SGLT2 Inhibitor-Associated Ketoacidosis vs Type 1 Diabetes-Associated Ketoacidosis

This cohort study examines the natural history and response to treatment of sodium glucose cotransporter 2 (SGLT2) inhibitor–associated ketoacidosis compared with that of type 1 diabetes–associated ketoacidosis.

Antibiotic prophylaxis in immunosuppressed patients - Missed opportunities from trimethoprim-sulfamethoxazole allergy label

Trimethoprim-sulfamethoxazole (TMP-SMX) is a broad spectrum antibiotic in use for more than 50 years. It has an important indication as first line agent in the prophylaxis of opportunistic infections, particularly Pneumocystis jirovecii pneumonia (PJP), in immunosuppressed patients. For those who have a history of allergy or severe intolerance to TMP-SMX, pentamidine, dapsone or atovaquone may be substituted; however there is evidence that TMP-SMX offers superior coverage for PJP, toxoplasmosis, and nocardiosis. Compared to pentamidine, it has the added benefit of cost-effectiveness and self-administration as opposed to required hospital attendance for administration. Many patients who report a history of allergy or adverse reaction to TMP-SMX (or "sulfur allergy") will be found not to be allergic; and even those who are allergic may be able to be desensitized. The evaluation and, where appropriate, removal of TMP-SMX allergy label enables the use of TMP-SMX for prophylaxis against opportunistic infections. This is a cost-effective intervention to optimize antimicrobial prescribing and reduce the risk of opportunistic infections in immunosuppressed patients.

Prescribing of antivirals for COVID-19 in a South Australian local health network according to statewide guidelines

Antiviral drugs were rapidly implemented into clinical practice for the treatment of high-risk patients with COVID-19, prompting the development of statewide guidelines. This South-Australian study reviewed guideline adherence, assessed prescribing patterns and highlighted the inappropriate management of relative drug-drug interactions and dosing for renal function. Additionally, it evaluated the impact of inappropriate antiviral drug use and suggested methods to improve quality use of medicines.

A community of practice to address system-based issues and promote clinical leadership among trainee medical officers in a large public health service: an evaluation of a trainee-led forum

Clinical leadership is necessary to improve the performance of large public hospitals. Trainee medical officers (TMOs) are important stakeholders in organisation-wide initiatives that affect the medical workforce and support clinician engagement. This case study describes the development of a representative body known as the 'TMO Forum' within the Central Adelaide Local Health Network as a mechanism to promote engagement between medical trainees and the hospital executive to facilitate escalation and discussion of system-based issues. Over the past 8 years, this group has evolved into a community of practice with steady and sustained growth since inception. Trainees have fostered relationships with the executive, and have engaged in leadership and quality improvement initiatives. Here we explore the evolution, value and barriers to success of the TMO Forum. Our discussion is supplemented with findings from anonymous online evaluation surveys of both the TMO and executive stakeholder groups. We propose that initiatives such as the described may offer reciprocal benefits to both constituent groups regarding communication, and that the development of a dedicated community of practice will enhance engagement of TMOs in health service improvement initiatives and advocacy. However, there are obstacles to overcome in order to attract a greater number of trainees and maximise the benefits from this initiative.

Artificial intelligence-enabled penicillin allergy delabelling: an implementation study

Inaccurate penicillin allergy labels may be delabelled following evaluation. The intervention in this study was an email-based notification system regarding the appropriateness for penicillin allergy evaluation, with a view to delabelling, as identified by a deep learning artificial intelligence algorithm. Of the intervention group (n = 59), three (5.1%) individuals had their penicillin allergies delabelled, which was significantly more than the control group (0%, P = 0.002). Further research to optimise such approaches is required.

Prevalence of Trimethoprim-Sulfamethoxazole Adverse Reaction Mislabelling in Australia

INTRODUCTION

Trimethoprim-sulfamethoxazole (TMP-SMX) is an important antibiotic, with the most compelling indications for Pneumocystis jirovecii pneumonia prophylaxis and methicillin-resistant Staphylococcus aureus treatment. Previous adverse reactions (AR) to TMP-SMX may limit the usability of TMP-SMX. Electronic medical record (EMR) of AR for other antibiotics has previously been shown to be inaccurate; however, the extent to which this occurs for TMP-SMX is unknown.

