Groups Of Immunocompromised Patients Research Articles

Oral <i>Candida</i> in β-thalassemia Major and Healthy Population and Their Fluconazole Susceptibility Pattern

<b>Objective:</b><b> </b><i>Candida </i>constitutes the main yeast flora in the oral cavity. Different species are known with<i> C. albicans </i>being the principal one. In healthy individuals,<i><b> </b></i>the balance among the oral microbial flora is maintained. However, this equilibrium might be altered in certain diseases resulting in the predominance of yeast flora over other microorganisms and behave as pathogens. Thalassemias constitute a large group of immunocompromised patients in our country with multiple hematological, immunological and endocrine disorders<b> </b>making them susceptible to local and systemic opportunistic yeast infections. Fluconazole is a globally used antifungal antibiotic especially in treating recurrent infections in immunocompromised patients.<i> </i>Little is known about the oral yeast carriage in the healthy individuals and thalassemic patients in our population, and their susceptibility pattern to fluconazole. This study has been done to assess the frequency of oral <i>Candida</i> carriage in a group of β-thalassemia major<b> </b>patients and sex and age-matched healthy controls, and to evaluate the susceptibility pattern of the isolates to fluconazole. <b>Place of study: </b>Microbiology Laboratory at College of dentistry/Hawler Medical University, Erbil, Iraq. <b>Methodology:</b> Two hundred subjects were included in the present study, 100 patients with β-thalassemia major<i><b> </b></i>(38 females &62 males) aged 4-26 years and 100 apparently healthy subjects age and sex-matched with thalassemic patients. Oral swab specimens were collected from each individual subject, cultured on sabouraud dextrose agar plates and incubated at 37<SUP>o</SUP>C for 48-72 hours. Identification of <i>Candida </i>species was based on colony morphology, germ tube test, biochemical reaction using API <i>Candida</i> system and growth characteristics on CHROMagar Candida. The disc diffusion method was applied to test sensitivity of the isolated strains to various concentrations of fluconazole. <b>Results</b><b>: </b>All the subjects included in this study harbored only <i>C. albicans </i>in their oral cavities, with higher carriage rate observed among thalassemic patients (20%) than healthy controls (7%). <i>Candida albicans was recovered much frequently from </i>healthy children (57%) and adolescent thalassemias (65%) than other age groups within each study group. However the statistical analysis showed no significant correlation between age and oral <i>C. albicans </i>carriage rate (χ<SUP><i>2</i></SUP><i> p</i>-value > 0.05). Healthy females showed higher carrier rate than males, meanwhile <i>C. albicans </i>was equally distributed between male and female thalassemic patients. Susceptibility of <i>C. albicans </i>isolates to a 25 μg/ml fluconazole showed that out of the 27 <i>C. albicans </i>isolates, 23 were resistant to fluconazole. The resistant <i>albicans </i>strains showed high resistance rate (>128 μg/ml) within both groups. Whereas the response of sensitive strains to fluconazole was variable ranged from >16 μg/ml in healthy subjects to 4 - >16 μg/ml in thalasemias. <b>Conclusion: </b><i>C. albicans </i>was the only isolated species from the oral cavity of thalassemic patients and healthy subjects. However the carrier rate was higher among thalassemias than healthy controls. Most of the isolated strains were resistant to fluconazole. Further studies are required to assess the sensitivity of oral <i>Candida </i>isolates to other antifungal drugs<i>.</i>

Pneumocystis Jirovecii Pneumonia In Recipients Of Autologous Hematopoietic Stem Cell Transplantation: A 10-Year Cohort Study

