M-mode and cross-sectional (2D)echocardiograms in the diagnosis of mitral valve prolpase

Forty-nine patients were studied to assess the value of M-modeand cross-sectional echocardiography in the diagnosis of mitralvalve prolapse. There were 20 normal subjects and 29 patientswith clinical and phonocardiographic evidence which suggestedprolapse. Using an arbitrary line connecting the base of theanterior and posterior leaflets at their attachment to the atrioventricularjunction, 22 of the 29 patients had abnormal arching of themitral leaflets into the left atrium on cross-sectional echocardiograms(CSE); this was not seen in the normal subjects. There were15 patients with double leaflet prolapse, five with lone anteriorand two with lone posterior leaflet prolapse. M-mode recordingsfailed to show prolapse in six of the 22 patients with positiveCSE but showed prolapse in one patient with an inadequate cross-sectionalechocardiogram. The difficulty in demonstrating prolapse onM-mode was caused by multiple systolic echoes in four subjects,and poor separation of the posterior leaflet from the posteriorleft ventricular wall echoes in two subjects. The anterior leafletwas well seen on CSE with long axis parasternal views but theposterior leaflet could not be seen on the long axis view in13 of the 29 subjects in the abnormal group; short axis fourchamber views from the apex allowed definition of the posteriorleaflet in nine of these 13 patients. We conclude that CSE is better than M-mode echocardiographyand should be used in conjunction with it for the diagnosisof mitral valve prolapse. Superior arching of the mitral leafletsinto the left atrium is the characteristic feature, and longaxis parasternal views should be supplemented by short axisfour chamber apical views.     

Guidelines for the management of hypertensive disorders of pregnancy 2008

This is the Executive Summary of updated guidelines developed by the Society of Obstetric Medicine of Australia and New Zealand for the management of hypertensive diseases of pregnancy. They address a number of challenging areas including the definition of severe hypertension, the use of automated blood pressure monitors, the definition of non-proteinuric pre-eclampsia and measuring proteinuria. Controversial management issues are addressed such as the treatment of severe hypertension and other significant manifestations of pre-eclampsia, the role of expectant management in pre-eclampsia remote from term, thromboprophylaxis, appropriate fluid therapy, the role of prophylactic magnesium sulfate and anaesthetic issues for women with pre-eclampsia. The guidelines stress the need for experienced team management for women with pre-eclampsia and mandatory hospital protocols for treatment of hypertension and eclampsia. New areas addressed in the guidelines include recommended protocols for maternal and fetal investigation of women with hypertension, preconception management for women at risk of pre-eclampsia, auditing outcomes in women with hypertensive diseases of pregnancy and long-term screening for women with previous pre-eclampsia.     

Evidence‐based recommendations for the monitoring and treatment of ankylosing spondylitis: results from the Australian 3E initiative in rheumatology

Aim: To develop a set of Australian recommendations for the monitoring and treatment of ankylosing spondylitis (AS) through systematic literature review combined with the opinion of practicing rheumatologists. Methods: A set of eight questions, four in each domain of monitoring and treatment, were formulated by voting and the Delphi method. The results of a systematic literature review addressing each question were presented to the 23 participants of the Australian 3E meeting. All participants were clinical rheumatologists experienced in the daily management of AS. Results: After three rounds of breakout sessions to discuss the findings of the literature review, a set of recommendations was finalized after discussion and voting. The category of evidence and strength of recommendation were determined for each proposal. The level of agreement among participants was excellent (mean 84%, range 64–100%). Conclusions: The 12 recommendations developed from evidence and expert opinion provide guidance for the daily management of AS patients. For most recommendations, we found a paucity of supportive evidence in the literature highlighting the need for additional clinical studies.     

Bovine lymphocyte antigens (BoLA) of bovine lymphocytes and derived lymphoblastoid lines transformed by Theileria parva and Theileria annulata

Summary The BoLA phenotypes of lymphocytes from seven cattle have been compared with those of 19 lymphoblastoid cell lines derived from them by infection in vitro with either Theileria parva or T. annulata. Two long-established lines were also studied. In all cases except one, the BoLA phenotypes of the lymphoblastoid lines were identical with those of the original animal from whose lymphocytes they were derived. The one exception was a chimeric twin where a minor population appeared to have been transformed by T. parva. The antigens present on this line were present in the parents of the chimera, but not detectable in its own peripheral blood. The implications of these results as they relate to the use of these cell lines in immunizing cattle against East Coast fever and tropical theileriosis are discussed.     

Nitric oxide inhibits establishment of macroschizont-infected cell lines and is produced by macrophages of calves undergoing bovine tropical theileriosis or East Coast fever

Nitric oxide (NO) was produced when bovine peripheral blood mononuclear cells (PBMC) or purified, adherent PBMC (macrophages) were incubated in vitro with bovine recombinant interferon gamma (Bo rIFN-γ). NO was produced by cells from naive, uninfected calves as well as by cells from cattle either infected with or recovered from infection with Theileria annulata or Theileria parva. PBMC of cattle undergoing tropical theileriosis (T. annulata infection) or East Coast fever (T. parva infection) synthesized NO spontaneously in vitro. NO was also induced when PBMC of immune, but not of naive, cattle were cultured with T. annulata macroschizont-infected cell lines. Macrophages alone were not stimulated to produce NO by such infected cells. In vitro establishment of macroschizont-infected cell lines was suppressed either by incubating sporozoites with S-nitroso-N-acetyl-DL-penicillamine (SNAP), a NO releasing molecule, prior to invasion of PBMC or by pulsing developing cultures of trophozoite-infected cells with SNAP. Proliferation of established macroschizont-infected cell lines was not affected by SNAP. Taken together with the well documented roles of NO in neurotransmission, vasodilatation, cell and tissue damage and immunosuppression, the results presented here indicate that NO may not only protect cattle against T. annulata and T. parva but, if produced in excess, play a prominent role in the pathogenesis of tropical theileriosis and East Coast fever.     

