in spring. From this we infer an autumnal migration. Because of the presence of mountains and the Mediterranean Sea, the δD gradient in precipitation in western Europe is less clear than on the American continent, where it has been used successfully to infer geographical origins of animals under certain conditions. Despite the complications encountered in Europe, the minimum separation distance model proved a useful first step to obtain a first range of possible origins of E. balteatus and the application of the model to other arthropod species in Europe warrants investigation.

Systemic panca-associated vasculitis with central nervous involvement causing recurrent myelitis: case report

BACKGROUND

We report on the case of an established perinuclear antineutrophil cytoplasmic antibody (pANCA) associated renal vasculitis being treated with prednisolone and rituximab, where the patient presented with leg weakness, urinary and faecal incontinence and buttock pain consistent with transverse myelitis.

CASE PRESENTATION

The patient underwent MRI scanning showing patchy cord enhancement from T10 to the conus, which was suggestive of a cord malignancy. Prior to a cord biopsy, he was treated with steroids and a repeat MRI showed resolution of the original lesion with a new similar lesion from C7 to T3.

CONCLUSIONS

He made a marked recovery after further treatment with high dose steroids and plasma exchange.

Estimators of annual probability of infection for quantitative microbial risk assessment

Four estimators of annual infection probability were compared pertinent to Quantitative Microbial Risk Analysis (QMRA). A stochastic model, the Gold Standard, was used as the benchmark. It is a product of independent daily infection probabilities which in turn are based on daily doses. An alternative and commonly-used estimator, here referred to as the Naïve, assumes a single daily infection probability from a single value of daily dose. The typical use of this estimator in stochastic QMRA involves the generation of a distribution of annual infection probabilities, but since each of these is based on a single realisation of the dose distribution, the resultant annual infection probability distribution simply represents a set of inaccurate estimates. While the medians of both distributions were within an order of magnitude for our test scenario, the 95th percentiles, which are sometimes used in QMRA as conservative estimates of risk, differed by around one order of magnitude. The other two estimators examined, the Geometric and Arithmetic, were closely related to the Naïve and use the same equation, and both proved to be poor estimators. Lastly, this paper proposes a simple adjustment to the Gold Standard equation accommodating periodic infection probabilities when the daily infection probabilities are unknown.

Validation of fixed sample size plans for monitoring lepidopteran pests of Brassica oleracea crops in North Korea

The combined action of two lepidoteran pests, Plutella xylostella L. (Plutellidae) and Pieris rapae L. (Pieridae),causes significant yield losses in cabbage (Brassica oleracea variety capitata) crops in the Democratic People's Republic of Korea. Integrated pest management (IPM) strategies for these cropping systems are in their infancy, and sampling plans have not yet been developed. We used statistical resampling to assess the performance of fixed sample size plans (ranging from 10 to 50 plants). First, the precision (D = SE/mean) of the plans in estimating the population mean was assessed. There was substantial variation in achieved D for all sample sizes, and sample sizes of at least 20 and 45 plants were required to achieve the acceptable precision level of D < or = 0.3 at least 50 and 75% of the time, respectively. Second, the performance of the plans in classifying the population density relative to an economic threshold (ET) was assessed. To account for the different damage potentials of the two species the ETs were defined in terms of standard insects (SIs), where 1 SI = 1 P. rapae = 5 P. xylostella larvae. The plans were implemented using different economic thresholds (ETs) for the three growth stages of the crop: precupping (1 SI/plant), cupping (0.5 SI/plant), and heading (4 SI/plant). Improvement in the classification certainty with increasing sample sizes could be seen through the increasing steepness of operating characteristic curves. Rather than prescribe a particular plan, we suggest that the results of these analyses be used to inform practitioners of the relative merits of the different sample sizes.

Regional-scale models for relating land cover to basin surface-water quality using remotely sensed data in a GIS

Plant-based management systems implementing deep-rooted, perennial vegetation have been identified as important in mitigating the spread of secondary dryland salinity due to its capacity to influence water table depth. The Glenelg Hopkins catchment is a highly modified watershed in the southwest region of Victoria, where dryland salinity management has been identified as a priority. Empirical relationships between the proportion of native vegetation and in-stream salinity were examined in the Glenelg Hopkins catchment using a linear regression approach. Whilst investigations of these relationships are not unique, this is the first comprehensive attempt to establish a link between land use and in-stream salinity in the study area. The results indicate that higher percentage land cover with native vegetation was negatively correlated with elevated in-stream salinity. This inverse correlation was consistent across the 3 years examined (1980, 1995, and 2002). Recognising the potential for erroneously inferring causal relationships, the methodology outlined here was both a time and cost-effective tool to inform management strategies at a regional scale, particularly in areas where processes may be operating at scales not easily addressed with on-site studies.