METHODS

A multi-centre retrospective observational study was conducted for consecutive inpatient admissions over a 2.5-year period commencing 2020. Adverse reactions to TMP-SMX recorded in the EMR were collected and reviewed by two independent medical officers using pre-defined expert criteria for the classification of allergies and intolerances.

RESULTS

TMP-SMX AR were present in the EMR of 759 individuals (prevalence 0.6%). The majority were labelled as allergy (725, 95.5%) rather than intolerance (34, 4.5%). Most common AR were rash, vomiting, and swelling. When classified against the gold-standard expert criteria, there were 437 allergies (57.6%) and 159 intolerances (21.0%). Overall, the number of incorrect EMR AR labels was 133/759 (17.5%). Both medical and surgical specialties had significant numbers of patients with TMP-SMX AR labels and incorrectly classified EMR AR labels.

CONCLUSION

TMP-SMX AR labels affect inpatients admitted under multiple specialty units. The user-entered categorization as allergy or intolerance labels in EMRs are frequently used incorrectly. These incorrect labels may inappropriately contraindicate the use of TMP-SMX, and formal evaluation of TMP-SMX ARs with immunological assessment and relabelling where appropriate may increase the use of this agent.

Protecting the heart

Blocking a protein known as EPAC1 may prevent the development of heart-related side effects caused by a chemotherapy drug.

Machine learning models automate classification of penicillin adverse drug reaction labels

There is a growing interest in the appropriate evaluation of penicillin adverse drug reaction (ADR) labels. We have developed machine learning models for classifying penicillin ADR labels using free-text reaction descriptions, and here report external and practical validation. The models performed comparably with expert criteria for the categorisation of allergy or intolerance and identification of high-risk allergies. These models have practical applications in detecting individuals suitable for penicillin ADR evaluation. Implementation studies are required.

Peri-colonoscopy Implications of Sodium-Glucose Cotransporter-2 Inhibitor Therapy: A Mini-review of Available Evidence

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a class of oral glucose-lowering agents commonly used for the treatment of type 2 diabetes. With increased use, there has been an increase in the incidence of the rare but life-threatening complication of euglycemic diabetic ketoacidosis. A common but underappreciated precipitant is colonoscopy. In this work, we outline the pathophysiology of the interaction between colonoscopy and SGLT2i use, the evidence regarding SGLT2i use in the periprocedural setting and Australian Diabetes Society guidelines.

Antibiotic Prescribing Practices Differ between Patients with Penicillin Intolerance and Penicillin Allergy Labels

INTRODUCTION

Penicillin allergy labels are common. However, many penicillin allergy labels have been applied incorrectly and in fact represent penicillin intolerance. Patients with penicillin intolerance can receive penicillin antibiotics. The effect of penicillin intolerance labels on prescribing practices is uncertain.

METHODS

This multicenter retrospective cohort study included consecutive general medicine patients admitted to two tertiary hospitals over a 12-month period. Electronic medical records were reviewed for allergy and prescribing practices. Instances of penicillin prescription to patients with previously labeled penicillin allergies underwent case note review.

RESULTS

There were 12,134 individual hospital admissions included in the study. The number of admissions with a previous penicillin allergy label was 1,312 (10.8%) and with a penicillin intolerance label was 60 (0.5%). Penicillin allergy labels were associated with increased likelihood of being prescribed vancomycin (odds ratio 1.42, 95% confidence interval 1.16-1.75, p = 0.001) and moxifloxacin (odds ratio 20.0, 95% confidence interval 13.4-29.9, p < 0.001). Penicillin intolerance was not associated with increased likelihood of receiving these antibiotics. There were 75 admissions during which an individual with a penicillin allergy label was prescribed one of the specified penicillins and only one adverse reaction in this group. These cases included eight deliberate challenges and 15 cases in which allergy history clarification was sufficient to delabel the allergy.

