Selective transmission of hepatitis B virus after percutaneous exposure.

In 3 clusters of postsurgical hepatitis B virus (HBV) infection, HBV DNA sequence mismatches were observed between the transmitting surgeons and the patients whom they infected. Sequence analysis of clones amplified from the C gene of HBV suggested that the mismatches were due to transmission of a minority variant in the circulation of each surgeon. Compared with 5 other transmitters from whom transmission of the dominant variant was demonstrated, the 3 surgeons who transmitted minority variants carried significantly more heterogeneous HBV populations. Transmission of minority variants was not correlated with the transmitters' hepatitis B antigen status, the presence of the position 1896 precore mutant, or the level of HBV viremia. In 1 cluster, a variant comprising <10% of the HBV population circulating in the transmitting surgeon established infection in all 3 patients who acquired HBV through him, which substantiates the phenomenon of true selection.

Human enteric pathogens identified in a London teaching hospital and a rural public health laboratory: 1994.

Two microbiology laboratories, one serving an inner city hospital and one a rural public health laboratory, collected data on the outcome of examining faecal specimens in 1994. Overall, 6.7% of the investigations were positive, but the rates were lower for hospital inpatients, for recently described pathogens, and in the absence of relevant clinical details; rates were higher for patients with a history of foreign travel. No benefit was gained by examining more than two specimens from any patient. Clostridium difficile was the only investigation frequently positive among patients already in hospital, and virological tests were often positive in patients investigated by general practitioners.

Differential maturation of avidity of IgG antibodies to gp41, p24 and p17 following infection with HIV-1.

We have evaluated solid-phase ELISA IgG antibody avidity studies as a means of identifying cases of recent HIV-1 infection. Although separate studies on the avidity of anti-gp41 and anti-p24 antibodies in seroconvertors have been reported, a comparison of the ability of patients to simultaneously mature their immune response to more than one HIV antigen immediately following seroconversion appears to be lacking. We have demonstrated a maturation in anti-gp41 avidity which reflects the time since seroconversion in all cases. In contrast, however, only some patients produced high-avidity anti-p24 or anti-p17 antibodies during the same time span. While the avidity of anti-gp41 antibodies remained high in cases of non-recent HIV infection, even in the face of advanced disease, we have confirmed the findings of others that the avidity of anti-p24 falls before the onset of ARC or AIDS. Therefore, whilst the avidity of anti-gp41 antibodies could reliably be of value in identifying cases of recent HIV infection, the avidity of anti-p24 or anti-p17 antibodies could not, but may be of prognostic value, even at an early stage. The time taken to reach maximum anti-p17, anti-p24 and anti-gp41 titres was variable, but anti-gp41 titres, like anti-gp41 avidity, remained high. In contrast, anti-p24 titres fell, even during the early followup period in some seroconvertors. Anti-p24 antibody avidity, however, appeared to be a better predictor of disease progression in 'remote' cases than anti-p24 titre. The avidity and titres of these antibodies are presented in relation to the clinical details, p24 antigen status, CD4 and CD8 counts where these are known.

HIV media campaigns and HIV-1 testing trends at London genitourinary medicine clinic, 1985-1993.

OBJECTIVE: To describe HIV-related media events in the context of first-time HIV-1-antibody testing trends at a London genitourinary medicine clinic. DESIGN: Demographic and behavioural data were collected prospectively for individuals tested for HIV-1 antibodies between September 1985 and September 1993, at the genitourinary medicine clinic of St Mary's Hospital, London. RESULTS: A total of 19,242 individuals were tested of whom 37% were women. Of the men tested 60% were heterosexual. The women at first time of testing were significantly younger [29.3 years; 95% confidence interval (CI), 28.8-29.7] than the men (32.5 years; 95% CI, 29.2-35.8); mean ages for both sexes did not change significantly over time. Overall, 199 women and 1539 men tested HIV-antibody-positive. The proportions of women testing positive increased significantly over time (chi 2 = 21.7, degrees of freedom = 1; P < 0.001), whereas the proportion of HIV-positive men remained constant for all sexual orientation groups. The proportion of heterosexual women testing positive (2.8%) was similar to the proportion of HIV-positive heterosexual men (2.9%). HIV-positive individuals were significantly older for both sexes. Throughout the study period numerous education campaigns were run using a variety of media complemented by a number of other HIV-related media events. CONCLUSIONS: Peak periods of attendance for HIV testing generally corresponded with increased HIV-related media activity and the greatest testing rates were observed when various HIV media events occurred concurrently. The increase in the number of heterosexuals tested suggests that the risk of heterosexual transmission of HIV has been recognized, at least among older individuals. The exact role of HIV-related media events, including celebrities disclosing their HIV-positive status, remains to be elucidated. Whether the relative under-representation of younger people is due to a lack of awareness, increased use of safer sex practices or reluctance to use the service also remains to be addressed. Given the increasing number of HIV-positive women and the relatively constant rate of HIV-positive tests in the male attendees an urgent need exists to assess the impact and effectiveness of specific HIV media campaigns.

