Liver abscess in adults: ten years experience in a UK centre

BACKGROUND: The epidemiology and management of liver abscess (LA) have evolved over time. Aim: To examine our experience over 10 years in a UK teaching centre. DESIGN: Retrospective review of patient records. METHODS: We reviewed the records of all patients aged >16 years discharged from Royal Hallamshire Hospital with a diagnosis of LA between April 1988 and December 1999. RESULTS: There were 69 patients with LA (65 pyogenic, 4 amoebic), giving a crude annual incidence rate of 2.3/100,000/year (18.15/100,000 hospital admissions). Median age was 64 years. Single lesions were found in 41 patients, multiple lesions in 28. Pre-admission, patients were symptomatic for a median 14 days, with the most common symptoms and signs being fever and abdominal pain/tenderness. Pathogens were identified in 74% and predisposing aetiology in 92% of those undergoing investigation. Spread of infection to the liver via the portal venous system was the commonest route of infection (46%), most frequently in patients aged >/=60 years (p=0.019). Abdominal ultrasound (US) was diagnostic for LA in >90% of cases. Treatment with anti-microbial therapy plus interventional radiology was optimal. The case fatality rate was 12.3%, mainly from associated underlying pathology. DISCUSSION: LA is commonly associated with underlying gastrointestinal pathology. Seeking out this underlying aetiology is an integral part of management. We recommend US as the first-line diagnostic tool with guided intervention plus antibiotic(s) as first-line treatment. Prognosis depends chiefly on the underlying pathology.     

Lung function tests and risk factors for pneumonia in adults with chickenpox

BACKGROUND: Varicella is 25 times more likely to be complicated by pneumonia in adults than in children. Data on changes in lung function following pneumonia are limited. This study was undertaken to describe the epidemiological factors associated with pneumonia and to investigate lung function up to 1 year following chickenpox. METHODS: Thirty eight consecutive suitable patients admitted to a university hospital were enrolled in the study; 19 had pneumonia and 19 did not. Epidemiological data and density of rash were recorded, spirometric tests were performed, and carbon monoxide transfer factor was measured. RESULTS: Varicella pneumonia was associated with the presence of respiratory symptoms (p=0.006), current smoking (p=0.003), and history of close contact (p=0.009). There was a trend towards patients with pneumonia having a more severe rash. No association was observed between pneumonia and age or sex. Current smokers had a higher mean number of spots than non-smokers (p=0.005). Carbon monoxide transfer factor at hospital discharge was reduced in 27 patients (71%), more markedly in the group with pneumonia (p=0.009). Nine patients (seven with pneumonia) still had a reduced carbon monoxide transfer factor (mean reduction 36%) at 12 months. CONCLUSION: Chickenpox may result in a defect in carbon monoxide transfer factor for at least a year after acute illness.     

Hypertrophic cardiomyopathy: a rare cause of vascular dementia. A case report

Herein, we report a case of a 51 year old man who experienced three ischemic cerebral infarcts in a time of few months. The patient consulted after the third accident. Neurological presentation included pseudobulbar syndrome with a mild cognitive deficit, aphasia, left hemiparesia, hemiasomatognosia and homonymous lateral hemianopsia. Cerebral tomodensitometry and magnetic resonance imaging evidenced large infarcts images involving right middle cerebral artery territory and bilateral borderline zones in the junction of the territories of the middle and posterior cerebral arteries. Ambulatory 24 hours ECG recording (Holter) revealed two hits of non-sustained ventricular tachycardia. Transoesophageal echocardiography conveyed to the diagnosis of hypertrophic cardiomyopathy and displayed the presence of a left auricular thrombus. Anticoagulant therapy and rehabilitation allowed a substantial recovering of the patient's cognitive functions and wasting of the intracardiac thrombus. The clinical features observed in our patient meet the recommended DSM IV diagnosis criteria of vascular dementia, an exceptional complication of HCM. The clinical findings, neuroimagery investigation results, and the chronological link between cerebral attacks and cognitive function deterioration argue for a demential syndrome of vascular origin resulting from multiple embolic infarcts involving medium sized arteries (multi-infarct dementia). The authors emphasize the rarity of such observation. HCM must be considered as a potential cause of embolic stroke and likewise a multi-infarct dementia.     

Changes in trabecular bone architecture in women during pregnancy

Objective To examine the effect of early and late pregnancy on the microarchitecture of maternal cancellous bone.
Sample Transilial bone biopsies were obtained from two groups of pregnant women one group (   n = 15  ) in the first trimester and the other (   n = 13  ) at term. Comparison was made with biopsy and autopsy samples from a group (   n = 25  ) of normal premenopausal nonpregnant women.
Methods Undecalcified sections were analysed under a low power optical microscope using an automated trabecular analysis system which measures a comprehensive range of structural variables including the bone volume, trabecular number, width, separation and connectivity.
Results In early pregnancy the quantity of cancellous bone fell from a mean relative bone volume of 23.07% (SD 5.49) in nonpregnant controls to 16.72% (SD 3.91) (   P < 0.001  ). This was primarily due to a decline in trabecular thickness from 122.9 pm (SD 10.5) to 97.2 pm (SD 21.8) (   P < 0.01  ) and was accompanied by a loss of trabecular connectivity expressed as a reduction in the trabecular node: terminus ratio from 0.90 (SD 0.71) to 0.38 (SD 0.26) (   P < 0.001  ). By late pregnancy the bone volume had been entirely restored to 23.41% (SD 9.76). This was primarily due to an increase in the number of trabeculae from 73.2 (SD 35.5) /field to 100.3 (SD 33.3) /field to (   P < 0.05  )with an associated reduction in trabecular separation from 431 pm (SD 150) to 315.8 pm (SD 78.5) (   P < 0.01  ).
Conclusions Pregnancy affects the maternal skeleton by producing a fluctuation in the cancellous bone volume in which early temporary bone loss through trabecular thinning is restored in entirety through the addition of new trabeculae to produce a modestly more complex system of thinner more numerous bars by term.     

