Familial hyperamylasaemia.

A six year old boy underwent extensive investigation for recurrent abdominal pain and was found to have a persistently raised serum amylase. Endoscopic retrograde cholangiopancreatography was normal and macroamylasaemia was excluded. Serum amylase concentrations were found to be raised in other family members spanning three generations, all of whom were asymptomatic. Clearance studies suggested no evidence of a renal tubular defect and serum lipase concentrations were normal. This is the first report of apparently familial hyperamylasaemia and the mode of inheritance is consistent with an autosomal dominant pattern.     

Does the use of mean or median Z-score of the thyroid volume indices provide a more precise description of the iodine deficiency disorder status of a population?

Endemic iodine deficiency is largely an environmental problem affecting whole populations. Currently, thyroid volume data from a population are analyzed with the sole objective of obtaining an estimate of goitre prevalence using +97th percentile or +2 standard deviations of an appropriate reference as cut-off. This paper proposes an alternative approach to the analysis and presentation of thyroid volume data using Z-scores (standard deviation scores) of the thyroid volume indices such as thyroid volume-for-age or thyroid volume-for-body surface area. The calculation of the summary statistics of the Z-scores, such as mean or median, provides an alternative to the prevalence-based approach for expressing severity of iodine deficiency disorders (IDD). An advantage of the mean or median Z-score is that it describes the thyroid volume profile (and therefore the IDD status) of the entire population directly, unlike goitre prevalence which gives information only about the extremes of distribution. The frequency curve or histogram of the Z-scores provides a complete picture of the whole distribution. Although qualitatively similar conclusions on IDD severity can be drawn from both analytical approaches, only the Z-score system is able to capture adequately the trends or changes in thyroid size over time, and to establish whether a previously iodine-deficient community's thyroid volume profile has returned to 'normal' (as indicated by a distribution that is not significantly different from that of the reference) following intervention. As a continuous variable, Z-scores are particularly useful for the analysis of data from populations where the sample size is relatively small, or where many individuals lie outside the extreme percentiles of the reference population. In view of its advantages in the context of activities based on single and multiple measurements, the Z-score system is to be preferred for the reporting and use of thyroid volume indices. A desirable consequence of this preference is that national goals will be oriented towards an improvement of the overall thyroid volume profile of the population, rather than just a reduction of the number of individuals at the extremes.     

Treatment with soluble interleukin-15Ralpha exacerbates intracellular parasitic infection by blocking the development of memory CD8+ T cell response

Interferon (IFN)-gamma-producing CD8+ T cells are important for the successful resolution of the obligate intracellular parasite Toxoplasma gondii by preventing the reactivation or controlling a repeat infection. Previous reports from our laboratory have shown that exogenous interleukin (IL)-15 treatment augments the CD8+ T cell response against the parasite. However, the role of endogenous IL-15 in the proliferation of activated/memory CD8+ T cells during toxoplasma or any other infection is unknown. In this study, we treated T. gondii immune mice with soluble IL-15 receptor alpha (sIL-15Ralpha) to block the host endogenous IL-15. The treatment markedly reduced the ability of the immune animals to control a lethal infection. CD8+ T cell activities in the sIL-15Ralpha-administered mice were severely reduced as determined by IFN-gamma release and target cell lysis assays. The loss of CD8+ T cell immunity due to sIL-15Ralpha treatment was further demonstrated by adoptive transfer experiments. Naive recipients transferred with CD44(hi) activated/memory CD8+ T cells and treated with sIL-15Ralpha failed to resist a lethal T. gondii infection. Moreover, sIL-15Ralpha treatment of the recipients blocked the ability of donor CD44(hi) activated/memory CD8+ T cells to replicate in response to T. gondii challenge. To our knowledge, this is the first demonstration of the important role of host IL-15 in the development of antigen-specific memory CD8+ T cells against an intracellular infection.     

Unscheduled Return Visits With and Without Admission Post Emergency Department Discharge

Background

Monitoring unscheduled return visits to the Emergency Department (ED) is useful to identify medical errors.

Objective

To investigate the differences between unscheduled return visit admissions (URVA) and unscheduled return visit no admissions (URVNA) after ED discharge.

Methods

From January 1, 2008 to March 31, 2008, URVA and URVNA patients who returned within 3 days after ED discharge were enrolled in the study. We compared the clinical characteristics, underlying diseases, ED crowding indicators, staff experience at the patient's first visit, and several other risk factors. We used multivariate logistic regression to evaluate differences between the two groups and to identify predictors of admission from unscheduled return visits.