CONCLUSIONS

This study supports that prescribing practices differ between patients with penicillin allergy labels and intolerance labels. Penicillin challenges may be undertaken safely in the inpatient setting. Further studies are required to investigate how best to interrogate penicillin allergy labels in this cohort.

Documentation of adverse drug reactions to opioids in an electronic health record

BACKGROUND

Allergy to opioids is the second most common drug allergy label in electronic health records (EHR). Adverse drug reactions (ADR) to opioids cause significant morbidity and contribute to healthcare costs, while incorrect opioid allergy labels may unnecessarily complicate patient management.

AIMS

To examine the documentation of opioid ADR in a large-scale hospital-based EHR.

METHODS

A cross-sectional retrospective review of EHR documentation of opioid ADR at four public hospitals in South Australia was conducted. Data were extracted from all ADR entries including the reported allergen, ADR category (allergy or intolerance) and reaction details. Expert criteria were used to determine consistency of ADR categorisation as allergy or intolerance.

RESULTS

Of 86 727 unique ADR reports, there were 13 781 ADR to opioids with most being entered as allergy (n = 8913, 64.7%) rather than intolerance (n = 4868, 35.3%). The most commonly documented reactions were nausea/vomiting (n = 3912, 28%), rash (n = 647, 5%), itch (n = 642, 5%) and hallucinations (n = 527, 4%). There were 362 (3%) ADR labels of anaphylaxis. Of those ADR containing a reaction description (n = 11 868), 89% of reports entered as allergy had a reaction description that was consistent with intolerance and 8% of the entered intolerances had descriptions consistent with allergy when assessed using predefined criteria.

CONCLUSIONS

This large EHR-based study demonstrates the high rate of opioid ADR labels in EHR. The majority of these labels were for symptoms suggestive of pharmacological intolerance. Reactions consistent with true allergy were uncommon. Systematic review of ADR by a dedicated clinical service would improve the accuracy of documentation.

Abdominal pain with intra-adrenal bleeding as an initial presentation of pheochromocytoma

A 55-year-old man presented with severe right upper quadrant abdominal pain and hypertension up to 231/171 mm Hg on a background of a known adrenal mass, intravenous drug use and recurrent anxiety attacks. CT showed heterogenous lesion of the right adrenal gland but the sudden severe pain remained unexplained. After correction of the blood pressure with analgesia and antihypertensives, the patient developed a type 2 non-ST-elevation myocardial infarction that was treated with aspirin and therapeutic enoxaparin. This resulted in worsening pain and a repeat CT angiogram showed a haemoretroperitoneum around the right adrenal lesion. On review, an occult intra-adrenal haemorrhage was identified on the initial CT scan. Presumably this concealed haemorrhage caused the initial pain crisis and later decompressed into the retroperitoneal space. Raised metanephrine levels confirmed the diagnosis of pheochromocytoma and after preoperative optimisation with phenoxybenzamine, an open right adrenalectomy was performed.

Scurvy presenting as lower limb ecchymoses in the setting of metastatic colorectal cancer

A 58-year-old woman presented with a 1-week history of lower limb bruising. She had a medical history of recurrent metastatic colon cancer with a sigmoid colectomy and complete pelvic exenteration leading to colostomy and urostomy formation. She had malignant sacral mass encroaching on the spinal cord. This caused a left-sided foot drop for which she used an ankle-foot orthosis. She was on cetuximab and had received radiotherapy to the sacral mass 1 month ago. On examination, there were macular ecchymoses with petechiae on the lower limbs. There was sparing of areas that had been compressed by the ankle-foot orthosis. Bloods showed mild thrombocytopaenia and anaemia with markedly raised inflammatory markers. Coagulation studies consistent with inflammation rather than disseminated intravascular coagulation. She was found to have Klebsiella bacteraemia secondary to urinary source. Skin biopsy showed dermal haemorrhage without vessel inflammation. Vitamin C levels were low confirming the diagnosis of scurvy.

