The PiNe box: Development and validation of an electronic device to time-lock multimodal responses to sensory stimuli in hospitalised infants

Recording multimodal responses to sensory stimuli in infants provides an integrative approach to investigate the developing nervous system. Accurate time-locking across modalities is essential to ensure that responses are interpreted correctly, and could also improve clinical care, for example, by facilitating automatic and objective multimodal pain assessment. Here we develop and assess a system to time-lock stimuli (including clinically-required heel lances and experimental visual, auditory and tactile stimuli) to electrophysiological research recordings and data recorded directly from a hospitalised infant's vital signs monitor. The electronic device presented here (that we have called 'the PiNe box') integrates a previously developed system to time-lock stimuli to electrophysiological recordings and can simultaneously time-lock the stimuli to recordings from hospital vital signs monitors with an average precision of 105 ms (standard deviation: 19 ms), which is sufficient for the analysis of changes in vital signs. Our method permits reliable and precise synchronisation of data recordings from equipment with legacy ports such as TTL (transistor-transistor logic) and RS-232, and patient-connected networkable devices, is easy to implement, flexible and inexpensive. Unlike current all-in-one systems, it enables existing hospital equipment to be easily used and could be used for patients of any age. We demonstrate the utility of the system in infants using visual and noxious (clinically-required heel lance) stimuli as representative examples.

Functional brain maturation and sleep organisation in neonates with congenital heart disease

OBJECTIVE

Neonates with Congenital Heart Disease (CHD) have structural delays in brain development. To evaluate whether functional brain maturation and sleep-wake physiology is also disturbed, the Functional Brain Age (FBA) and sleep organisation on EEG during the neonatal period is investigated.

METHODS

We compared 15 neonates with CHD who underwent multichannel EEG with healthy term newborns of the same postmenstrual age, including subgroup analysis for d-Transposition of the Great Arteries (d-TGA) (n = 8). To estimate FBA, a prediction tool using quantitative EEG features as input, was applied. Second, the EEG was automatically classified into the 4 neonatal sleep stages. Neonates with CHD underwent neurodevelopmental testing using the Bayley Scale of Infant Development-III at 24 months.

RESULTS

Preoperatively, the FBA was delayed in CHD infants and more so in d-TGA infants. The FBA was positively correlated with motor scores. Sleep organisation was significantly altered in neonates with CHD. The duration of the sleep cycle and the proportion of Active Sleep Stage 1 was decreased, again more marked in the d-TGA infants. Neonates with d-TGA spent less time in High Voltage Slow Wave Sleep and more in Tracé Alternant compared to healthy terms. Both FBA and sleep organisation normalised postoperatively. The duration of High Voltage Slow Wave Sleep remained positively correlated with motor scores in d-TGA infants.

INTERPRETATION

Altered early brain function and sleep is present in neonates with CHD. These results are intruiging, as inefficient neonatal sleep has been linked with adverse long-term outcome. Identifying how these rapid alterations in brain function are mitigated through improvements in cerebral oxygenation, surgery, drugs and nutrition may have relevance for clinical practice and outcome.

The impact of premature extrauterine exposure on infants' stimulus-evoked brain activity across multiple sensory systems

Prematurity can result in widespread neurodevelopmental impairment, with the impact of premature extrauterine exposure on brain function detectable in infancy. A range of neurodynamic and haemodynamic functional brain measures have previously been employed to study the neurodevelopmental impact of prematurity, with methodological and analytical heterogeneity across studies obscuring how multiple sensory systems are affected. Here, we outline a standardised template analysis approach to measure evoked response magnitudes for visual, tactile, and noxious stimulation in individual infants (n = 15) using EEG. By applying these templates longitudinally to an independent cohort of very preterm infants (n = 10), we observe that the evoked response template magnitudes are significantly associated with age-related maturation. Finally, in a cross-sectional study we show that the visual and tactile response template magnitudes differ between a cohort of infants who are age-matched at the time of study but who differ according to whether they are born during the very preterm or late preterm period (n = 10 and 8 respectively). These findings demonstrate the significant impact of premature extrauterine exposure on brain function and suggest that prematurity can accelerate maturation of the visual and tactile sensory system in infants born very prematurely. This study highlights the value of using a standardised multi-modal evoked-activity analysis approach to assess premature neurodevelopment, and will likely complement resting-state EEG and behavioural assessments in the study of the functional impact of developmental care interventions.

