The effect of HIV prevalence, CD4 counts and disease severity on the outcome of total knee arthroplasty for haemophilic arthropathy: a systematic review and meta-analysis

PURPOSE

End-stage knee arthropathy is a recognised complication of haemophilia. It is often treated by total knee arthroplasty (TKA), which is more technically challenging in patients with haemophilia (PwH). It remains unclear what factors may predict implant survivorship and deep infection rate. Therefore, we systematically review the evidence regarding TKA survivorship and infection in PwH, compared to the general population, and determine the important factors influencing survivorship, particularly HIV and CD4 + count.

METHODS

A systematic literature review was conducted using MEDLINE, EMBASE, and PubMed for studies reporting Kaplan-Meier survivorship for TKA in PwH (PROSPERO CRD42021284644). Meta-analysis was performed for survivorship, and the results compared to < 55-year-olds from the National Joint Registry (NJR). Meta-regression was performed to determine the impact of relevant variables on 10-year survivorship, with a sub-analysis focusing on HIV.

RESULTS

Twenty-one studies were reviewed, totalling 1338 TKAs (average age 39 years). Implant survivorship for PwH at 5, 10, and 15 years was 94%, 86%, and 76% respectively. NJR-reported survivorship for males < 55 years was 94%, 90%, and 86%. Survivorship improved over time (1973-2018), and correlated inversely with HIV prevalence. Infection rate was 5%, compared to 0.5-1% in the NJR. Infection was not significantly increased with higher HIV prevalence, and CD4 + count had no effect. Complications were inconsistently reported.

CONCLUSION

Survivorship was similar at 5 years but declined thereafter, and infection rate was six-fold higher. HIV was related to worse survivorship, but not increased infection. Meta-analysis was limited by inconsistent reporting, and standardised reporting is required in future studies.

P12 Sustainability: staff knowledge of which items of waste can be recycled in the orthopaedic operating theatre

Introduction

NHS England generates over 20 million tonnes of CO2 per year, representing 4% of the nation's greenhouse gas emissions. One third of all hospital waste comes from operating theatres. Our aim was to investigate the degree of knowledge of sustainable waste segregation amongst theatre staff in an elective orthopaedic centre and identify ways to improve their waste segregation practice.

Methods

Over a one-week period, 20 randomly selected theatre staff of different roles, completed a questionnaire asking them which disposal bin 11 commonly used orthopaedic theatre items should be placed in – general waste or recycling. After initial data collection, posters specifically identifying recyclable items were created and displayed in each operating theatre. Following this intervention, data was re-collected from another 20 randomly selected theatre staff using the same questionnaire.

Results

Results from the initial questionnaire showed general waste and recyclable items were correctly identified by staff in 65% (78/120 responses) and 59% (59/100 responses), respectively. Following the educational intervention, the percentage of correct responses increased to 68.3% (82/120 responses) and 85% (85/100 responses); i.e. staff knowledge of what can go into a recycling bin improved by 36%.

Conclusion

Educating staff by placing posters in the operating theatre can improve knowledge of what orthopaedic theatre items can be recycled and is a simple and effective way of producing sustainable change in surgery. Guiding and empowering individuals to exercise sustainable practice in the operating theatre will help the NHS to overcome the significant challenge of achieving net zero carbon by 2045.

Take-home message

Educating staff by placing posters in the operating theatre is a simple and effective way of improving waste segregation practice and will help the health service to overcome the significant challenge of achieving net zero carbon.

An audit of mammographic screen detected lesions of uncertain malignant potential (B3) diagnosed on initial image guided needle biopsy: how has our practice changed over 10 years?

AIM

To review all cases of B3 lesion diagnosed at initial image-guided needle biopsy over two 5-year cohorts to identify upgrade rates to malignancy and the effect of changing guidance on the management of such lesions.

MATERIALS AND METHODS

Data was collected retrospectively. Mammographic features, biopsy type and management were recorded for each lesion. Upgrade rates for each B3 histological category were quantified. Statistical analysis was performed using SPSS.