▪ BackgroundPneumocystis jirovecii pneumonia (PJ), previously known as Pneumocystis carinii (PCP), is a potentially life-threatening disease in immunocompromised patients. The at-risk population includes patients with HIV infection and low CD4 counts, hematological malignancies, hematopoietic stem cell (HSC) and solid organ transplant recipients, and patients receiving glucocorticoids or other immunomodulatory agents. The highest-risk group of immunocompromised patients tends to be those with HIV (human immunodeficiency virus) infection, where PJ follows an indolent course. However, in non-HIV immunocompromised patients, such as HSC transplant recipients, the infection tends to present with respiratory failure. The incidence of Pneumocystic jirovecii pneumonia (PCP) in autologous BMT (bone marrow transplant) has not been clearly determined, and the indication for prophylaxis in this setting remains unclear. In this study we evaluate the incidence of PJ infection over a 10-year period in recipients of autologous transplants. MethodsRetrospective analysis of 1191 consecutive autologous HSC transplants performed between 1/1/2000 and 6/30/2011 at the University of Michigan Blood and Marrow Transplantation Program. The data was obtained from the BMT Program Database at The University of Michigan Comprehensive Cancer Center. The diagnosis of PJ pneumonia was established by both bronchoscopy with brochoaveolar lavage (BAL) with polymerase chain reaction (PCR). We analyzed the following risk factors for the development of PJ pneumonia: diabetes, glucocorticoid use (in the setting of primary disease relapse, chemotherapy-induced pneumonitis, or idiopathic thrombocytopenic purpura), infections (Pseudomonal urinary tract infection, candidiasis, herpes simplex virus), cutaneous T-cell lymphoma, hypertension, and seizure disorder. ResultsA total number of 5 PJ infections were diagnosed during study period, resulting in a cumulative incidence incidence of 0.42% (95%CI [0.136449% -- 0.976969%]) over the 10 year period. All cases occurred between 2001 and 2006, and 3 months or later following transplantation. Most patients (n=4) were older than 50 years old, and all of them were on steroids. Diagnoses included non-Hodgkin's lymphoma (n=3), Hodgkin's lymphoma (n=1) and multiple myeloma (n=1). Conditioning regimen was BEAM (BCNU, etoposide, cytarabine, melphalan, n=4) and high dose melphalan (n=1). Only 2/5 patients were neutropenic at the time of the pneumonia, and this did not correlate with the CD34+ cell infused, which was ≥2.2x10E6/kg for all patients. Four patients were on corticosteroids for relapsed lymphoma (n=2), ITP (n=1), BCNU pneumonitis (n=1). The remainder patient was on florinef and was coinfected with candida and herpes virus. There were no particular comorbidities associated with the diagnosis of PJ pneumonia. One patient died of PJ, the remainder were treated successfully. ConclusionThis is the largest cohort of patients undergoing autologous transplantation evaluated for PJ pneumonia over a long period of time. Our low incidence and successful therapy suggest that PJ prophylaxis is not routinely warranted in patients undergoing autologous HSCT. Special consideration may be given to patients with additional risk factors such as corticosteroids. Disclosures:No relevant conflicts of interest to declare.

Is Cytomegalovirus Testing of Blood Products Still Needed for Hematopoietic Stem Cell Transplant Recipients in the Era of Universal Leukoreduction?

Hematopoietic stem cell transplantation (HSCT) recipients are a high-risk, immunocompromised group of patients who receive frequent transfusions after transplantation. Transfusion of cytomegalovirus (CMV)-negative blood products has long been the standard of care to prevent transfusion-transmitted CMV in this patient population. Leukoreduction of blood products before transfusion has been shown to significantly reduce the risk of transfusion-transmitted CMV. In the era of universal leukoreduction in Canada, the need for CMV testing of blood products remains unclear. We sought to identify whether there is a difference in transfusion-transmitted CMV viremia in patients receiving only leukoreduced versus CMV-negative and leukoreduced blood products in HSCT recipients. Patients who were CMV negative and received an allogeneic HSCT from a CMV-negative donor between October 1, 1999 and June 30, 2012 were included in the analysis. Transfusion data were collected from The Ottawa Hospital Blood Bank and Canadian Blood Services. CMV viremia was defined as PCR positivity. One hundred sixty-six patients were identified who met the inclusion criteria. Of these, 89 patients received an HSCT before January 2007, during the time when patients received leukoreduced and CMV-negative blood products. Seventy-seven patients received an HSCT after this time, receiving only leukoreduced blood products. The 2 groups did not differ in terms of age, gender, diagnosis, graft type, graft source, conditioning regimen, or ABO compatibility (P > .05). CMV viremia was detected in 3 patients who received CMV-negative leukoreduced blood products (3.37%) and in 1 patient who received only leukoreduced blood products (1.30%, P = .6244). Of the patients who developed CMV viremia, 2 developed suspected CMV disease. Both of these patients were transfused with CMV-negative blood products. Secondary outcomes, including total length of stay in hospital, admission to the intensive care unit, acute and chronic graft versus host disease, and 100-day nonrelapse mortality, did not differ between the groups. In the era of universal leukoreduction of blood products, this study demonstrates that testing for CMV-negative blood products is not needed for HSCT recipients.