A Deep Shared Multi-Scale Inception Network Enables Accurate Neonatal Quiet Sleep Detection with Limited EEG Channels

In this paper, we introduce a new variation of the Convolutional Neural Network Inception block, called Sinc, for sleep stage classification in premature newborn babies using electroencephalogram (EEG). In practice, there are many medical centres where only a limited number of EEG channels are recorded. Existing automated algorithms mainly use multi-channel EEGs which perform poorly when fewer numbers of channels are available. The proposed Sinc utilizes multi-scale analysis to place emphasis on the temporal EEG information to be less dependent on the number of EEG channels. In Sinc, we increase the receptive fields through Inception while by additionally sharing the filters that have similar receptive fields, overfitting is controlled and the number of trainable parameters dramatically reduced. To train and test this model, 96 longitudinal EEG recordings from 26 premature infants are used. The Sinc-based model significantly outperforms state-of-the-art neonatal quiet sleep detection algorithms, with mean Kappa 0.77 0.01 (with 8-channel EEG) and 0.75 0.01 (with a single bipolar channel EEG). This is the first study using Inception-based networks for EEG analysis that utilizes filter sharing to improve efficiency and trainability. The suggested network can successfully detect quiet sleep stages with even a single EEG channel making it more practical especially in the hospital setting where cerebral function monitoring is predominantly used.

Carbohydrate biopolymers, lignin based adsorbents for removal of heavy metals (Cd2+, Pb2+, Zn2+) from wastewater, regeneration and reuse for spent adsorbents including latent fingerprint detection: A review

Living organisms are created by carbohydrate biopolymers such as chitosan, carboxymethyl cellulose, alginate and lignin. These carbohydrate biopolymers have been extensively used for environmental applications because they are bio-degradable, bio-compatible, non-toxic and inexpensive. Recently, carbohydrate biopolymers have been used to prepare different nanocomposite adsorbents for treatment of wastewater. These adsorbents explored the removal effectiveness of inorganic pollutants from aqueous solution. This review article discusses the synthesis and application of chitosan, carboxymethyl cellulose, alginate and lignin nanocomposites as adsorbents for heavy metals. Toxic metals can be efficiently absorbed by cross-linkers, distributed in aqueous solutions of divalent heavy metal ions to examine their polymer absorption capacity. These nanocomposites were used for the adsorption of highly toxic metals such as Cd2+, Pb2+ and Zn2+ in water. To make heavy metal ion uptake more effective, more functionalization has been implemented such as blending, grafting, or mixing with different nanomaterials with an extra functional group. The integration of the second part into the main polymer chain not only adds functionality but also increases mechanical efficiency, one of the core criteria for adsorbent recyclability. The remediation method of metal ions from wastewater is cheaper as long as the adsorbent is reused. Furthermore, they exhibited good performance for the reuse of spent adsorbents after adsorption-desorption processes including latent fingerprint detection with nanomaterials by using the powder dusting method. Chitosan, carboxymethyl cellulose, alginate and lignin based nanocomposites have demonstrated better adsorption activities due to great physical and chemical properties for the chelation of heavy metals such as Cd2+, Pb2+ and Zn2+ from water and also higher regeneration with various eluents after several desorption-adsorption cycles. In addition, reuse of the spent adsorbents in latent fingerprint detection with different nanomaterials is discussed. Finally, this review article makes recommendations for future studies in light of environmentally favourable and economical applications.

Applying a data-driven approach to quantify EEG maturational deviations in preterms with normal and abnormal neurodevelopmental outcomes

Premature babies are subjected to environmental stresses that can affect brain maturation and cause abnormal neurodevelopmental outcome later in life. Better understanding this link is crucial to developing a clinical tool for early outcome estimation. We defined maturational trajectories between the Electroencephalography (EEG)-derived ‘brain-age’ and postmenstrual age (the age since the last menstrual cycle of the mother) from longitudinal recordings during the baby’s stay in the Neonatal Intensive Care Unit. Data consisted of 224 recordings (65 patients) separated for normal and abnormal outcome at 9–24 months follow-up. Trajectory deviations were compared between outcome groups using the root mean squared error (RMSE) and maximum trajectory deviation (δ^max). 113 features were extracted (per sleep state) to train a data-driven model that estimates brain-age, with the most prominent features identified as potential maturational and outcome-sensitive biomarkers. RMSE and δ^max showed significant differences between outcome groups (cluster-based permutation test, p < 0.05). RMSE had a median (IQR) of 0.75 (0.60–1.35) weeks for normal outcome and 1.35 (1.15–1.55) for abnormal outcome, while δ^max had a median of 0.90 (0.70–1.70) and 1.90 (1.20–2.90) weeks, respectively. Abnormal outcome trajectories were associated with clinically defined dysmature and disorganised EEG patterns, cementing the link between early maturational trajectories and neurodevelopmental outcome.

A convolutional neural network outperforming state-of-the-art sleep staging algorithms for both preterm and term infants

OBJECTIVE

To classify sleep states using electroencephalogram (EEG) that reliably works over a wide range of preterm ages, as well as term age.

APPROACH

A convolutional neural network is developed to perform 2- and 4-class sleep classification in neonates. The network takes as input an 8-channel 30 s EEG segment and outputs the sleep state probabilities. Apart from simple downsampling of the input and smoothing of the output, the suggested network is an end-to-end algorithm that avoids the need for hand-crafted feature selection or complex pre/post processing steps. To train and test this method, 113 EEG recordings from 42 infants are used.

