Optimising the utility of pleural fluid adenosine deaminase for the diagnosis of adult tuberculous pleural effusion in Hong Kong.

INTRODUCTION: Pleural fluid adenosine deaminase level can be applied to rapidly detect tuberculous pleural effusion. We aimed to establish a local diagnostic cut-off value for pleural fluid adenosine deaminase to identify patients with tuberculous pleural effusion, and optimise its utility. METHODS: We retrospectively reviewed the medical records of consecutive adults with pleural fluid adenosine deaminase level measured by the Diazyme commercial kit (Diazyme Laboratories, San Diego [CA], United States) during 1 January to 31 December 2011 in a cluster of public hospitals in Hong Kong. We considered its level alongside early (within 2 weeks) findings in pleural fluid and pleural biopsy, with and without applying Light's criteria in multiple scenarios. For each scenario, we used the receiver operating characteristic curve to identify a diagnostic cut-off value for pleural fluid adenosine deaminase, and estimated its positive and negative predictive values. RESULTS: A total of 860 medical records were reviewed. Pleural effusion was caused by congestive heart failure, chronic renal failure, or hypoalbuminaemia caused by liver or kidney diseases in 246 (28.6%) patients, malignancy in 198 (23.0%), non-tuberculous infection in 168 (19.5%), tuberculous pleural effusion in 157 (18.3%), and miscellaneous causes in 91 (10.6%). All those with tuberculous pleural effusion had a pleural fluid adenosine deaminase level of ≤100 U/L. When analysis was restricted to 689 patients with pleural fluid adenosine deaminase level of ≤100 U/L and early negative findings for malignancy and non-tuberculous infection in pleural fluid, the positive predictive value was significantly increased and the negative predictive value non-significantly reduced. Using this approach, neither additionally restricting analysis to exudates by Light's criteria nor adding closed pleural biopsy would further enhance predictive values. As such, the diagnostic cut-off value for pleural fluid adenosine deaminase is 26.5 U/L, with a sensitivity of 87.3%, specificity of 93.2%, positive predictive value of 79.2%, negative predictive value of 96.1%, and accuracy of 91.9%. Sex, age, and co-morbidity did not significantly affect prediction of tuberculous pleural effusion using the cut-off value. CONCLUSION: We have established a diagnostic cut-off level for pleural fluid adenosine deaminase in the diagnosis of tuberculous pleural effusion by restricting analysis to a level of ≤100 U/L, and considering early pleural fluid findings for malignancy and non-tuberculous infection, but not Light's criteria.

A snapshot of Chlamydia trachomatis genetic diversity using multilocus sequence type analysis in an Australian metropolitan setting.

High-resolution screening methodologies which enable the differentiation of Chlamydia trachomatis at the strain level, directly from clinical samples, can provide the detailed information required for epidemiological questions such as the dynamics of treatment failure. In addition, they give a detailed snapshot of circulating C. trachomatis genetic variation, data which are currently lacking for the Australian population. In the context of two Australian clinical trials, we assessed the genetic diversity of C. trachomatis and compared these to strains circulating globally. We used high-resolution multilocus sequence typing (MLST) of five highly variable genetic regions of C. trachomatis to examine variation in Australia. Samples with established genovars were drawn from a pool of 880 C. trachomatis-positive samples from two clinical studies, whereby 76 sample pairs which remained C. trachomatis-positive for the same genovar after treatment underwent MLST analysis to distinguish between treatment failure and reinfection. MLST analysis revealed a total of 25 sequence types (STs), six new allele variants and seven new STs not described anywhere else in the world, when compared to those in the international C. trachomatis MLST database. Of the eight most common global STs, seven were found in Australia (four derived from men who have sex with men (MSM) and three from heterosexuals). Newly identified STs were predominantly found in samples from the MSM population. In conclusion, MLST provided a diverse C. trachomatis strain profile, with novel circulating STs, and could be used to identify local sexual networks to focus on interventions such as testing and partner notification to prevent reinfection.

Higher organism load associated with failure of azithromycin to treat rectal chlamydia.