Results

The unscheduled return visit rate was 3.1%. Of the 413 patients included, 147 patients (36%) were admitted, and had a mortality rate of 4.1%. The most common reason for the return visit was an illness-based factor (47.9%). Compared to URVNA patients, unscheduled return visit admissions had higher prevalence rates for old age, non-ambulatory status, high-grade triage, and underlying diseases (e.g., malignancy, diabetes mellitus, hypertension, coronary artery disease, heart failure, and chronic obstructive pulmonary disease). The independent predictors for URVA were: age ≥ 65 years (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.4–3.5); high-grade triage (adjusted OR 2.1, 95% CI 1.3–3.2); and doctor-based factors (adjusted OR 3.5, 95% CI 2.0–6.1). More advanced staff experience (p = 0.490) and ED crowding were not significant predictors (p = 0.498 for whole-day number of patients, p = 0.095 for whole-shift number of patients).

Conclusion

Old age, high-grade triage, and doctor-based factors were found to be significant predictors for URVA, whereas advanced staff experience and ED crowding were not.     

Legume genome evolution viewed through the Medicago truncatula and Lotus japonicus genomes

Genome sequencing of the model legumes, Medicago truncatula and Lotus japonicus, provides an opportunity for large-scale sequence-based comparison of two genomes in the same plant family. Here we report synteny comparisons between these species, including details about chromosome relationships, large-scale synteny blocks, microsynteny within blocks, and genome regions lacking clear correspondence. The Lotus and Medicago genomes share a minimum of 10 large-scale synteny blocks, each with substantial collinearity and frequently extending the length of whole chromosome arms. The proportion of genes syntenic and collinear within each synteny block is relatively homogeneous. Medicago-Lotus comparisons also indicate similar and largely homogeneous gene densities, although gene-containing regions in Mt occupy 20-30% more space than Lj counterparts, primarily because of larger numbers of Mt retrotransposons. Because the interpretation of genome comparisons is complicated by large-scale genome duplications, we describe synteny, synonymous substitutions and phylogenetic analyses to identify and date a probable whole-genome duplication event. There is no direct evidence for any recent large-scale genome duplication in either Medicago or Lotus but instead a duplication predating speciation. Phylogenetic comparisons place this duplication within the Rosid I clade, clearly after the split between legumes and Salicaceae (poplar).     

The impact of topical mupirocin on peritoneal dialysis infection rates in Singapore General Hospital.

BACKGROUND: Peritonitis and exit-site infections (ESI) are major causes of technique failure and morbidity in peritoneal dialysis (PD) patients. Topical mupirocin on the exit-site has been shown to reduce such complications and prolong life in PD. Since the year 2000, such an approach has been adopted for our new incident PD population. We now report the results of this new protocol. We also studied the effect of co-morbidity on peritonitis occurrence. METHODS: A total of 740 incident PD patients were studied. Patients were divided into two groups based on year of entry into PD (Group 1 from January 1998-December 1999 without topical mupirocin and Group 2 from January 2000-March 2004 with topical mupirocin). Variables studied included gender, age, diabetic status, ischaemic heart disease, peripheral vascular disease, cerebrovascular disease and serum albumin. RESULTS: Topical mupirocin at the exit-site has led to a significant reduction in peritonitis rate (0.443 vs 0.339 episodes/patient-year; P<0.0005) and ESI (0.168 vs 0.156 episodes/patient-year; P<0.005) attributed primarily to the significant reduction in Staphylococcus aureus infections. There was an unexpected finding of lower Pseudomonas aeruginosa peritonitis in the mupirocin group (P<0.005). Stepwise multiple logistic regression analysis revealed that only mupirocin application and serum albumin were significant predictors of peritonitis. CONCLUSIONS: Our study, although limited by its retrospective nature, demonstrated that topical mupirocin was associated with a significant reduction in ESI and peritonitis with unexpected findings of lower Pseudomonas peritonitis. Serum albumin prior to the initiation of PD was a strong predictor of subsequent peritonitis. Mupirocin, with its low toxicity, ease of application and demonstrable beneficial effect in reducing ESI and peritonitis is now used on all incident PD patients.     

A case report of oxaliplatin extravasation.

A 64-year-old Caucasian man presented with synchronous metastaticadenocarcinoma of the sigmoid colon and extensive liver metastases.He was treated with 5-fluorouracil and folinic acid weekly fromthe time of diagnosis in December 2001. He presented in March2002 with an acute large bowel obstruction and underwent emergencysurgery. He was then referred to the Peter MacCallum CancerInstitute for further chemotherapy. In view of extensive livermetastases, and logistical reasons, we decided to treat himwith oxaliplatin