The frequency of change in five-point scale score with a Bayesian penalised likelihood PET reconstruction algorithm on interim FDG PET-CT and its potential implications for therapy decisions in Hodgkin's lymphoma

AIM

To assess the effect of a Bayesian penalised likelihood (BPL) reconstruction algorithm on the five-point scale (5-PS) score, response categorisation, and potential implications for therapy decisions after interim 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)-computed tomography (CT) (iPET-CT) to guide treatment in classical Hodgkin's lymphoma (HL).

MATERIALS AND METHODS

The present study included new patients with HL undergoing iPET-CT from 2014-2019 after two cycles of doxorubicin (Adriamycin), bleomycin, vincristine, and dacarbazine (ABVD). Two reporters categorised response using the 5-PS and measured maximum standardised uptake values (SUV_max) of the most avid tumour residuum, mediastinal blood pool, and normal liver with ordered subset expected maximisation (OSEM) and BPL reconstructions.

RESULTS

Eighty-one iPET-CT examinations were reviewed. Compared with OSEM, BPL increased the 5-PS score by a single score in 18/81 (22.2%) patients. The frequency of potential treatment intensification by changing a score of 3-4 was 13.6% (11/81) and represented 25% (11/44) of patients with a score of 3 on OSEM. All 11 patients remained in remission without a change in therapy (mean 63 months) except one who required second-line treatment for refractory disease. Median SUV_max of tumour residuum was significantly higher with BPL compared with OSEM (2.7 versus 2.4, p<<0.0001), whilst liver SUV_max was significantly lower for both reporters (up to 6.6%, p<0.0001).

CONCLUSION

BPL PET reconstruction increased the 5-PS score on iPET-CT in 22% of HL patients and can potentially result in unnecessary treatment escalation in over half of these patients.

A 10-fold and greater increase in D-dimer at admission in COVID-19 patients is highly predictive of pulmonary embolism in a retrospective cohort study

Background:

COVID-19 patients present with both elevated D-dimer and a higher incidence of pulmonary embolism (PE). This single-centre retrospective observational study investigated the prevalence of early PE in COVID-19 patients and its relation to D-dimer at presentation.

Methods:

The study included 1038 COVID-19-positive patients, with 1222 emergency department (ED) attendances over 11 weeks (16 March to 31 May 2020). Computed tomography pulmonary angiogram (CTPA) for PE was performed in 123 patients within 48 h of ED presentation, of whom 118 had D-dimer results. The remaining 875 attendances had D-dimer performed.

Results:

CTPA performed in 11.8% of patients within 48 h of ED presentation confirmed PE in 37.4% (46/123). Thrombosis was observed at all levels of pulmonary vasculature with and without right ventricular strain. In the CTPA cohort, patients with PE had significantly higher D-dimer, prothrombin time, C-reactive protein, troponin, total bilirubin, neutrophils, white cell count and lower albumin compared with non-PE patients. However, there was no difference in the median duration of inpatient stay or mortality. A receiver operator curve analysis demonstrated that D-dimer could discriminate between PE and non-PE COVID-19 patients (area under the curve of 0.79, p < 0.0001). Furthermore, 43% (n = 62/145) of patients with D-dimer >5000 ng/ml had CTPA with PE confirmed in 61% (n = 38/62), that is, 26% of >5000 ng/ml cohort. The sensitivity and specificity were related to D-dimer level; cutoffs of 2000, 3000, 4000, and 5000 ng/ml, respectively, had a sensitivity of 93%, 90%, 90% and 86%, and a specificity of 38%, 54%, 59% and 68%, and if implemented, an additional 229, 141, 106 and 83 CTPAs would be required.

Conclusion:

Our data suggested an increased PE prevalence in COVID-19 patients attending ED with an elevated D-dimer, and patients with levels >5000 ng/ml might benefit from CTPA to exclude concomitant PE.

Comminuted nasogastric tube fracture: a rare complication

A nasogastric tube is commonly used as a method of enteral feeding or gastric decompression in clinical practice and its insertion is occasionally associated with local complications. In this case report, we present an extremely rare complication of a comminuted nasogastric tube fracture in a 54-year-old male patient receiving enteral feeding in hospital secondary to a diagnosis of haemophagocytic lymphohistiocytosis.