Seroprevalence of human polyomavirus 9 and cross-reactivity to African green monkey-derived lymphotropic polyomavirus

Human polyomavirus 9 (HPyV9) was discovered recently in immunocompromised patients and shown to be genetically closely related to B-lymphotropic polyomavirus (LPyV). No serological data are available for HPyV9, but human antibodies against LPyV have been reported previously. To investigate the seroepidemiology of HPyV9 and the sero-cross-reactivity between HPyV9 and LPyV, a capsomer-based IgG ELISA was established using the major capsid protein VP1 of HPyV9 and LPyV. VP1 of an avian polyomavirus was used as control. For HPyV9, a seroprevalence of 47 % was determined in healthy adults and adolescents (n = 328) and 20 % in a group of children (n =101). In both groups, the seroreactivities for LPyV were less frequent and the ELISA titres of LPyV were lower. Of the HPyV9-reactive sera, 47 % reacted also with LPyV, and the titres for both PyVs correlated. Sera from African green monkeys, the natural hosts of LPyV, reacted also with both HPyV9 and LPyV, but here the HPyV9 titres were lower. This potential sero-cross-reactivity between HPyV9 and LPyV was confirmed by competition assays, and it was hypothesized that the reactivity of human sera against LPyV may generally be due to cross-reactivity between HPyV9 and LPyV. The HPyV9 seroprevalence of liver transplant recipients and patients with neurological dysfunctions did not differ from that of age-matched controls, but a significantly higher seroprevalence was determined in renal and haematopoietic stem-cell transplant recipients, indicating that certain immunocompromised patient groups may be at a higher risk for primary infection with or for reactivation of HPyV9.

Epidemiology, laboratory characteristics and outcome of blood stream infections in a regional oncology unit: Category: Lesson in Microbiology & Infection Control

Infection is a common cause of morbidity and mortality in oncology patients. The most important risk factor is neutropenia secondary to cytotoxic chemotherapy, although other treatment associated risk factors such as surgery, radiotherapy and use of invasive devices, as well as tumour associated risk factors are important. This immunocompromised group of patients are predisposed to severe, rapidly progressive infections often without development of concurrent inflammation. This, in conjunction with the constantly changing epidemiology of microorganisms, means it is crucial to ensure that locally appropriate empirical antibiotic therapy guidelines are in place.

Unit-Based Care for Stem Cell Transplant (SCT) Patients Requiring Non Invasive Ventilator Assistance

Stem cell transplant (SCT) recipients are part of a markedly immunocompromised group of patients receiving myeloablative and intense immunosuppressive therapies. Respiratory complications are observed throughout this process and may lead to mechanical ventilation and transfer to an intensive care unit (ICU). Significant morbidity and mortality is associated with these patients requiring mechanical ventilation (Gruson et al, 1999). A less invasive means of providing respiratory support while maintaining expert care on the unit would appear to be beneficial.