Transcranial Magnetic Stimulation of Human Adult Stem Cells in the Mammalian Brain

Introduction: The burden of stroke on the community is growing, and therefore, so is the need for a therapy to overcome the disability following stroke. Cellular-based therapies are being actively investigated at a pre-clinical and clinical level. Studies have reported the beneficial effects of exogenous stem cell implantation, however, these benefits are also associated with limited survival of implanted stem cells. This exploratory study investigated the use of transcranial magnetic stimulation (TMS) as a complementary therapy to increase stem cell survival following implantation of human dental pulp stem cells (DPSC) in the rodent cortex.

Methods: Sprague-Dawley rats were anesthetized and injected with 6 × 10⁵ DPSC or control media via an intracranial injection, and then received real TMS (TMS_{0.2 Hz}) or sham TMS (TMS_sham) every 2nd day beginning on day 3 post DPSC injection for 2 weeks. Brain sections were analyzed for the survival, migration and differentiation characteristics of the implanted cells.

Results: In animals treated with DPSC and TMS_{0.2 Hz} there were significantly less implanted DPSC and those that survived remained in the original cerebral hemisphere compared to animals that received TMS_sham. The surviving implanted DPSC in TMS_{0.2 Hz} were also found to express the apoptotic marker Caspase-3.

Conclusions: We suggest that TMS at this intensity may cause an increase in glutamate levels, which promotes an unfavorable environment for stem cell implantation, proliferation and differentiation. It should be noted that only one paradigm of TMS was tested as this was conducted as a exploratory study, and further TMS paradigms should be investigated in the future.

Respiratory viruses in a hospitalized paediatric population in Edinburgh 1985-1994

We describe the incidence of respiratory viruses identified in children admitted to an Edinburgh hospital between October 1985 and July 1994. Respiratory syncytial (RS) virus, influenza viruses and parainfluenza viruses showed seasonal activity whereas adenoviruses and rhinoviruses did not. Parainfluenza viruses were the most changeable in their epidemiological behaviour and RS virus the least.

Mycoplasma pneumoniae infection: early diagnosis by detection of specific IgM by immunofluorescence

An indirect immunofluorescent antibody test for early detection of IgM antibodies to Mycoplasma pneumoniae is described, using sera from which IgG antibodies have been removed. The results over a five-year period were studied and compared with complement fixation testing and isolation of the organism. During the epidemic season of November 1990 to April 1991, the immunofluorescent IgM test was used as a first-line test on specimens taken both early and late in the illness to provide a simple, inexpensive and clinically useful test, with 151 positive results being obtained from 886 sera tested.

Use of recombinant human parvovirus B19 antigens in serological assays

AIMS--To compare the sensitivity, specificity, and practicality of recombinant proteins in serological tests for the detection of human parvovirus B19 IgG and IgM. METHODS--Indirect enzyme linked immunosorbent assays using B19 structural proteins expressed in Escherichia coli were developed for the detection of B19 specific IgG and IgM (rELISA-G and rELISA-M). Cells infected with baculovirus expressing B19 structural proteins were also used in an indirect immunofluorescence assay for IgG and IgM antibodies (IFA-G and IFA-M). Antibody capture radioimmunoassays for IgG and IgM (GACRIA and MACRIA) were used as comparative assays. RESULTS--Twenty nine pools of intravenous immunoglobulin were clearly positive for B19 IgG by rELISA-G and contained low IgG titres by GACRIA. From 113 samples tested by all methods, sensitivities of 92% (77/84) and 97% (68/70) were obtained for ELISA and immunofluorescence, respectively, when compared with GACRIA. One hundred and sixteen samples from patients presenting with rash or arthralgia were compared by MACRIA, rELISA-M, and IFA-M. Sensitivities of both recombinant tests were more than 95%. Despite pretreatment to remove IgG or rheumatoid factor, false positive results were a problem in the rELISA-M but were not seen with the IFA-M. CONCLUSIONS--The limited supply of native antigen has severely restricted the wide application of serology for parvovirus B19. The use of recombinant antigens permitted the introduction of local screening tests which had many advantages, including quicker results and relief of the burden on the Reference Laboratory. The use of rELISA-M for sensitivity and IFA-M for specificity and confirmation proved a useful and practical combination for diagnosis of recent infection with B19, and rELISA-G allowed the immune response to be determined in selected populations.

