Cryptococcal disease of the CNS in immunocompetent hosts: influence of cryptococcal variety on clinical manifestations and outcome.

We performed a retrospective review of cases of cerebral cryptococcosis among patients admitted to 12 Australian teaching hospitals between 1985 and 1992. Of 118 cases identified, 35 occurred in immunocompetent hosts. When cases due to Cryptococcus neoformans variety neoformans were compared with those due to Cryptococcus neoformans variety gattii, we found that the latter tended to occur in healthy hosts whose residence or job was located in a rural area, and cerebral mass lesions and/or hydrocephalus and pulmonary mass lesions were more common. For a subgroup of patients with infection due to C. neoformans variety gattii, multiple enhancing lesions were observed on cerebral computed tomograms, and papilledema, high CSF and serum cryptococcal antigen titers, and a worse prognosis (despite prolonged amphotericin B therapy and intraventricular shunt insertion) were also noted. No significant difference in clinical course or outcome in terms of variety of C. neoformans was noted for patients with cryptococcal meningitis whose computed tomographic scans appeared normal on presentation.

Bacteraemia and fungaemia in an Australian general hospital--associations and outcomes.

OBJECTIVE: To obtain a comprehensive overview of bacteraemia and fungaemia in a general hospital and thus to determine the incidence, primary sites of sepsis, organisms involved and associated mortality. DESIGN: A prospective laboratory and clinical evaluation of all episodes where microorganisms were cultured from blood over one year. SETTING: The two major hospitals in the Australian Capital Territory which have both community and referral functions. These hospitals provide obstetric and paediatric services along with adult medicine and surgery. PATIENTS: All those who acquired bacteraemia in hospital or presented with a blood-stream infection documented by a positive blood culture. RESULTS: During 1990, 474 clinical episodes of bacteraemia or fungaemia were detected in 446 patients. Significant isolates were identified in 317 of these episodes. The incidence of significant sepsis was 8.1 episodes per 1000 admissions. The most common organisms isolated were Staphylococcus aureus (75 episodes) and Escherichia coli (70 episodes). One hundred and twenty-eight episodes were hospital acquired. Intravenous catheters were the primary sites of sepsis in 68 episodes. Fifty patients died. Higher mortality rates were associated with patients over 60 years of age, respiratory tract sepsis, endocarditis and the presence of an underlying malignancy. CONCLUSION: Bacteraemia and fungaemia are common problems. Nosocomial bacteraemia accounted for 40% of episodes. Half of these nosocomial infections were iatrogenic. Many of the episodes of intravenous catheter sepsis were potentially preventable. Ongoing programs of surveillance of bacteraemia, with the evaluation of primary site, associated features and mortality, are essential to monitor the dimensions of this problem and aid in implementing effective preventive strategies.

Screening for job placement: an in-house placement screening programme.

A system of screening for all types of job placement has recently been introduced at British Airways, following consultation with all interested parties. The rationale, development and practical aspects are described.

Invasive Haemophilus influenzae infection in the Australian Capital Territory region.

OBJECTIVE: To investigate the pattern of invasive Haemophilus influenzae disease in the Australian Capital Territory (ACT) region with a view to assessing the possible benefits of vaccination in this community. SETTING AND DESIGN: The microbiology department of Royal Canberra Hospital processes all specimens from the three public hospitals in the ACT. Together these hospitals provide all paediatric medical and approximately 80% of adult inpatient beds available in the ACT. We identified all laboratory isolates of H. influenzae obtained from normally sterile sites from 1984 to 1990, and reviewed the clinical records of these patients. Also included in this analysis were all cases of acute epiglottitis identified in hospital discharge summaries, intensive care and coroners' records. Epidemiological, clinical and microbiological data were gathered and assessed. RESULTS: We identified 138 cases of infection. Forty per cent (36 of 66 cases of meningitis, 5 of 44 cases of epiglottitis, 10 of 12 cases of cellulitis) occurred in children aged less than 18 months. Meningitis (48%), epiglottitis (32%), cellulitis (9%) and primary bacteraemia (4%) were the most common syndromes seen. The annual incidence of invasive H. influenzae disease in Canberra was 63.2 per 100,000 children aged under five years. Approximately 1 in 225 children under five years of age and resident in Canberra developed invasive H. influenzae disease. Ninety-eight per cent of isolates serotyped were type b. CONCLUSION: A vaccination program effective in preventing H. influenzae type b infection, completed in infants before 6 months of age, could prevent upwards of 80% of invasive H. influenzae disease in our population. Such a program should be cost effective although precise assessment is hampered by the lack of accurate data on the acceptance rate, costs and efficacy of the current childhood vaccination schedule in our region.