Pulmonary thrombosis in Covid-19: before, during and after hospital admission

Disordered coagulation, endothelial dysfunction, dehydration and immobility contribute to a substantially elevated risk of deep venous thrombosis, pulmonary embolism (PE) and systemic thrombosis in coronavirus disease 2019 (Covid-19). We evaluated the prevalence of pulmonary thrombosis and reported RV (right ventricular) dilatation/dysfunction associated with Covid-19 in a tertiary referral Covid-19 centre. Of 370 patients, positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), 39 patients (mean age 62.3 ± 15 years, 56% male) underwent computed tomography pulmonary angiography (CTPA), due to increasing oxygen requirements or refractory hypoxia, not improving on oxygen, very elevated D-dimer or tachycardia disproportionate to clinical condition. Thrombosis in the pulmonary vasculature was found in 18 (46.2%) patients. However, pulmonary thrombosis did not predict survival (46.2% survivors vs 41.7% non-survivors, p = 0.796), but RV dilatation was less frequent among survivors (11.5% survivors vs 58.3% non-survivors, p = 0.002). Over the following month, we observed four Covid-19 patients, who were admitted with high and intermediate-high risk PE, and we treated them with UACTD (ultrasound-assisted catheter-directed thrombolysis), and four further patients, who were admitted with PE up to 4 weeks after recovery from Covid-19. Finally, we observed a case of RV dysfunction and pre-capillary pulmonary hypertension, associated with Covid-19 extensive lung disease. We demonstrated that pulmonary thrombosis is common in association with Covid-19. Also, the thrombotic risk in the pulmonary vasculature is present before and during hospital admission, and continues at least up to four weeks after discharge, and we present UACTD for high and intermediate-high risk PE management in Covid-19 patients.

Bombay phenotype (Oh ) and high-titer anti-H in pregnancy: two case reports and a review of the literature

BACKGROUND

Antenatal cases of Bombay-phenotype (O_h ) individuals and hemolytic disease of the fetus and newborn (HDFN) are not well described in the literature. We present two case reports of high-titer anti-H in pregnant O_h individuals and their serologic investigation, clinical management, and subsequent outcomes. We describe current published cases detailing pregnancy in O_h individuals, to add to the evidence base for clinical decision making and management of pregnancy.

STUDY DESIGN AND METHODS

We describe two case reports of high-titer anti-H in pregnancy in O_h individuals. We summarize published cases to date, to inform clinical decision making and antenatal management in individuals with the Bombay phenotype.

RESULTS

Of the case reports described, neither were affected by HDFN due to anti-H. Antibody titers were high in both cases (immunoglobulin G titer scores, 512 and 4000, respectively) and would be expected to cause some degree of HDFN, a surprising finding. Regular mean cerebral artery Doppler ultrasound was normal. Patient blood management (PBM) techniques ensured that the patient's hemoglobin (Hb) levels were monitored and maintained. Transfusion intervention was not required, with minimal blood loss recorded at birth in both cases.

CONCLUSION

High-titer anti-H in O_h pregnancies may, in rare cases, cause HDFN, but evidence suggests that this may not be the case in all pregnancies. We recommend a multidisciplinary approach, with prompt referral to a fetomaternal medicine unit, combined with PBM strategies, and a planned delivery with the provision of rare-phenotype units (if available and if indicated) on standby.

Use of core biopsy in diagnosing cervical lymphadenopathy: a viable alternative to surgical excisional biopsy of lymph nodes?

OBJECTIVES Lymphoma often presents with a neck mass and while fine-needle aspiration cytology may be suggestive, tissue biopsy is required for reliable diagnosis and classification of a lymphoma that is sufficient to deliver the correct treatment for the patient. Traditionally, excisional biopsy of a lymph node has been the standard method of tissue sampling, providing ample tissue for assessment. However, this requires theatre time, and preceding fine-needle aspiration cytology, which may incur a delay. With careful use of tissue, coupled with advances in immunohistochemical and molecular investigative techniques, core biopsy provides a possible alternative to traditional fine-needle aspiration and excisional biopsy. In this study, we aimed to determine the efficacy of diagnosing neck masses. METHOD A retrospective analysis was performed of patients being investigated for a neck mass who were undergoing ultrasound-guided core biopsies of cervical lymph nodes over a 17-month period. The final histology report was scrutinised to assess whether adequate tissue was obtained to allow for full tissue diagnosis. RESULTS Over the 17-month period analysed, 70 patients with cervical lymphadenopathy underwent core biopsy. Of these, 63 (90%) were diagnostic for either lymphoma or other pathology and did not require further tissue sampling. Overall, 19 patients were diagnosed with lymphoma, of which only 1 required further biopsy due to inconclusive initial core biopsy. CONCLUSIONS Current guidelines for investigating lymphomas require that excisional biopsy be performed to obtain ample tissue to allow full nodal architecture assessment and ancillary investigation to reach an accurate histological classification. Within our head and neck multidisciplinary team, however, it is considered that results from core biopsies can be obtained in a more timely fashion and with histological accuracy equal to those of open biopsy. The results obtained demonstrate that core biopsy is an effective tool for investigation. We believe this should be the first-line investigation of choice, as it reduces the need for patients to undergo surgery, is more cost effective and offers a faster diagnosis.

Safety of long-term treatment with Pegvisomant: analysis of Spanish patients included in global ACROSTUDY

PURPOSE

To evaluate the long-term safety of Pegvisomant (PEG) in the Spanish cohort of ACROSTUDY.

METHODS

As of July 2013, 199 Spanish patients were included in ACROSTUDY, a global non interventional safety PEG surveillance study. Patients were observed for safety, biochemical outcome and magnetic resonance imaging evaluations.

