Immune-mediated neutropenia in the neonate

Alloimmune neonatal neutropenia, neonatal autoimmune neutropenia and autoimmune neutropenia of infancy have remained nebulous entities with difficulties in both clinical and laboratory identification. These disorders are reviewed in this article.     

Stimulation of early eosinophil progenitors by a heat stable alveolar macrophage product from ovalbumin-sensitized and non-sensitized guinea pigs

Background Alveolar macrophages (AM) may participate in brochopulmonary hyperreactivity by secreting cytokines that recruit mature eosinophils, or induce eosinophil production from recruited circulating progenitors. Objective To define whether AM products can contribute to lung eosinophil production in immunized guinea pigs (GP), by analysing the effect of AM culture supernatatits (AM-SN) on in vitro eosinophilopoiesis. Methods Liquid and semi-solid bone marrow (BM) cultures were seeded witb SN from 95% pure AM exposed to LPS. Results AM-SN increased very significantly the long-term viability, cell proliferation and eosinophil production in liquid culture and supported formation of eosinophil-bearing mixed colonies, by acting on progenitors depleted of mature eosinophils. The effect on eosinophil production was not duplicated by natural or recombinant sources of GM-CSF (which nevertheless supported GM colony formation by GP BM), not by rhIL-8 (which was active on GP cells) and was not due to residual LPS. FPLC separation of active AM SN yielded a peak of apparent m.w. 43 kDa, active on both liquid and semi-solid cultures. The active moiety was heat- and trypsin-resistant. Neutralizing monoclonal antibodies to hGM-CSF, mGM-CSF, hIL-3 and mIL-3 failed to deplete the activity in AM-SN. Ovalbumin immunization induced its production by AM even without LPS challenge. Conclusions The lack of T lymphocytes among factor-producing AM, the properties of the active material, the inability of GM-CSF to reproduce these effects, and the failure of MoAbs to GM-CSF and to IL-3 to neutralize the activity indicate it is not due to the major eosinopoietic factors GM-CSF, IL-3 or IL-5.     

HERPES SIMPLEX VIRUS TYPE 2 IN BRAZIL: SEROEPIDEMIOLOGIC SURVEY

Background. The incidence of genital herpes is increasing worldwide. Herpes simplex virus type 2 (HSV–2) is the most common cause of genital ulcerations among the sexually transmitted diseases (STDS). In order to investigate the sexual transmission of genital herpes infection in Brazil, the prevalence of specific antibodies to HSV-2, in populations of high and low risk for STDS was evaluated. Methods. The population at low risk for STDS was composed of 155 voluntary blood donors at the University Hospitals between February and August, 1994. The population at high risk for STDS was composed of 85 HIV-seropositive persons, consisting of homosexual and promiscuous heterosexual men. A group of 20 highly active prostitutes was also studied between May and July, 1994. All blood samples were screened using an enzyme-linked immunosorbent assay (ELISA) that detects type-specific antibodies to HSV–2 glycoprotein G. Before donating blood, all persons in the study group were given a questionnaire concerning risk factors for acquisition of STDS and suitable to show the socioepidemiologic characteristics of the subjects. Results. The prevalence of ELISA showing HSV–2 infections among HIV-seroposite persons, was 73% (P < 0.01). In the whole group at high risk for STDS, the prevalence was 72% (P < 0.05). Infection with HSV-2, as determined by seroprevalence, was significantly and independently associated with years of sexual activity, history of previous STDS, number of sexual partners in the previous month, number of pregnancies, and previous induced abortions, as well as the percentage of sexual acts involving receptive anal intercourse.     

Oral midazolam compared with diazepam-droperidol and trimeprazine as premedicants in children

Ninety children were assigned randomly to one of three groups for premedication with oral midazolam 0.5 mg·kg⁻¹, diazepam 0.25 mg·kg⁻¹ with droperidol 0.25 mg·kg⁻¹, or trimeprazine 2 mg·kg⁻¹. On arrival at the anaesthetic room, anxiolysis was satisfactory in 26 out of 29 (90%) children who received midazolam compared with 23 out of 29 (79%) who received diazepam-droperidol and 18 out of 29 (62%) who received trimeprazine ( P <0.05); at induction of anaesthesia these proportions were 24 out of 29 (83%), 16 out of 29 (55%) and 11 out of 29 (40%) respectively ( P <0.001). When individual groups were compared, anxiolysis was significantly greater in the midazolam group compared with the trimeprazine group on arrival in the anaesthetic room ( P <0.05) and significantly greater in the midazolam group than in either the diazepam-droperidol or the trimeprazine groups at induction of anaesthesia ( P <0.05 and P <0.001 respectively). There were no significant differences in times to early recovery between the groups (25.4, 24.4 and 28.5 min). Analysis of behavioural questionnaires completed two weeks after hospitalization showed a trend towards fewer postoperative behavioural disturbances in children who received midazolam or diazepam-droperidol compared with trimeprazine (47 and 44% vs 75%); when the results for the benzodiazepine-containing premedicants were combined, the difference between these groups and trimeprazine was statistically significant ( P <0.05).     