Pneumatosis Coli Associated with Sigmoid Volvulus and Colonoscopy

A case of interstitial emphysema involving the mesentery and serosa of the sigmoid colon after volvulus reduced by colonoscopy is presented. The case is reported as a form of pneumatosis intestinalis although it does not conform to the classical clinicopathologic picture of pneumatosis cystoides intestinalis. The infrequent occurrence of this condition in association with volvulus and/or colonoscopy is discussed.     

Serum interleukin-8 in inflammatory bowel disease

To investigate the relationship between serum concentrations of interleukin-8 (IL-8) and disease activity in inflammatory bowel disease, serum IL-8 concentrations were measured by enzyme-linked immunosorbent assay (ELISA) in 93 patients. Interleukin-8 levels were compared with plasma interleukin-6 (IL-6) levels in 80 of these patients. Interleukin-8 levels were also measured in ten patients with active Crohn's disease, before and after treatment with a defined formula polymeric diet. Of these patients, 70 out of 93 IL-8 concentrations were below the detection limit of the assay. Levels were higher in patients with active ulcerative colitis (median < 20 pg/mL, 75th centile value = 190) compared with inactive disease (median and 75th centile value < 20; P 0.05). Interleukin-8 concentrations correlated with a combined score for disease severity and extent (P= 0.01). Thirty-eight per cent (8/20) of patients with active Crohn's disease also had high levels of IL-8 but there was no significant difference between active and inactive disease. There was no correlation between serum IL-8 and plasma IL-6; on the contrary, very few patients had raised blood levels of both cytokines. In the diet treated group, serum IL-8 fell significantly after treatment (median = 37 pg/mL, range < 20–4615 before treatment, median < 20, range < 20–104 after treatment; P= 0.03). The results suggest that although IL-8 may be involved in the inflammatory process in inflammatory bowel disease, it is a poor marker of disease activity.     

A picture is worth a thousand words: Children's representations of family as indicators of early attachment

To ascertain whether attachment representations at age 7 are related to early attachment behaviour, family drawings of 123 7-year-olds of known infant attachment status (25 avoidant, 80 secure, 18 resistant) were scored in four ways. Three of these were based in previous attachment research and one was based on a clinical method. The attachment-based coding schemes included specific markers for each attachment pattern (Kaplan & Main, 1985), global ratings (Fury, Carlson, & Sroufe, 1997) and efforts to classify each drawing as belonging to one of the three primary infant attachment groups (secure, avoidant, resistant). In the clinical scheme, children who had been resistant infants were distinguished from the others by use of overlapping and encapsulated figures. For the attachment based schemes, although individual markers were not successful in discriminating attachment groups, the more global approaches (aggregation of markers, global rating scales and judgments of attachment classification) succeeded in this task. In regression analyses controlling for concurrent child and parent measures, infant attachment did not make a significant contribution to predicting insecurity markers in drawings, although child current emotional functioning did. These findings linking attachment relationships with later representations of family relationships were in accord with the conception that avoidant attachment strategies de-emphasize intimate relationships, while resistant attachment strategies are preoccupied with close relationships. These links are most evident in global interpretive strategies rather than those that rely on specific markers.     

The influence of HLA-matched sibling donor availability on treatment outcome for patients with AML: an analysis of the AML 8A study of the EORTC Leukaemia Cooperative Group and GIMEMA

To determine whether patients with a HLA-identical sibling donor have a better outcome than patients without a donor, an analysis on the basis of intention-to-treat principles was performed within the framework of the EORTC-GIMEMA randomized phase III AML 8A trial. Patients in complete remission (CR) received one intensive consolidation course. Patients with a histocompatible sibling donor were then allocated allogeneic bone marrow transplantation (alloBMT), the patients without a donor were randomized between autologous BMT (ABMT) and a second intensive consolidation (IC2). 831 patients <46 years old and alive >8 weeks from diagnosis were included. HLA typing was performed in 672 patients. AlloBMT was performed during CR1 in 180 (61%) out of 295 patients with a donor. Another 38 patients were allografted: five in resistant disease, 14 during relapse and 19 in CR2. ABMT was performed in 130 (34%) out of 377 patients without a donor in CR1, in six (2%) patients during relapse and in 38 (10%) patients during CR2. The disease-free survival (DFS) from CR for patients with a donor was significantly longer than for patients without a donor (46% v 33% at 6 years; P = 0.01, RR 0.78, 95% confidence interval 0.63–0.96). The overall survival from diagnosis for patients with a donor was longer, but not statistically significant, than for patients without a donor (48% v 40% at 6 years; logrank P = 0.24). When patients were stratified according to prognostic risk groups, the same trend in favour of patients with a donor was seen for survival duration and the DFS remained significantly longer for this group of patients.