Detection of respiratory syncytial virus in acute bronchiolitis in infants

Direct detection of respiratory syncytial (RS) virus antigen in nasopharyngeal secretions (NPS) provides the most rapid diagnostic test for RS infection, but more sensitive methods might be more beneficial in the study of virus shedding. RS virus RNA was extracted from cells stored at -70 degrees C either in suspension with added RNAse inhibitor or as a pellet without inhibitor. The RNA was reverse transcribed, the resultant cDNA amplified by the polymerase chain reaction and detected by ethidium bromide staining after electrophoresis through agarose gel (RT-PCR). Of 217 specimens tested, 106 were positive by antigen detection, 99 by RT-PCR, and 92 by virus isolation. In a series of 97 sequential NPS specimens from 15 infants in whom RS virus induced bronchiolitis was confirmed, antigen detection proved most sensitive in the first week after onset and RT-PCR detected most positive specimens in the second week. Storage of the cells as a pellet proved more satisfactory than storage as a suspension. A further round of amplification using nested primers increased the number of positive results obtained by RT-PCR. The sensitivity of antigen detection using directly labelled monoclonal antibody to RS virus was slightly higher than that of RT-PCR, but the specificity was slightly lower.

How many bloods will a 'HIVCHEK' check? Multiple tests for HIV antibody for a single screening kit

Detection of HIV infection in blood donors or populations is usually by testing sera for antibodies to HIV-1 and HIV-2. Screening tests are now highly sensitive and specific, but still expensive and scarce in Africa. We tested the commercially available kits 'HIVCHEK 1 + 2' in two field laboratories, on specimens from blood donors and antenatal women in rural Zaire. We describe a method of using one test kit for up to five serum samples, saving money and time. In 491 antenatal mothers in Eastern Zaire, among whom the HIV seroprevalence was 3.3%, we compared 'HIVCHEK' results with results obtained by ELISA and Western blot. The 'HIVCHEK' multiple-sample method had a sensitivity of 82% and a specificity of 99.6%. In an area with an HIV seroprevalence of < 4%, using 'HIVCHEK' by the multiple sample method would lead to a saving of about 2,400 pounds for every 1000 individuals tested.

Prevalence of HIV among childbearing women and women having termination of pregnancy: multidisciplinary steering group study

OBJECTIVE

To determine the prevalence of HIV among pregnant women, in particular those whose behaviour or that of their partners put them at "low risk" of infection.

DESIGN

Voluntary named or anonymous HIV testing of pregnant women during 21 months (November 1988 to July 1990).

SUBJECTS AND SETTING

All women who planned to continue their pregnancy and attended clinics serving the antenatal populations of Edinburgh and Dundee. All women admitted for termination of pregnancy to gynaecology wards serving the pregnant populations of Dundee and outlying rural areas.

MAIN OUTCOME MEASURES

Period prevalence of HIV antibody positivity.

RESULTS

91% of antenatal clinic attenders and 97% of women having termination of pregnancy agreed to HIV testing on a named or anonymous basis. HIV period prevalences for antenatal clinic attenders and women having termination of pregnancy tested in Dundee were 0.13% and 0.85% respectively, and for antenatal clinic attenders tested in Edinburgh 0.26%. For those at "low risk" rates for antenatal clinic attenders and women having termination of pregnancy in Dundee were 0.11% and 0.13%, and for antenatal clinic attenders in Edinburgh 0.02%. In Dundee HIV prevalence among women having a termination of pregnancy (0.85%) was significantly greater than that among antenatal clinic attenders (0.13%).

CONCLUSIONS

HIV infection is undoubtedly occurring among women at "low risk," and it is clear that a policy of selective testing of those at only "high risk" is inadequate for pregnant women living in areas of high prevalence such as Edinburgh and Dundee. Moreover, when studying pregnant populations in such areas there is the need to include those having a termination of pregnancy.