Screening for glaucoma in a Brisbane general practice — the role of tonometry

Objectives: (1) To pilot, and evaluate, a tonometry training intervention for general practitioners; (2) to evaluate the efficacy of three types of tonometer (Perkins, Schiotz and Tonopen) in the hands of these general practitioners; (3) to evaluate the predictive value of tonometry in screening for glaucoma in a general practice population; and (4) to evaluate the acceptability of tonometry to general practice patients. Design: After being trained, three general practitioners recruited 73 of their patients over 50 years of age to attend for measurement of intraocular pressure by tonometry. Intraocular pressure was initially measured by an ophthalmologist using the Goldmann applanation tonometer, and then recorded in random order by GPs using three types of tonometer — the Perkins, Schiotz and Tonopen. Setting: A group general practice in a middle-class suburb in southern Brisbane. Outcome measures: (1) Comparison of measurements on the Perkins, Schiotz and Tonopen tonometers with that of the ‘gold standard’, the Goldmann Applanation tonometer; (2) Prevalence of disc and perimetric abnormality suggestive of glaucoma among those patients with increased intraocular pressure; and (3) the acceptability of contact tonometry to general practice patients. Results: There was considerable variability between intraocular values obtained across doctors and across instruments (6% to 95% of values within 4 mm of the ‘gold standard’). The Schiotz tonometer provided the most uniform assessment of intraocular pressure across the groups. Nineteen of the 73 patients (26%) had intraocular pressures ≥21 mmHg using the ‘gold standard’. Of these, 18 were followed up with funduscopy, gonioscopy, repeat measurement of intraocular pressure and visual field assessment. Five had persistent elevations of intraocular pressure ≥21 mmHg on subsequent assessment, and two had mild abnormalities of cup—disc ratio with normal fields on testing with Humphrey computerised perimetry. Conclusion: No one hand-held tonometer proved highly accurate in the hands of all three doctors. Even measured optimally, increased intraocular pressure alone was a poor predictor of glaucoma. Of the population screened, two patients (3%) showed evidence of mild cup-disc abnormality requiring follow-up.     

FK 506 associated disorders in liver transplantation

Immunosuppressive regimens are usually required for patients receiving organ transplants. The development of a post-transplant lymphoproliferative disorder is an infrequent complication of such therapy. FK 506 is a new immunosuppressant agent that has recently been used in patients receiving organ transplantation. This report describes a 20 month old Saudi child who developed post-transplant lymphoproliferative disorder while receiving FK 506 following liver transplantation. Such a complication has been recognized with cyclosporine but has not been well addressed as yet with FK 506. The child also developed progressive renal complications. There was also a difficulty in interpreting the results for IgM antibodies to different viruses. The overall features of progressive renal toxicity and those of lymphadenopathy, hepatosplenomegaly, fever, neutropenia and thrombocytopenia reversed following discontinuation of FK 506 therapy. It is concluded that all the above complications, though reversible, may well be linked to the new immunosuppressant agent FK 506.     

WHY DO OUTPATIENTS FAIL TO KEEP THEIR CLINIC APPOINTMENTS? RESULTS FROM A SURVEY AND RECOMMENDED REMEDIAL ACTIONS

SUMMARY We undertook a survey of 2555 outpatients (both new and review) to look at the reasons for high non-attendance (DNA) rates. Completed questionnaires (n=983, 38.5% response) indicated the main reasons: forgetting or not receiving the appointment because of illness, and less often because of feeling better; transport problems; and short notice. Our remedial actions included improving the clerical system, announcing DNA rates on a regular basis in GP surgeries and in the outpatient department, introducing a tear-off slip with the appointment letter for patients to return, installing a free answerphone, active GP/consultant involvement in DNA-related problems and local publicity campaigns. A new scheme in our trust – outpatient telephone follow-up – may also help in reducing DNA rates.