RESULTS

PEG was administered during an average period of 6.7 ± 2.1 years and a mean daily dose of 15.5 ± 7.5 mg. 48.2% of patients received PEG monotherapy. 90.9% of patients had received other medical treatment before PEG start. 195 adverse events (AEs) were reported in 88 patients (44.2%), and serious AEs were described in 31 patients (15.6%). There were no cases of liver tests >10 ULN, or permanent liver damage. Tumor size changes were locally reported in 61 cases (33.5%), with increases observed in 11 patients (6%). In acromegalic patients with diabetes mellitus a decrease in fasting serum glucose value was reported, reaching statistical significance after 1 and 4 years of treatment (-24.6 and -25.9 mg/dl, p = 0.04). After 60 months, normal or lower limit of normal (LLN) IGF-I levels were found in 67.9% of patients. 85.5% of patients showed an IGF-I normal or <LLN at any time after PEG start. Most patients with uncontrolled IGF-I levels were on submaximal PEG doses.

CONCLUSIONS

ACROSTUDY carried out with the Spanish cohort confirmed that PEG has a favorable safety and efficacy profile. The percentage of patients considered under control was similar to data reported globally and in other local ACROSTUDY results.

Laparoscopic retroperitoneal/mesenteric lymph node sampling: a safe and effective technique

INTRODUCTION

Needle aspiration and core biopsies are commonly used to assess retroperitoneal lymph nodes. However, the tissue obtained by this method is insufficient to define and type the tumour. This article demonstrates the feasibility and safety of the laparoscopic approach in obtaining an adequate volume of lymph node tissue for typing.

METHODS

Laparoscopic retroperitoneal lymph node biopsy was performed on 12 patients over a period of five years. A pneumoperitoneum was induced with a Veress needle, and an initial 10-mm trocar was inserted in the sub-umbilical region in order to carry a 30-degree telescope. Two or more 5-mm ports were inserted into the targeted areas under laparoscopic guidance to achieve optimal triangulation in order to access the nodal tissue.

RESULTS

The procedure was successful in 11 out of the 12 patients. An average volume of 1.7 cm3 of tissue was harvested for each patient. In one patient with preoperatively undiagnosed portal hypertension, laparoscopy was converted to an open procedure due to bleeding. In all patients, the histology was adequate and contributed to the diagnosis, allowing rapid institution of treatment. The diagnosis was reactive lymphadenopathy in three patients and sarcoidosis in one patient. Seven others suffered from various conditions, including lymphoma, leukaemia, secondary from unknown origin and Castleman's disease.

CONCLUSION

Laparoscopy allows access to perihepatic and perisplenic areas, and is a procedure of choice when needle biopsy is not possible or fails to provide an adequate sample.

Use of Zidovudine and Interferon Alfa With Chemotherapy Improves Survival in Both Acute and Lymphoma Subtypes of Adult T-Cell Leukemia/Lymphoma

Purpose

Adult T-cell leukemia/lymphoma (ATLL) is a mature (post-thymic) T-cell lymphoma associated with human T-lymphotropic virus type 1 infection. Survival in aggressive subtypes remains poor, and treatment resistance is frequent. Use of zidovudine (ZDV) and interferon alfa (IFN-α) has been associated with improved response rates in small studies and prolonged overall survival in leukemic ATLL subtypes in a recent meta-analysis.

Patients and Methods

We report the clinicopathologic characteristics, treatment, and outcome of 73 patients with aggressive ATLL (acute ATLL, 29; lymphoma ATLL, 44) diagnosed and treated in England between 1999 and 2009. The impact of ZDV/IFN-α on treatment response and survival was assessed.

Results

The overall response rate ranged from 49% with chemotherapy alone to 81% with combined first-line therapy (chemotherapy with concurrent/sequential ZDV/IFN-α). Median overall survival (OS) was 9 months: 7.5 months for acute ATLL and 10 months for lymphoma ATLL. Use of ZDV/IFN-α at any time prolonged survival in acute (P < .001) and lymphoma ATLL (P < .001) and was the sole factor associated with reduction in risk of death in aggressive ATLL (hazard ratio, 0.23; 95% CI, 0.09 to 0.60; P = .002). Combined first-line therapy prolonged median OS in acute (P = .0081) and lymphoma ATLL (P = .001) compared with chemotherapy alone.

Conclusion

These data support the use of low-dose ZDV/IFN-α with chemotherapy in first-line treatment of acute and lymphoma ATLL.

[Cost analysis of 3 candins in the treatment of invasive candidiasis in adult non-neutropaenic patients in Spain]

OBJECTIVE

To estimate the cost of 3 candins (anidulafungin, caspofungin and micafungin) in the treatment of adult non-neutropaenic patients with invasive candidiasis (IC) in a Spanish hospital pharmacy setting.