Seroepidemiology of parvovirus B19 in the Frankfurt am Main area, Germany: evaluation of risk factors

Parvovirus B 19 is a virus that is distributed by respiratory droplets. It is known to be an initiator of erythema infectiosum (children's fifth disease), with erythroblasts being the target cells of infection. In case of vertically transmission, hydrops fetalis has been documented. Parvovirus B19 seroprevalence was investigated in serum samples routinely collected from patients who had been admitted to the University Hospital in Frankfurt a. M., Germany. Patients were classified in different groups in order to analyze parovirus B19 seroprevalences in terms of risk factors. Between June 2007 and March 2010, a total of 2,197 serum samples were analyzed for parvovirus B19-immunoglobulin G using an enzyme-linked immunosorbent assay. The study population included six groups of patients, namely, patients suffering from haemophilia, malignant disease, immunodeficiency diseases, common gynecological ailments, pregnant women and children with malignant diseases. Of the 2,197 serum samples, 1,383 contained antibodies to parvovirus B19 (62.9%). The overall seroprevalence in adults (20 to ≥60years of age) was 71%. Gradually rising prevalences were recorded in children/adolescents with increasing age. We found a positive serostatus in 54.9% of adult patients with malignant disease, in 64.2% of patients with haemophilia (1 to ≥60years), in 66.7% of patients under immunosuppression with various drugs (1 to ≥60years) and in 41.7% of oncological patients aged 1-19years. Of the pregnant women (aged 15-49years), 71.1% were seropositive. The seroprevalence of parvovirus B19 in patients admitted to the University Hospital in Frankfurt a.M. was, on average, lower than that among the general population in Germany. Infection among patients in specific risk groups did not spread more than that in age-matched non-selected patients, with the exception of the group of immunocompromised patients.

Purulent Pericardial Effusion in a 14-Year-Old Girl

Purulent Pericardial Effusion in a 14-Year-Old Girl

Performance of Tests for Latent Tuberculosis in Different Groups of Immunocompromised Patients

Immunocompromised persons infected with Mycobacterium tuberculosis (MTB) have increased risk of tuberculosis (TB) reactivation, but their management is hampered by the occurrence of false-negative results of the tuberculin skin test (TST). The T-cell interferon (IFN)-gamma release blood assays T-SPOT.TB (TS.TB) [Oxford Immunotec; Abingdon, UK] and QuantiFERON-TB Gold In-Tube (QFT-IT) [Cellestis Ltd; Carnegie, VIC, Australia] might improve diagnostic accuracy for latent TB infection (LTBI) in high-risk persons, although their performance in different groups of immunocompromised patients is largely unknown. Over a 1-year period, we prospectively enrolled patients in three different immunosuppressed groups, as follows: 120 liver transplantation candidates (LTCs); 116 chronically HIV-infected persons; and 95 patients with hematologic malignancies (HMs). TST, TS.TB, and QFT-IT were simultaneously performed, their results were compared, and intertest agreement was evaluated. Overall, TST provided fewer positive results (10.9%) than TS.TB (18.4%; p < 0.001) and QFT-IT (15.1%; p = 0.033). Significantly fewer HIV-infected individuals had at least one positive test (9.5%) compared with LTCs (35.8%; p < 0.001) and patients with HMs (29.5%; p < 0.001). Diagnostic agreement between tests was moderate (kappa = 0.40 to 0.65) and decreased in the HIV-infected group when the results of the TS.TB were compared with either TST (kappa = 0.16) or QFT-IT (kappa = 0.19). Indeterminate blood test results due to low positive control values were significantly more frequent with QFT-IT (7.2%) than with TS.TB (0.6%; p < 0.001). Blood tests identified significantly more patients as being infected with MTB than TST, although diagnostic agreement varied across groups. Based on these results, we recommend tailoring application of the new blood IFN-gamma assays for LTBI in different high-risk groups and advise caution in their current use in immunosuppressed patients.