MAIN RESULTS

For quiet sleep detection (the 2-class problem), mean kappa between the network estimate and the ground truth annotated by EEG human experts is 0.76. The sensitivity and specificity are 90% and 88%, respectively. For 4-class classification, mean kappa is 0.64. The averaged sensitivity and specificity (1 versus all) respectively equal 72% and 91%. The results outperform current state-of-the-art methods for which kappa ranges from 0.66 to 0.70 in preterm and from 0.51 to 0.61 in term infants, based on training and testing using the same database.

SIGNIFICANCE

The proposed method has the highest reported accuracy for EEG sleep state classification for both preterm and term age neonates.

HIV/HCV/HBV testing in the emergency department: a feasibility and seroprevalence study

OBJECTIVES

The aims of this study were to to assess the feasibility of simultaneous testing for the blood-borne viruses (BBV), HIV, hepatitis C (HCV) and hepatitis B (HBV), in the Emergency Department (ED) and ascertain the seroprevalence for these three viruses in this setting.

METHODS

A pilot BBV testing program was undertaken as part of routine clinical care in the ED. All ED attendees aged between 16 and 65 years old who were able to consent were tested over a 55 week period on an opt out basis. Patients with positive test results were linked to clinical services. Interventions aimed at improving testing rates were implemented and evaluated by quality improvement (QI) methodology.

RESULTS

Of 25,520 age-eligible ED attendees, 6108 (24%) underwent BBV testing; an additional 1160 (4.5%) underwent a standalone HIV test (total of 7268 (28%) individuals).There were 83/7268 (1.1%) non-negative (ie reactive or equivocal) results for HIV and 103/6108 (1.7%) and 32/6108 (0.52%) for anti-HCV IgG and HBsAg, respectively. Of these, 12 (0.17%), 16 (0.26%) and 8 (0.13%) were new reactive tests for HIV, HCV and HBV, respectively, which were able to be confirmed on a second test. Specific QI interventions led to temporary increases in testing rates.

CONCLUSIONS

An opt out BBV testing program in the ED is feasible and effective at finding new cases. However, the testing rate was low at 24%. Although QI interventions led to some improvement in testing rates, further studies are required to identify ways to achieve sustained increases in testing in this setting.

A Bayesian parametric model for quantifying brain maturation from sleep-EEG in the vulnerable newborn baby

Newborn babies, particularly preterms, can exhibit early deviations in sleep maturation as seen by Electroencephalogram (EEG) recordings. This may be indicative of cognitive problems by school-age. The current 'clinically-driven' approach uses separate algorithms to first extract sleep states and then predict EEG 'brain-age'. Maturational deviations are identified when the brain-age no longer matches the Postmenstrual Age (PMA, the age since the last menstrual cycle of the mother). However, the PMA range where existing sleep staging algorithms perform optimally, is limited, which subsequently limits the PMA range for brain-age prediction. We introduce a Bayesian Parametric Model (BPM) as a single end-to-end solution to directly estimate brain-age, modelling for sleep state maturation without requiring a separately optimized sleep staging algorithm. Comparison of this model with a traditional multi-stage approach, yields a similar Krippendorff's $\alpha = 0.92$ (a performance measure ranging from 0 (chance agreement) to 1 (perfect agreement)) with the BPM performing better at younger ages <30 weeks PMA. The BPM's potential to detect maturational deviations is also explored on a few preterm babies who were abnormal at 9 months follow-up.

Review of sleep-EEG in preterm and term neonates

Neonatal sleep is a crucial state that involves endogenous driven brain activity, important for neuronal survival and guidance of brain networks. Sequential EEG-sleep analysis in preterm infants provides insights into functional brain integrity and can document deviations of the biologically pre-programmed process of sleep ontogenesis during the neonatal period. Visual assessment of neonatal sleep-EEG, with integration of both cerebral and non-cerebral measures to better define neonatal state, is still considered the gold standard. Electrographic patterns evolve over time and are gradually time locked with behavioural characteristics which allow classification of quiet sleep and active sleep periods during the last 10weeks of gestation. Near term age, the neonate expresses a short ultradian sleep cycle, with two distinct active and quiet sleep, as well as brief periods of transitional or indeterminate sleep. Qualitative assessment of neonatal sleep is however challenged by biological and environmental variables that influence the expression of EEG-sleep patterns and sleep organization. Developing normative EEG-sleep data with the aid of automated analytic methods, can further improve our understanding of extra-uterine brain development and state organization under stressful or pathological conditions. Based on those developmental biomarkers of normal and abnormal brain function, research can be conducted to support and optimise sleep in the NICU, with the ultimate goal to improve therapeutic interventions and neurodevelopmental outcome.

