Life-threating complication of parapharyngeal abscess and mediastinitis in a 10-year-old otherwise healthy girl following elective tonsillectomy - first reported paediatric case.

BACKGROUND: Parapharyngeal abscess and mediastinitis are rare but very severe post-operative complications following an elective tonsillectomy. Parapharyngeal abscess as a complication to tonsilectomy is very seldom described in the literature and no cases in the paediatric population have been described.Case reportThis paper presents, to our knowledge, the first case of life-threatening parapharyngeal abscess and mediastinitis following elective adenotonsillectomy in an otherwise healthy, fully vaccinated 10-year-old girl. CONCLUSION: Diagnosing parapharyngeal abscess and mediastinitis can be challenging, but should be suspected and ruled out in cases of post-operative odynophagia, fever, and/or neck swelling and thoracic pain. Diagnosis is made based on magnetic resonance imaging and computed tomography findings. Prompt broad-spectrum intravenous antibiotic treatment and surgical drainage should be initiated. Other severe complications such as meningitis should also be considered.

Cost-effectiveness of integrated collaborative care for comorbid major depression in patients with cancer.

OBJECTIVES: Comorbid major depression is associated with reduced quality of life and greater use of healthcare resources. A recent randomised trial (SMaRT, Symptom Management Research Trials, Oncology-2) found that a collaborative care treatment programme (Depression Care for People with Cancer, DCPC) was highly effective in treating depression in patients with cancer. This study aims to estimate the cost-effectiveness of DCPC compared with usual care from a health service perspective. METHODS: Costs were estimated using UK national unit cost estimates and health outcomes measured using quality-adjusted life-years (QALYs). Incremental cost-effectiveness of DCPC compared with usual care was calculated and scenario analyses performed to test alternative assumptions on costs and missing data. Uncertainty was characterised using cost-effectiveness acceptability curves. The probability of DCPC being cost-effective was determined using the UK National Institute for Health and Care Excellence's (NICE) cost-effectiveness threshold range of £ 20,000 to £ 30,000 per QALY gained. RESULTS: DCPC cost on average £ 631 more than usual care per patient, and resulted in a mean gain of 0.066 QALYs, yielding an incremental cost-effectiveness ratio of £ 9549 per QALY. The probability of DCPC being cost-effective was 0.9 or greater at cost-effectiveness thresholds above £ 20,000 per QALY for the base case and scenario analyses. CONCLUSIONS: Compared with usual care, DCPC is likely to be cost-effective at the current thresholds used by NICE. This study adds to the weight of evidence that collaborative care treatment models are cost-effective for depression, and provides new evidence regarding their use in specialist medical settings.

Prevalence of depression in adults with cancer: a systematic review.

BACKGROUND: Depression has substantial effects on cancer patients' quality of life. Estimates of its prevalence vary widely. We aimed to systematically review published studies to obtain the best estimate of the prevalence of depression in clinically meaningful subgroups of cancer patients. DESIGN: Systematic review that addressed the limitations of previous reviews by (i) including only studies that used diagnostic interviews; (ii) including only studies that met basic quality criteria (random or consecutive sampling, ≥70% response rate, clear definition of depression caseness, sample size ≥100); (iii) grouping studies into clinically meaningful subgroups; (iv) describing the effect on prevalence estimates of different methods of diagnosing depression. RESULTS: Of 66 relevant studies, only 15 (23%) met quality criteria. The estimated prevalence of depression in the defined subgroups was as follows: 5% to 16% in outpatients, 4% to 14% in inpatients, 4% to 11% in mixed outpatient and inpatient samples and 7% to 49% in palliative care. Studies which used expert interviewers (psychiatrists or clinical psychologists) reported lower prevalence estimates. CONCLUSIONS: Of the large number of relevant studies, few met our inclusion criteria, and prevalence estimates are consequently imprecise. We propose that future studies should be designed to meet basic quality criteria and employ expert interviewers.

Evaluating an active case-finding strategy to identify smear-positive tuberculosis in rural Ethiopia.