The obstacles to maximising the impact of public access defibrillation: an assessment of the dispatch mechanism for out-of-hospital cardiac arrest

OBJECTIVES

To determine the diagnostic accuracy of advanced medical priority dispatch system (AMPDS) software used to dispatch public access defibrillation first responders to out-of-hospital cardiac arrests (OHCA).

DESIGN

All true OHCA events in North and West Belfast in 2004 were prospectively collated. This was achieved by a comprehensive search of all manually completed Patient Report Forms compiled by paramedics, together with autopsy reports, death certificates and medical records. The dispatch coding of all emergency calls by AMPDS software was also obtained for the same time period and region, and a comparison was made between these two datasets.

SETTING

A single urban ambulance control centre in Northern Ireland.

POPULATION

All 238 individuals with a presumed or actual OHCA in the North and West Belfast Health and Social Services Trust population of 138 591 (2001 Census), as defined by the Utstein Criteria.

MAIN OUTCOME MEASURES

The accurate dispatch of an emergency ambulance to a true OHCA.

RESULTS

The sensitivity of the dispatch mechanism for detecting OHCA was 68.9% (115/167, 95% confidence interval (CI) 61.3% to 75.8%). However, the sensitivity for arrests with ventricular fibrillation (VF) was 44.4% (12/27) with sensitivity for witnessed VF of 47.1% (8/17). The positive predictive value was 63.5% (115/181, 95% CI 56.1% to 70.6%).

CONCLUSIONS

The sensitivity of this dispatch process for cardiac arrest is moderate and will constrain the effectiveness of Public Access Defibrillation (PAD) schemes which utilise it.

TRIAL REGISTRATION

controlled-trials.com ISRCTN07286796.

The Northern Ireland Public Access Defibrillation (NIPAD) study: effectiveness in urban and rural populations

OBJECTIVE

To assess the impact of mobile automated external defibrillators (AEDs) on out-of-hospital cardiac arrests (OHCAs) in urban and rural populations.

DESIGN

Prospective before and after intervention, population study.

SETTING

Urban and rural areas of 160,000 each. Patients, interventions and

MAIN OUTCOME MEASURES

In 2004-6 the demographics of OHCAs were assessed. In 2005-6 AEDs were deployed (29 urban, 53 rural): 335 urban first responders (FRs) and 493 rural FRs were trained in AED use and dispatched to OHCAs. Call-to-response interval (CRI), resuscitation and survival-to-discharge rates for OHCA were compared.

RESULTS

In 2004 there were 163 urban OHCAs and the emergency medical services (EMS) attended 158 (ventricular fibrillation (VF) 27/158 (17.1%)). In 2005-6 there were 226 OHCAs, EMS attended 216 (VF 30/216 (13.9%)). In 2005-6 FRs were paged to 128 OHCAs (56.6%), FRs attended 88/128 (68.8%): 18/128 (14.1%) reached before the EMS. The best combined FR/EMS mean (SD) CRI in 2005-6 (5 min 56 s (4)) was better than the EMS alone in 2004 (7 min (3); p = 0.002). Survival rate was 5.1% in 2004, 1.4% in 2005-6 (p = NS). In 2004 there were 131 rural OHCAs, EMS attended 121 (VF 19/121 (15.7%)). In 2005-6 there were 122 OHCAs, EMS attended 114 (VF 19/114 (16.7%)). In 2005-6 FRs were paged to 49 OHCAs, FRs attended 42/49 (85.7%): 23/49 (46.9%) reached before the EMS. The best combined FR/EMS mean (SD) CRI in 2005-6 (9 min 22 s (6)) was better than the EMS alone in 2004 (11 min 2 s (6); p = 0.018). Survival rate was 2.5% in 2004, 3.5% in 2005-6 (p = NS).

CONCLUSIONS

Despite improvement in CRI there was no impact on survival (witnessed arrest 32.8%, VF 15.6%).

TRIAL REGISTRATION NUMBER

ISRCTN07286796.