An Automated Quiet Sleep Detection Approach in Preterm Infants as a Gateway to Assess Brain Maturation

Sleep state development in preterm neonates can provide crucial information regarding functional brain maturation and give insight into neurological well being. However, visual labeling of sleep stages from EEG requires expertise and is very time consuming, prompting the need for an automated procedure. We present a robust method for automated detection of preterm sleep from EEG, over a wide postmenstrual age (PMA = gestational age + postnatal age) range, focusing first on Quiet Sleep (QS) as an initial marker for sleep assessment. Our algorithm, CLuster-based Adaptive Sleep Staging (CLASS), detects QS if it remains relatively more discontinuous than non-QS over PMA. CLASS was optimized on a training set of 34 recordings aged 27–42 weeks PMA, and performance then assessed on a distinct test set of 55 recordings of the same age range. Results were compared to visual QS labeling from two independent raters (with inter-rater agreement Kappa = 0. 93), using Sensitivity, Specificity, Detection Factor (DF = proportion of visual QS periods correctly detected by CLASS) and Misclassification Factor (MF = proportion of CLASS-detected QS periods that are misclassified). CLASS performance proved optimal across recordings at 31–38 weeks (median DF = 1.0, median MF 0–0.25, median Sensitivity 0.93–1.0, and median Specificity 0.80–0.91 across this age range), with minimal misclassifications at 35–36 weeks (median MF = 0). To illustrate the potential of CLASS in facilitating clinical research, normal maturational trends over PMA were derived from CLASS-estimated QS periods, visual QS estimates, and nonstate specific periods (containing QS and non-QS) in the EEG recording. CLASS QS trends agreed with those from visual QS, with both showing stronger correlations than nonstate specific trends. This highlights the benefit of automated QS detection for exploring brain maturation.

Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review

INTRODUCTION

Gastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management.

AIM

The aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population.

METHOD

Between January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases.

RESULTS

Thirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days-12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease.

CONCLUSION

Invasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.

Intussusception as a presenting feature of Burkitt lymphoma: implications for management and outcome

PURPOSE

Intussusception is a recognised but unusual presenting feature of Burkitt lymphoma. We sought to identify the clinical features associated with intussusception in this setting, and assess the outcome following protocol directed chemotherapy.

METHODS

A retrospective case note review was performed on patients treated for Burkitt lymphoma at our institution between 1976 and 2010. Cases presenting with intussusception were identified from hospital records and oncology database.

RESULTS

Fourteen of the 210 children seen with a diagnosis of Burkitt lymphoma during the study period (6.7%) developed intussusception. Median age was 6.1 years (range 2.5-10.9). Twelve patients presented with recurrent abdominal pain, and two patients with a jaw mass associated with endemic Burkitt lymphoma. Nine patients underwent a right hemicolectomy with ileo-colic anastomosis, and five had segmental small-bowel resections. Three patients had bone marrow involvement at diagnosis, two of whom died. All patients received chemotherapy. Median follow-up was 6.07 years (range 0.1-28.8).

CONCLUSIONS

Small bowel lymphoma should be considered in children presenting with intussusception above the normal infantile peak age range. The presentation is often insidious, and complete obstruction may not be apparent. However, when surgically resected, the majority can achieve a good outcome with additional chemotherapy.

RYR1 mutations are a common cause of congenital myopathies with central nuclei

OBJECTIVE

Centronuclear myopathy (CNM) is a rare congenital myopathy characterized by prominence of central nuclei on muscle biopsy. CNM has been associated with mutations in MTM1, DNM2, and BIN1 but many cases remain genetically unresolved. RYR1 encodes the principal sarcoplasmic reticulum calcium release channel and has been implicated in various congenital myopathies. We investigated whether RYR1 mutations cause CNM.

METHODS

We sequenced the entire RYR1 coding sequence in 24 patients with a diagnosis of CNM from South Africa (n = 14) and Europe (n = 10) and identified mutations in 17 patients. The most common genotypes featured compound heterozygosity for RYR1 missense mutations and mutations resulting in reduced protein expression, including intronic splice site and frameshift mutations.

RESULTS

The high incidence in South African patients (n = 12/14) in conjunction with recurrent RYR1 mutations associated with common haplotypes suggested the presence of founder effects. In addition to central nuclei, prominent histopathological findings included (often multiple) internalized nuclei and type 1 fiber predominance and hypotrophy with relative type 2 hypertrophy. Although cores were not typically seen on oxidative stains, electron microscopy revealed subtle abnormalities in most cases. External ophthalmoplegia, proximal weakness, and bulbar involvement were prominent clinical findings.

INTERPRETATION

Our findings expand the range of RYR1-related phenotypes and suggest RYR1 mutations as a common cause of congenital myopathies with central nuclei. Corresponding to recent observations in X-linked CNM, these findings indicate disturbed assembly and/or malfunction of the excitation-contraction machinery as a key mechanism in CNM and related myopathies.