Repeat rectal chlamydia infection is common in men who have sex with men (MSM) following treatment with 1 g azithromycin. This study describes the association between organism load and repeat rectal chlamydia infection, genovar distribution, and efficacy of azithromycin in asymptomatic MSM. Stored rectal chlamydia-positive samples from MSM were analysed for organism load and genotyped to assist differentiation between reinfection and treatment failure. Included men had follow-up tests within 100 days of index infection. Lymphogranuloma venereum and proctitis diagnosed symptomatically were excluded. Factors associated with repeat infection, treatment failure and reinfection were investigated. In total, 227 MSM were included - 64 with repeat infections [28·2%, 95% confidence interval (CI) 22·4-34·5]. Repeat positivity was associated with increased pre-treatment organism load [odds ratio (OR) 1·7, 95% CI 1·4-2·2]. Of 64 repeat infections, 29 (12·8%, 95% CI 8·7-17·8) were treatment failures and 35 (15·4%, 95% CI 11·0-20·8) were reinfections, 11 (17·2%, 95% CI 8·9-28·7) of which were definite reinfections. Treatment failure and reinfection were both associated with increased load (OR 2·0, 95% CI 1·4-2·7 and 1·6, 95% CI 1·2-2·2, respectively). The most prevalent genovars were G, D and J. Treatment efficacy for 1 g azithromycin was 83·6% (95% CI 77·2-88·8). Repeat positivity was associated with high pre-treatment organism load. Randomized controlled trials are urgently needed to evaluate azithromycin's efficacy and whether extended doses can overcome rectal infections with high organism load.

Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials.

BACKGROUND: There has been recent debate questioning the efficacy of azithromycin for the treatment of urogenital chlamydia infection. We conducted a meta-analysis to compare the efficacy of 1 g azithromycin with 100 mg doxycycline twice daily (7 days) for the treatment of urogenital chlamydia infection. METHODS: Medline, PubMed, Embase, Cochrane Controlled Trials Register, Cochrane reviews, and Cumulative Index to Nursing and Allied Health Literature were searched until 31 December 2013. Randomized controlled trials comparing azithromycin with doxycycline for the treatment of genital chlamydia with evaluation of microbiological cure within 3 months of treatment were included. Sex, diagnostic test, follow-up time, attrition, patient symptomatic status, and microbiological cure were extracted. The primary outcome was the difference in efficacy at final follow-up. Study bias was quantitatively and qualitatively summarized. RESULTS: Twenty-three studies were included evaluating 1147 and 912 patients for azithromycin and doxycycline, respectively. We found a pooled efficacy difference in favor of doxycycline of 1.5% (95% confidence interval [CI], -.1% to 3.1%; I(2) = 1.9%; P = .435; random effects) to 2.6% (95% CI, .5%-4.7%; fixed effects). Subgroup analyses showed that the fixed effects pooled efficacy difference for symptomatic men was 7.4% (95% CI, 2.0%-12.9%), and the random effects was 5.5% (95% CI, -1.4% to 12.4%). CONCLUSIONS: There may be a small increased efficacy of up to 3% for doxycycline compared with azithromycin for the treatment of urogenital chlamydia and about 7% increased efficacy for doxycycline for the treatment of symptomatic urethral infection in men. However, the quality of the evidence varies considerably, with few double-blind placebo-controlled trials conducted. Given increasing concern about potential azithromycin failure, further well-designed and statistically powered double-blind, placebo-controlled trials are needed.

BDNF Val66Met polymorphism is associated with Stage III-IV endometriosis and poor in vitro fertilization outcome.

