Urban trench fever presenting as culture-negative endocarditis.

A young Russian man presented with increasing shortness of breath and signs of worsening aortic regurgitation. A diagnosis of infective endocarditis was made before emergency valve replacement. The infective cause was not discovered by routine culture but was suggested by electron microscopy and confirmed by serology and PCR testing.

The effect of Plasmodium falciparum infection on expression of monocyte surface molecules.

Plasmodium falciparum infection may result in severe malaria in susceptible individuals. The pathogenesis of severe disease is probably a combination of the sequestration of infected erythrocytes and overstimulation of the immune response. Monocytes are a key source of many of the pro-inflammatory agents implicated but also are found sequestered in blood vessels. However, little is known about the monocyte phenotype in malaria disease. Flow cytometry was performed on fresh whole blood to determine surface expression of four receptors during acute severe and non-severe malaria and again during convalescence when uninfected. Three hundred and fifty-six children with P. falciparum infection were studied and were found to show increased expression of intercellular adhesion molecule-1 (ICAM-1), urokinase plasminogen activator receptor (uPAR), CD23 and chemokine receptor 5 (CCR5) (P<0.001) during acute disease compared with convalescent levels. Using multivariate analysis, it was found that large increases in expression of ICAM-1 (odds ratio (OR) 2.44, 95% CI 1.80-3.32) and uPAR (OR 3.14, 95% CI 1.93-5.09) but small increases in expression of CD23 (OR 0.82, 95% CI 0.68-0.96) were independently associated with severe malaria. These results give an insight into the cellular processes occurring in severe malaria and suggest that pathology is based on a complex repertoire of pro- and anti-inflammatory processes.

Scrotal mass with fever and generalized lymphadenopathy in a young man secondary to Chlamydia trachomatis infection.

A young man presented with systemic upset and generalised lymphadenopathy. Later, it transpired that he was under investigation for a scrotal mass. Investigations were carried out to ascertain the cause of his symptoms including lymph node biopsy. Because of the presence of a scrotal mass in a sexually active male, a urinary Chlamydia ligase chain reaction (LCR) test was carried out. The result was positive and he was treated with doxycycline for 2 weeks. His symptoms settled and further, the urinary LCR was negative. We propose that Chlamydia trachomatis infection caused his illness and that urine PCR or LCR tests for Chlamydia is a convenient and useful investigation in sexually active males with generalised lymphadenopathy and fever of unknown origin.

What proportion of primary psychiatric interventions are based on evidence from randomised controlled trials?

OBJECTIVES: To estimate the proportion of psychiatric inpatients receiving primary interventions based on randomised controlled trials or systematic reviews of randomised controlled trials. DESIGN: Retrospective survey. SETTING: Acute adult general psychiatric ward. SUBJECTS: All patients admitted to the ward during a 28 day period. MAIN OUTCOME MEASURES: Primary interventions were classified according to whether or not they were supported by evidence from randomised controlled trials or systematic reviews. RESULTS: The primary interventions received by 26/40 (65%; 95% confidence interval (95% CI) 51% to 79%) of patients admitted during the period were based on randomised trials or systematic reviews. CONCLUSIONS: When patients were used as the denominator, most primary interventions given in acute general psychiatry were based on experimental evidence. The evidence was difficult to locate; there is an urgent need for systematic reviews of randomised controlled trials in this area.

Effect of measuring ambulatory blood pressure on sleep and on blood pressure during sleep.

OBJECTIVE: To assess whether recording of ambulatory blood pressure at night causes arousal from sleep and a change in the continuous blood pressure recorded simultaneously. DESIGN: Repeated measurement of blood pressure with two ambulatory blood pressure machines (Oxford Medical ABP and A&D TM2420) during continuous measurement of beat to beat blood pressure and continuous electroencephalography. SETTING: Sleep research laboratory. SUBJECTS: Six normal subjects. MAIN OUTCOME MEASURES: The duration of electroencephalographic arousal and the beat to beat changes in blood pressure produced by the measurement of ambulatory blood pressure; the size of any changes that this arousal and change in blood pressure produced in the blood pressure recorded by the ambulatory machine. RESULTS: Both ambulatory blood pressure machines caused arousal from sleep: the mean duration of arousal was 16 seconds (95% range 0-202) with the ABP and 8 seconds (0-73) with the TM2420. Both also caused a rise in beat to beat blood pressure. During non-rapid eye movement sleep, this rise led to the ABP machine overestimating the true systolic blood pressure during sleep by a mean of 10 (SD 14.8) mm Hg and the TM2420 by a mean of 6.3 (8.2) mm Hg. On average, diastolic pressure was not changed, but measurements in individual subjects changed by up to 23 mm Hg. These changes varied in size among subjects and stages of sleep and were seen after measurements that did not cause any electroencephalographic arousal. CONCLUSIONS: Ambulatory blood pressure machines cause appreciable arousal from sleep and therefore alter the blood pressure that they are trying to record. This effect should be taken into account when recordings of blood pressure at night are interpreted in clinical work and epidemiological research.

Lipolytic activity and degradation of rapeseed oil and rapeseed by spoilage fungi.

Aspergillus, Eurotium and Penicillium spp. from rapeseed were able to grow and produce lipases over a range of water activities (aw) at both 15 and 25 degrees C on tributyrin agar. The ability to produce lipases was not directly related to growth rate. The clearing zone: growth rate ratios gave lipase indices which varied markedly between test fungi and with aw. The fungi with the highest indices were Aspergillus candidus and Aspergillus versicolor and Penicillium expansum and Penicillium hordei. The Aspergillus spp. generally grew faster on a 1% crude rapeseed oil at 25 degrees C and 0.995 and 0.95 aw than on the tributyrin agar. P. hordei degraded the rapeseed oil more rapidly than Eurotium amstelodami or Penicillium aurantiogriseum, with optimum activity at 0.98 aw. E. amstelodami was the least effective at degrading the rapeseed oil under all aw conditions. The lipase indices were compared with the ability of the test fungi to degrade irradiated rapeseed. Dry matter loss over 4-week periods were greater at 25 than 15 degrees C, regardless of aw. At 15 degrees C, Penicillium spp. caused significantly greater dry matter losses than Aspergillus spp. A. niger degraded rapeseed faster than other Aspergillus spp. tested at 0.98 aw, but at 0.95 and 0.90 aw there was little difference between species.