RESULTS

There were 224 cases in 2005-2010 and 240 cases in 2010-2015. Mammographically 211 lesions were microcalcifications, 182 masses, 65 distortions and six asymmetric densities with no difference in the mammographic features in the two cohorts. Two hundred and eight 14 G core biopsies and 256 initial vacuum-assisted biopsies were performed. There was a statistically significant reduction in benign surgical biopsies and an increase in second-line vacuum biopsy/excision in the latter cohort, with no significant change in the upgrade rate. There was an overall 6% upgrade to invasive malignancy and 13% upgrade to ductal carcinoma in situ (DCIS). The upgrade rates for the following histological categories were atypical intraductal epithelial proliferation (AIDEP) 33.2% (21/63); classical (not pleomorphic) in situ lobular neoplasia (ISLN) 18.2% (6/33); flat epithelial hyperplasia (FEA) 21.7% (20/92); papilloma with atypia 53.8% (7/13), without atypia 12.1% (8/66); and radial scar/complex sclerosing lesion with atypia 16.7% (2/12), and without atypia 7.9% (6/76).

CONCLUSION

Upgrade rates remain high for some histological categories even with first-line use of vacuum biopsy. Management of borderline lesions should be considered carefully in a multidisciplinary meeting. In many cases, the need for diagnostic surgical excision has been replaced by image-guided vacuum sampling.

Host-Parasite Relationships and Life Histories of Trypanosomes in Australia

Trypanosomes constitute a group of flagellate protozoan parasites responsible for a number of important, yet neglected, diseases in both humans and livestock. The most significantly studied include the causative agents of African sleeping sickness (Trypanosoma brucei) and Chagas disease (Trypanosoma cruzi) in humans. Much of our knowledge about trypanosome host-parasite relationships and life histories has come from these two human pathogens. Recent investigations into the diversity and life histories of wildlife trypanosomes in Australia highlight that there exists a great degree of biological and behavioural variation within and between trypanosomes. In addition, the genetic relationships between some Australian trypanosomes show that they are unexpectedly more closely related to species outside Australia than within it. These findings have led to a growing focus on the importance of understanding parasites occurring naturally in wildlife to (1) better document parasite biodiversity, (2) determine evolutionary relationships and degree of host specificity, (3) understand host-parasite interactions and the role of parasites in the natural ecosystem and (4) identify biosecurity issues of emerging disease in both wildlife and human populations. Here we review what is known about the diversity, life histories, host-parasite interactions and evolutionary relationships of trypanosomes in Australian wildlife. In this context, we focus upon the genetic proximity of key Australian species to the pathogenic T. cruzi and discuss similarities in their biology and behaviour that present a potential risk of human disease transmission by Australian vectors and wildlife.

A comparison of the accuracy of film-screen mammography, full-field digital mammography, and digital breast tomosynthesis

AIM

To measure the change in diagnostic accuracy of conventional film-screen mammography and full-field digital mammography (FFDM) with the addition of digital breast tomosynthesis (DBT) in women recalled for assessment following routine screening.

MATERIALS AND METHODS

Ethics approval for the study was granted. Women recalled for assessment following routine screening with screen-film mammography were invited to participate. Participants underwent bilateral, two-view FFDM and two-view DBT. Readers scored each lesion separately for probability of malignancy on screen-film mammography, FFDM, and then DBT. The scores were compared with the presence or absence of malignancy based on the final histopathology outcome.

RESULTS

Seven hundred and thirty-eight women participated (93.2% recruitment rate). Following assessment 204 (26.8%) were diagnosed as malignant (147 invasive and 57 in-situ tumours), 286 (37.68%) as benign, and 269 (35.4%) as normal. The diagnostic accuracy was evaluated by using receiving operating characteristic (ROC) and measurement of area under the curve (AUC). The AUC values demonstrated a significant (p = 0.0001) improvement in the diagnostic accuracy with the addition of DBT combined with FFDM and film-screen mammography (AUC = 0.9671) when compared to FFDM plus film-screen mammography (AUC = 0.8949) and film-screen mammography alone (AUC = 0.7882). The effect was significantly greater for soft-tissue lesions [AUC was 0.9905 with the addition of DBT and AUC was 0.9201 for FFDM with film-screen mammography combined (p = 0.0001)] compared to microcalcification [with the addition of DBT (AUC = 0.7920) and for FFDM with film-screen mammography combined (AUC = 0.7843; p = 0.3182)].