METHODS

The overall cost impact was evaluated by varying the percentage dosage required of each candin in different possible scenarios. The prices (in euros) for each presentation were obtained from the Drug Catalogue (in August 2010). Only drug purchase costs were considered. The results are expressed as total cost for each of the 3 candins.

RESULTS

The cost per episode (14 days) of anidulafungin was constant at €5400 per patient. The cost of caspofungin varied from €4281 to €7991, depending on patient weight and liver dysfunction. The cost of micafungin varied from €6000 (100mg/day) to €9000 (when increasing the dose due to inadequate response). Based on a hypothetic cohort of 100 patients with IC, the total cost of anidulafungin treatment would be €540,000, for caspofungin it would be €631,459, and for micafungin it would be €632,998, depending on any dose adjustment required.

CONCLUSION

Patients treated with anidulafungin did not require dose adjustment, unlike those treated with caspofungin or micafungin. The use of anidulafungin is a cost-saving treatment for adult non-neutropaenic patients with IC, which would result in better control of the Spanish pharmacy budget.

Fusion of high b-value diffusion-weighted and T2-weighted MR images improves identification of lymph nodes in the pelvis

Accurate identification of lymph nodes facilitates nodal assessment by size, morphological or MR lymphographic criteria. We compared the MR detection of lymph nodes in patients with pelvic cancers using T2-weighted imaging, and fusion of diffusion-weighted imaging (DWI) and T2-weighted imaging. Twenty patients with pelvic tumours underwent 5-mm axial T2-weighted and DWI (b-values 0-750 s/mm(2)) on a 1.5T system. Fusion images of b = 750 s/mm(2) diffusion-weighted MR and T2-weighted images were created. Two radiologists evaluated in consensus the T2-weighted images and fusion images independently. For each image set, the location and diameter of pelvic nodes were recorded, and nodal visibility was scored using a 4-point scale (0-3). Nodal visualisation was compared using Relative to an Identified Distribution (RIDIT) analysis. The mean RIDIT score describes the probability that a randomly selected node will be better visualised relative to the other image set. One hundred fourteen pelvic nodes (mean 5.9 mm; 2-10 mm) were identified on T2-weighted images and 161 nodes (mean 4.3 mm; 2-10 mm) on fusion images. Using fusion images, 47 additional nodes were detected compared with T2-weighted images alone (eight external iliac, 24 inguinal, 12 obturator, two peri-rectal, one presacral). Nodes detected only on fusion images were 2-9 mm (mean 3.7 mm). Nodal visualisation was better using fusion images compared with T2-weighted images (mean RIDIT score 0.689 vs 0.302). Fusion of diffusion-weighted MR with T2-weighted images improves identification of pelvic lymph nodes compared with T2-weighted images alone. The improved nodal identification may aid treatment planning and further nodal characterisation.

Endovascular repair of a pseudoaneurysm of the abdominal aorta secondary to translumbar aortography

This report describes an incidental finding of a pseudoaneurysm of the abdominal aorta on a computed tomography (CT) renal angiogram during investigation of chronic renal failure in a 73-year-old man. The patient had undergone a translumbar aortogram 20 years previously. An increase in the size of the aneurysm by 7 mm over 6 months prompted treatment and the aneurysm underwent successful endovascular repair with a custom-made stent-graft.

Epistaxis and oral anticoagulant therapy

Epistaxis in the anticoagulated patient poses a complicated management problem, which requires interdisciplinary collaboration. The aetiology of the majority of cases of epistaxis remains idiopathic, but an ageing population and the prevalence of ischaemic heart disease and peripheral vascular disease has meant that there are increasing numbers of patients on long term oral anticoagulant therapy. This has led to a concomitant increase in the incidence of complications experienced. We have reviewed the available relevant literature and guidelines in the current management practice in this scenario. In light of this, we propose a more standardised algorithm for the management of epistaxis in this challenging group of patients.

[Diagnosis of septo-pyramidal defects. Our report]

OBJECTIVE

The aim of the study is to determine the characteristics of patients who are operated on because of a nasal or septal deformity: clinical features before surgery, physical examination, anterior active rhinomanometry, and computed tomography (CT).

METHODS

We retrospectively reviewed prospective data collected on 372 patients operated on between January 1998 and June 2002 by means of a septoplasty or a rhinoplasty.

RESULTS

Gender distribution was: 253 male, 119 female. A smaller percentage of men underwent correction of pyramidal deformities in comparison to women. Nasal endoscopic examination diagnosed associated inflammatory pathologies in 12.4% of patients. We found a significant relationship between previous nasal trauma, laterorrinia and defects of the dorsum. Anterior active rhinomanometry had a high variability between patients.

CONCLUSIONS

Prospective data collected on these patients was useful to know more precisely our activities and how to adapt them to suit management decisions. Endoscopic examination proved high efficiency in the diagnosis of this pathology.