Evaluation of fixed sample-size plans for Plutella xylostella (Lepidoptera: Plutellidae) on broccoli crops in Australia

Fixed sample-size plans for monitoring Plutella xylostella (L.) (Lepidoptera: Plutellidae) on broccoli and other Brassica vegetable crops are popular in Australia for their simplicity and ease of application. But the sample sizes used are often small, approximately 10-25 plants per crop, and it may be that they fail to provide sufficient information upon which to base pest control decisions. We tested the performance of seven fixed sample-size plans (10, 15, 20, 30, 35, 40, and 45 plants) by resampling a large data set on P. xylostella in commercial broccoli crops. For each sample size, enumerative and presence-absence plans were assessed. The precision of the plans was assessed in terms of the ratio of the standard error to the mean; and at least 45 and 35 samples were necessary for the enumerative and presence-absence plans, respectively, to attain the generally accepted benchmark of < or = 0.3. Sample sizes of 10-20 were highly imprecise. We also assessed the consequences of classifications based on action thresholds (ATs) of 0.2 and 0.8 larvae per plant for the enumerative case, and 0.15 and 0.45 proportion of plants of infested for the presence-absence case. Operating characteristic curves and investigations of the frequency of correct decisions suggest improvements in the performance of plans with increased sample size. In both the enumerative and presence-absence cases, the proportion of incorrect decisions was much higher for the lower of the two ATs assessed, and type II errors (i.e., failure to suggest pest control upon the AT is exceeded) generally accounted for the majority of this error. Type II errors are the most significant from a producer's standpoint. Further consideration is necessary to determine what is an acceptable type II error rate.

Is the risk of illness through consuming vegetables irrigated with reclaimed wastewater different for different population groups?

The use of reclaimed wastewater for irrigation of horticultural crops is commonplace in many parts of the world and is likely to increase. Concerns about risks to human health arising from such practice, especially with respect to infection with microbial pathogens, are common. Several factors need to be considered when attempting to quantify the risk posed to a population, such as the concentration of pathogens in the source water, water treatment efficiency, the volume of water coming into contact with the crop, and the die-off rate of pathogens in the environment. Another factor, which has received relatively less attention, is the amount of food consumed. Plainly, higher consumption rates place one at greater risk of becoming infected. The amount of vegetables consumed is known to vary among ethic groups. We use Quantitative Microbial Risk Assessment Modelling (QMRA) to see if certain ethnic groups are exposed to higher risks by virtue of their consumption behaviour. The results suggest that despite the disparities in consumption rates by different ethnic groups they generally all faced comparable levels of risks. We conclude by suggesting that QMRA should be used to assess the relative levels of risk faced by groups based on divisions other than ethnicity, such as those with compromised immune systems.

Scytalidium dimidiatum causing recalcitrant subcutaneous lesions produces melanin

Scytalidium dimidiatum is a pigmented dematiaceous coelomycete that typically causes chronic superficial skin diseases and onychomycosis, as well as deeper infections, such as subcutaneous abscesses, mycetoma, and even fungemia in immunocompromised patients. A second species, Scytalidium hyalinum, has hyaline hyphae and arthroconidia and is considered by some authors to be an albino mutant of S. dimidiatum. This study aimed to confirm the presence of melanin or melanin-like compounds (which have been previously implicated in the virulence of other fungal pathogens) in S. dimidiatum from a patient with multiple subcutaneous nodules. Treatment of the hyphae and arthroconidia with proteolytic enzymes, denaturant, and concentrated hot acid yielded dark particles, which were stable free radicals, consistent with their identification as melanins. Extracted melanin particles from S. dimidiatum cultures were labeled by melanin-binding monoclonal antibodies (MAbs) from Sporothrix schenckii, Aspergillus fumigatus, and Cryptococcus neoformans. Lesional skin from the patient infected with S. dimidiatum contained fungal cells that were labeled by melanin-binding MAbs, and digestion of the tissue yielded dark particles that were also reactive. S. hyalinum was also subjected to the melanin extraction protocol, but no dark particles were yielded.

Accounting for cluster sampling in constructing enumerative sequential sampling plans

Green's sequential sampling plan is widely used in applied entomology. Green's equation can be used to construct sampling stop charts, and a crop can then be surveyed using a simple random sampling (SRS) approach. In practice, however, crops are rarely surveyed according to SRS. Rather, some type of hierarchical design is usually used, such as cluster sampling, where sampling units form distinct groups. This article explains how to make adjustments to sampling plans that intend to use cluster sampling, a commonly used hierarchical design, rather than SRS. The methodologies are illustrated using diamondback moth, Plutella xylostella (L.), a pest of Brassica crops, as an example.

A dynamic binomial sequential sampling plan for Plutella xylostella (Lepidoptera: Plutellidae) on broccoli and cauliflower in Australia

Binomial sequential sampling plans have been used widely for monitoring invertebrate pest populations. Such plans are typically based upon a single action threshold (AT), which represents the level of infestation that the grower is prepared to accept before using a control measure. For many cropping systems this acceptable infestation level is likely to vary, being dependent on factors such as the growth stage of the crop and the value or demands of the destination market (e.g., local or high-quality export). We developed and validated a computer-assisted plan that uses a dynamic AT. The plan has been developed for monitoring diamondback moth, Plutella xylostella (L.) on broccoli (Brassica oleracea variety botrytis L.) and cauliflower (Brassica oleracea variety botrytis L.), but the concepts and methodologies could be readily applied to other systems.