CONCLUSION

The addition of DBT increases the accuracy of mammography compared to FFDM and film-screen mammography combined and film-screen mammography alone in the assessment of screen-detected soft-tissue mammographic abnormalities.

Developing environment-specific water quality guidelines for suspended particulate matter

It is generally well recognised that suspended particulate matter (SPM), from nano-scale particles to sand-sized sediments, can cause serious degradation of aquatic ecosystems. However, at present there is a poor understanding of the SPM conditions that water quality managers should aim to achieve in contrasting environments in order to support good ecological status. In this article, we analyse long-term SPM data collected from a wide range of reference-condition temperate environments in the UK (638 stream/river sites comprising 42 different ecosystem-types). One-way analysis of variance reveals that there is a statistically significant difference (p < 0.001) between the background SPM concentrations observed in contrasting ecosystems that are in reference condition (minimal anthropogenic disturbance). One of the 42 ecosystems studied had mean background concentrations of SPM in excess of the current European Union (EU) water quality guideline, despite being in reference condition. The implications of this finding are that the EU's current blanket water quality guideline (25 mg L(-1) for all environments) is inappropriate for this specific ecosystem-type which will be non-compliant with the guideline regardless of the intensity of land-use. The other 41 ecosystems studied had mean concentrations below the current EU water quality guideline. However, this does not necessarily mean that the guideline is appropriate for these ecosystems, as previous research has demonstrated that detrimental impacts can be experienced by some freshwater organisms, of all trophic levels, when exposed to concentrations below 25 mg L(-1). Therefore, it is suggested here that it is likely that some ecosystems, particularly those with mean concentrations in the 0.00-5.99 mg L(-1) range, require much lower guideline values in order to be effectively protected. We propose a model for predicting environment-specific water quality guidelines for SPM. In order to develop this model, the 638 reference condition sites were first classified into one of five mean background SPM ranges (0.00-5.99, 6.00-11.99, 12.00-17.99, 18.00-23.99 and >24.00 mg L(-1)). Stepwise Multiple Discriminant Analysis (MDA) of these ranges showed that a site's SPM range can be predicted as a function of: mean annual air temperature, mean annual precipitation, mean altitude of upstream catchment, distance from source, slope to source, channel width and depth, the percentage of catchment area comprised of clay, chalk, and hard rock solid geology, and the percentage of the catchment area comprised of blown sand as the surface (drift) material. The MDA technique, with cross-validation (Wilks-Lambda 0.358, p 0.000), can predict the correct or the next closest SPM range of a site in 90% of cases. This technique can also predict SPM range membership in a probabilistic manner, allowing for an estimate of uncertainty to be made in the allocation of a site to an environment-specific SPM range.

Host and parasite genomics, an Australasian perspective

The last decade has seen rapid advances in the genetic technology that is allowing researchers to examine host-pathogen interactions at a whole organism level. The advent of 'affordable' post-genomic technology has opened up a world of proteomic, transcriptomic and metabolomic methodologies that have been utilized by research groups in the Australasian region to examine the hosts' response to parasitic infections. Significant contributions have been made to many areas of parasitic infections with particular strengths being in malaria vaccine development, genetic susceptibility to leishmaniasis, genomic and proteomic analysis of schistosomiasis and genetic determination of resistance to helminthes in domestic animals. This review highlights some of these studies that have made significant contributions to our knowledge of the pathogenesis of parasitic diseases with a particular emphasis placed on studies reported in the last couple of years.

Mammographic casting-type calcification associated with small screen-detected invasive breast cancers: is this a reliable prognostic indicator?

