Clinical audit: virological and immunological response to combination antiretroviral therapy in HIV patients at a Sydney sexual health clinic.

AIM: Bigge Park Centre (BPC) is a sexual health clinic located in a socially disadvantaged area in Southwest Sydney. This served as a retrospective clinical audit, documenting patient demographics, identifying factors associated with virological, immunological and discordant responses, evaluating the centre's ability in HIV control and investigating changes in practice from 1996 to 2007. METHOD: Data including age, gender, ethnicity, mode of transmission, hepatitis co-infection, prior acquired immune deficiency syndrome (AIDS)-defining-illness, HIV-1 RNA and CD4+cell counts of patients on combination antiretroviral therapy (CART) for treatment of HIV with at least 1-year follow up at the BPC were analysed. Results were compared with other cohorts in medical literature. RESULTS: BPC manages HIV patients from diverse backgrounds. Sequential monotherapy was associated with poor virological control, lower CD4+cell recovery and discordant response. When patients who had sequential monotherapy were excluded, Caucasian race, high viral load at 1 month and triple-NRTI (nucleoside reverse transcriptase inhibitor) regimen were associated with lack of virological control. Lower baseline viral load and triple-NRTI regimen were associated with lower CD4+cell recovery. Lower baseline CD4+cell count and prior diagnosis of AIDS were associated with discordant response. Virological control and CD4+cell recovery achieved were comparable to that documented in medical literature. There was no significant change over time in terms of timing of CART initiation, attainment of immunological response or virological control since the late 1990 s. CONCLUSION: HIV control achieved at the BPC was comparable to that reported in medical literature. Enhancement of strategies to promote screening and improve adherence as well as performance of HIV resistance assessment and avoidance of triple-NRTI therapy will likely improve patient care.

A simple radioactive binding assay for the detection of rheumatoid factor in serum.

A simple radioactive binding assay for the detection of rheumatoid factor (RF-RBA) is described. Test sera are complement inactivated by incubation in 0.13 M ethylene diaminetetraacetic acid (EDTA) at 37 degrees C and then incubated with 125I-labelled heat-aggregated IgG. Rheumatoid factor bound, labelled IgG is separated from free by precipitation with 2.5% (w/v) polyethylene glycol 6000. Sera from 78 patients and 24 controls were tested in the RF-RBA assay and the results compared with those obtained by the rheumatoid latex test and the rheumaton test. 37 sera were positive and 59 sera were negative for rheumatoid factor by the 3 methods used. A positive correlation (r = 0.56, P less than 0.01) was observed between the rheumaton titre and the RF-RIA result.

Solid and papillary epithelial tumour of the pancreas: cytological case study with ultrastructural and flow cytometric evaluation.

An intraoperative cytological diagnosis of a rare solid and papillary epithelial tumor of the pancreas was made at laparotomy in a 15-year-old Indian female. The characteristic cytological features were the presence of numerous large branching papillary clusters with central vascular stalks lined by multiple layers of uniform bland cells. Perivascular metachromatic material was prominent on Romanovsky stain. Ultrastructural identification of endocrine and exocrine features supports a multipotential cell origin in small pancreatic ductules. DNA analysis, not previously reported for this tumour, demonstrated a diploid population of tumour cells with a low S-phase fraction (0.4%). This would explain the bland nuclear morphology and favourable prognosis with a high rate of surgical cure for this neoplasm.

Lysosomal enzyme activities in sheep plasma and lymph.

The activities of acid phosphatase, beta-glucuronidase and N-acetyl-beta-glucosaminidase were measured in blood plasma, afferent and efferent popliteal lymph, intestinal lymph and in four different organs of the sheep. Acid phosphatase had an optimum activity at pH 4-5 while beta-glucuronidase and N-acetyl-beta-glucosaminidase had optimal activities at pH 5-0 and pH 4-5-5-0, respectively. Comparative studies showed that the sheep had very low activities of acid phosphatase and relatively low activities of N-acetyl-beta-glucosaminidase in the blood plasma compartment in relation to the activities of these enzymes in the plasma of the rabbit and the rat. The tissue activities of all three enzymes were relatively high when compared with those in the two non-ruminant species. It is considered that the low plasma activities of acid phosphatase in the sheep reflect a rapid turnover of this enzyme in the plasma compartment. The activities of the three enzymes in regional lymph indicated that acid phosphatase was being added to the capillary filtrate at a regional tissue level, whereas beta-glucuronidase and N-acetyl-beta-glucosaminidase in lymph were derived from filtration from the blood plasma compartment on a molecular weight basis. The high lymph: plasma ratios observed for acid phosphatase activity in intestinal lymph may indicate a function of this enzyme in lipid absorption in the sheep.