Effects of high altitude and water deprivation on arginine vasopressin release in men

High-altitude exposure changes the distribution of body water and electrolytes. Arginine vasopressin (AVP) may influence these alterations. The purpose of this study was to examine the effect of a 24-h water deprivation trial (WDT) on AVP release after differing altitude exposures. Seven healthy males (age 22 +/- 1 yr, height 176 +/- 2 cm, mass 75.3 +/- 1.8 kg) completed three WDTs: at sea level (SL), after acute altitude exposure (2 days) to 4,300 m (AA), and after prolonged altitude exposure (20 days) to 4,300 m (PA). Body mass, standing and supine blood pressures, plasma osmolality (Posm), and plasma AVP (PAVP) were measured at 0, 12, 16, and 24 h of each WDT. Urine volume was measured at each void throughout testing. Baseline Posm increased from SL to altitude (SL 291.7 +/- 0.8 mosmol/kgH2O, AA 299.6 +/- 2.2 mosmol/kgH2O, PA 302.3 +/- 1.5 mosmol/kgH2O, P < 0.05); however, baseline PAVP measurements were similar. Despite similar Posm values, the maximal PAVP response during the WDT (at 16 h) was greater at altitude than at SL (SL 1.7 +/- 0.5 pg/ml, AA 6.4 +/- 0.7 pg/ml, PA 8.7 +/- 0.9 pg/ml, P < 0.05). In conclusion, hypoxia appeared to alter AVP regulation by raising the osmotic threshold and increasing AVP responsiveness above that threshold.

Improving ultrasound reflectivity and stability of echogenic liposomal dispersions for use as targeted ultrasound contrast agents

Targeted echogenic liposome dispersions for ultrasonic enhancement of vasoactive and pathological components of endothelium and atherosclerosis have recently been developed. The component lipids required for acoustic and targeting properties include phosphatidylcholine, phosphatidylethanolamine phosphatidylglycerol (PG), and cholesterol (CH), initially in a 60:8:2:30 mol % ratio. Component lipids, lyophilization, sugars, and freezing conditions were varied to optimize acoustic ultrasound reflectivity and acoustic stability. Echogenic liposome dispersions were made by using the dehydration-rehydration process. The lipid concentrations were varied (CH in the range 1 to 40 mol % and PG from 1 to 16 mol %). Variations in type and concentration of sugars were examined. The effect of freezing conditions and re-lyophilization was examined. Ultrasound reflectivity was assessed by using a 20-MHz intravascular ultrasound catheter and computer-assisted videodensitometry. Ultrasound reflectivity was optimized at a CH concentration of 10 mol %; PG concentration variation had essentially no effect on initial values of echogenicity. Optimal acoustic stability was observed with concentrations of 10-15 mol % CH and with a PG concentration greater than 4 mol %. Preparations made with 0.2 M mannitol were more ultrasound reflective than those made with lactose, trehalose, and sucrose. Re-lyophilization and freezing temperatures below -20 degrees C increased ultrasound reflectivity. We optimized the ultrasound properties of echogenic liposomal dispersions, the conditions of which provide some insight into the underlying lipid structures responsible. The preparations developed are now more stable and acoustically reflective than our previous preparations. This advances the development of echogenic lipid dispersions as targeted ultrasound contrast agents for use in general ultrasound as well as cardiovascular imaging.

Detection of melanin-like pigments in the dimorphic fungal pathogen Paracoccidioides brasiliensis in vitro and during infection

Melanins are implicated in the pathogenesis of several human diseases, including some microbial infections. In this study, we analyzed whether the conidia and the yeasts of the thermally dimorphic fungal pathogen Paracoccidioides brasiliensis produce melanin or melanin-like compounds in vitro and during infection. Growth of P. brasiliensis mycelia on water agar alone produced pigmented conidia, and growth of yeasts in minimal medium with L-3,4-dihydroxyphenylalanine (L-DOPA) produced pigmented cells. Digestion of the pigmented conidia and yeasts with proteolytic enzymes, denaturant, and hot concentrated acid yielded dark particles that were the same size and shape as their propagules. Immunofluorescence analysis demonstrated reactivity of a melanin-binding monoclonal antibody (MAb) with the pigmented conidia, yeasts, and particles. Electron spin resonance spectroscopy identified the yeast-derived particles produced in vitro when P. brasiliensis was grown in L-DOPA medium as a melanin-like compound. Nonreducing polyacrylamide gel electrophoresis of cytoplasmic yeast extract revealed a protein that catalyzed melanin synthesis from L-DOPA. The melanin binding MAb reacted with yeast cells in tissue from mice infected with P. brasiliensis. Finally digestion of infected tissue liberated particles reactive to the melanin binding MAb that had the typical morphology of P. brasiliensis yeasts. These data strongly suggest that P. brasiliensis propagules, both conidia and yeast cells, can produce melanin or melanin-like compounds in vitro and in vivo. Based on what is known about the function of melanin in the virulence of other fungi, this pigment may play a role in the pathogenesis of paracoccidioidomycosis.