AIM

The aim of the present study was to establish whether mammographic casting-type calcification associated with small screen-detected invasive breast cancers is a reliable prognostic indicator.

METHODS AND MATERIALS

We retrospectively identified 50 consecutive women diagnosed with an invasive cancer less than 15 mm who showed associated casting calcification on their screening mammograms. Controls were identified that showed no microcalcification and were matched for tumour size, histological type and lymph node status. A minimum of 5 years follow-up was obtained, noting recurrence and outcome. Conditional and unconditional logistic regression, depending on the outcome variable, were used to analyse the data, taking the matched design into account in both cases. Where small numbers prohibited the use of logistic regression, Fisher's exact test was used.

RESULTS

Five deaths from breast cancer occurred out of the 50 cases, of which three were lymph node positive, two were lymph node negative and none were grade 3. None of the 78 control cases died from breast cancer. The difference in breast cancer death rates was significant by Fisher's exact test (p=0.02). Risk of recurrence was also significantly increased in the casting cases (OR=3.55, 95% CI 1.02-12.33, p=0.046).

CONCLUSION

Although the overall outcome for small screen-detected breast cancers is good, our study suggests that casting calcification is a poorer prognostic factor. The advantage of a mammographic feature as an independent prognostic indicator lies in early identification of high-risk patients, allowing optimization of management.

Automatic forensic face recognition from digital images

Digital image evidence is now widely available from criminal investigations and surveillance operations, often captured by security and surveillance CCTV. This has resulted in a growing demand from law enforcement agencies for automatic person-recognition based on image data. In forensic science, a fundamental requirement for such automatic face recognition is to evaluate the weight that can justifiably be attached to this recognition evidence in a scientific framework. This paper describes a pilot study carried out by the Forensic Science Service (UK) which explores the use of digital facial images in forensic investigation. For the purpose of the experiment a specific software package was chosen (Image Metrics Optasia). The paper does not describe the techniques used by the software to reach its decision of probabilistic matches to facial images, but accepts the output of the software as though it were a 'black box'. In this way, the paper lays a foundation for how face recognition systems can be compared in a forensic framework. The aim of the paper is to explore how reliably and under what conditions digital facial images can be presented in evidence.

Asbestos-related benign pleural disease

Benign pleural disease is the commonest manifestation of asbestos exposure encountered by radiologists. Benign pleural thickening can appear as circumscribed parietal pleural plaques or as more diffuse thickening of the visceral pleura. Benign-asbestos induced pleural effusions are a significant and under-recognized manifestation of asbestos exposure with important sequelae, such as diffuse pleural thickening which may be associated with functional impairment and for which compensation may be sought. This review concentrates on the strengths and weaknesses of chest radiography and computed tomography for the detection and characterization of benign asbestos-related pleural disease and the relevance of imaging abnormalities to compensation and functional impairment.Peacock, C. (2000). Clinical Radiology55, 422-432.

Preliminary clinical experience of a contracture correction device

Joint contractures which do not respond to conventional physiotherapy can be difficult to treat. Serial plastering has been used effectively but is expensive, inconvenient to the patient and does not permit daily hygiene or clinical inspection. A mechanical device has been developed consisting a hinged orthosis which spans the affected joint to which is attached a gas strut to provide a corrective moment about the anatomical joint. Such an arrangement enables prescribed corrective moments to be applied accurately following clinical assessment using routine physiotherapy techniques. The inherently low spring rate of a gas strut ensures that the specified corrective torque is maintained as correction occurs. Initial treatment experience under the control of the developers had generated wider interest in the system. A geographically distant independent orthotic supply centre was trained in the techniques of application. They treated nine elbow and three knee joints in patients who had not responded to physiotherapy treatment. All of the patients experienced improvement. The average for elbow joints was a reduction in the contracture of 25.6 degrees with a corrective moment of 6.8 Nm over a period of 3.9 weeks. For the knee joints the averages were a reduction in contracture of 10.7 degrees with a corrective moment of 12.7 Nm over a period of 4 weeks. The results confirmed the practicality of transferring the system to independent clinical centres and provide evidence to support funding for a formal prospective clinical trial of the treatment approach.