OBJECTIVE: To assess an active case-finding strategy for the identification of smear-positive pulmonary tuberculosis (TB) in a rural district of Amhara Region, Ethiopia. METHODS: Study kebeles (smallest administrative units) were randomly selected in a cross-sectional study. House-to-house visits involving individuals aged >or=15 years in all households of the kebeles were conducted. The heads of households were asked to identify subjects with TB symptoms. Identified suspects were asked to provide three sputum samples for smear microscopy. RESULTS: Among the 47,478 individuals living in households that were screened, 1006 TB suspects and 38 cases were detected. This resulted in 38 cases of smear-positive TB, i.e., 80 per 100,000 population, using cluster sampling. The ratio of active vs. passive case detection was 2.5:1, indicating 2.5 undetected TB cases in the community for every smear-positive TB case receiving treatment during the survey period. A higher proportion of female patients was detected by the survey. CONCLUSION: The study revealed a very high proportion of undiagnosed TB. This indicates that the potential for a large infectious pool and significant transmission of TB in the community is high. The expansion of diagnostic facilities and the active involvement of health extension workers is necessary to expedite early detection, timely referral and treatment of TB.

Food insufficiency in rural Kilimanjaro, Tanzania.

OBJECTIVES: To estimate the prevalence of reported food insufficiency associated socio-demographic factors and health indicators in rural Tanzania. DESIGN: A cross-sectional study. SETTING: A rural community in Kilimanjaro, Tanzania. SUBJECTS: Eight hundred and ninety nine individuals aged 15-36 years. A structured questionnaire was administered to collect information on socio-demographic factors, health indicators and food insufficiency. Participants were tested for HIV-1 using saliva samples. RESULTS: The prevalence of food insufficiency was 25.3% with no sex difference. After controlling for potential confounders age (Adjusted Odds Ratio [AOR] = 1.05; 95% Confidence Interval [CI]: 1.02-1.08), low education level (AOR = 4.73; CI: 1.30-17.11), being a peasant (AOR = 2.29; CI: 1.04-5.04), poor self-rated health status (AOR = 4.35; CI: 1.71-11.00) and having health problems (AOR = 2.23; CI: 1.21-4.08) were associated with food insufficiency among women but not men. In unadjusted analysis, women with food insufficiency had over twice the odds of testing HIV positive although the association did not reach statistical significance (AOR = 2.12; CI: 0.87-5.19) in adjusted analysis. CONCLUSIONS: Food insufficiency was prevalent in rural Tanzania. It was associated with sociodemographic factors and health indicators among women but not men. Our findings suggest that food insufficiency may play a role in increasing vulnerability to HIV infection particularly among women however; more research is needed to explore further this relationship.

Progress in serodiagnosis of Mycobacterium tuberculosis infection.

One-third of the world population is estimated to have Mycobacterium tuberculosis infection. Accurate and timely identification of infected individuals is critical for treatment and control. The current diagnostic methods lack the desired sensitivity and specificity, require sophisticated equipment and skilled workforce or take weeks to yield results. Diagnosis of extrapulmonary TB, TB-HIV co-infection, childhood TB and sputum smear-negative pulmonary TB pose serious challenges. Interest in developing serodiagnostic methods is increasing because detection of antibody is rapid, simple and relatively inexpensive, and does not require a living cell for detection. Three types of tests, namely screening tests to overcome diagnostic delay, specific tests for diagnosis of extrapulmonary TB and other bacteriologically negative cases, and tests for vaccine-induced immunity need critical consideration. Several factors must be considered to develop serodiagnostic methods for TB. Antigen recognition by infected individuals is highly heterogeneous due to stage of disease, differences in HLA types, strain of the bacilli, health of the patient and bacillary load. With advances in molecular biological techniques, a number of novel antigens have been identified. Some of these antigens have proven valuable in detecting specific antibodies in some of the most challenging TB patients. The best example is a fusion protein containing several M. tuberculosis proteins (e.g. CFP-10, MTB8, MTB48, MTB81 and the 38-kDa protein) which showed encouraging results in detecting antibodies in sera of patients, including TB-HIV co-infection. This review presents progress made in the serodiagnosis of TB during the last decade.