Red blood cell catabolism in lymph nodes of the sheep and rat: quantitation.

Estimates have been made of the number of red blood cells catabolised in the lymph nodes of the sheep and the rat. These estimates were based on observations on the output of bilirubin in intestinal lymph of the sheep and on bilirubin output in thoracic duct lymph of the rat. It was calculated that some 2 to 15 X 10(9) red blood cells were catabolised in a 24 hour period by the lymph nodes of the intestinal region of the sheep, representing approximately 3% of all the red cells destroyed in this period. Similarly, 0.9 to 4.6 X 10(8) red blood cells were estimated to be catabolised every 24 hours in the lymph nodes of those areas drained by the thoracic duct of the rat, representing approximately 6% of all the red cells destroyed in a 24 hour period. Calculations extending these results to include all areas of the body in both species indicated that the lymph nodes may account for some 6-7% of the total number of red blood cells catabolised in the animal.

High concentration of bilirubin in post-nodal lymph associated with red blood cell catabolism in lymph nodes of the sheep.

Qualitative and quantitative analysis of post-nodal lymph of the sheep has shown that the distinct yellow colour of this fluid pool is due to the presence of relatively large amounts of bilirubin. In efferent lymph from thepopliteal, prefemoral, prescapular, renal and intestinal lymph nodes total bilirubin concentrations were 3-8 times higher than the corresponding concentrations in blood plasma. In contrast the total bilirubin concentrations in afferent lymph from the lower leg and kidney were less than the corresponding concentrations in blood plasma. Histological examination of several popliteal and mesenteric lymph nodes revealed the presence of free iron and bilirubin in the cytoplasm of cells located near the lymphatic sinuses of the node. In addition, the concentration of bilirubin in efferent lymph from the popliteal node was observed to increase following an induced rise in the number of red blood cells reaching the node by way of the afferent lymphatic duct. These latter observations suggest that the bilirubin in post-nodal lymph is associated with the catabolism of extravascular red cells by reticulo-endothelial cells within the lymph nodes.

The effect of anaesthesia and surgery on lymph flow, protein and leucocyte concentration in lymph of the sheep.

Anaesthesia and the trauma of surgery, associated with the cannulation of lymphatic ducts in various regions of the body of the sheep, had a profound effect on lymph flow, protein concentration and leucocyte concentration of lymph. In general lymph flow was depressed and the protein concentration elevated in lymph collected at the time of cannulation, or within the first 24 hours of recovery from surgery. The changes in protein concentration in lymph draining the peripheral regions of the body appeared to be due to surgical interference in the region of drainage. The greatest changes in lymph flow were observed in lymph draining peripheral regions (skin, tendon, muscular areas) while lymph draining soft tissues in central regions (kidney, liver) was less affected by the anaesthesia and surgical stress. A neutrophilia was observed in venous blood collected under anaesthesia while the overall numbers of lymphocytes in three sources of efferent lymph were depressed. It is suggested that corticosteroid hormones may play a role in the changes in leucocyte migration observed during anaesthesia and surgical stress. Changes observed in the cellular content of afferent lymph appeared to be due to a low grade inflammation associated with surgical interference in the region of lymphatic drainage.

Interferon therapy for acute hepatitis C viral infection--a review by meta-analysis.