Demographic, social and clinical correlates of Raynaud phenomenon.

Our study has identified the demographic, social and clinical correlates of primary Raynaud phenomenon (RP) from a case-control study involving 235 subjects who were identified from a population-based prevalence survey of RP. All potential cases and a sampling of probable non-cases, identified by a screening questionnaire, were invited to a medical clinic for diagnostic testing and assignment of case or control status. Odds ratios (OR) for risk indicators for primary RP were estimated using multiple logistic regression to obtain 95% confidence intervals. The regression yielded statistically significant (p less than 0.05) positive associations for sex (OR = 3.0 for females versus males), self-reported alcohol use (OR = 1.1) and diastolic blood pressure (OR = 1.2) in those on antihypertensive medication. A significant (p = less than 0.01, OR = 0.4) negative association was found for Quetelet index (a measure of obesity). Near-significant or suggestive but non-significant negative associations were found between RP and marital status (p = 0.05, OR = 2.5), increased years of education and, for those on antihypertensive medication, higher systolic blood pressure (both p = 0.07).

Major clinical diagnoses found among patients with Raynaud phenomenon from the general population.

This study of 62 individuals with Raynaud phenomenon (RP) drawn from the general population of South Carolina shows a profile of associated diseases that is different from the one reported from hospital based studies. We found that connective tissue diseases affect a much smaller fraction of patients with RP than previously reported. Compared to RP negative controls, our RP positive group was found to suffer more frequently from a variety of diseases, both RP related and not RP related.

Disseminated prostatic carcinoma presenting with acute interstitial nephritis and microangiopathic haemolytic anaemia.

A 74-year-old man with metastatic prostatic carcinoma developed acute oliguric renal failure, a microangiopathic haemolytic anaemia and thrombocytopaenia. A renal biopsy showed an acute interstitial nephritis but no changes suggestive of the haemolytic uraemic syndrome. He recovered normal renal function after treatment with haemodialysis and prednisone 20 mg daily for five days. Previous assumptions about the renal lesion in patients with malignancy-associated microangiopathic haemolytic anaemia may need review.

Prevalence of Raynaud phenomenon in the adult population of South Carolina.

A prevalence estimate for Raynaud phenomenon among adult residents of South Carolina was based on data obtained from respondents in a statewide health survey, followed by face-to-face interviews and clinical screening for Raynaud phenomenon, using a screening procedure developed by the authors. The survey obtained 5246 personal interviews from a probability sample of over 3000 households, and 494 survey subjects participated in the clinical screening. The prevalence estimates and their standard errors were computed using survey case weights, design-based estimation, and logistic modelling techniques. The prevalence of Raynaud phenomenon among adult residents of South Carolina was determined to be 3.5%, with a standard error of 0.6%. Prevalence was higher for females (4.3%, SE = 0.7%) than for males (2.7%, SE = 0.6%). These figures are much lower than most estimates in the existing literature on Raynaud phenomenon.

Prevalence of scleroderma spectrum disorders in the general population of South Carolina.

The prevalence of scleroderma spectrum disorders (including systemic sclerosis [SSc] meeting the American Rheumatism Association criteria and the less typical disorders meeting only our study criteria) was determined in a random sample of 6,998 subjects from the general population of South Carolina. The results suggest that the prevalence of these disorders may range from 67 to 265 per 100,000, which is 4.9 to 19.2 times higher than previously reported for definite SSc. The ratio of nondefinite cases to definite cases of SSc (those meeting American Rheumatism Association criteria) was 2.5. Most of the nondefinite cases were unrecognized prior to our study, which suggests the need for improved early diagnosis of scleroderma spectrum disorders. Brief histories of the 7 patients with scleroderma spectrum disorders whose cases formed the basis for our calculation of prevalence rates are included in this report.

Nephronophthisis-cystic renal medulla complex: diagnosis by computerized tomography.