[Is there a place for otorhinolaryngology in primary care? Analysis of different areas]

Otolaryngological disorders do have a high incidence, and prevalence and require specific physical examinations amongst general population. As a result, it is believed that it would be efficient to have otorhinolaryngologists within the primary care system. The main aim of this study was to assess the differences in hospital referrals comparing primary care units with and without ENT specialists. The study was carried out in Osona County (Catalonia, Spain). We studied the referrals to the hospital from two different primary care units, one with otorhinolaryngology services and the other without them. We analysed the morbidity, follow up and demographic variables of first visits in the hospital ENT department referred by these two primary care units. The primary care organisation without ENT specialist tends to refer more patients (3.96 first visits more per 1000 inhabitants a year, CI 95% 2.84-5.09) with ENT problems than the primary care one with ENT specialist. The difference is mainly due to an higher number of referrals that do not require hospital treatment (i.e. acute otitis, patients without an ENT clear diagnosis). In the area with ENT specialist, GP's also tend to refer patients directly to the hospital, hampering the organisation efficiency. The referrral pattern of GPs from the two organisations is quite similar, and they refer a high percentage of patients that do not need ENT hospital care. The study shows that ENT specialists in primary care units refer less patients with ENT disorders that can be successfully diagnosed and treated outside the hospital.

Partner notification in HIV-1 infection: a population based evaluation of process and outcomes in Scotland

OBJECTIVES

To evaluate the process and outcomes of HIV partner notification (PN) activity in Scotland.

DESIGN

Retrospective population based study.

SUBJECTS

114 adults newly diagnosed with HIV infection (index patients) in Scotland between September 1995 and August 1996.

SETTING

Healthcare settings in which all 114 new HIV diagnoses were made: 42 (37%) from genitourinary medicine; 32 (28%) infectious diseases; 18 (16%) general practice; and 22 (19%) from other sites.

MAIN OUTCOME MEASURES

Number of partners notified and tested up to 9 months after initial diagnosis.

RESULTS

Of 114 index patients (IPs), information on current partners was available for 102 (89%). PN was not appropriate for 47 of the 102 IPs. The remaining 55 IPs identified 63 current partners at risk, of whom 51 were notified: 44 underwent HIV testing, which yielded 11 new HIV positive diagnoses. Information on previous partners was available for only 56 IPs (49%). PN was not appropriate for 30 of the 56 IPs; the remaining 26 IPs identified 46 previous partners at risk, of whom 12 were notified: four were tested, but yielded no new diagnoses.

CONCLUSIONS

Notification of current partners was performed well and was an effective strategy for identification of HIV positive individuals at a presymptomatic stage. Notification of previous partners was limited. Partner notification was attempted in a wide range of healthcare settings. Given the clinical effectiveness of antiretroviral therapy, partner notification as a tool towards early diagnosis of HIV disease deserves renewed attention.

Interferon alpha and zidovudine therapy in adult T-cell leukaemia lymphoma: response and outcome in 15 patients

Adult T-cell leukaemia lymphoma (ATLL) is an aggressive disease caused by the human T-lymphotropic virus 1 (HTLV-I) with a short survival. Responses to interferon alpha (IFN-alpha) and zidovudine (AZT) have been documented but not with long-term follow-up. We treated 15 ATLL patients with IFN and AZT. Eleven patients had acute ATLL, two had lymphoma and two smouldering ATLL, with progression. The main features were: organomegaly (14), skin lesions (10), high white blood cell (WBC) count (11) and hypercalcaemia (9). Eleven patients had previously received chemotherapy and one had received an autograft. At the time of the study, seven patients had progressive disease and eight were in partial or complete clinical remission. Responses (PR) lasting 2+ to 44+ months were seen in 67%; 26% did not respond (NR) and one patient was not evaluable. Hypercalcaemia predicted a poor outcome but differences were not significant. Eight of the 15 patients have died 3-41 months from diagnosis. Median survival for the 15 patients was 18 months. Survival of the NR ranged from 4 to 20 months; six PR patients are alive 8-82 months from diagnosis. The differences in survival between NR (median: 6 months) and PR (55% of patients alive at 4 years) were statistically significant (P = 0.002). In conclusion, IFN and AZT improves the outcome of ATLL patients and helps maintain responses.

Hepatitis E virus: relevance in blood donors and other risk groups

BACKGROUND AND OBJECTIVES

Hepatitis E virus (HEV) infection usually causes an acute self-limited disease. HEV is associated with feces-contaminated drinking water, but other vectors, such as blood, are possible. The aim of this study was to investigate the prevalence of HEV in blood donors and in two groups at high risk of parenteral infections, namely, hemodialysis patients and children infected with hepatitis C virus (HCV) via blood transfusion.

MATERIALS AND METHODS

We investigated the prevalence of anti-HEV in 863 blood donors, 63 hemodialysis patients, and 42 children infected with HCV posttransfusion.

RESULTS

The prevalence rates were 2.8, 6. 3%, and 0 respectively.

CONCLUSIONS

(1) The incidence of HEV in Spain is similar to that in other western European countries, and (2) HEV is probably not transmitted parenterally to children.