P.022 Human cytomegalovirus (HCMV) UL40 variability in renal transplant recipients

Bronchoalveolar lavage (BAL) is a useful tool in the diagnosis of pulmonary infections in immunocompromised patients. We aimed to compare the spectrum of infectious pulmonary complications diagnosed using BAL in a large consecutive cohort of immunocompromised patients.The diagnostic yield of 1066 BAL specimens was analyzed in 4 different groups of immunocompromised patients (HIV; solid organ transplants; high-dose chemotherapy and/or stem cell transplants; other immunosuppressive therapy) suffering from fever, respiratory symptoms and/or infiltrates on chest X-ray. Specimens were analyzed for bacteria, mycobacteria, fungi, Pneumocystis jiroveci, cytomegalovirus (CMV) and other viruses. Two time periods were compared (1992–1996; 1997–2003).The overall diagnostic yield of BAL was 34% for bacteria, 22% for CMV, 15% for P. jiroveci, 6% for other viruses, 6% for mycobacteria and 2% for aspergillus. There were significant changes in the pattern of opportunistic infections between the 2 time periods. Mycobacterial infections decreased considerably in the HIV group (17.9 vs. 8.5%, P=0.02), while the incidence of P. jiroveci decreased mainly in the transplant group (32.6 vs. 7.9%, P<0.00001).This study demonstrates a changed pattern of pulmonary infections in immunocompromised patients diagnosed by BAL. The overall diagnostic yield of BAL remains high in immunocompromised patients with respiratory symptoms.

Occult hepatitis B virus infection in immunocompromised patients

Occult hepatitis B infection is characterized by hepatitis B virus (HBV) DNA in the serum in the absence of hepatitis B surface antigen (HBsAg). We assessed occult HBV infection prevalence in two groups of immunocompromised patients (maintenance hemodialysis patients and HIV-positive patients) presenting HBsAg-negative and anti-HBc positive serological patterns, co-infected or not by HCV. Thirty-four hemodialysis anti-HIV negative patients, 159 HIV-positive patients and 150 blood donors who were anti-HBc positive (control group) were selected. HBV-DNA was detected by nested-PCR. Occult hepatitis B infection was not observed in the hemodialysis patients group but was found in 5% of the HIV-patients and in 4% of the blood donors. Immunosuppression in HIV positive patients was not a determining factor for occult HBV infection. In addition, no significant relationship between HBV-DNA and HCV co-infection in the HIV-positive patient group was found. A lack of significant associations was also observed between positivity for HBV-DNA and CD4 count, viral load and previous lamivudine treatment in these HIV-positive patients.

Fatal right-sided endocarditis due toAspergillusin a kidney transplant recipient

Invasive aspergillosis (IA) is an emerging infectious disease in different groups of immunocompromised patients. In transplant recipients, intensification of immunosuppressive therapy to treat allograft rejection poses a major risk factor for IA. We present the clinical features, diagnostic findings and outcome of a kidney transplant recipient who developed pulmonary aspergillosis complicated by endocarditis of his native tricuspid valve. Despite replacement of the valve and treatment with combined antifungal therapy, the patient died of an acute pulmonary bleeding.

Pulmonary infections diagnosed by BAL: A 12-year experience in 1066 immunocompromised patients

Bronchoalveolar lavage (BAL) is a useful tool in the diagnosis of pulmonary infections in immunocompromised patients. We aimed to compare the spectrum of infectious pulmonary complications diagnosed using BAL in a large consecutive cohort of immunocompromised patients. The diagnostic yield of 1066 BAL specimens was analyzed in 4 different groups of immunocompromised patients (HIV; solid organ transplants; high-dose chemotherapy and/or stem cell transplants; other immunosuppressive therapy) suffering from fever, respiratory symptoms and/or infiltrates on chest X-ray. Specimens were analyzed for bacteria, mycobacteria, fungi, Pneumocystis jiroveci, cytomegalovirus (CMV) and other viruses. Two time periods were compared (1992-1996; 1997-2003). The overall diagnostic yield of BAL was 34% for bacteria, 22% for CMV, 15% for P. jiroveci, 6% for other viruses, 6% for mycobacteria and 2% for aspergillus. There were significant changes in the pattern of opportunistic infections between the 2 time periods. Mycobacterial infections decreased considerably in the HIV group (17.9 vs. 8.5%, P=0.02), while the incidence of P. jiroveci decreased mainly in the transplant group (32.6 vs. 7.9%, P<0.00001). This study demonstrates a changed pattern of pulmonary infections in immunocompromised patients diagnosed by BAL. The overall diagnostic yield of BAL remains high in immunocompromised patients with respiratory symptoms.