Polymyositis in African HIV-infected subjects

Polymyositis in HIV-infected subjects, clinically and pathologically resemble polymyositis in non-HIV-infected subjects. We report 14 consecutive HIV-associated polymyositis cases and compare specific features with 25 polymyositis cases seen over the same 6.5 year period. The HIV-polymyositis cases were all female and compared to the polymyositis cases were younger (median age 33 years, interquartile range (IQR) 29; 37 vs. 46 years, IQR 38; 52, p=0.002), and with 4-fold lower serum creatine kinase (CK) values (median 1158 vs. 5153IU/l; p=0.019). A definite clinical improvement on prednisone therapy was documented in eight HIV-polymyositis cases and one improved with anti-retroviral therapy alone. The recognition of HIV-polymyositis which is treatable, but may present with serum CK elevations less than twofolds above normal, is clinically relevant in sub-Saharan Africa where electromyography and muscle biopsies are not readily available.

Multi-walled carbon nanotubes as adsorbents for the removal of parts per billion levels of hexavalent chromium from aqueous solution

The adsorption capabilities for the removal of parts per billion levels (ppb) of hexavalent chromium by three adsorbents namely activated carbon, functionalized multi-walled carbon nanotubes (MWCNTs) and unfunctionalized multi-walled carbon nanotubes were investigated as a function of contact time, initial solution pH, initial Cr(VI) concentrations and the presence of competing anions. The unfunctionalized MWCNTs showed the highest adsorption capability with up to 98% of a 100 ppb Cr(VI) solution being adsorbed. Both functionalized and non-functionalized MWCNTs showed a superior adsorption capability to that of activated carbon. The removal of Cr(VI) was higher at lower pH. Furthermore, the uptake of Cr(VI) was hindered by the presence of the competing anions, Cl(-) and SO(4)(2-). Both Langmuir and Freundlich isotherms have been used to describe the Cr(VI) adsorption process. The major mechanisms for Cr(VI) removal have been identified as an ion exchange mechanism, intraparticle diffusion and electrostatic interactions. The adsorbed Cr(VI) could also be desorbed readily from the MWCNTs surface at high pH.

High-risk sexual behaviour in men attending a sexually transmitted infection clinic in Durban, South Africa

OBJECTIVES

A study of men with genital ulcer disease (GUD) in Durban, South Africa, at the start of the local HIV epidemic in 1988/1989 found that 36% of men with GUD continued with sexual intercourse despite symptoms. The aim of this study was to determine whether this high-risk behaviour was still prevalent and to enquire about similar risk behaviours with other sexually transmitted infection (STI)-related problems.

METHODS

650 Men attending the main Durban STI clinic with a new complaint were enrolled. A standard questionnaire was administered. Polymerase chain reaction (PCR) tests were performed to diagnose genital herpes from ulcer specimens and gonorrhoea and chlamydia from those with urethral discharge and/or dysuria. Serology tests were performed for HIV, herpes simplex virus type 2 (HSV-2) and syphilis.

RESULTS

Sex since the start of symptoms was reported by between 33.3% and 43.9% of men with GUD, herpetic ulcers, gonorrhoea and/or chlamydia or dysuria. The incidence of condom use was very low in all groups having sex despite symptoms. In 87 men with genital ulcers confirmed positive for genital herpes by PCR testing, 30 (34.4%) had had sex since the start of symptoms, 28 (93.3%) of whom had had unprotected sex.

CONCLUSIONS

There is a high level of risk behaviour in this group of men in whom genital herpes is the most common cause of GUD. This risky sexual behaviour could reflect disinhibition, possibly because so many have already been infected with HSV-2, lack of education or other unknown factors. Syndromic STI management should be strengthened with intensive health education to promote community awareness of both genital ulceration and genital herpes and their role in facilitating HIV transmission. The low level of condom use indicates that condom promotion programmes still have much to achieve.

Poikiloderma, tendon contracture and pulmonary fibrosis: a new autosomal dominant syndrome?

Members of two generations of a South African family have a unique syndrome comprising poikiloderma, tendon contractures and progressive pulmonary fibrosis. The condition is clinically important as the skin changes, which involve the face, have considerable cosmetic impact, while lung involvement is potentially lethal in adulthood. Skin manifestations which facilitate diagnosis include facial telangiectasia, mottled hypo- and hyperpigmentation, papules and epidermal atrophy. The scalp, facial and body hair are fine and scanty. The tendon contractures lead to progressive digital flexion deformities and abnormalities of the ankles and feet, with disturbance of gait. Pulmonary involvement manifests as progressive dyspnoea. Pedigree data are compatible with an autosomal dominant mode of transmission. Poikiloderma of Weary is characterized by linear sclerotic and fibrous bands and not tendon contractures and is not associated with potentially lethal pulmonary fibrosis. Rather than name this disorder a variant of Weary syndrome, it might be prudent to use as an umbrella title one composed by Weary himself: 'hereditary sclerosing poikiloderma' (HSP), under which variants such as HSP Weary type, HSP with cardiac involvement (aortic stenosis described as inconsistently associated with Weary syndrome) and HSP with tendon/pulmonary involvement (current family) may be classified. The manifestations in this family differ from other poikilodermata and, to the best of our knowledge, have not been previously documented.