BACKGROUND The recently identified human brain-derived neurotrophic factor (BDNF) Val66Met polymorphism was found to be associated with altered susceptibility to some neuropsychiatric disorders. Interestingly, BDNF together with its receptors TrkB and p75 are extensively expressed in female reproduction system. The aim of this study is to investigate whether the BDNF Val66Met polymorphism plays a role in endometriosis, endometriosis-related infertility and the outcomes of IVF and embryo transfer (IVF-ET). METHODS A case-control study included 425 endometriosis patients and 244 control Chinese Han women. The genotyping of the BDNF Val66Met polymorphism was performed by the fluorescence resonance energy transfer method. The plasma and follicular fluid concentrations of BDNF on the day of oocyte retrieval were measured by ELISA. The general clinical data from the endometriosis-related and tubal obstructed infertile patients treated with IVF-ET were analyzed. RESULTS There was no association between the BDNF Val66Met polymorphism and overall endometriosis (P> 0.05), whereas higher genotype and allele frequencies of the BDNF(Met) polymorphism were found in the Stage III-IV endometriosis (both P< 0.01) and endometriosis-related infertile patients (both P< 0.05). Moreover, during IVF and embryo transfer (IVF-ET) treatment, fewer mature oocytes (P< 0.05) and lower fertilization rate (P< 0.01) were found in BDNF(Met/Met) carriers compared with those in BDNF(Val/Val) carriers with infertility. Follicular-fluid BDNF concentration in BDNF(Met/Met) carriers was lower compared with that in BDNF(Val/Val) individuals (P< 0.01). CONCLUSIONS Our results suggest that the BDNF(Met) single-nucleotide polymorphism might contribute to the increased susceptibility to the Stage III-IV endometriosis and endometriosis-related infertility. Moreover, infertile patients with the BDNF(Met/Met) genotype had a poorer IVF outcome compared with the BDNF(Val/Val) genotype individuals, which might in part be due to the decreased BDNF levels in follicular fluids after controlled ovarian hyperstimulation.

Increased survival rate in patients with massive burns.

A review of 113 patients with massive burns treated in our centre from 1970 to 1989 is presented. There were 57 adults patients with massive burns (> or = 50 per cent TBSA) in 1980-89 who were compared with 56 patients with similar massive burns in the period between 1970 and 1979. The results show a significant improvement (P < 0.01) in survival rate of the more recent patients. The increased survival rate is attributed to improvements in the early treatment of inhalation injury, sepsis and multiorgan failure.

[In vitro quantitative study on invasive process of two human nasopharyngeal carcinoma cell lines, CNE-1 and CNE-2Z].

Computer-image processing system was used in the quantitative study on invasion in organ culture of two human nasopharyngeal carcinoma cell lines of different degree of differentiation, CNE-1 and CNE-2Z. For invasion of tumor cells into precultured heart fragments (PHF), observations were done on days 1,3,5 and 7 after organ culture. The results showed that the invasion of both CNE-1 and CNE-2Z cells was progressive. The invasion of CNE-1 tumor cells covered 82.22% of PHF on day 7, but on days 1 to 3 the invasion of CNE-2Z tumor cells covered 80-92% of PHF. This indicates that CNE-2Z cells are more invasive then CNE-1 cells.

[The invasive behavior of two human nasopharyngeal carcinoma (NPC) cell lines CNE-1, CNE-2Z in vitro].

Method of co-culture of tumor cells with precultured heart fragments (PHF) in vitro was used in studying the invasive behavior of human nasopharyngeal carcinoma (NPC) cell lines CNE-land CNE-2Z respectively. This improved method was based on the gyrotory shaker organ culture technique originally established by Mareel in order to show NPC cell invasiveness in a rather identical image. Histopathological sections revealed that the tumor cells might invade into the cell layer of fibroblasts surrounding the heart tissue. This would make the heart muscle cells degenerated, atrophied and necrotic and finally displaced by the fibrotic tissue. Data also pointed out that CNE-2Z cells showed more active invasive ability than that of the CNE-1 cells in the organ culture.

Bilateral visual loss after severe burns in a child.

A girl who sustained severe burns was admitted to the hospital 16 h postburn. The patient developed sudden visual loss on day 15 postburn. She responded to treatment with significant return of visual acuity by 5 weeks after injury at the time of discharge from hospital.

[An analytic epidemiologic survey of epilepsy in the Hui and Han nationality districts of Yinchuan].

An analytical epidemiologic survey of epilepsy was made with random sampling in the inhabitants of Han and Hui nationalities of Yinchuan city, Ningxia Autonomous Region. The sample of the population consisted of 10,415 subjects, including 1420 Hui nationality people and 8995 Han nationality people. The sex proportion, age, occupation distribution, and the residential years of Han and Hui nationality groups were essentially the same, rendering them comparable statistically. Through cross sectional comparative studies, it was revealed that the prevalence rates of epilepsy in the Hui nationality people were much higher than those in the Han nationality people. In order to find clues relating to the cause of such a difference between these groups, several possible risk factors were investigated and analyzed, but no definite conclusion could yet be made.