V3 sequence analysis and biological characterization of HIV-1 isolates from asymptomatic and early symptomatic Tanzanian individuals.

The aim of this study was to determine HIV-1 V3 sequences, in vitro biological characteristics and co-receptor usage of virus isolates from Tanzania. Virus was isolated from 14 of 17 samples investigated. Four of the isolates induced syncytia in MT-2 cells and used the CXCR4 co-receptor, while the remaining 10 isolates used the CCR5 co-receptor characteristic of non-MT-2 tropic viruses. One of the four MT-2 tropic isolates also used the CCR5 and CCR3 co-receptors. Proviral DNA was detected in all 14 isolates and PCR products were subjected to DNA sequencing. Unambiguous V3 amino acid sequences were obtained from 11 amplificates. Phylogenetic analysis indicated that these sequences were divergent and clustered in HIV-1 subtypes A, C or D. Sequences from the viruses that induced syncytia in MT-2 cells presented characteristic V3 phenotype-associated amino acids. Results of co-receptor analysis are in concordance with the isolate phenotype as determined by replication and induction of syncytia in MT-2 cells. The considerable diversity illustrated by a limited number of isolates from Tanzania is in accordance with reports from other regions of Africa.

Determinants for the syncytium-inducing phenotype of HIV-1 subtype F isolates are located in the V3 region.

The HIV-1 syncytium-inducing phenotype is determined by virus replication and the presence of cytopathic effects in MT-2 cells. There is a strong correlation between the syncytium-inducing/MT-2-tropic phenotype and positively charged amino acids at positions 306 and 320 in the V3 loop for HIV-1 subtypes A, B, D, and E. In contrast, a lack of correlation between signature amino acids and syncytium formation in MT-2 cells for subtype F viruses from Romania has been reported. Virus phenotype and V3 loop amino acid sequences from Romanian HIV-1 subtype F isolates were further investigated in the present study. While the determinants of MT-2 tropism are clearly harbored in the V3 loop of subtype F isolates from Romania, the induction of syncytium formation occurs in the presence or absence of positively charged amino acids at positions 306, 320, and/or 324. However, the net positive charge of V3 loop sequences derived from syncytium-inducing viruses was higher than that of the nonsyncytium-inducing isolate.

HIV-1 diversity in Romania.

OBJECTIVES: To evaluate the prevalence and the dynamics of HIV-1 subtypes in Romanian adults and children, and to investigate the origins of the nosocomial epidemic. DESIGN: A total of 1000 serum and plasma samples, from adults (n = 579) and children (n = 421) who were diagnosed as being HIV-1-infected during 1990-1997 in 39 of the 41 Romanian districts, were serotyped. Viral DNA was isolated from blood samples of 84 patients and the viruses were genotyped. METHODS: Serotyping was performed with a peptide subtype-specific enzyme immunoassay (SSEIA), based on in vitro competition for antibody binding between the representative V3 peptides of the different clades (A-F). Proviral HIV-1 DNA was genotyped by heteroduplex mobility assay or by sequence analysis of the C2-V3 env region. RESULTS: SSEIA showed that 93% of the samples from horizontally infected children were serotype F, 1% were serotype B, and the remaining 6% were uninterpretable. In vertically infected children, 74% of strains were serotype F, 10% were serotype A, 3% were serotype B, and 3% were serotype E. Serotype F was also the dominant subtype in adults (68%), but serotypes A, B, C, D and E were also detected. SSEIA gave indeterminate results in 7% of cases. A strong correlation (90%) between serotyping and genotyping for subtype F was found. Analysis of the relative incidence of the different serotypes over a 7-year period (1990-1997) showed a stable distribution. CONCLUSIONS: Subtype F largely dominates the epidemiology of HIV-1 infection in both children and adults in Romania, although other major subtypes are present. The predominance of subtype F in Romania may be a future potential source of HIV-1 variability in Europe.

Evaluation of two novel immunoassays designed to detect HIV antibodies in oral fluids.