Hepatitis E virus: relevance in blood donors and risk groups

BACKGROUND AND OBJECTIVES

Hepatitis E virus (HEV) infection usually causes acute self-limited disease. HEV is associated with faecal-contaminated drinking water, but other vectors, such as blood, are possible. The aim of this study was to investigate the prevalence of HEV in blood donors and in two groups at high risk for parenteral infections, namely, haemodialysis patients, and children infected with HCV via blood transfusion.

MATERIALS AND METHODS

We investigated the prevalence of anti-HEV in 863 blood donors, 63 haemodialysis patients, and 42 children infected post transfusion with HCV.

RESULTS

The prevalence rates were 2.8, 6.3%, and zero, respectively.

CONCLUSIONS

(1) The incidence of HEV in Spain is similar to that in other Western European countries, and (2) HEV is probably not transmitted parenterally to children.

Semiquantitative culture of subcutaneous segment for conservative diagnosis of intravascular catheter-related infection

BACKGROUND

Sensitivity and negative predictive values of combined surface cultures (skin and hub) are high in the presumptive diagnosis of catheter-related infection, but specificity and PPVs are poor. The purpose of the study was to evaluate the yield of the semiquantitative culture of the subcutaneous segment in the diagnosis of colonization of the catheter tip without removal of the catheter.

METHODS

A prospective study was performed in 124 nontunneled central venous catheters that were removed because of suspected infection or the end of therapy. Catheter colonization was considered if >15 colony-forming units (CFU) in the roll procedure or > 1,000 CFU in the quantitative Cleri procedure were recovered from the tip cultures ("gold standard"). Before removing the catheter, a semiquantitative culture of skin surrounding the point of insertion, a semiquantitative culture of the subcutaneous segment (after removing the catheter only 2 cm), a semiquantitative cultures of the hub, and a pareated quantitative blood culture were performed. Receiver operating characteristic curves were calculated to estimate the cutoff points, and a culture was considered positive when CFUs were > or =15, > or =15, and > or =5 for skin, hub, and subcutaneous segment cultures, respectively.

RESULTS

Catheter colonization was detected in 51 catheters. The mean duration of catheterization was 14 +/- 8 days, and the rates of incidence of tip colonization and bacteremia were 2.9 per 100 catheter days and 1.2 per 100 catheter days, respectively. Sensitivity of skin, subcutaneous, and hub cultures analyzed individually were < or =61%; however, specificity and positive predictive values (PPVs) of subcutaneous segment cultures were significantly higher than skin cultures (94% and 88.5% vs 71.6% (p = .001) and 62% (p = .014), respectively). Sensitivity of the combined skin and hub cultures and of the combined subcutaneous segment and hub cultures were similar: 86.2% and 84.3%, respectively; however, specificity and PPVs of this latter combination were significantly higher than former: 82% and 78.1% vs 59.7% (p = .008) and 61.9% (p = .07), respectively. The likelihood ratio of a positive test for the combined subcutaneous segment and hub culture was 4.68, and only 2.13 for the combined skin and hub culture.

CONCLUSIONS

These results indicate that the combined subcutaneous segment and hub culture constitutes an easy, effective procedure for the conservative diagnosis of catheter colonization.

Gastrointestinal mucormycosis complicated by arterio-enteric fistula in a patient with non-Hodgkin's lymphoma

Gastrointestinal mucormycosis is a rare, often fatal, systemic infection found predominantly in immunocompromised patients. We report a case of gastrointestinal mucormycosis in a 53-year-old female with non-Hodgkin's lymphoma. Following her first course of chemotherapy, bowel obstruction developed as a result of mucormycosis. Despite treatment with antifungal therapy, she required a laparotomy owing to severe haemorrhage caused by mucormycosal invasion of her iliac artery. With continued antifungal treatment and further chemotherapy, she ultimately underwent reversal of her Hartmann's procedure and remains disease-free.

Abnormal lipids and the acquired immunodeficiency syndrome: is there a problem and what should we do about it?

Recent research has shown abnormal lipids in acquired immunodeficiency syndrome (AIDS). In human immunodeficiency virus (HIV) infection hypocholesterolaemia, hypertriglyceridaemia and also low high density lipoprotein (HDL)-cholesterol have all been described. In addition, increased dense low density lipoprotein (LDL) particles and also lipoprotein (a) have been observed in some patients. The use of the protease inhibitors has been associated with diabetes mellitus and also features of insulin resistance. This article looks at these lipid abnormalities in detail and discusses possible therapeutic options that may be available, in order to address them.

[Acute hepatitis E in Spain]

Hepatitis E virus (HEV) is the worldwide leading cause of non-A non-B enterically transmitted hepatitis, and affects most commonly the population in developing countries. Cases outside this area, are nearly always imported, although apparent local acquisition has been occasionally reported. We assisted three patients with acute HEV hepatitis, confirmed by the presence of serum anti-HEV IgM. One of them did not report travelling outside of Spain in the previous years. HEV has to be included in the differential diagnosis of acute non-A non-B non-C hepatitis, even in cases in which an exposure in endemic areas cannot be recalled.

