Hand weakness in Charcot-Marie-Tooth disease 1X

There have been suggestions from previous studies that patients with Charcot-Marie-Tooth disease (CMT) have weaker dominant hand muscles. Since all studies to date have included a heterogeneous group of CMT patients we decided to analyse hand strength in 43 patients with CMT1X. We recorded handedness and the MRC scores for the first dorsal interosseous and abductor pollicis brevis muscles, median and ulnar nerve compound motor action potentials and conduction velocities in dominant and non-dominant hands. Twenty-two CMT1X patients (51%) had a weaker dominant hand; none had a stronger dominant hand. Mean MRC scores were significantly higher for first dorsal interosseous and abductor pollicis brevis in non-dominant hands compared to dominant hands. Median nerve compound motor action potentials were significantly reduced in dominant compared to non-dominant hands. We conclude that the dominant hand is weaker than the non-dominant hand in patients with CMT1X.

The psychological impact of facial changes in scleroderma

The physical disabilities associated with scleroderma are well known but the psychological impact of the condition has received less attention. Few studies have examined appearance related issues, most notably of the face. The aim of this study is to evaluate the psychological impact of facial, aesthetic and functional changes in scleroderma. One hundred seventy-one patients with a clinical diagnosis of scleroderma were recruited into the study. Digital photographs were objectively graded into groups based on severity of disfigurement as judged by an observer. Facial movement was recorded using a modified House-Brackmann Grading Scale. Psychological evaluation comprised the Derriford Appearance Scale short-form (DAS), the Noticeability and Worry score and the Hospital Anxiety and Depression Scale (HADS). Severity of disfigurement predicted decreased mouth opening, the extent to which participants judged their appearance as noticeable to others, and the level of appearance-related concern as measured by the DAS24. There was an inverse relationship with age. Facial changes were ranked as the most worrying aspect of the condition. This study shows facial disfigurement impacts on patient with scleroderma independent of functional changes related to systemic disease. The major difficulty is with the perceived noticeably of the condition to other people and the resulting self-consciousness in social encounters.

HIV prevalence and testing practices among tuberculosis cases in London: a missed opportunity for HIV diagnosis?

BACKGROUND

Universal testing for HIV in patients with tuberculosis (TB) has been advocated for over a decade. The aim of this study was to describe the prevalence and testing practices of HIV in TB centres in London.

METHODS

A cohort study was undertaken of all patients with TB in Greater London in 2003-4 (n = 1941). Logistic regression was used to assess factors affecting being offered and accepting testing and having a positive HIV result.

RESULTS

The overall known prevalence of HIV was 9.9% (193/1941). In those with a test result (including those diagnosed previously) it was 25.6%. Overall, 50.8% of patients aged > or =20 years without previous testing were offered HIV testing and, of these, 73% accepted. In multivariable analysis, factors associated with being HIV positive were age 20-49 years, black ethnicity and being born overseas. Those with smear-negative disease and with a poor understanding of English were significantly less likely to be offered HIV testing. Factors associated with refusal of an offered test were female gender or age >49 years. HIV status was not associated with smear status, drug resistance or death, but was associated with CNS disease (OR 1.8, 95% CI 1.0 to 3.0, p = 0.003).

CONCLUSIONS

Nearly half the patients with TB in London in 2003-4 were not offered HIV testing. In those offered testing, uptake was high. Patients in higher risk groups were more likely to be offered testing but, even within the highest risk groups, testing was not universally offered. This represents a missed opportunity for diagnosing HIV in patients with TB in London.

Abandoned babies in the UK - a review utilizing media reports

BACKGROUND

In the absence of national policy or comprehensive data, the phenomenon of abandoned babies is poorly understood in the UK. This study aims to use media reports as a resource to collate existing information on abandoned babies and to draw conclusions to inform future response.

METHODS

An exhaustive media search using electronic searches and media monitoring was undertaken to glean systematic information on all abandoned babies in the UK from 1998-2005. These were matched onto two databases - the UK Crime Statistics and the UK Abandoned Children Register in an attempt to align information on infant abandonment. Media reports were coded to list gender, survival, age, parental finding and circumstantial data.

RESULTS

Our figures suggest an average of 16 babies abandoned yearly, while official sources give conflicting indications because of incomplete data gathering and child over-inclusion. Through systematic coding of media reports, 124 babies were identified over a 7-year period. Of these, 96 (77.4%) were newborns (<1 week old) and 28 (22.6%) were older babies (>1 week old). Adjusted logistic regression analysis found the strongest predictors of survival were age at abandonment and 'findability'. Newborn babies were less likely to survive than older babies (33.7% newborns died vs. 0% older babies, P < 0.0001). Babies left in a non-findable location (34%) had a 5.19 (2.06, 13.11) higher odds of death compared with those to be found. Most babies (74%) were abandoned outdoors and only 9.7% were left with a memento. Few mothers, almost exclusively those of older babies, were found (37.1%). Of those found, 92% were located within 3 days of abandoning their baby. Media interest is transient - 44.8% cases have a single report - and are typified by negative headlines (81.5%).