The testing of oral fluid samples for the detection of HIV antibodies offers several advantages over the testing of blood. Our objective was to evaluate a new generation of rapid and simple assays designed specifically to detect HIV-1 and HIV-2 antibodies in oral fluids (saliva). Serum and oral fluid pairs were collected from 615 high- and low-risk individuals in the United States, Peru, and the ivory Coast. Two different oral fluid collection devices and rapid assay systems included: (1) the Orapette/SalivaCard HIV-1/ HIV-2 and (2) the Omni-Sal/ImmunoCcmb II HIV-1 and HIV-2. The corresponding serum pairs were analyzed by conventional ELISAs, and all reactive sera were confirmed with HIV-1 and HIV-2 Western blots. The results indicated a 100% sensitivity for both rapid oral fluid assays, including successful detection of HIV-2 antibodies. Specificities ranged from 99.8% to 100%. One sample produced a reactive result by the SalivaCard while being nonreactive by the other assays including the Western blots. Both assays performed excellently, indicating that antibodies to HIV can be detected reliably in oral fluids by simple and rapid assays. This combination of rapid testing technology and the use of easily collected oral fluid samples offers an efficient and accurate alternative to conventional testing and can be appropriately applied to a variety of testing situations for the laboratory diagnosis of HIV infection.

HIV-1 proviral DNA sequences of env gp41 PCR amplificates from Tanzania.

The polymerase chain reaction (PCR) and direct DNA sequencing were used to detect and characterize selected regions of the HIV-1 proviral genome in whole blood samples from Tanzania. Specific PCR amplification products were obtained in gag and/or env (gp41) regions from 15 of the 19 HIV-1 seropositive samples investigated. Env regions from 12 different amplificates were further characterized using the dideoxy sequencing method. Preliminary results indicate that, despite scattered nucleotide mismatches, HIV-1 gp41 amino acid sequences from Tanzania conform to the 1990 Los Alamos African consensus sequence and resemble the HIV-1 subtype A or D consensus sequences in the characterized regions.

[Introduction and evaluation of HIV tests in the North-East part of Tanzania]. / Innføring og evaluering av HIV-tester i den nordøstlige del av Tanzania.

The MUTAN (Tanzanian Norwegian AIDS Project) virology programme has comprised research, intervention, surveillance and education as part of the Tanzanian National AIDS Control Programme. HIV testing of blood donors was introduced in 1988 in the regions Arusha and Kilimanjaro. Simple and rapid HIV-tests have been evaluated continuously, as well as the possible use of alternative specimen samples for testing. The polymerase chain reaction for detection of HIV proviral DNA was established at the Northern Zone Reference Hospital, The Kilimanjaro Christian Medical Centre in Moshi, in 1993.

Characterization of HIV type 1 from Romanian children: lack of correlation between V3 loop amino acid sequence and syncytium formation in MT-2 cells.

The biological properties and amino acid sequences of the third variable domain (V3 loop and flanking regions) of the env region of 34 HIV-1 isolates obtained from Romanian children were analyzed. Unambiguous nucleic acid sequences were obtained from 31 isolates. The derived V3 amino acid sequences were highly homologous (93-100%) and clustered with the HIV-1 subtype F Romanian consensus. Five of the 31 isolates presented a syncytium-inducing phenotype in MT-2 cells and established continuous viral replication in various CD4+ cell lines (rapid/high phenotype). The V3 sequence from one of these isolates showed a slightly lesser degree of homology with the consensus sequence. The presence of positively charged amino acids at positions 306 and 320 has been strongly associated with the ability to induce syncytia in MT-2 cells, whereas negatively or uncharged amino acids at these positions are present in non-syncytium-inducing isolates (slow/low phenotype). There was, however, no correlation between phenotype and amino acid sequence in the five syncytium-inducing isolates; negatively or uncharged amino acids were conserved at positions 306 and 320 for all 31 isolates in sequences obtained from PBMCs. A tendency toward a more positive net charge in the V3 loop of syncytium-inducing isolates was noted. These data confirm the recent observations that HIV-1 isolates from Romania not only cluster in subtype F, but also show a high degree of interpatient homogeneity in the V3 region.(ABSTRACT TRUNCATED AT 250 WORDS)

Successful use of two rapid HCV assays in a high prevalence Romanian population.