‘The Corporate University’ Training And Learning

The training and development of employees in the airline industry usually take place within a decentralized structure and may result in fragmented and costly initiatives. To improve the current practice a corporate university (CU) model to be implemented in the airline is proposed. For the purpose of the study qualitative interviews were held, human documents were studied and participant observation and the views of employees of the South African airline industry were sought regarding training in general and CUs in particular. The study revealed support for the CU concept because it would encourage continuous learning at all levels in the organisation and would place emphasis on both employee and organisational needs.

An evaluation of molecular markers for improved detection of breast cancer metastases in sentinel nodes

BACKGROUND AND OBJECTIVES

In patients with breast cancer (BC), the sentinel node (SN) is the first node in the axillary basin that receives the primary lymphatic flow and can be used to accurately assess the axillary nodal status without removal of the axillary contents. Currently, histology and/or immunohistochemistry are the routine methods of SN analysis. The primary objective of this study was to develop a reproducible reverse transcription (RT) PCR assay, with emphasis on achieving high specificity for accurate detection of BC micrometastases in the SN. To correct for the heterogeneity of BC cells, a multimarker approach was followed, with the further aim of improving the detection rate of the assay.

METHODS

In total, 73 markers were evaluated, of which 7 were breast epithelial markers and 66 were either cancer testis or tumour associated antigens. Twelve BC cell lines and 30 SNs (from 30 patients) were analysed using RT-PCR to determine the in vitro and in vivo detection rates for each of the markers. In addition, 20 axillary nodes obtained from a patient with brain death were used as controls to optimise the PCR cycle numbers for all the markers.

RESULTS

Of the 30 SNs, 37% (11/30) were positive on haematoxylin and eosin analysis. Extensive immunohistochemical (IHC) analyses of the haematoxylin and eosin negative nodes confirmed the presence of very small numbers of BC cells in an additional 40% (12/30) of SNs. Molecular analysis with the hMAM-A alone identified metastases in 70% (21/30) of SNs. Using MAGE-A3 in combination with hMAM-A identified metastases in 90% (27/30) of patients. Seven SNs (23%) were negative for micrometastases (with haematoxylin and eosin and IHC) but RT-PCR positive for either hMAM-A or MAGE-A3.

CONCLUSIONS

As IHC analysis resulted in a 77% detection rate compared with 37% for haematoxylin and eosin analysis, we consider that IHC is essential in order not to miss SN micrometastases. Molecular analysis with hMAM-A and MAGE-A3 allows detection of BC micrometastases with a 90% detection rate. However, the clinical value of histologically negative but RT-PCR positive SNs can only be determined with long term follow up.

Routinely available cotrimoxazole prophylaxis and occurrence of respiratory and diarrhoeal morbidity in infants born to HIV-infected mothers in South Africa

OBJECTIVES

To examine the influence of cotrimoxazole (CTM) prophylaxis on incidence of lower respiratory tract infections (LRTIs) and diarrhoea.

DESIGN

A prospective observational cohort study. Morbidity and feeding data on infants born to HIV-infected mothers were collected routinely at clinic visits at 1 week, 6 weeks and 3 months, and 3-monthly thereafter, with blood drawn for determining HIV status.

SETTING

Two hospitals in Durban, South Africa. In one hospital (King Edward VIII Hospital), infants born to HIV infected mothers received CTM prophylaxis and in the other (McCord Hospital) infants did not receive CTM prophylaxis.

SUBJECTS

Infants born to HIV-infected mothers. Outcome measures. Incidence of LRTI and diarrhoea.

RESULTS

In multivariate analysis controlling for breast-feeding status, number of clinic visits and HIV infection status, HIV infected infants with access to CTM prophylaxis had a significantly lower incidence of LRTI (82%) than those without access to prophylaxis. However in HIV-uninfected infants, this was not the case. CTM prophylaxis was associated with a non-significant increased risk for diarrhea in both infected (odds ratio (OR) 1.58, p = 0.45) and uninfected infants (OR 1.52, p = 0.10).

CONCLUSIONS

This observational study confirms current thinking that CTM prophylaxis is protective against LRTIs in HIV-infected children. However, because of a possible association between CTM prophylaxis and an increased risk of diarrhoea, HIV status of infants should be determined as early as possible in order to prevent unnecessary exposure of uninfected infants to CTM prophylaxis, while further studies to quantify both beneficial and adverse effects of CTM prophylaxis are undertaken.

Interdigitating dendritic cell sarcoma: a report of four paediatric cases and review of the literature

AIMS

To report a series of four paediatric cases of interdigitating dendritic cell sarcoma (IDCS) and add to the known extranodal sites of occurrence for this tumour. Neoplasms derived from interdigitating dendritic cells are rare, with only 33 cases being reported in the literature (Medline search). These tumours usually occur in lymph nodes in the adult population.