CONCLUSIONS

This database currently represents the most accurate and comprehensive picture of the newborn abandonment phenomenon in the UK, a phenomenon that is rare but with high media and social interest. If the future well-being of mother and baby are to be catered for, clearer evidence-based policy and provision is vital.

Prediction of phenotypic susceptibility to antiretroviral drugs using physiochemical properties of the primary enzymatic structure combined with artificial neural networks

OBJECTIVES

Genotypic interpretation systems extrapolate observed associations in datasets to predict viral susceptibility to antiretroviral drugs (ARVs) for given isolates. We aimed to develop and validate an approach using artificial neural networks (ANNs) that employ descriptors of physiochemical properties for mutations in HIV-1 protease (PR) and reverse transcriptase (RT) to predict phenotypic susceptibility to all currently approved ARVs.

METHOD

We extracted pairs of PR and RT gene sequences (n=1507; 98.5% sub-type B) and their corresponding exact phenotype values (PhenoSense only, n=10 132) from the Stanford HIV database. All amino acid positions and mixture codes were accounted for. For each ARV, an ANN was trained with 10-fold internal cross-validation. The predictive abilities of these trained ANNs were validated on separate datasets.

RESULTS

Correlation coefficients between observed and predicted phenotype values in the 10-fold cross-validation ranged from: 0.75 (tenofovir) to 0.94 [lamivudine (3TC)] for nucleoside RT inhibitors (NRTIs); 0.82 [efavirenz (EFV)] to 0.83 [nevirapine (NVP)] for non-nucleoside RT inhibitors (NNRTIs); and 0.83 (atazanavir) to 0.92 (ritonavir) for PR inhibitors (PIs). For the validation set the correlation coefficients ranged from 0.76 (didanosine) to 0.96 (3TC) for NRTIs; 0.68 (EFV) to 0.81 (NVP) for NNRTIs; and 0.88 (amprenavir) to 0.95 (saquinavir) for PIs. For C sub-type predictions, with ANNs trained on sub-type B data, the correlation coefficient was 0.89.

CONCLUSIONS

ANNs, based on the physiochemical properties of the PR and RT amino-acid sequences, predict phenotypic susceptibility to ARVs inhibiting these enzymes to an extent that is comparable to routine phenotypic susceptibility testing. These ANNs can also be used to predict resistance to C sub-types.

Women who decline antenatal screening for HIV infection in the era of universal testing: results of an audit of uptake in three London hospitals

Universal screening for HIV in early pregnancy is strongly promoted policy in the United Kingdom with a target of 90 per cent uptake. We identified characteristics of women declining screening by conducting an audit at three hospitals in inner north London. In early 2002 midwives were asked to complete an audit form following first antenatal appointment. Of 2,710 women attending 401 (15 per cent) declined an HIV test. Of women who declined 38 per cent reported they had been tested for HIV in the past; 65 per cent accepted every other antenatal test. In multivariable analysis parity (OR: 1.19; 95 per cent CI 1.10-1.29 per additional child), declining other tests (OR: 3.10; 95 per cent CI 2.44-3.93 per test declined) and previous HIV testing (OR: 1.70; 95 per cent CI 1.30-2.23) were predictors of declining an HIV test. Women declining screening were not obviously from high-risk demographic groups: women from sub-Saharan Africa were not at greater risk of declining an HIV test than women from other regions.

Retinal and extraocular cytomegalovirus end-organ disease in HIV-infected patients in Europe: a EuroSIDA study, 1994-2001

This multicentre prospective cohort study by the EuroSIDA study group was designed to determine the factors affecting the incidence of cytomegalovirus (CMV) end-organ disease (CMVD) and the rate of survival after diagnosis in patients with AIDS during the years 1994-2001. This period includes two eras, the pre-HAART era and the HAART era, because HAART affects the natural history of HIV infection, especially with respect to opportunistic infections, including CMV infection. Clinical and laboratory data were collected from the charts of 8,556 patients in 63 AIDS clinics in Europe. A total of 707 patients had CMVD at recruitment and at follow-up: 449 with retinitis (CMVR), 190 with extraocular CMV disease (EOCMVD), and 58 with both. Of the cases of EOCMVD, 66% involved the gastrointestinal tract and 17% the central nervous system. Of patients with a CD4+ count of < or =200 mm(-3) initially, 1.8% on HAART developed CMVD within a 24-month period, as compared to 11.1% on dual therapy and 14.3% without treatment (P<0.0001). There were highly significant differences in survival according to the calendar year (P<0.0001), with mortality declining from 79% during the years 1994-1995 to 42% in 2000-2001. The incidence of death after any CMVD was 28.4 per 100 patient-years of follow-up. Median survival of CMVR patients and EOCMVD patients was 11 and 7 months, respectively, the prognosis being better among patients with gastrointestinal rather than neurological CMVD. The initiation of HAART was associated with a 37% decrease in mortality (P<0.05). Eighteen percent of all deaths were caused by EOCMVD itself. This study describes a decline in the incidence and mortality of CMVR and EOCMVD during the HAART era of the HIV epidemic. It furthermore serves as a reminder of the importance of EOCMVD as a cause of morbidity and mortality in AIDS in the pre-HAART era.