Association between secretor status and respiratory viral illness

OBJECTIVE

To determine whether non-secretion of blood group antigens is associated with respiratory virus diseases.

DESIGN

Study of secretor status in patients with respiratory virus diseases determined by an enzyme linked immunosorbent assay (ELISA) developed to identify Lewis (Le) blood group antigen phenotypes (Le(a) non-secretor; Le(b) secretor).

SUBJECTS

Patients aged 1 month to 90 years in hospital with respiratory virus diseases (584 nasal specimens).

MAIN OUTCOME MEASURES

Criteria for validation of ELISA (congruence between results on ELISA testing of 1155 saliva samples from a previous study and previously established results on haemagglutination inhibition (HAI) testing, proportions of Le(a), Le(b), and Le- phenotypes in 872 samples of nasal washings from a previous study compared with the normal population). Secretor status of patients determined by ELISA and viruses isolated.

RESULTS

Agreement between HAI and ELISA for 1155 saliva samples was 97%. Lewis antigens were detected by ELISA in 854 (97.9%) of nasal washings (Le(a) 233 (26.7%), Le(b) 621 (71.2%), and Le- 18 (2.1%)) in proportions predicted for a northern European population. Secretors were significantly overrepresented among patients from whom influenza viruses A and B (55/64, 86%; p less than 0.025), rhinoviruses (63/72, 88%; p less than 0.01), respiratory syncytial virus (97/109, 89%; p less than 0.0005), and echoviruses (44/44, p less than 0.0005) had been isolated compared with the distribution of secretors in the local population.

CONCLUSION

Secretion of blood group antigens is associated with respiratory virus diseases.

Detection of respiratory syncytial virus antigen and nucleic acid in clinical specimens using synthetic oligonucleotides

Rapid detection of respiratory syncytial (RS) virus in nasopharyngeal secretions (NPS) was carried out on cytospin cell preparations using a directly labelled monoclonal antiserum to RS virus to detect viral antigen and digoxigenin-labelled synthetic oligonucleotides to detect viral nucleic acid. Sequences of 27 and 30 bases in length from within the fusion protein and nucleocapsid genes respectively were selected for use as probes. The oligonucleotide in situ hybridization test was easy to perform and could be completed within 24 hours, but antigen detection was much more rapid and more sensitive. During 1989-1990, more positive results were obtained by antigen detection (193) than by isolation (185), but of 43 confirmed RS-virus-positive specimens, only 21 (49%) were detected by ISH. Antigen detection remains the most suitable single method of rapid detection of RS virus for a diagnostic laboratory.

Rapid detection of respiratory syncytial virus antigens in nasopharyngeal secretions

The combined use of fluorescein-labelled monoclonal antibody and a cytocentrifuge for preparation of cell spots greatly reduced the time for rapid diagnosis, and improved the sensitivity and ease of detection of respiratory syncytial (RS) virus antigen in specimens of nasopharyngeal secretions.

Vertical transmission of HIV: a prospective study

Forty nine infants of HIV seropositive women were followed up for a median of 24 months, together with 24 controls. The infection status of 11 index children under 18 months of age was indeterminate; 34 were presumed uninfected while four showed clinical and laboratory evidence of HIV disease. Based on current definitions of HIV infection and excluding children under 18 months old as well as those who had not been studied from birth, two out of 28 children were infected. The estimated rate of maternofetal transmission was therefore 7.1%. In children with proved infection, sequential laboratory data showed that hypergammaglobulinaemia was noted as early as 6 months and often predated clinical signs. This observation, in the presence of non-specific clinical findings, was helpful in alerting the paediatrician to a diagnosis of HIV infection.