METHODS AND RESULTS

The patients were a 10-year-old girl with a large soft tissue mass bulging into the left chest, a 12-year-old girl with a right paraspinal mass, a 21-month-old boy with generalized lymphadenopathy and hepatosplenomegaly and a 6-year-old girl with a large bladder mass. Paraffin blocks and haematoxylin and eosin slides were available in all cases. In addition, immunohistochemistry and electron microscopy were performed. A diagnosis of IDCS was made in all cases.

CONCLUSION

The diagnosis of IDCS can rarely be entertained on clinical information alone. Microscopically, there is a wide spectrum of features. Thus, immunohistochemistry and electron microscopy are crucial in making the diagnosis. The differential diagnosis includes inflammatory pseudotumour, follicular dendritic cell sarcoma, true histiocytic lymphoma, malignant Langerhans cell histiocytosis, anaplastic large-cell lymphoma, melanoma, and a range of sarcomas. IDCS displays aggressive behaviour and approximately half of the patients die of the disease.

Ageing of chromium(III)-bearing slag and its relation to the atmospheric oxidation of solid chromium(III)-oxide in the presence of calcium oxide

Slag arising in ferrochromium and stainless steel production is known to contain residual levels of trivalent chromium. As the chromium is normally bound in the slag matrix in various silicate or spinel phases, and hence not easily mobilised, utilisation or controlled disposal of such slag is generally considered unproblematic. Experimental test work with a number of slag materials indicates, however, that very gradual oxidation of trivalent to hexavalent chromium does occur when the slag is exposed to atmospheric oxygen, rendering a quantifiable but small portion of chromium in this much more mobile and toxic form. Mechanisms and rates of the oxidation reaction were investigated in a number of long-term studies using both original slag materials and artificial mixes of chromium and calcium oxides. Powders of these materials, some of them rolled into balls, were left to age under different conditions for periods of up to 12 months. In the slag samples, which contained between 1 and 3 wt.% chromium, 1000-10000 microg Cr(VI) were found per gram of chromium within 6-9 months of exposure to an ambient atmosphere. The rate of the oxidation reaction decreased exponentially, and the reaction could generally be said to have ceased within 12 months. In mixtures of calcium and chromium oxides the oxidation reaction is presumed to occur at the boundaries between chromium oxide and calcium oxide phases through diffusion of oxygen along the grain boundaries and of Cr(3+) across the boundaries, resulting in the formation of calcium chromate. In the slags, where calcium and chromium oxide can form a solid solution, the oxidation is likely to occur at the exposed surface of grains containing this solution.

Morbidity in children born to women infected with human immunodeficiency virus in South Africa: does mode of feeding matter?

AIM

To examine infant morbidity risks associated with refraining from breastfeeding where it is used in an attempt to prevent mother-to-child transmission (MTCT) of human immunodeficiency virus (HIV).

METHODS

The population consisted of infants born to HIV-infected women in South Africa who were participating in a vitamin A intervention trial to prevent MTCT of HIV. Women chose to breastfeed or formula feed their infants according to UNAIDS guidelines. Actual feeding practices and morbidity were recorded at clinic follow-up visits at I wk, 6 wk, 3 mo and every 3 mo thereafter until 15 mo of age or cessation of breastfeeding. The infant's HIV status was assessed according to a predetermined algorithm.

RESULTS

HIV-infected infants who were never breastfed had a poorer outcome than those who were breastfed; 9 (60%) of those who were never breastfed had 3 or more morbidity episodes compared with 15 (32%) of breastfed children [odds ratio (OR) 4.05, 95% confidence interval (95% CI) 0.91-20.63, p = 0.05]. During the first 2 mo of life, never-breastfed infants (regardless of HIV status) were nearly twice as likely to have had an illness episode than breastfed infants (OR 1.91, 95% CI 1. 17-3.13, p = 0.006).

CONCLUSION

The significant extra morbidity experienced in the first few months by all never-breastfed infants and at all times by HIV-infected infants who are not breastfed needs to be considered in all decisions by mothers, health workers and policy makers so as not to offset any gains achieved by decreasing HIV transmission through avoiding breastfeeding.

Association of angiomyolipoma and oncocytoma of the kidney: a case report and review of the literature

AIM

The association between renal carcinoma and angiomyolipoma is rare. Only 14 cases have been reported in the literature. The purpose of this paper is to present an additional case and review the literature on this association.

PATIENT AND METHODS

A healthy 42 year old woman was found to have a left flank mass incidentally when she presented for a Papanicolaou smear. The computerised tomography scan revealed a left lower pole renal mass consistent with a renal cell carcinoma. A nephrectomy was performed and the patient recovered uneventfully. The nephrectomy specimen was processed routinely. In addition to haematoxylin and eosin staining, immunohistochemistry for CAM 5.2, vimentin, CD34, antismooth muscle actin, and HMB45 was carried out. Transmission electron microscopy was also performed.