Regional and temporal changes in AIDS in Europe before HAART

In a prospective observational study 4,485 patients from 46 clinical centres in 17 European countries were followed between April 1994 and November 1996. Information on AIDS-defining events (ADEs) were collected together with basic demographic data, treatment history and laboratory results. The centres were divided into four geographical regions (north, central, south-west and south-east) so that it was possible to identify any existing regional differences in ADEs. The regional differences that we observed included a higher risk of all forms of Mycobacterium tuberculosis infections (Tb) and wasting disease in the south-west and an increased risk of infections with the Mycobacterium avium complex (MAC) in the north. In Cox multivariable analyses, where north was used as the reference group, we observed hazard ratios of 6.87, 7.77, 2.29 and 0.16 (P < 0.05 in all cases) for pulmonary Tb, extrapulmonary Tb, wasting disease and MAC respectively in the south-west. Pneumocystis carinii pneumonia (PCP) was less commonly diagnosed in the central region (RH = 0.51, 95% CI 0 32-0.79, P = 0.003) and most common in the south-east (RH = 1.04, 95% CI 0.71-1.51, P = 0.85). Comparisons with a similar 'AIDS in Europe' study that concentrated on the early phase of the epidemic reveal that most of the regional differences that were observed in the 1980s still persist in the mid-1990s.

Changes in the cause of death among HIV positive subjects across Europe: results from the EuroSIDA study

OBJECTIVES

The causes of death among HIV-positive patients may have changed since the introduction of highly active antiretroviral therapy (HAART). We investigated these changes, patients who died without an AIDS diagnosis and factors relating to pre-AIDS deaths.

METHODS

Analyses of 1826 deaths among EuroSIDA patients, an observational study of 8556 patients. Incidence rates of pre-AIDS deaths were compared to overall rates. Factors relating to pre-AIDS deaths were identified using Cox regression.

RESULTS

Death rates declined from 15.6 to 2.7 per 100 person-years of follow-up (PYFU) between 1994 and 2001. Pre-AIDS incidence declined from 2.4 to 1.1 per 100 PYFU. The ratio of overall to pre-AIDS deaths peaked in 1996 at 8.4 and dropped to < 3 after 1998. The adjusted odds of dying following one AIDS defining event (ADE) increased yearly (odds ratio, 1.53; P < 0.001), conversely the odds of dying following three or more ADE decreased yearly (odds ratio, 0.79; P < 0.001). The proportion of deaths that followed an HIV-related disease decreased by 23% annually; in contrast there was a 32% yearly increase in the proportion of deaths due to known causes other than HIV-related or suicides. Injecting drug users (IDU) were significantly more likely to die before an ADE than homosexuals (relative hazard, 2.97; P < 0.0001) and patients from northern/eastern Europe (relative hazard, 2.01; P < 0.0001) were more likely to die pre-AIDS than southern patients.

CONCLUSIONS

The proportion of pre-AIDS deaths increased from 1994 to 2001; however, the incidence of pre-AIDS deaths and deaths overall declined. IDU and subjects from northern/eastern Europe had an increased risk of pre-AIDS death. HIV-positive patients live longer therefore it is essential to continue to monitor all causes of mortality to identify changes.

Evaluation of a sustained-release theophylline product in children with asthma

The purpose of this study was to determine the dose requirements and dose interval of a sustained-release theophylline sprinkle preparation (Somophyllin-12) necessary to maintain therapeutic serum theophylline concentrations in children with asthma. Eighteen patients aged 3-7 years (subgroup 1) and 21 patients aged 8-12 years (subgroup 2), who had been on continuous theophylline therapy with Somophyllin-12, completed the study. Prior to entry into the study, each patient's dosage of Somophyllin-12 was titrated to achieve predose and peak (4-hour postdose) theophylline levels in the therapeutic range (8-20 mg/L). The patients subsequently had predose and peak serum theophylline levels determined at baseline (week 0) and at weeks 2 and 4 of the study. The majority of children maintained theophylline levels in the therapeutic range throughout the 4-week trial, and t-tests showed no significant change from baseline in mean values of peak, trough, or peak-trough theophylline differences in either patient subgroup at weeks 2 and 4. Nevertheless, some individual patients had considerable variation from baseline in peak and trough theophylline levels at follow-up visits. Dosage requirements standardized for weight were significantly higher in patients in subgroup 1 than in subgroup 2 (21.3 +/- 4.5 mg/kg per day versus 17.5 +/- 4.7 mg/kg per day; p less than 0.05). The majority of the patients required 12-hourly administration of Somophyllin-12, but seven of 39 patients required 8-hour dosing.(ABSTRACT TRUNCATED AT 250 WORDS)