BACKGROUND: Hepatitis C viral (HCV) infection poses a major health problem for Australia. Currently interferon therapy is approved only for people with chronic infection, yet the literature contains a number of studies that show that there is a better response to interferon in symptomatic acute HCV. AIM: To review the response to interferon therapy in acute HCV by way of meta-analysis. METHODS: This study was a retrospective review of the data on the use of interferon therapy in acute HCV. The meta-analysis was performed using the methods of DerSimonian and Laird. Data were presented by calculating the risk difference which estimated efficacy by calculating the proportion of patients in treatment groups who responded better (0 to +1.0) or worse (0 to -1.0) than untreated control groups. RESULTS: A meta-analysis of six studies on the use of 3MU of interferon alpha 2b (IFN-alpha 2b) three times a week for six to 24 weeks showed a significant response as measured by long term (> 12 months) normalisation of alanine aminotransferase (ALT) and clearance of HCV RNA (as measured by polymerase chain reaction). The risk of difference was +0.31 (95% CI of +0.19 to +0.43, p < 0.01) and +0.33 (95% CI of +0.08 to +0.58, p < 0.001) respectively. Slightly better results were seen with daily doses of 3MU of interferon beta (IFN-beta) given intravenously over four to seven weeks. This produced a risk difference of +0.57 (95% CI of +0.26 to +0.88, p < 0.02) for normalisation of ALT and +0.83 (95% CI of +0.61 to 1.00, p < 0.001) for clearance of HCV. Results for higher daily doses of both IFN alpha and beta were limited to a few studies and most were uncontrolled. 6MU of IFN-alpha 2b three times a week for 16 to 24 weeks produced a risk difference of +0.53 (95% CI +0.17 to +0.89, p < 0.05) for normalisation of ALT and +0.44 (95% CI +0.06 to +0.82) for clearance of HCV RNA. Results with 6MU daily for eight weeks of IFN-beta in an uncontrolled study, showed up to 90% patients cleared HCV long term. Preliminary results with 10MU of IFN-alpha 2b daily for four to six weeks also showed long term clearance of HCV RNA and normalisation of ALT in 90% of treated patients. CONCLUSION: Short term (six weeks to six months) treatment of symptomatic acute HCV with interferon (both alpha and beta) produced a better long term response rate than prolonged therapy (> 12 months) in chronic HCV. Daily doses of 6MU and 10MU produced better responses than 3MU but more studies are needed to determine the optimum regime.

Relationship between the recirculation of lymphocytes and protein concentration of lymph in sheep.

The concentration and output of lymphocytes in lymph from the popliteal node in sheep were varied by antigenic stimulation of the lymph node and by intravenous administration of bovine anti-lymphocyte serum (ALS). The 4-5-fold increase in output and concentration of lymphocytes in lymph following antigenic stimulation of the node was accompanied by a 25-35% increase in the concentration of total protein and albumin. The above changes were not observed in afferent lymph draining the site of antigen injection. There was a 75-80% decrease in concentration of lymphocytes in lymph from the unstimulated popliteal lymph node following the administration of ALS and this was accompanied by decreases of 10-35% in the concentration of albumin and immunoglobulin. Essentially the same changes were observed when ALS was administered 6 days after antigenic stimulation of the node. Administration of ALS to sheep with cannulated intestinal lymphatic ducts was followed by a 75-80% reduction in lymphocyte concentration and in decreases ranging from 12-50% in the concentration of albumin, IgM and IgG-2. It is suggested that a significant loss of plasma protein is associated with the migration of lymphocytes between the endothelial cells of the post-capillary venules in lymph nodes.

The influence of the lymph node on the protein concentration of efferent lymph leaving the node.

1. Experiments have been performed in sheep to determine the contribution of lymph formed within a lymph node to the total protein output in lymph leaving the node. 2. The lymphatic duct leaving the popliteal lymph node was cannulated and the protein and lymphocyte output in efferent lymph determined. The afferent lymph flow to the popliteal node was then diverted and lymph formed only within the lymph node collected from the efferent cannula. It appeared from the results that the popliteal lymph node forms lymph at the rate of approximately 1 ml. per hour and may contribute 30-50% of the protein output observed in efferent lymph. 3. The importance of lymph formation within the lymph node varied between nodes found in different regions of the body. This was due in part to the different protein concentrations in the afferent lymph to the different nodes. 4. A positive correlation was found between the protein and lymphocyte concentrations in efferent lymph from the popliteal lymph node in seven out of eleven sheep and in lymph formed within the popliteal lymph node in two out of three sheep. It is suggested that this relationship may be due to an increased transfer of plasma proteins through the post-capillary venules in the lymph node accompanying the continual traffic of lymphocytes across the wall of these vessels. The results indicated that the protein transfer across the post-capillary venules was not an indiscriminate transfer of plasma per se but a selective transport from the blood plasma compartment based on molecular size.

