BRUCELLOSIS COMPLICATED BY AORTIC VALVE ENDOCARDITIS

A 30 year old veterinary surgeon developed a febrile illness with serological evidence of Brucellosis. He was known to have aortic valve disease and during the course of the illness, the clinical features of endocarditis became evident, with a vegetation visible echocardiographically on the aortic valve. Because of persisting fever despite appropriate antibiotic therapy, aortic valve replacement with a viable cryopreserved allograft aortic valve was undertaken. Organisms consistent with Brucella species were demonstrated in the excised vegetation. The patient received a six week course of antibiotics and his post-operative course was uneventful.     

DESIGNING STUDIES FOR DOSE RESPONSE

‘Dose response’ refers to the regression of a response on a stimulus. We review a number of options for dose–response designs, and compare various designs which may be used in practice. We start with two group designs. Next, we introduce basic optimal approximate design theory for simple linear and quadratic regression illustrating different criteria of optimality and their effect on the allocation of the levels of the dose. Then we obtain the efficiencies of these optimal approximate designs and some simple designs which have intuitive appeal (symmetry, equal spacing of treatments, reduced numbers of observations at the highest and lowest doses).     

HELICOBACTER PYLORI-SPECIFIC TUMOUR-INFILTRATING T CELLS PROVIDE CONTACT DEPENDENT HELP FOR THE GROWTH OF MALIGNANT B CELLS IN LOW-GRADE GASTRIC LYMPHOMA OF MUCOSA-ASSOCIATED LYMPHOID TISSUE

Previous studies have shown that tumour cells from low-grade B-cell gastric lymphomas of mucosa-associated lymphoid tissue (MALT) type proliferate in vitro in response to heat-killed whole cell preparations of Helicobacter pylori , but only in the presence of tumour-infiltrating T cells. This response is strain-specific in that the tumours studied responded optimally to different strains of H. pylori . It was unclear from these studies, however, whether the ability to recognize the specific stimulating strains of H. pylori was a property of the tumour cells or the tumour-infiltrating T cells. This study shows that whereas the tumour cells do not respond to H. pylori , both freshly isolated tumour-infiltrating T cells and a T cell line derived from these cells proliferate in response to stimulating strains of H. pylori . T cells from the spleen of one of the patients do not share this property. These results suggest that B-cell proliferation in cases of low-grade gastric lymphoma of MALT type in vitro in response to H. pylori is due to recognition of H. pylori by tumour-infiltrating T cells, which in turn provide help for tumour cell proliferation. The observations provide an explanation for properties of gastric MALT-type lymphoma, such as regression following eradication of H. pylori and the tendency of the tumour to remain localized to the primary site.     

MUTATION OF THE VHL GENE IS ASSOCIATED EXCLUSIVELY WITH THE DEVELOPMENT OF NON-PAPILLARY RENAL CELL CARCINOMAS

To define the possible role of the VHL gene in the development of sporadic renal cell carcinomas, 91 different parenchymal tumours of the kidney have been investigated for mutation of the VHL gene by single strand conformation polymorphism (SSCP) and/or heteroduplex (HD) techniques. Chromosome 3p deletion was detected in 98 per cent of non-papillary renal cell carcinomas and in 25 per cent of chromophobe renal cell carcinomas. In 22 of the 43 non-papillary renal cell carcinomas, abnormally migrating DNA bands were detected by SSCP and/or HD analysis. No mobility shift was seen in any of the 23 chromophobe renal cell carcinomas. In addition, 15 papillary renal cell tumours and ten renal oncocytomas, which are characterized by genetic changes other than loss of chromosome 3p sequences, were analysed for mutation of the VHL gene. None of these tumours showed abnormal migration patterns. The results indicate that mutation of the VHL gene is associated exclusively with the development of non-papillary renal cell carcinoma.     