Importance of physician identification of airflow limitation in stable asthmatics

The physician's ability to recognize airflow limitation was assessed in 92 stable asthmatics between seven and 12 years of age. A parental symptom score was obtained. The physician assigned a physical sign score and a clinical impression score based on the severity and lability of symptoms. Airflow limitation was considered significant if the forced expiratory flow between 25 and 75% of the vital capacity (FEF25-75) was less than 50% predicted. The FEF25-75 did not correlate with any of the scores and was less than 50% predicted in 27 of 92. There was no clinical suspicion of abnormality in 12 of 27. The FEF25-75 increased significantly after salbutamol inhalation in 22 of 23 but was persistently abnormal on follow-up in 9 of 21. We conclude that without pulmonary function tests the physician may fail to identify significant reversible airflow limitation in 13% of stable asthmatic children.

Epstein-Barr virus antibodies in patients with ataxia-telangiectasia and other immunodeficiency diseases

An unusual antibody response to the Epstein-Barr virus (EBV) has been noted in patients with ataxia-telangiectasia. Of a group of 16 such patients 8 were found to have antibodies in their serum to the EBV viral capsid antigen (VCA), and 4 of them also had antibodies to the EBV early antigen (EA); antibodies to the nuclear antigen (EBNA), however, were absent in 3 of the 8. The antibody pattern persisted for more than 2 years in the patients available for follow-up study. In comparison, of 24 patients with various other immunodeficiency syndromes 9 were found to have EBV-VCA antibodies in their serum, but none of the 9 had EA antibodies and 3 lacked EBNA antibodies. Two other groups of subjects, all of whom had EBV-VCA and EBNA antibodies in their serum late after an EBV infection, were also studied; 82 had infectious mononucleosis and 55 were healthy and had no such history. EA antibodies were detected in 45 of the first group during the acute phase of the illness but persisted in only 6 of the 68 who were followed up for more than 2 years, and they were detected in only 7 of the second group.All eight lymphoblastoid cell lines established from the peripheral blood of the four patients with ataxia-telangiectasia who are still available for follow-up study express EBV-VCA, whereas most similar cell lines established from normal individuals express only EBNA. In two of these patients cell-mediated immunity, as assessed from lymphocyte transformation induced by mitogens, was markedly decreased but autologous cell-mediated immune regression of EBV-induced transformation of B (bone-marrow-derived)-lymphocytes was normal. The percentage of T (thymus-derived)-helper cells was greatly decreased in two of the three patients in whom it was measured, and the percentage of T-suppressor cells was greatly increased in one of them, but the percentage of total T-lymphocytes was within normal limits in all three.The possible significance of these findings - in particular, the persistence of EA antibodies and the diminished restriction of expression of EA - in the late development of tumours after an EBV infection in patients with ataxia-telangiectasia deserves careful attention. Finally, the apparent correlation between immunoglobulin deficiency and poor or absent EBNA antibody response warrants further study.

Pharmacokinetic analysis of the disposition of intravenous theophylline in young children

The disposition of a single intravenous dose of theophylline, 3.2 mg/kg, was studied using a high-pressure liquid chromatographic assay in ten asthmatic children one to four years of age. The man plasma theophylline clearance was 0.100 +/- 0.036 l/kg/hr, kel 0.49 +/- 0.30 hr-1, betat1/2 3.38 +/- 1.11 hr, alphat1/2 0.13 +/- 0.09 hr, and V1 0.25 +/- 0.13 1/kg. Plasma theophylline clearance was approximately 40% greater in these children than that reported in adults, mainly due to an increased rate of drug elimination. Large interindividual differences were observed. Analysis of data using either a two- or one-compartment model yielded almost identical dosage regimens designed to rapidly achieve and maintain a chosen plasma theophylline concentration. Calculations based upon mean values of pharmacokinetic constants predict that a maintenance dose rate for aminophylline of 30 mg/kg/day, after a loading dose of 5.6 mg/kg, would rapidly achieve and maintain a mean steady-state plasma concentration of theophylline of 10 mg/1. Potential toxicity of such a regimen has not been excluded, since therapeutic trials (with achievement of steady state) have not yet been conducted.