Autochthonous hepatitis E in developed countries and HEV/HIV coinfection

A novel hepatitis virus was long suspected as the cause of outbreaks of unexplained hepatitis with high maternal mortality in Asia. An outbreak of unexplained hepatitis in a Soviet military camp in Afghanistan led one investigator to ingest a pooled fecal extract from affected service personnel. This resulted in the discovery of the hepatitis E virus (HEV) in 1983. Subsequent studies showed that HEV was endemic in large parts of the developing world. Its incidence in industrialized nations was initially attributed to travel-related exposure. For many years after the discovery of HEV, it was considered a "new" virus, and of no relevance to developed countries. This perceived wisdom has proven to be hopelessly inaccurate. Human infections with HEV are not "new," and are of considerable global importance, including in developed countries.

A case-control study of community-associated Clostridium difficile infection

OBJECTIVES

The aim of this study was to determine the incidence of and risk factors for community-associated Clostridium difficile infection (CDI).

METHODS

Prospective surveillance of community-derived faecal samples for C. difficile cytotoxin, followed by a questionnaire-based case-control study in two distinct patient cohorts (one semi-rural and the other urban).

RESULTS

The proportion of randomly selected faecal samples positive for C. difficile cytotoxin was 2.1% in both patient cohorts (median ages 73 and 45 years for the urban and semi-rural cohorts, respectively). Exposure to antibiotics in the previous 4 weeks, particularly multiple agents (P < 0.001), aminopenicillins (P < 0.05) and oral cephalosporins (P < 0.05), was significantly more frequent among cases than controls. Hospitalization in the preceding 6 months was significantly associated with CDI (45% versus 23%; P = 0.022). However, almost half the cases had not received antibiotic therapy in the month before C. difficile detection, and approximately one-third neither had exposure to antibiotics nor recent hospitalization. Contact with infants aged < or =2 years was significantly associated with CDI (14% versus 2%; P = 0.02). Prior exposure to gastrointestinal-acting drugs (proton pump inhibitor, H2 antagonist or non-steroidal anti-inflammatory) was not significantly more common in CDI cases. C. difficile PCR ribotype 001 caused 60% and 13% of urban and semi-rural community-associated CDI cases, respectively.

CONCLUSIONS

Reliance on antibiotic history and age (> or =65 years) will contribute to missed diagnoses of community-associated CDI. Potential risk factors for community-associated CDI should be explored further to explain the large proportion of cases not linked to recent antibiotic therapy or hospitalization.

Autochthonous hepatitis E in Southwest England: a comparison with hepatitis A

The incidence of hepatitis A is falling. In contrast, autochthonous hepatitis E is an emerging infection in developed countries. The objective of this study was to compare both laboratory-confirmed cases of hepatitis A and autochthonous hepatitis E over a 2-year period in Cornwall and Devon and anti-hepatitis A virus (HAV) IgG and anti-hepatitis E virus (HEV) IgG seroprevalence in blood donors. The databases of microbiology laboratories in Cornwall and Devon were searched for the number of diagnostic HEV and HAV assays performed during 2005-2006 and the number of confirmed cases of acute hepatitis A and hepatitis E detected. Patients were followed up until recovery or death. Sera from 500 blood donors from the regional centre were tested for HEV and HAV IgG. In total, 28 cases of autochthonous hepatitis E were identified from 838 assays, and 20 cases of hepatitis A were identified from 4503 assays. Compared to hepatitis A cases, patients with hepatitis E were older (mean age 61 vs. 45 years, P = 0.003), less likely to present in winter (P = 0.028) and had more complications (five vs. one). The IgG seroprevalence rates in blood donors were 45% for HAV and 16% for HEV. There was no relationship between HAV and HEV IgG seropositivity. Autochthonous hepatitis E may be more common than hepatitis A, affects older patients, is less likely to occur in winter and may be associated with more complications. Patients with acute hepatitis, whatever their age or travel history, should be tested for HEV.

Serological response to hepatitis E virus genotype 3 infection: IgG quantitation, avidity, and IgM response

Sequential sera were collected from 18 acute cases of UK-acquired hepatitis E. The virus strains in all cases were of genotype 3. The IgM and IgG response to acute infection were documented over time using EIA kits based on a peptide antigen, pE2, which is derived from a genotype 1 strain of hepatitis E virus (HEV). Ninety-five percentage of acute sera were IgM positive; after 6 months or more only 12% remained positive. The kit was adapted to quantify the IgG response (in WHO U/ml) and to determine antibody avidity. Following acute infection, anti-HEV IgG concentrations rose between 6.9- and 90-fold. IgG avidity was low (<25%) in most acute sera. After 6 months IgG avidity was greater than 50% in all cases. One patient with a poor IgM response and high avidity antibody in acute sera may have had a second HEV infection. Taken together, these results confirm that the pE2-based EIA kits are suitable for diagnosing acute HEV genotype 3 infection. With simple modifications the IgG kit can measure anti-HEV concentration and avidity, which can be used to confirm acute infection.

Autochthonous hepatitis E in southwest England

Although autochthonous hepatitis E has been reported in developed countries, its extent and nature in the United Kingdom are unclear. The aim of the present study was to report the natural history, lifestyle risk factors and molecular epidemiology of autochthonous hepatitis E infection in southwest England. Three hundred and thirty-three patients with unexplained hepatitis were tested for markers of hepatitis E virus (HEV) infection over a 7-year period. HEV RNA isolated from the cases was amplified and characterized. Of the 333 patients, 21 had autochthonous hepatitis E. Patients were middle-aged or elderly and males were more commonly affected. Clinical manifestations ranged from asymptomatic infection to severe hepatitis. Of the 21 patients, 20 recovered within 6 weeks. None of the cases had travelled to an area endemic for HEV. None of the patients were vegetarian and all ate pork. Of the 21 cases, 20 occurred in the spring, summer and autumn months. All polymerase-chain-reaction-confirmed cases carried HEV genotype 3, which bore close sequence homology to HEV circulating in UK pigs. In the United Kingdom, autochthonous hepatitis E may be more common than previously recognized. Although the mode of transmission remains to be determined, it may be a zoonosis with pigs as a reservoir. Hepatitis E should be considered a public health issue in the United Kingdom.