IMMUNOHISTOCHEMICAL ASSAY FOR OESTROGEN RECEPTORS IN PARAFFIN WAX SECTIONS OF BREAST CARCINOMA USING A NEW MONOCLONAL ANTIBODY

The aim of this study was to evaluate the utility of a new monoclonal antibody (AER311) that targets the oestrogen receptor (ER) in an immunohistochemical assay (IHA) applied to breast cancers. Ninety-seven cases of invasive ductal carcinoma were studied by AER311-IHA using a pressure-cooking antigen retrieval technique applied to formaldehyde-fixed, paraffin-embedded tissue sections; immunostaining was assessed by semi-quantitative scoring ( H score). There was 80 per cent concordance between the ER status measured by dextran-coated charcoal (DCC) assay and AER311-IHA, with 63/97 (65 per cent) tumours positive and 15/97 (15 per cent) tumours negative by both assays. Of the 12 DCC-positive cases that were negative by AER311-IHA, 11 were borderline positive (3–8 fmol/mg). Similarly, six of seven DCC-negative cases that scored positive by AER311-IHA had only borderline positive H scores (<50). When AER311-IHA was compared with 1D5-IHA, there was good concordance in ER status (77 per cent) and a significant correlation ( r =0·7, P <0·001) between H scores. Nevertheless, the correlation between ER level determined by AER311-IHA and that measured by DCC ( r =0·53, P <0·001) was higher than that for 1D5-IHA ( r =0·32, P =0·002). AER311-IHA can therefore provide reliable information about the ER status of breast carcinoma on paraffin sections and is an acceptable alternative to other commercially available monoclonal antibodies.     

Left Septal Atrial Tachycardias: Electrocardiographic and Electrophysiologic Characterization of a Paraseptal Focus

Left Septal Atrial Tachycardias. Objective: The objective was to characterize the electrocardiographic and electrophysiological features of focal atrial tachycardia (FAT) originating from the left septum (LS). Background: FAT is recognized to occur at predefined anatomic locations rather than randomly throughout the atria. We describe the ECG and EP features of ATs originating from the LS as an important site for apparent perinodal tachycardias. Methods: Nine patients presenting with LS FAT from a consecutive series of 384 underwent EP/RFA for symptomatic FAT. Results: The mean age was 56 ± 12 years; 7 female with symptoms for 36 ± 28 months. P wave morphology (PWM) was negative/positive in lead V1 and across the precordial leads and negative or negative/positive in inferior leads in all patients. Tachycardia was incessant in 6 out of 9 patients with a mean tachycardia cycle length 421 ± 56 milliseconds. His A was ahead of P wave in all patients (mean ?15 ± 5 milliseconds) and earlier than CS proximal (mean 4 ± 9 milliseconds). Successful acute focal ablation achieved at a mean of 31 ± 12 milliseconds ahead of P wave with no recurrences at a mean follow‐up of 30 ± 28 months. Conclusion: Although the left septum is an uncommon site for focal AT an awareness of this location for harboring foci is particularly important when mapping apparently right‐sided septal tachycardias. (J Cardiovasc Electrophysiol, Vol. 24, pp. 413‐418, April 2013)     

Nurse-led case management for community dwelling older people: an explorative study of models and costs

Aim To compare community matrons with other nurses carrying out case management for impact on service use and costs. Background In England, nurses working in general practice, as district nurses and disease-specific nurses, undertake use case management. Community matrons were introduced to case management to reduce unplanned hospitalizations of people with complex conditions. Methods Managers in three Primary Care Trusts (PCTs) identified four nurses/matrons engaged in case management. Nurses/matrons recruited five community-dwelling patients referred to them for case management. Patients reported use of health/social services for 9 months, 2008 to 2009. Nurses/matrons completed activity diaries. Results Service use data were available for 33 patients. Compared with other nurse case managers, community matrons had: smaller caseloads; more patient contact time (mean 364 vs. 80 minutes per patient per month); and older patients (mean age 81 vs. 75 years, P = 0.03) taking more medications (mean 8.9 vs. 5.6, P = 0.014). Monthly costs were significantly higher for patients managed by community matrons (add £861), and who lived alone (add £696). Hospitalizations were not associated with patient or service delivery factors. Conclusion Further research on cost-effectiveness of case management models is required. Implications for Nursing Management The case for continued investment in community matrons remains to be proven.     

Recurrent Herpes Simplex Infection in Multiple Locations in an Otherwise Healthy Boy

Abstract:  An 8-year-old boy developed vesicular lesions on the skin in different parts of the body, occurring four to six times a year. He had a history of eczema herpeticum as a young child. We confirmed a diagnosis of multifocal herpes simplex infection, and hypothesize that this was a result of his previous eczema herpeticum, an unusual complication, in an otherwise healthy and immunocompetent child.