[Prospective study of Staphylococcus aureus with reduced susceptibility to glycopeptides]

The emergence of clinical methicillin-resistant Staphylococcus aureus with reduced susceptibility to glycopeptides has recently been documented. Heterogeneous levels of glycopeptides susceptibility have been demonstrated in these isolates. Prospectively, we investigated the presence of S. aureus isolates with reduced susceptibility to vancomycin in our hospital from October 1997 to January 1998. The vancomycin and teicoplanin susceptibility of 248 consecutively methicillin-susceptible and -resistant S. aureus isolates from clinical and surveillance specimens was studied by broth microdilution and agar dilution methods. In addition, 108 CFU/mI of overnight cultures were plated onto BHI-agar plates containing 6 and 10 microg/ml of vancomycin and were incubated for 48 hours at 35 degrees C. Under these conditions selected colonies were subcultured onto vancomycin plates and vancomycin susceptibility (E-test) was determined again. Vancomycin MIC(90) values by the agar dilution technique for methicillin-susceptible and -resistant isolates were 2 and 4 microg/ml, respectively No selected colonies were observed on 10 microg/ml vancomycin plates. In contrast, 12 isolates, including 8 (3.9%) methicillin-susceptible and 4 (9. 1%) methicillin-resistant isolates, showed subpopulations at a frequency rate of 10(-6)-10(-7) on 6 microg/ml vancomycin plates. Nevertheless, a significant increase in MIC values for vancomycin was not observed in these S. aureus subpopulations.

Malaria in inner London

This retrospective analysis was performed to describe the malarial cases treated in an inner London hospital during a single year (1996). A total of 44 case records were available for review, 40 (90.9%) were due to Plasmodium falciparum. Thirty-seven patients were admitted to hospital, there were no deaths. Only two (4.5%) patients had taken adequate malarial prophylaxis. A total of 119 inpatient bed-days were utilized in the treatment of malaria in 1 year. In 75 (63%) of these bed-days, observation was the only reason for continued inpatient treatment. The commonest laboratory findings are mild elevation of serum bilirubin to a mean of 28 micromol/l, and a low platelet count to a mean of 124x10(12)/l. A bilirubin greater than 20 micromol/l was found in 72.9% of patients (95% CI; 58.7-87.3%). The platelet count was less than 150x10(12)/l in 77.3% of patients (95%, CI; 64.9-89.7%). We found that malaria is not uncommon in inner London. Whilst most cases are admitted few complications are usually seen. Many cases may well be able to be treated with a brief hospital admission, possibly to an accident and emergency observation ward.

ABO blood groups, rhesus factor and Helicobacter pylori

BACKGROUND

The aim of this study was to demonstrate an association between Helicobacter pylori infection, ABO blood groups and Rhesus factor; providing the association between duodenal ulcer and O group blood as well as the former and H. pylori infection.

METHODS

Three-hundred and one healthy subjects were prospectively studied. In all of them ABO blood groups and Rhesus factor were determined by standard techniques. Systemic IgG antibodies against H. pylori were assayed using a quantitative enzyme-linked immunosorbent assay technique (Helico-G, Porton, Cambridge, UK).

RESULTS

The overall seroprevalence was 52.2%. H. pylori infection distribution was similar among ABO blood groups and Rhesus factor. No statistically significant differences were observed in mean values of IgG antibodies among different blood groups.

CONCLUSIONS

Distribution of H. pylori seroprevalence does not differ between different ABO or Rhesus factor blood groups. This excludes a possible link between this microorganism and the high ulcer prevalence in O blood group.

Soft salt-mannitol agar-cloxacillin test: a highly specific bedside screening test for detection of colonization with methicillin-resistant Staphylococcus aureus

The early detection of colonization with methicillin-resistant Staphylococcus aureus (MRSA) of patients in intensive-care units is an essential step in the strategy for preventing MRSA epidemics. In this study, tubes containing soft salt-mannitol agar with cloxacillin (6 microg/ml) (SSMAC) were prepared for inoculation of clinical samples at patients' bedsides by personnel of an intensive-care unit. A total of 1,914 swabs from different sample sites of 81 patients were dipped into SSMAC tubes, and after 24 h of incubation (in an incubator located near the intensive-care unit), an evident color change was considered by the intensive-care-unit personnel to be an MRSA alarm. Sixty-three (3.3%) SSMAC tubes were considered positive for MRSA, 1,827 (95.4%) were considered negative, and 24 (1.2%) were considered intermediate. Compared with values for parallel conventional surveillance cultures for MRSA, excluding tubes with intermediate results, the SSMAC test had a sensitivity of 72.7%, a specificity of 99.2%, a positive predictive value of 76.2%, and a negative predictive value of 99.0%. When intermediate tubes were considered positive, the corresponding values were 75.3, 98.2, 63.2, and 99.0%, respectively. The sensitivity and specificity values of the test to identify MRSA-colonized patients were 89.4 and 100%, respectively. Oropharyngeal and naris specimens were the most reliable samples for MRSA detection. False-negative results were frequent in bronchial aspirates with low (< 10(3) to 10(6) CFU/ml) MRSA counts. False-positive results were mainly due to methicillin-resistant Staphylococcus haemolyticus. The SSMAC tube is a useful, rapid, and inexpensive tool for the early identification of MRSA-colonized patients and, consequently, for the implementation of measures to prevent the spread of MRSA.