Ganciclovir treatment for cytomegalovirus infection in immunocompromised patients with renal disease.

The safety and efficacy of a 10-day course of ganciclovir therapy was assessed in 17 consecutive patients with proven cytomegalovirus infection. The patients were receiving immunosuppressive therapy for a variety of non-malignant renal conditions, including renal transplantation (seven patients), small vessel vasculitis (six patients), systemic lupus erythematosus (three patients) and Goodpasture's disease (one patient). Fifteen patients were pyrexial at the time of their cytomegalovirus infection. Twelve patients had pneumonitis manifesting as a pulmonary parenchymal infiltrate or a reduction in gas transfer. Fourteen patients had a significant lymphopenia (lymphocyte count less than 1 x 10(9)/l), nine were leucopenic (white cell count less than 3.5 x 10(9)/l) and nine had abnormal liver biochemistry. One patient had an infection of the ileum and one an infection of the larynx. All these disease manifestations responded completely to a single course of ganciclovir therapy. There were no clinical relapses and no side effects were observed. Ganciclovir is a safe and effective therapy when administered early in the course of cytomegalovirus infection in immunosuppressed patients with renal impairment.

A prospective study of acute idiopathic neuropathy. II. Antecedent events.

The incidence of antecedent events and serological evidence of preceding infection were studied in 100 patients with acute idiopathic neuropathy and age and sex matched control subjects in South-East England. Symptoms of respiratory infections occurred within one month before onset of neuropathic symptoms in 38% of patients and 12% of controls (p less than 0.001) and symptoms of gastrointestinal infections in 17% of patients and 3% of controls (p less than 0.005). Immunisations, insect bites and animal contact were equally common in the patient and control subjects. Eight per cent of patients had undergone an operation within the preceding 3 months. Six per cent of patients had co-existing "autoimmune" diseases. Serological evidence of recent infection was identified in 31% of patients. Campylobacter jejuni (14%) and cytomegalovirus (11%) were both significantly more frequently demonstrated in patients than controls. Serological evidence of recent infection with mycoplasma (1%), Epstein Barr virus (1-2%) and parvovirus B19 (4%) was also identified in the patients but not more frequently than in the controls. Possible explanations for the association of these agents with acute idiopathic neuropathy include possession of antigens shared with myelin and inhibition of suppressor mechanisms.

Detection of rubella-specific IgM in subclinical rubella reinfection in pregnancy.

Seven cases of asymptomatic rubella reinfection in early pregnancy are described. In each, there was a history of exposure to a rubelliform illness and low levels of rubella-specific IgM subsequently appeared in the serum. Four of the women had been immunised, after having been shown to be susceptible to rubella, one had been immunised at school without previous antibody screening, and two were uncertain about immunisation. One pregnancy was terminated and rubella virus was not isolated from the products of conception. Six pregnancies went to term and the infants showed no evidence of intrauterine infection. In a further case it was impossible to discriminate between reinfection and primary infection, and termination of pregnancy was offered.

Use of the soleus muscle flap to cover part of the distal tibia.

A method for covering soft-tissue defects overlying the distal tibia with a proximally based soleus muscle flap is described. The flap can be used to cover a portion of the distal tibia by extending the distal reach of the soleus muscle. The muscle is extended by several relaxing incisions in the epimysium. This simple procedure enables the soleus muscle to be advanced distally, extending its application for coverage of the distal lower leg. The method has been used successfully clinically, eliminating the need for more time-consuming or difficult procedures.