Leukemia inhibitory factor is synthesized and released by human eosinophils and modulates activation state and chemotaxis

BACKGROUND

The cytokine leukemia inhibitory factor (LIF) is known to be produced by both inflamed peripheral autonomic nerves and several cell types involved in the regulation of the immune response. We have recently demonstrated that several structural cell types in human airways produce LIF in response to inflammatory stimuli and that LIF augments contractile responses to tachykinins in airway explants. Because the eosinophil is a major effector cell in asthma and often found adjacent to the nerves, we hypothesized that eosinophils produce LIF and that LIF primes and upregulates eosinophil recruitment and function, allowing bidirectional neuroimmune interactions and augmentation of eosinophil-mediated injury.

OBJECTIVE

The purpose of this study was to demonstrate that human eosinophils synthesize and release LIF, to determine the effects of LIF on eosinophil functions (ie, chemotaxis, granule protein release, expression of the activation marker CD69, and apoptosis), and to compare serum LIF levels between atopic and nonatopic individuals.

METHODS

Reverse-transcription PCR, ELISA, immunocytochemistry, chemotaxis assay, and flow cytometry were used.

RESULTS

Peripheral blood eosinophils express LIF and messenger RNA for LIF and LIF receptor. Serum LIF levels were higher in atopic patients with mild asthma than in nonatopic normal donors. Eosinophils from nonatopic donors were stimulated by calcium ionophore to release small amounts of LIF (from almost none to 5.3 +/- 1.8 pg/10(6) cells). Eosinophils from atopic donors showed a 10-fold increase (from 45.1 +/- 38.7 pg/106 cells to 414.5 +/- 189.9 pg/10(6) cells). Preincubation of eosinophils with LIF increased eosinophil peroxidase release 4-fold. LIF was not chemotactic for eosinophils but augmented chemotaxis mediated by substance P by 82% and by platelet-activating factor by 31%. LIF did not effect eosinophil apoptosis but increased CD69 expression.

CONCLUSION

LIF has proinflammatory roles in eosinophil-dependent airway disorders.

Cervical spine movements during laryngoscopy. Comparison of the Macintosh and McCoy laryngoscope blades

We studied cervical spine movement in 10 patients scheduled for elective surgery under general anaesthesia. Each patient was fitted with a rigid cervical collar before undergoing direct laryngoscopy for orotracheal intubation. Laryngoscopy was performed using the McCoy laryngoscope in the activated position and the standard Macintosh blade. Displacement of the cervical spine at laryngeal exposure was measured using lateral cervical spine X-rays. Flexion and extension movements of the cervical spine during the use of the two laryngoscope blades were compared. For each blade, the greatest degree of extension occurred at the joint between the first and second cervical vertebrae. There was no significant difference in cervical spine movement when the two blades were compared.

Use of tracheobronchography as a diagnostic tool in ventilator-dependent infants

OBJECTIVE

Comparison of investigations of the airway in ventilator-dependent infants.

DESIGN

Consecutive infants with suspected upper airway abnormalities were investigated using rigid bronchoscopy and tracheobronchography.

SETTING

Tertiary pediatric and neonatal intensive care units.

PATIENTS

Eight infants with suspected airway abnormalities.

INTERVENTIONS

Rigid bronchoscopy and tracheobronchography.

MEASUREMENTS AND MAIN RESULTS

Structural abnormalities, segmental narrowing of the airways and the effect of various levels of positive-end expiratory pressures on the narrowings were documented. In six of the eight cases, additional airway abnormalities were diagnosed with tracheobronchography compared with rigid bronchoscopy.

CONCLUSIONS

In cases of suspected abnormalities of the upper airway in small infants unable to be weaned from ventilatory support, tracheobronchography may be a more reliable investigation method than rigid bronchoscopy. The ability to assess the structural and dynamic components of the airway accurately and safely allows a correct and long-term treatment plan to be established in this group of patients.