The detection of immune complexes of different immunoglobulin class.

Immune complexes were detected in 51 sera from patients with a variety of immunological diseases; 14 systemic lupus erythematosus (SLE); 14 infectious mononucleosis (IM); 12 rheumatoid arthritis (RA) and 11 subacute bacterial endocarditis (SBE). Three methods were used to detect complexes: the fluid--phase Clq binding assay (Clq.BA); the solid--phaseClq binding assay (Clq.SP) and the Raji cell radio-immunoassay (RIA). Modification of the Clq.SP and the Raji cell RIA by use of monospecific antisera to immunoglobulins G, A and M enabled the class of antibody in the immune complexes to be determined. Antibodies of all three classes were found in each disease, the predominant ones being IgG and IgM in SLE and SBE, IgM and IgA in RA and IgM in IM.

The origin of the immunoglobulins in intestinal lymph of sheep.

Various immunoglobulins were labelled with radioactive iodine and their distribution between intestinal lymph and plasma followed in order to determine the origin of the immunoglobulins found in intestinal lymph. By comparing specific activities in plasma and lymph, it was computed that 25 percent of the IgG1 and IgG2 and 90 percent of the IgA in intestinal lymph were locally synthesised. The results suggest that virtually all of the IgA and a proportion of the IgG1 computed to be synthesised locally were derived from plasma cells of corresponding specificity in the lamina propria of the intestine.

Response of the regional lymphatic system of the sheep to acute stress and adrenaline.

An acute pain stimulus resulted in elevated lymph flow and output of cells from the popliteal lymph node of the sheep in the first 15 min after the stress. Efferent lymph flow increased by an average of 93% above the mean resting flow and cell output rose by an average of 170% during this period, but by 30 min after the stress, values for both lymph flow and cell output had returned to normal. The cell content of the efferent lymph was significantly higher in the first 15 min after the acute stress and it is suggested that there is a sizeable pool of lymphocytes within the resting popliteal node which can be mobilized into the lymph by an acute stress. A single intravenous injection of 1 mg adrenaline the efferent lymph flow in all the sheep examined but gave rise to an increased cell output in only 50% of the sheep. This indicated that there may be other factors, possibly hormonal, involved in the movement of the pool of lymphocytes out of the regional lymph node following acute stress. Both acute pain stress and adrenaline resulted in an increased afferent popliteal lymph flow and output of cells from the regional tissues in the first 15 min after administration. The results are suggestive of a small pool of lymphocytes in the regional tissues which may be readily mobilized by either acute stress or adrenaline. Part of the increases in efferent and afferent lymph flow observed following acute stress and adrenaline appeared to be due to an increased lymph formation, presumably as a result of an increased capillary pressure. Nevertheless, it is considered that the greater part of the increased flow of lymph from both regions resulted from an accelerated movement of performed lymph.

Use of archival and fresh cytologic material for the polymerase chain reaction. Detection of the bcl-2 oncogene in lymphoid tissue obtained by fine needle biopsy.

A technique for extracting DNA from archival and fresh tissue from fine needle biopsy (FNB) samples for the polymerase chain reaction (PCR) is described. The method was used to detect the bcl-2 oncogene in various cytologic lymphoid preparations. The DNA was amplified with primers specific for the major break point region of the t(14;18) translocation, and the presence of the bcl-2 oncogene was correlated with clinical, cytomorphologic, histologic and immunologic findings. Thirty patients who had FNB of lymphoid tissue were randomly selected, 18 retrospectively and 12 prospectively. Bcl-2 was present in 3 of 8 cases of reactive lymphadenopathy and 9 of 22 cases of non-Hodgkin's lymphoma. Of these, seven had follicular small cleaved cell lymphoma, and two had large cell lymphoma. Smears, both archival and fresh, and cell suspensions provided sufficient DNA for PCR amplification. The technique has potential applications in several areas of cytologic and hematologic practice.

Studies of lymphocytotoxins in infectious mononucleosis: reduced lymphocyte killing in the acute phase.