Usefulness of the combined IgG and IgA antibody determinations for serodiagnosis of Helicobacter pylori infection

BACKGROUND

Serology is a good alternative, minimally invasive, diagnostic and screening test for Helicobacter pylori infection. Several immunoglobulin G (IgG) enzyme-linked immunosorbent assay (ELISA) commercial kits have been evaluated. Information on IgA ELISAs is relatively poor, and on the combined use of IgG and IgA ELISAs very scarce.

OBJECTIVE

We intended to evaluate the sensitivity, specificity and predictive values of two quantitative commercial IgG and IgA ELISAs (Helico-G and GAP, respectively) and more particularly the accuracy of their combined use.

PATIENTS AND METHODS

Serum samples and gastric biopsy specimen culture findings from 400 patients were evaluated.

RESULTS

The sensitivity, specificity, positive and negative predictive values of the IgG ELISA Helico-G test in detecting IgG antibodies to H. pylori were 97.2, 85.4, 98.3 and 77.8%, respectively, when compared with those of the reference method used. The corresponding findings for detection of IgA antibodies with the GAP test were 96.4, 80.5, 97.7 and 71.1%, respectively. When considering a patient infected with H. pylori when both tests were positive, the sensitivity, specificity, positive and negative predictive values were 94.1, 85.3, 98.2 and 62.5%, respectively. On the other hand, when at least one test was positive, the corresponding values were 99, 80, 97 and 94%, respectively.

CONCLUSION

The IgG ELISA Helico-G and IgA ELISA GAP, taken separately, are good and reliable tests for the detection of antibodies to H. pylori. Furthermore, the combined use of both serological methods provided more useful information compared with single IgG and IgA determinations.

Helicobacter pylori infection in a healthy population in Spain

OBJECTIVE

To determine the seroprevalence of Helicobacter pylori infection in healthy individuals in Spain and its relationship with different epidemiological features.

PATIENTS AND METHODS

The study was conducted on a large group of healthy individuals without ulcer disease antecedents or other gastrointestinal disease; moreover, information, was obtained on symptoms attributable to the gastrointestinal tract, smoking, alcohol consumption, non-steroidal anti-inflammatory drug (NSAID) use as well as the presence of peptic ulcer disease antecedents among first-degree relatives. The H. pylori infection status was ascertained by immunoglobulin G (IgG) antibody determination, using a quantitative enzyme-linked immunosorbent assay.

RESULTS

Three hundred and eighty-one individuals (138 males and 243 females) were included in the study (mean age: 34.3 +/- 12.9 years; range: 5-77). Two hundred and two individuals (53%) were positive for H. pylori IgG antibodies. A consistent increase in H. pylori infection seroprevalence with increasing age was observed. No association was observed between H. pylori infection and consumption of alcohol, NSAID use or smoking. On the other hand, the presence of digestive symptoms and peptic ulcer disease antecedents among first-degree relatives were associated with a higher prevalence of infection in a given individual (P < 0.05).

CONCLUSION

H. pylori infection seroprevalence in healthy individuals in Spain is similar to that in countries with high socio-economic standards and other Western countries. Digestive symptoms and previous antecedents of peptic ulcer disease in first-degree relatives were associated with a higher prevalence of Helicobacter pylori infection.

Autoimmune haemolytic anaemia in infancy with anti-Kpb specificity

Autoimmune haemolytic anaemia (AIHA) in infancy is rare. We report a case of AIHA in a male infant whose serum contained an antibody with apparent anti-Kpb specificity. Autoantibody with anti-Kpb specificity has been described in adults; to our knowledge, this is the first case of this kind described in infancy with AIHA. Clinical course and response to red cell transfusion are described.

HIV-disease and bone marrow changes: a study of 60 cases

We report our experience of peripheral blood and bone marrow changes in patients with HIV disease. Abnormalities were most commonly seen in patients with advanced disease. In AIDS group IV patients (CDC classification) anaemia (92%) neutropenia (85%) monocytopenia (75%) and thrombocytopenia (61%) have their highest incidence, the reason being a combination of factors such as infection, myelosuppressive drugs and HIV infection itself. Bone marrow examinations were performed most commonly for microbiological culture (25%) and the investigation of anaemia (16%). Morphological changes in the bone marrow were non-specific and not pathognomic; however erythroid hypoplasia was found to be a distinctive feature associated with MAI infection. The procedure provided a high yield for microbiological culture, particularly in MAI infection.