A newly described possible complication of lymphangioma circumscriptum

Lymphangioma circumscriptum is a rare disorder of lymphatic channels, the cause of which is poorly understood. It is an unpleasant, but benign, condition conventionally managed by wide local excision, which provides symptom control and often prevents recurrence. No long term complications and no association with squamous cell carcinoma have been previously documented. We present a 20-year-old patient with lymphangioma circumscriptum involving the vulval and perianal areas, which recurred after surgery and seems to have predisposed to squamous cell carcinoma 11 years after presentation.

Nocardiosis in HIV-positive patients: an autopsy study in West Africa

BACKGROUND

There are many reports of nocardiosis associated with HIV infection in industrialized and developing countries, but its true prevalence is unknown.

MATERIALS AND METHODS

An autopsy study was performed of HIV-positive and HIV-negative patients dying on the general medical wards of a large hospital in Abidjan, Ivory Coast, in 1991.

RESULTS

247 HIV-positive adult cadavers were examined. 10 (4%) had nocardiosis of the lung, of whom 6 showed disseminated disease. 8 patients had one or more AIDS-defining pathologies, and 5 had nocardiosis as the main cause of death. Pulmonary tuberculosis was found in 87 cadavers (35%), giving a ratio of pulmonary nocardial to tuberculous disease of 1:9. No nocardiosis was seen in 42 HIV-negative cadavers.

CONCLUSIONS

This is the highest recorded prevalence of HIV-associated nocardiosis in a representative sample. The prevalence of nocardiosis varies geographically, and in zones where HIV-associated tuberculosis is common, it is possible that some patients diagnosed as smear-negative pulmonary tuberculosis actually have nocardiosis. A revised strategy of sputum examination with gram stain is suggested to detect nocardia.

Contribution of tuberculosis to slim disease in Africa

OBJECTIVES

To assess the contribution of tuberculosis to the aetiology of the HIV wasting syndrome (slim) in Africa, a condition usually considered an enteropathy.

METHODS

Clinical examination and representative necropsy study of adult patients positive for HIV.

SETTING

Hospital medical wards in Abidjan, Ivory Coast.

SUBJECTS

Adults positive for HIV.

MAIN OUTCOME MEASURES

CD4 T lymphocyte counts before death, clinical and anthropometric data, and gross and microscopic pathology.

RESULTS

Necropsy was done on 212 HIV positive adults. Tuberculosis was found in 41 of 93 with the clinical HIV wasting syndrome and in 32 of 119 without (odds ratio 2.1, 95% confidence interval 1.2 to 4.0). A significant association existed between the prevalence of tuberculosis at necropsy and the degree of cadaveric wasting (no wasting 25% (15/59); moderate wasting 40% (23/58); skeletal wasting 44% (42/95); P = 0.02). Wasting was also associated with a history of chronic diarrhoea, but no association existed between diarrhoea and tuberculosis. Median CD4 T lymphocyte counts were lowest in wasted patients irrespective of findings at necropsy and in those with chronic diarrhoea (< 60 x 10(6)/l).

CONCLUSION

Wasting and chronic diarrhoea are late stage manifestations of HIV disease in Africa. The importance of tuberculosis as a contributing factor in the pathogenesis of the slim syndrome has been underestimated. In nearly half of patients dying with severe wasting, tuberculosis was the dominant pathological finding.

The mortality and pathology of HIV infection in a west African city

BACKGROUND

HIV disease is epidemic in Africa, but associated mortality, underlying pathology and CD4+ T-lymphocyte counts have not previously been evaluated in a representative study. Such data help to determine the management of HIV-positive people. Both HIV-1 and HIV-2 infections are prevalent in Côte d'Ivoire, and the pathology of HIV-2 infection in Africa is unclear.

METHODS

Consecutive adult medical admissions to a large city hospital in Côte d'Ivoire were studied in 1991, and a sample of HIV-positive deaths autopsied.