RESULTS

Macroscopically, the lower pole of the kidney contained a well circumscribed, non-encapsulated, tan coloured tumour with a large area of central haemorrhage measuring 10.5 cm. In addition, there was a 0.4 cm poorly circumscribed unencapsulated yellow nodule adjacent to the tumour. Microscopically, the larger tumour showed characteristic features of an oncocytoma. Numerous mitochondria were seen on electron microscopy. The smaller yellow nodule was an angiomyolipoma.

CONCLUSIONS

This paper presents an additional case of oncocytoma associated with angiomyolipoma. Of the 15 cases described in the literature, three were associated with the tuberous sclerosis complex, all from a single study. In tuberous sclerosis, angiomyolipomas are more commonly associated with renal cell carcinoma. If angiomyolipomas are found incidentally in nephrectomy specimens together with other tumours, it is important to exclude tuberous sclerosis retrospectively.

Users' attitudes towards home and hospital treatment: a comparative study between South Asian and white residents of the British Isles

This study examines attitudes, of adult users of mental health services, towards hospital and home treatment in a crisis or emergency. A comparison was made between South Asian clients (n = 35) and white residents of the British Isles (n = 26) with a diagnosis of schizophrenia as defined by the International Classification of Diseases (ICD 10). The aim was to broaden the knowledge base of the psychiatric service providers in an under-researched area. Data were collected using a structured 15-item questionnaire, measured on a five-point Likert scale. Although both groups of respondents expressed preference for home treatment, the reasons stated differed. There were statistical differences (P = 0.05) in five of the 15 items, including diet, stigma, treatment concordance, religious practices and faith healing, which form the bulk of the discussion. Greater client satisfaction is conditional upon a quality of care responsive to individual needs. These needs may vary according to ethnicity, religious beliefs, diet, language and family life, among other factors. As the cultural constitution of Britain continues to alter, it is increasingly important that healthcare professionals are sensitive, knowledgeable and skilled in caring for such a culturally diverse population. In turn, this may avoid stereotyping or mislabelling.

ALK protein expression in rhabdomyosarcomas

AIMS

The ALK p80 chimeric protein is thought to be up-regulated as a result of the t(2;5) as classically seen in anaplastic large cell lymphoma. However, rhabdomyosarcomas (in particular, the alveolar subtype) have also been noted to show expression of this protein. This study set out to examine ALK expression in a large number of rhabdomyosarcomas.

METHODS AND RESULTS

Eighty-three cases of rhabdomyosarcomas and 16 cases of malignant mixed müllerian tumours with a rhabdomyosarcomatous component were retrieved from the archives of the Department of Anatomical Pathology for the period 1983-2001. The sections were stained with polyclonal ALK antibody. There were 52 male and 30 female patients. In one case, the gender of the patient was not indicated. The ages ranged from 1 week to 77 years. The most common site was the head and neck region, followed by the pelvis and extremities. Thirty-one cases were of the alveolar subtype while 40 cases were embryonal. There were four mixed embryonal/alveolar, six pleomorphic and two unclassifiable rhabdomyosarcomas. Fourteen of the 31 (45%) alveolar rhabdomyosarcomas stained positively for the ALK protein, while only six of the 40 embryonal (15%) cases showed positivity. One case each of the mixed embryonal/alveolar, pleomorphic and unclassified cases was also immunopositive. The rhabdomyosarcomatous component in the malignant mixed müllerian tumours was positive in four of the 16 cases.

CONCLUSION

We conclude that a proportion of alveolar rhabdomyosarcomas (in particular) exhibit ALK protein expression. However, ALK expression is not restricted to this subtype. An extension of this study is to determine if this over-expression is as a result of the t(2;5) translocation.

Malakoplakia in association with colorectal carcinoma: a series of four cases

AIMS

Malakoplakia is a characteristic inflammatory condition which is usually seen in the urogenital tract. Gastrointestinal malakoplakia is seen in association with a variety of conditions such as ulcerative colitis, diverticular disease, adenomatous polyps and carcinoma. The purpose of this paper is to report four additional cases of colorectal cancer associated with malakoplakia and review the literature on this association.

METHODS

All specimens were colectomies for cancer. Routine handling of the specimen with lymph node harvesting was performed. In addition to H&E stains, PAS, Perls' Prussian Blue and von Kossa stains were performed.

RESULTS

Three of the cases were encountered in males and the patients ranged in age from 55 to 64 years. One case each occurred in the caecum/ascending colon and descending colon, while the remaining two were located in the rectum. All four cases were Dukes' stage B tumours. Furthermore, all four cases had spread to pericolic fat and two had perforated. Microscopic examination showed the malakoplakia to be present at the infiltrating edge of the tumours. The draining lymph nodes were involved by malakoplakia to varying degrees in all cases.

CONCLUSIONS

From this series and the literature review, malakoplakia associated with colorectal cancer tends to occur in elderly males in the rectum. The malakoplakia is found at the infiltrating front of the tumour and is not admixed with the neoplastic glands. Although lymph node involvement by malakoplakia has been reported only once previously, all four cases in this series showed evidence of involvement. The association does not appear to have any prognostic significance.