Fifty sera from twenty-five patients with uncomplicated infectious mononucleosis (IM) were tested for lymphocytotoxic activity (LCA) against pools of lymphocytes collected from (a) normal donors (b) ten patients during the acute phase of IM and (c) four of these patients during the convalescent phase. The LCA of twenty-four sera from patients with systemic lupus erythematosus (SLE) was also tested against the same panels of cells. The percentage of acute phase lymphocytes killed by sera from patients with IM or SLE was significantly less (P less than 0.001 and P less than 0.05 respectively) than the percentage of normal or convalescent cells killed by the same sera. This reduction could not be explained by lymphocyte donor variation as the same donors were used in the acute and convalescent phases of IM. It is suggested that changes in the surface characteristics of acute IM lymphocytes cause a temporary failure of interaction with circulating lymphocytotoxins. Such a phenomenon could have important influences on the self-limiting nature of the disease.

Studies of lymphocytotoxins in infectious mononucleosis and systemic lupus erythematosus: evidence for immune complex-mediated cytotoxicity.

The hypothesis that serum lymphocytotoxins are antigen-antibody complexes was examined. High molecular weight fractions from the sera of eighteen patients with infectious mononucleosis (IM), thirteen patients with systemic lupus erythematosus (SLE) and six healthy controls, were prepared by precipitation with polyethylene glycol 6000 (PEG). The lymphocytotoxic activity (LCA) of these PEG precipitates was significantly greater (P less than 0.01) than that of the corresponding sera and a significant correlation (r = 0.66, P less than 0.01) was observed between the LCA of sera and the PEG precipitates. In contrast to the concentration of LCA in the PEG precipitates, the heterophil antibody titres of the precipitates from IM sera were significantly less (P less than 0 05) than serum titres. Antisera raised against PEG precipitates from sera from nine patients with IM contained significant LCA. The nature of this LCA differed from that of the LCA in the original sera in temperature dependence and the molecular size. Antigen-antibody complexes in seven sera (four IM, three SLE) were dissociated at low pH (3.0) and fractionated by gel filtration at pH 3.9. The LCA of these fractions was compared with the LCA of equivalent fractions obtained by gel filtration at pH 7.2. The heterophil antibody present in sera from patients with IM and the cytotoxicity of anti-lymphocyte globulin (ALG) were used as 'antibody controls'. In this way it was shown that the LCA in patient sera, but not heterophil antibody or ALG cytotoxicity was significantly reduced (P less than 0.001) by low pH gel filtration.

IgA deficiency, superior mediastinal tumour with unusual clinical manifestations.

The clinical course of a 17-year-old man with selective IgA deficiency and anaplastic carcinoma in the superior mediastinum is described. High swinging fevers, neutrophil leucocytosis reaching 60 x 10(9)/l, polyarthralgia and skin vasodilatation were unusual manifestations of the tumour. Marked tissue reactions in the neck and polyserositis occurred with a neutrophil granulocyte tissue reaction and progressed to fibrosis. Circulating immune complexes were present and IgE levels were grossly raised. It was not established whether the unusual clinical manifestations were due solely to the tumour or were an abnormal response of an IgA-deficient host. Review of the literature of malignancy in selective IgA deficiency casts doubt upon an increased incidence of neoplasm in this immune deficiency.

Impairment of acute protein reactivity in chronic renal failure.

The acute phase protein response was studied after elective surgery in 13 normal subjects and 9 patients with severe chronic renal failure. Total haemolytic complement reactivity (CH50) and serum concentrations of C1q, C1s, C4, C3, factor B, properdin, C5, C9, C-reactive protein (CRP), caeruloplasmin, alpha1-acid glycoprotein and haptoglobin were measured preoperatively and on days 2, 4 and 6 after operation. Abnormalities were seen in the group with chronic renal failure. Firstly, there was no significant acute phase response of C1s, C3, C5, C9 and CH50 and a significant reduction in the response of factor B. Secondly, CRP showed prolonged elevation in the post-operative period in contrast to the transient rise seen in the control group. With the possible exception of alpha1-acid glycoprotein, the behaviour of the non-complement proteins (caeruloplasmin and haptoglobin) was comparable for the two groups. These defects could impair the physiological response to infection in patients with severe chronic renal failure.