RESULTS

Of 5401 patients evaluated, 50% were HIV-positive; 38% of these died, with a median survival of 1 week. At autopsy (n = 294, including 24% of HIV-positive deaths in hospital), tuberculosis (TB), bacteraemia (predominantly Gram-negative rods) and cerebral toxoplasmosis caused 53% of deaths. TB was seen in 54% of cadavers with AIDS-defining pathology and Pneumocystis pneumonia in 4%. The median CD4+ T-lymphocyte counts in those who died was < 90 x 10(6)/l. Compared with HIV-1-positives, patients with HIV-2-positivity had a greater frequency of severe cytomegalovirus infection, HIV encephalitis and cholangitis.

CONCLUSIONS

In this population, HIV-positive adults present to hospital with advanced disease associated with high mortality. The three major underlying pathologies (TB, toxoplasmosis and bacteraemia) are either preventable or treatable. TB is an underestimated cause of the 'slim' syndrome in Africa. The patterns of pathology in HIV-2-positive patients suggest a more prolonged terminal course compared with HIV-1. There is an urgent need for attention towards the issues of therapy and care for HIV disease in developing countries.

International policies on alcohol-impaired driving: a review

A review is presented of policies to curb alcohol-impaired driving. The principal measure applied against drinking and driving in most industrial countries is the implementation of laws limiting the amount of alcohol which can be legally consumed by a person who subsequently takes charge of a motor vehicle on a public road. This strategy seems to have been the most effective to date, although national variations in legislation, rigor of application, and the extent of public knowledge are reflected in the range of outcomes reported. The effectiveness of "random breath testing" appears to be related to the degree to which drivers believe that the law is enforced. Other strategies aimed at the reduction of drinking and driving are education, publicity, and exhortation; the rehabilitation of convicted offenders; and restrictions on the availability of alcohol. However, due to factors such as the lack of evaluation, or limited scope, or nonspecificity to drinking and driving, these measures appear to have been less successful in curbing alcohol-impaired driving than the application of legal powers.

Expression of LPG and GP63 by different developmental stages of Leishmania major in the sandfly Phlebotomus papatasi

Development and forward migration of Leishmania parasites in the sandfly gut is accompanied by morphological transformation to highly motile, non-dividing 'metacyclic' forms. Previous studies in vitro have demonstrated that this metacyclogenesis is associated with developmentally regulated changes in expression of two major surface glycoconjugates of Leishmania, the lipophosphoglycan (LPG) and the glycoprotein protease GP63. Studies presented here are the first to examine in situ the changes in expression of these two important surface molecules which occur during amastigote-initiated development of L. major in its natural vector Phlebotomus papatasi. Immunocytochemical analysis using a GP63-specific monoclonal (3.8), and others recognizing metacyclic-specific (3F12) and common (WIC79.3) epitopes of LPG on logarithmic and metacyclic promastigotes, demonstrates: (1) clear expression of LPG and GP63 from 2 and 7 days post-bloodfeeding, respectively; (2) developmental modification of the LPG molecule as parasites undergo forward migration and morphological changes associated with metacyclogenesis; and (3) striking deposition of large amounts of parasite-free excreted LPG on/in the epithelial cells of the gut wall.

Metabolism of mannitol by Coccidioides immitis

Lones, George W. (National Institute of Allergy and Infectious Diseases, U.S. Public Health Service, Bethesda, Md.), and Carl Peacock. Metabolism of mannitol by Coccidioides immitis. J. Bacteriol. 87:1114-1117. 1964.-Strain M-11 of Coccidioides immitis was found to utilize mannitol for growth in the mycelial form but not in the spherule form. Cell-free extracts of both forms, grown on glucose, were capable of reducing nicotinamide adenine dinucleotide with mannitol-1-PO(4) but not with mannitol. The extracts accomplished a rapid oxidation of reduced nicotinamide adenine dinucleotide by fructose-6-PO(4), the expected product of mannitol-1-PO(4) oxidation. Fructose was inactive. Paper electrophoresis and chromatography with several solvent systems demonstrated a substance in extracts of both mycelium and spherules having a migration consistent with that of mannitol.