The management of children born to human immunodeficiency virus seropositive women

Increasing numbers of children born to human immunodeficiency virus (HIV) antibody-positive women are being identified, but guidelines as to their management are lacking. We have therefore established a paediatric counselling and screening clinic for managing such children in Edinburgh. During a period of 3 years, 49 infants and children of 43 HIV seropositive women have been seen. After a median follow-up period of 23 months, four children were found to have clinical evidence of HIV disease which was non-specific and could have been missed had they not been regularly monitored. Thus, close surveillance of infants born to seropositive women is important. Identifying a single clinic where this is done has allowed experience to accumulate on issues beyond the medical management of these infants as well as contributing to the clinical care of infants with symptoms. Based on this experience, we have developed guidelines for managing children born to HIV antibody-positive women.

Heterosexual spread of human immunodeficiency virus in Edinburgh

Heterosexual transmission of human immunodeficiency virus (HIV) was investigated in 123 subjects with no apparent risk factor for infection other than having had heterosexual intercourse with a person who was either infected with HIV or at high risk of being infected with it. Seven subjects were found to be infected with the virus. Risk factors for transmission included being the regular sexual partner of an abuser of intravenous drugs and having a sexual relationship of more than 18 months' duration. Anal intercourse was not a risk factor in the three subjects who admitted to it. There were 41 regular partnerships with abusers of intravenous drugs in which the antibody state and history were fully known for both partners. In these partnerships male to female transmission of the virus occurred in five out of 34 (15%) and female to male in one out of seven. In 30 couples in whom one partner was known to be positive for HIV and an abuser of intravenous drugs four female partners were found to be seropositive at first testing, but there were no new positive results on subsequent serial testing. In six of these 30 couples both partners abused intravenous drugs but the partner who was negative for HIV remained so. Few of the partnerships always practised safe sexual techniques, even after a partner was known to be positive for HIV. Heterosexual transmission of HIV occurred but was incomplete and may be related to the timing of the relationship with the infection.

Human immunodeficiency virus and drug misuse: the Edinburgh experience

During 1985 many drug abusers who lived in Edinburgh were found to be infected with the human immunodeficiency virus (HIV). As a result an alternative counselling and screening clinic for testing for antibodies to HIV was established for use by drug abusers. Four hundred and forty one patients were counselled in the first year, and over 60% were either drug abusers or their sexual contacts. One hundred and fourteen (26%) patients were positive for HIV antibody, and 100 (88%) of these were current or former drug abusers. The HIV seropositivity rate in drug abusers was 52% but was only 7% in their sexual contacts. Services were provided for these people as well as counselling before and after the test. The cost of this counselling service for the first year was 27,000 pounds or 61.22 pounds per patient. The unexpected mobility of 23% of the Edinburgh drug abusers, particularly to other areas of Britain, suggests that similar services need to be set up elsewhere.

Respiratory viruses in children admitted to hospital in Edinburgh 1972-1985

The temporal incidence of respiratory viruses identified in children admitted to an Edinburgh hospital over a period of 14 years, 1972-1985, is described, Respiratory syncytial (RS) virus was identified most often, usually (but not in 1979 and 1985) with single peaks of activity in the winter months. Influenza virus infections were seen in the winter and spring but we failed to find evidence of interference between RS and influenza virus. Of the viruses studied, the parainfluenza viruses were the least predictable in their epidemiological behaviour. The results of this study are compared with those of others and the role of certain aspects of the weather is considered.

Rapid diagnosis of herpes simplex virus infections in conventional and shell vial cell cultures using monoclonal antibodies

One hundred specimens for herpes simplex virus (HSV) isolation were tested in parallel by conventional and by centrifugation-enhanced cell culture, followed by identification using monoclonal antibodies to HSV-1 and HSV-2. Sensitivity was comparable by the two methods; conventional culture was only marginally slower and was easier to fit into the routine of a busy laboratory. It is, therefore, advocated for HSV detection in clinical specimens.