A comparison of IgG anti-rubella activity in frozen serum stored in primary gel separation tubes or secondary tubes

AIMS

To determine the suitability of primary gel separation tubes for the storage of frozen sera intended for serological testing.

METHODS

Blood samples from 102 patients were collected into gel separation tubes. The sera from these samples were split between the primary gel separation tubes and conventional plastic storage tubes and frozen. A year later, the tubes were thawed and anti-rubella IgG concentrations were compared for the serum pairs using the Wilcoxon signed rank test.

RESULTS

No significant difference was detected between the two storage methods.

CONCLUSIONS

Frozen storage of serum samples in primary gel separation tubes is a practical alternative to storing separated sera in secondary containers. Adopting this practice has advantages for laboratories in reducing specimen handling and reducing errors in labelling stored samples.

Offering routine antenatal testing for HIV and hepatitis B in the rural setting of Cornwall

Before Department of Health directives to offer HIV and hepatitis B (HBV) testing to all pregnant women, there was little such screening in Cornwall. Through a multiagency collaborative approach a new antenatal screening programme for HIV/HBV has been introduced with high uptake in the first year (HIV 92% and HBV 93%). We also report the findings of a questionnaire survey of community midwives who alone offer antenatal HIV/HBV testing in Cornwall.

The potential effect on Neisseria gonorrhoeae of the use of clindamycin vaginal cream in the empirical treatment of vaginal discharge

The minimum inhibitory concentrations (MIC) of clindamycin for 62 consecutive isolates of Neisseria gonorrhoeae were found to be 0.03-4 mg/L; the MIC50 and MIC90 were 0.125 and 2.0 mg/L respectively. Seven women treated with clindamycin vaginal cream had cervical mucus samples taken after seven days treatment. The concentrations of clindamycin achieved in the cervical mucus were 30-150 times higher (141-337 mg/L) than the highest MIC of the 62 N. gonorrhoeae isolates. Clindamycin vaginal cream is being used increasingly in Genitourinary Medicine clinics and General Practice for the treatment of bacterial vaginosis. This study shows that clindamycin vaginal cream achieves intra cervical concentrations that are high enough to inhibit N. gonorrhoeae. Empirical use of this therapy should be preceded by urethral and cervical swabs for N. gonorrhoeae in any woman at risk of gonorrhoeae.

Mutagenicity screening of foods. II. Results with fruits and vegetables

A survey of the mutagenic potential of a wide variety of food products has been initiated with results for 28 different beverages reported previously [Stoltz et al, 1982b]. Here, results for samples of 46 widely consumed fruits and vegetables from six general categories are given. Each sample was concentrated and fractionated by polarity and solubility to give five fractions, each of which was assayed for mutagenic potential with Salmonella typhimurium TA98 and TA100. Although statistical analysis of the data resulted in positive findings for 22 fruit and vegetable samples, only six products (grapes, onions, peaches, raisins, raspberries, strawberries) demonstrated potent mutagenic activity.

Mutagenicity screening of foods I. Results with beverages

Following a number of recent reports on the presence of mutagens in certain foods, a general survey of the mutagenic potential of a wide variety of food products has been initiated. Here, results for samples of 28 widely consumed beverages from 13 general categories are reported. Each sample was concentrated and fractionated by polarity and solubility to give up to seven fractions, each of which was assayed for mutagenic potential with Salmonella typhimurium TA98 and TA100 +/- fortified liver homogenate. Fractions showing evidence of either mutagenicity or toxicity were retested at the same and lower concentrations. The utility of the fractionation procedure and the sensitivity of the screening strategy were established by assaying six beverages spiked with known mutagens prior to fractionation. Statistical analysis of the data resulted in positive findings for seven beverages, although confirmation of these results through analysis of a second sample was obtained only for red wine, grape juice, and instant coffee. The remaining 21 beverages showed no strong evidence of mutagenic activity. For those foods for which the variation among replicate plates was largest, the false-positive rate for the two-stage screening procedure employed was estimated to be less than 1% while the false-negative rate for a beverage inducing a threefold increase in the background mutation rate was conservatively estimated to be limited to 14%.

ANTERIOR TRANSPERITONEAL LUMBAR FUSION

1. Anterior transperitoneal lumbar fusion is a successful method of stabilising painful mechanical derangements which have not responded to the usual conservative measures.

2. The operation in this series was done mainly for backache; it should not be contemplated if there is definite evidence of nerve root compression, because sequestrated disc material cannot be removed from the spinal canal from the anterior route.

3. Careful technique has resulted in few complications attributable to the operation.

4. This method is sometimes thought to be inapplicable in cases of spondylolisthesis with a displacement of more than one-third. However, in this series we have seen the block type of graft used with a good measure of clinical and radiological success.

5. There is no doubt that for those patients who have had previous unsuccessful laminectomies or posterior fusions anterior interbody fusion offers an excellent prospect of recovery.

Arthroplasty of the hip (demonstration)

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Cytogenetic studies with cyclamate and related compounds

Cyclamate, cyclohexylamine, N-hydroxycyclohexylamine, and dicyclohexylamine can induce chromosomal damage in human leukocyte cultures.

Initial impressions of Kiel bone in bone grafting

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