Prediction of protein orientation upon immobilization on biological and nonbiological surfaces

We report on a rapid simulation method for predicting protein orientation on a surface based on electrostatic interactions. New methods for predicting protein immobilization are needed because of the increasing use of biosensors and protein microarrays, two technologies that use protein immobilization onto a solid support, and because the orientation of an immobilized protein is important for its function. The proposed simulation model is based on the premise that the protein interacts with the electric field generated by the surface, and this interaction defines the orientation of attachment. Results of this model are in agreement with experimental observations of immobilization of mitochondrial creatine kinase and type I hexokinase on biological membranes. The advantages of our method are that it can be applied to any protein with a known structure; it does not require modeling of the surface at atomic resolution and can be run relatively quickly on readily available computing resources. Finally, we also propose an orientation of membrane-bound cytochrome c, a protein for which the membrane orientation has not been unequivocally determined.     

Prevalence and incidence of diabetes in HIV-infected minority patients on protease inhibitors

In HIV-infected patients, the use of protease inhibitors (PIs) is associated with a constellation of abdominal obesity; buffalo hump; decreased facial and subcutaneous fat; hyperlipidemia and type-2 diabetes mellitus, a so-called HAART-associated dysmetabolic syndrome. The incidence and prevalence of one of its components, the type-2 diabetes mellitus, among minority population is unknown. In August and September 1999, we reviewed 101 charts of HIV-infected patients who visited an inner-city HIV outpatient clinic. The age, gender, ethnicity, BMI, fasting plasma glucose, random serum glucose, triglycerides, CD4 counts, and the type and duration of antiretroviral drugs were recorded. Three years later (2002), the same patient charts were reviewed for evidence of new-onset diabetes. Ten percent of the subjects were identified as diabetic at baseline. The prevalence of diabetes was 12% among those who were taking PIs, compared to 0% among those who were not taking PIs. The incidence of newly diagnosed diabetes during this three-year period was 7.2%. Diabetes occurred only in the group taking PIs. Diabetic subjects were older than their nondiabetic counterparts. All were African Americans. Our study suggests that PIs increase the likelihood of diabetes developing with increasing age in African Americans infected with HIV.     

Comparative evaluation of two fixed doses of 185 and 370 MBq 131I, for the treatment of Graves' disease resistant to antithyroid drugs

Radioiodine (131I) treatment is often applied for the treatment of Graves' disease (GD). The optimal dose of 131I for Graves' hyperthyroidism is debated. Various techniques suggest either fixed doses or varying doses based on elaborate calculations of the gland size, 131I uptake, and 131I turnover. Fixed dose regimens avoid dose calculations but there is no consensus on the actual dose to be administered. We compared two routinely recommended fixed 131I doses of 185 and 370 MBq for this purpose. Fifty nine patients with GD who had not been previously treated with 131I were randomized in two groups. Group A consisted of 33 patients who were treated with 185 MBq of 131I. Group B consisted of 26 patients who were treated with 370 MBq of 131I. Group A patients were 21% male and 78% female, mean age 38.1+/-14.4, range 15 to 77 y. Group B patients were 27% male and 73% female, mean age 40.7+/-11.7, range 27 to 72 y. All patients were reexamined every six months for two years. The following clinical outcomes were noticed: a) Persistent hyperthyroidism, which was considered as failure to treatment, requiring further 131I treatment. b) Hypothyroidism; requiring life-long replacement treatment. c) Euthyroid state. Euthyroid and hypothyroid states were considered as a response to treatment of hyperthyroidism. In Group A, 10 patients (30.3%) became euthyroid and 6 (18.2%) hypothyroid (an overall response of 48.5%), while 17 (51.5%) remained hyperthyroid by the end of the follow-up period. In Group B, 10 patients (38%) became euthyroid and 13 (50%) hypothyroid, an overall response of 88.5%. Non responders were 3 patients (11.5%). No correlation was noted between the outcome of treatment and age, sex, size of the thyroid gland or thyroid uptake in each Group of patients, while a significant correlation was noted between the disease outcome and the amount of administered 131I (P<0.003). The incidence of hypothyroidism by the end of two years of follow up was less in Group A than in Group B and the incidence of non responders to treatment was lower in Group A. In view of the higher cost of treatment, the longer time elapsing to treatment, the number of office visits by the patients and the higher number of patients with persistent hyperthyroidism in Group A, we conclude that a fixed dose of 131I of 370 MBq is more useful and effective for the treatment of GD as compared to 185 MBq of 131I.