Respiratory syncytial virus and innate immunity: a complex interplay of exploitation and subversion

Respiratory syncytial virus causes significant disease in infants, the elderly and select groups of immunocompromised patients. Healthy individuals are also naturally infected with respiratory syncytial virus repeatedly throughout life. Therefore, safe and effective vaccines and therapies are needed. However, a number of factors have prevented development of such antiviral interventions to date. These include a failed vaccine trial, the very young age of the primary target population (neonates), the inability of natural infection to induce long-term protective immunity, and an incomplete understanding of virus–host interactions. The identification of pattern recognition receptors has led to significant increases in our understanding of induction and regulation of innate immune responses. This review will address the impact of these findings on respiratory syncytial virus research.

Recombinant antigens as diagnostic markers for aspergillosis

Eight recombinant proteins and purified galactomannan of Aspergillus fumigatus were tested by enzyme-linked immunosorbent assay to quantify the anti- Aspergillus antibodies in sera of patients with aspergilloma, allergic bronchopulmonary aspergillosis (ABPA), and invasive aspergillosis (IA). In spite of the variability observed in the immune responses of individual patients, quantification of the antibody titers against the 18-kDa ribonuclease (RNU), the 360-kDa catalase (CAT), and the 88-kDa dipeptidylpeptidase V (DPPV) was useful for the diagnosis of aspergilloma and ABPA. Differential diagnosis of ABPA was even possible among cystic fibrosis as well as noncystic fibrosis patients. In the group of immunocompromised patients with IA, no antibody response was mounted in response to the Aspergillus infection in any of the patients. Interestingly, about half of the patients with proven IA came to the hospital with high titers of anti- Aspergillus antibodies, suggesting that they were infected upon entry to the hospital. These results suggest that recombinant RNU, CAT, and DPPV have a great potential in the serodiagnosis of all forms of aspergillosis in the immunocompromised and immunocompetent patient.

Nosocomial Neonatal Candidiasis

The Pediatric Infectious Disease Journal 24(9):p 831-832, September 2005. | DOI: 10.1097/01.inf.0000178291.40568.ef

Real time-PCR HBV-DNA analysis: Significance and first experience in armed forces

Background: HBV DNA quantitation is used extensively world wide for the diagnosis and monitoring of treatment of Hepatitis B virus (HBV) infection. However, it has still to be popular in India. The aim of this study was to quantitate HBV — DNA by Real time — PCR method in Hepatitis B and in immuno-compromised patients, to compare the results with HBeAg detection and to monitor the response to therapy of chronic Hepatitis B patients to antivirals. Methods: Ninety one serum samples of Hepatitis group of patients (all HBsAg positive), 41 samples from immuno-compromised patients (all HBsAg negative) and 49 patients of Chronic Hepatitis B group (all HBsAg positive) were the subjects of this first ever study in Armed Forces. Twenty serum samples from healthy volunteers and non-hepatitis B patients served as negative controls. The amplification detection was carried out in a Rotor-Gene 2000-sequence detector. Results: Amongst Hepatitis B group, 33% (30/91) of the samples were positive for HBV-DNA and 26% (24/91) of samples were positive for HBeAg. In the immuno-compromised group of patients 14.6% (6/11) of samples were positive for HIV-DNA and 9.7% (4/41) were positive for HBeAg. Of the Chronic Hepatitis B patients on treatment, all (100%) were positive by HBV-DNA, whereas 29/49 (59.2%) were positive by HBeAg before treatment. After treatment with antivirals, 06/49 (12.2%) were positive by both tests and 11/49 (22.5%) were positive only by HBV-DNA. 32/49 (65.3%) patients became negative serologically after therapy. Conclusion: HBeAg status did not necessarily reflect HBV-DNA level in the serum, as 10/91 (11%) in the Hepatitis B group, 2/41 (4.9%) in the immuno compromised group and 20/49 (40.8%) patients in the Chronic Hepatitis B group were positive for HBV-DNA but negative for HBeAg. HBV-DNA was not found to be positive amongst any of the negative controls. Real time — PCR is a sensitive and reproducible assay for HBV-DNA quantitation and may be started in Armed Forces referral centers in the near future.