A comparison of the reactivity and immunogenicity of RA 27/3 strain rubella vaccine prepared in WI-38 or MRC5 human diploid cells

The immunogenicity and clinical reactivity of rubella vaccine derived from WI-38 or MRC5 human diploid cells was compared in 125 seronegative adolescent females. Seroconversion rates, assessed by single radial haemolysis testing of paired pre- and post-vaccination samples exceeded 98% (56/57 and 68/68 vaccinees, respectively) for both vaccines. Quantitative assessment of rubella-specific antibodies in 53 post-vaccination sera by an ELISA technique also failed to reveal any difference in immunogenicity between the vaccines. Assessable calendar records documenting the occurrence of local and systemic signs and symptoms in the four weeks following vaccination were returned by 106 subjects. No important statistically significant difference in parameters of clinical reactivity between the vaccine groups was observed although the incidence of pain at the injection site was found to be significantly higher for vaccinees receiving WI-38 derived vaccine.

Epidemic of AIDS related virus (HTLV-III/LAV) infection among intravenous drug abusers

Stored blood samples from 164 intravenous drug abusers who attended a Scottish general practice were tested for HTLV-III/LAV (human T cell lymphotropic virus type III/lymphadenopathy associated virus) infection. Of those tested, 83 (51%) were seropositive, which is well above the prevalence reported elsewhere in Britain and Europe and approaches that observed in New York City. The timing of taking samples of negative sera and continued drug use suggest that as many as 85% of this population might now be infected. The infection became epidemic in late 1983 and early 1984, thereafter becoming endemic. The practice of sharing needles and syringes correlated with seropositivity, which, combined with the almost exclusive intravenous use of heroin and other behavioural patterns, may explain the high prevalence of HTLV-III/LAV infection in the area. Rapid and aggressive intervention is needed to control the spread of infection.

Subclinical chronic Q fever

Seven patients are described in whom chronic Q fever was detected by serology (Coxiella burneti phase I antibody titre greater than 1:200) during routine screening at admission for cardiac catheterisation. None had clinical evidence of endocarditis, hepatitis or other foci of infection. Three of the patients were kept under observation without antibiotic treatment for periods of six, 18 and 20 months. In two patients of this group, cardiac tissue was obtained at operation and in one patient seroconversion following guinea-pig inoculation indicated the presence of Coxiella burneti infection. Four patients were given antibiotic treatment when Q fever was confirmed by serology. Courses of antibiotic treatment with a combination of two drugs were maintained for four to six years and in three of these patients phase I antibody titres fell to very low levels with no appearance of overt infection. The fourth patient died after resection of an aortic aneurysm, seven months after starting antibiotic treatment. Cases reported in the literature indicate that while endocarditis is the most common manifestation of chronic Q fever, the infection can persist at other sites. Of the seven cases of subclinical chronic Q fever reported here, the infection was localised in only one. Patients with this subclinical form of infection pose the therapeutic dilemma of whether or not they should receive antibiotic treatment.

Severe Chlamydia psittaci sepsis in pregnancy

Two patients with severe chlamydial sepsis in pregnancy are described and compared with previously published case reports. The infections appear to have been zoonotic, the patients acquiring their infections as a result of exposure to enzootic abortion of ewes. This is an important but poorly recognised human infection which because of its severity in pregnancy deserves consideration in patients with an appropriate occupational history.

Comparison of atypical rotaviruses from calves, piglets, lambs and man

Some rotaviruses from calves, piglets, and lambs were detected by electron microscopic examination of faeces but not by an enzyme-linked immunosorbent assay which relies on detection of group antigen. On further examination by polyacrylamide gel electrophoresis, these viruses had 11 segments of dsRNA, as had typical rotaviruses, but arranged in atypical patterns. From humans, three rotaviruses with atypical electrophoretypes were also detected. Gnotobiotic animals were infected with atypical calf, piglet and lamb rotaviruses, and used to provide antigen and antiserum for an immunofluorescent comparison of these rotaviruses with conventional rotaviruses and other previously described atypical rotaviruses from piglets and chickens. Two atypical rotaviruses from humans failed to infect gnotobiotic piglets. The atypical rotaviruses could be tentatively categorized into two groups serologically distinct from each other and from conventional rotaviruses, and these distinctions were consistent with electrophoretypes . The atypical chicken rotavirus may form a fourth distinct group. These findings are consistent with the hypothesis that rotaviruses belong to at least four separate groups definable by serology and electrophoretype .