Hepatitis C virus (HCV) infection is of significant concern for recipients of blood and for patients who share resources such as hemodialysis machines. In many developing countries and in small peripheral laboratories, facilities and capabilities to perform ELISA assays may not be available. We evaluated two newly marketed rapid HCV serologic assays to determine their ability and suitability to detect antibodies to HCV in hemodialysis patients in Bucharest, Romania. Results indicated that both the Rapid HCV Ab assay (Clonatec, Paris, France) and the HCV-SPOT (Diagnostic Biotechnology, Singapore) detected HCV antibody in 23 of 27 patients. All 23 samples were also reactive by a routine HCV ELISA and were confirmed using a supplemental assay (HCV blot, Diagnostic Biotechnology, Singapore). Only one sample produced equivocal result by the Rapid HCV Ab assay. In this high prevalence population (90%), the use of recombinant or synthetic peptide rapid HCV assays has been successful in detecting confirmed positive cases of HCV and has shown excellent correlation with an ELISA screening assay. The tests are simple to perform, can be performed by individuals with minimal training, and have built-in quality control measures. We conclude that these tests may have important applicability in certain testing situations.

Detection of antibodies to HIV in homologous sets of plasma, urine and oral mucosal transudate samples using rapid assays in Tanzania.

The aim of this study was to evaluate the performance of commercially available anti-HIV assays when testing plasma, urine and oral mucosal transudate (OMT) samples for the presence of antibodies to HIV. Homologous sets of plasma, urine and oral mucosal transudate specimens were collected from 288 hospitalized patients in northern Tanzania and tested for antibodies to HIV using a routine enzyme immunoassay (Recombinant 3rd Generation EIA, Abbott) and two rapid assays (Testpack HIV-1/HIV-2; Abbott and SUDS HIV-1, Murex). Incubation times and/or sample volumes when testing OMT or urine were increased as compared to those recommended for plasma. The corresponding plasma specimens from all repeatedly reactive samples and samples presenting discordant results were subjected to confirmational testing by an HIV-1/2 Western blot. A total of 15.3% (44/288) of the plasma samples were anti-HIV-1 positive by Western blot. The sensitivity using plasma was 100% by all assays, 69.7-97.7% using urine, and 92.7-100% using oral transudate specimens. The sensitivity of both rapid assays was excellent and higher than the EIA when testing OMT. Specificities ranged from 98.8-100% for plasma, 99-100% for urine and were 100% by all assays using oral samples. The results obtained using oral mucosal transudate specimens and rapid assays were at least comparable to those obtained with plasma, while the use of urine specimens produced suboptimal sensitivities with two of the three assays. The testing of alternative body fluids for antibodies to HIV is yet another strategy that may be applicable, particularly in developing countries.

Evaluation of a rapid membrane enzyme immunoassay (Testpack HIV-1/HIV-2) at zonal, regional and district hospital laboratories in Tanzania.

The performance of a rapid and simple membrane enzyme immunoassay for antibodies to HIV-1 and HIV-2 (Testpack HIV-1/HIV-2) was evaluated by testing 1000 sera from the Kilimanjaro region of Tanzania. A sensitivity of 100% (118/118 positives) and specificity of 95.1% were obtained following the manufacturer's procedure. The specificity was significantly enhanced to 97.2% (P = 0.026) by modifying the Testpack procedure by including an extra was after serum adsorption to the unit membrane. The testing of a single specimen could be completed in 8 min and up to 10 individual tests could be run simultaneously. There was complete agreement in interpretation when the results were read independently by two trained technicians. A built-in control insured against incorrect procedures or inactive reagents. In a subsequent field trial including 450 sera, one strongly reactive sample failed to be detected at a participating field hospital for unknown reasons. The Testpack reagents proved stable for up to one year at room temperature (25-30 degrees C). The data indicate that Testpack is suitable for the detection of serum antibodies to HIV and is especially applicable in laboratories with limited facilities. When used to test African sera which are known to produce a high degree of false positivity, an extra wash of the membrane after serum adsorption is recommended.