A 19-year-old man with renal failure and mild hypertension was found to have juvenile nephronophthisis. The diagnosis was established by computerized tomography of the kidneys after other imaging techniques had proved inconclusive. Computerized tomography is advocated as the investigation of choice if this diagnosis is considered.

Familial clustering of scleroderma spectrum disease.

This is the second case report of familial scleroderma (systemic sclerosis) in South Carolina. The family includes two cases of scleroderma meeting American Rheumatism Association criteria, one of systemic sclerosis sine scleroderma, and two other cases of undifferentiated connective tissue disease with features of scleroderma spectrum disorders; there are also two cases of Raynaud's phenomenon (one associated with rheumatoid arthritis), for a total of seven affected relatives. Evidence of scleroderma spectrum disorders was sought in six siblings of the two co-index cases and in 23 of the 35 offspring. Laboratory studies included antinuclear antibody determinations and typing for the following genetic markers: HLA (A, B, C, DR), complotypes, Gm and Km allotypes, and alpha-1 antitrypsin phenotypes. No common genetic markers restricted to affected members of this family were found, and no environmental exposures were detected that could explain this familial clustering of cases. This report should, however, add to the slowly accumulating information on the genetic characteristics of families at unusually high risk for scleroderma spectrum disorders. Positive antinuclear antibody tests at a titer of 1/40 or higher were present in 57 percent of the first-degree relatives of the affected cases.

Acute epiglottitis in childhood, Christchurch 1970-84.

The case records of 31 children presenting to Christchurch Hospital with acute epiglottitis over the last 15 years have been reviewed. There has been a significant increase in incidence over this period (p less than 0.05). Despite generally classical presenting features the disease was recognised in only 26% of children when seen by general practitioners prior to admission. The increasing problem of ampicillin resistance to Haemophilus influenzae type b locally has resulted in a change in first line antibiotic therapy in recent years. Changes have also occurred in methods of airway management with elective nasotracheal intubation now the usual procedure.

Genetic susceptibility to scleroderma-like syndrome induced by vinyl chloride.

Vinyl chloride (VC) monomer can induce a scleroderma-like syndrome in a proportion of workers exposed to it during production of polyvinyl chloride. As part of a 5-year follow-up study HLA A, B, and DR antigens and anti-centromere and anti-scleroderma-70 antibodies were determined in 44 such workers. 21 of these had severe and 23 mild forms of vinyl-chloride disease. 50 patients with "classical" scleroderma and 148 healthy hospital workers acted as controls. 11 of the 21 patients classified as having severe VC disease were DR3 positive, and 8 of these had both B8 and DR3 antigens. None of the 23 patients with mild disease carried either antigen. The HLA-antigen frequencies in VC disease mirrored those found in scleroderma (raised DR5 frequency and increased linkage disequilibrium between B8 and DR3). There were, however, significant differences in the frequency of autoantibodies in the two conditions.

Separation fluoroimmunoassay methods for phenytoin in serum.

A separation fluoroimmunoassay system for phenytoin was established based on the use of a specific rabbit antiserum, a fluorescein-labelled ligand, and precipitation of the antibody-bound fraction of the labelled ligand with sodium sulphate. Simple measures were taken to obviate non-specific binding and matrix effects. Either the free fraction (in the supernatant) or thebound fraction of the labelled ligand was quantitated fluorimetrically. Assays of patient serum samples by either method correlated well with established gas-liquid chromatographic and radioimmunoassay techniques. Advantages of a separation based procedure as compared with previously described non-separation hapten fluoroimmunoassay techniques are that only simple instrumentation and assay reagents are required, and that the separation step may enable the removal of any interfering intrinsic fluorescence of serum samples.

Polarisation fluoroimmunoassay of phenytoin.

A polarisation fluoroimmunoassay for the determination of phenytoin levels in serum is described. Fluoresceinthiocarbamyl alpha,alpha-diphenylglycine (FTC-DPG) is used as an easily prepared fluorescent-labelled analogue of phenytoin. Interference from the non-specific binding of FTC-DPG by serum proteins is eliminated by proteolytic degradation of samples prior to assay. The method employs stable, non-radioactive reagents, requires no separation procedure, and involves only 1.25 microliter of serum. Analyses of serum samples from patients receiving phenytoin correlate well (r = 0.96) with an established gas-liquid chromatographic method.