Molecular cloning, phylogenetic analysis and three-dimensional modeling of Cu,Zn superoxide dismutase ( CnSOD1 ) from three varieties of Cryptococcus neoformans

Cryptococcus neoformans (Cn), causal agent of fungal meningoencephalitis, has three varieties with variable host predilection. To explore mechanisms for these pathogenic differences, we have characterized Cu,Zn SOD gene (CnSOD1). A Saccharomyces cerevisiae sod1Delta mutant was complemented with Cn var. grubii yeast expression library. The complementing clone had an ORF of 462 bp and the deduced 154 aa sequence showed 61% identity with S. cerevisiae SOD1 and 53-65% with other eukaryotic SOD1s. Cn var. grubii CnSOD1 cDNA was used to clone corresponding cDNAs from var. neoformans and var. gattii. ORFs from three varieties revealed 20-29% differences in deduced aa (s) with a significant 6% non-synonymous aa substitution between Cn var. grubii and Cn var. gattii. Cosmid library screening and PCR cloning were used to obtain genomic SOD1, which was split by five introns with identical placements and a typical 5' splice junction sequence, GTNNGY. These introns also showed a large nt variation among the three Cn varieties. Phylogenetic analyses revealed CnSOD1 to be in a group distinct from other eukaryotic SOD1s and with a significant divergence of the var. grubii from var. gattii. The CnSOD1 -deduced protein was modeled based on the crystal structure of S. cerevisiae SOD1, which showed an excellent fit. Most of the non-synonymous aa substitutions occurred on the outside of the molecule and these may contribute to differences in antigenicity among the three varieties. Notably, Cn var. neoformans and var. gattii Cu,Zn SOD had three substitutions of glycine (Gly26, Gly92 and Gly123 for Asn26, Ser92 and Ser123) that may contribute to the observed lower thermostability of this enzyme vis-a-vis Cn var. grubii. This is the first nucleotide and structural comparison of a protein-encoding gene from the three Cn varieties, which may provide a framework for future studies on the role of Cu,Zn SOD in Cn pathogenesis.

Production of a species specific monoclonal antibody against a 56-kDa Mycobacterium marinum antigen which is potentially useful in culture identification

A monoclonal antibody (MoAb) designated 1H11 has been produced against a 56-kDa antigen from Mycobacterium marinum. This MoAb has been shown to be species specific by both enzyme-linked immunosorbent assay and Western blot. The relationship of this 56 kDa to other known mycobacterial antigens is currently under investigation. MoAb 1H11 recognised bacilli taken from cultures by both immunofluorescence and immunoperoxidase staining. This MoAb 1H11 may provide a simple method for rapid identification of M. marinum from cultures of clinical isolates.

Stereotactic biopsy of intracranial brain lesions. High diagnostic yield without increased complications: 65 consecutive biopsies with early postoperative CT scans

Diagnostic yield and complication rate were analyzed for a series of 65 consecutive stereotactic biopsies of intra-axial brain lesions. The diagnostic yield was 98.5 +/- 1.5% and the complication rate was 1.5%. A median number of 14 biopsies (range 1-48) were taken per lesion. The biopsy sites followed a clockwise pattern, going from the superficial margin to the center and the deep margin of the lesion with respect to the inner table of the skull. A side window cannula biopsy needle was used. All patients underwent immediate postoperative CT scans within 4 h of biopsy to rule out intracranial complications. All patients were discharged within 24 h after biopsy, unless medical reasons unrelated to the biopsy required further hospitalization. We attribute the high diagnostic yield in our series to the high number of systematically taken biopsies per lesion. The higher number of biopsies did not lead to an increase in complications. From our experience, it appears safe to discharge patients the same day or within 24 h after a stereotactic biopsy if the postoperative CT shows no complication. Stereotactic biopsy could often safely be performed on an outpatient basis.