The incidence of hyperglycemia in hematopoietic stem cell transplant recipients receiving total parenteral nutrition: A pilot study

Objective To determine whether total parenteral nutrition (TPN)-induced hyperglycemia is associated with adverse clinical outcomes. Design A retrospective cohort investigation comparing the medical records of hematopoietic stem cell transplant patients was conducted to determine clinical differences between those who received TPN and those who did not receive TPN during transplant. Subjects/setting Forty-eight adult patients (≥18 years) undergoing initial autologous or allogeneic hematopoietic stem cell transplant at two urban university-affiliated hospitals were eligible for inclusion. Main outcome measures Hyperglycemia (glucose ≥6.1 mmol/L or 110 mg/dL), presence of infection, infection duration, and in-hospital mortality. Statistical analyses performed χ 2, Student t, and Wilcoxon rank-sum tests were used to detect differences among the study participants. Results Patients had similar baseline demographic and clinical characteristics, with 63% receiving TPN during transplant. When standardized for time, TPN recipients at both institutions experienced significantly more hyperglycemia ( P<.05) after TPN initiation. TPN patients also experienced 69% of all infections and 100% of repeat positive cultures. Additionally, significantly greater differences for TPN recipients were found for length of stay and daily charges than those who did not receive TPN. No differences were found for in-hospital mortality. Conclusions TPN is strongly associated with hyperglycemia, which may be linked to increased infections of longer duration in a profoundly immunocompromised group of patients who frequently receive TPN. The implications of these findings are limited by the small number of subjects; a larger investigation is warranted.

Editorial

Over the past three years it has become apparent to me that referring to ‘current affairs’ in these columns can be a mistake, serving only to highlight inevitable printing delays. By the time this edition arrives on your doormat Euro 2004, ‘Big Brother’ and the early summer heat wave will be nothing but a distant memory. However the ‘recent’ publication of the Royal College of Physicians document ‘Acute Medicine – making it work for patients’ cannot be allowed to pass without a mention. This report represents a significant shift in the position of the College in relation to Acute Medicine since the previous working party reported its findings in 2000. The value of consultants specialising in Acute Medicine is now clearly recognised and supported – every trust should now have one, with the minimum figure of three per hospital being proposed by 2008. Whether this is achievable will depend on the rapid development of training schemes across the UK, as well as the generation of enthusiasm for the specialty amongst junior staff. The number of applicants for our Wessex programme indicates no shortage of the latter. Although developing a training scheme takes a lot of hard work, it is vital that those already working in the specialty make this a high priority. We have already seen benefits from the appointment of high quality middle grade staff and are looking forward to a ‘flood’ of future applicants for local consultant posts, 4 years from now. This edition comprises four more important review papers on aspects of acute medicine, along with the first in our ‘Controversies in acute medicine’ series. The latter was designed to try to stir up some correspondence, for future publication. The confusion over oxygen delivery in the acute setting seems to reign fairly widely amongst junior, and indeed some more senior medical staff. Hopefully Dr Cooper’s well-written paper will serve to dismiss some of the misconceptions in this area. Our reviews cover relatively uncommon, but nonetheless important aspects of acute medicine. Tuberculosis and HIV are both on the increase in the UK. The success of anti-retroviral therapy will undoubtedly lead HIVrelated illness to be a significant part of our practice over the next decade. An understanding of the range of conditions specific to this group of immunocompromised patients is therefore crucial for physicians involved in the acute take. Hypoglycaemia and suspected bacterial meningitis are both conditions which require immediate action by medical staff. Both of these reviews comprehensively cover their respective topics with a combination of well written text, illustrations tables and algorithms. Dr Hartman highlights recent evidence supporting the use of dexamethosone in bacterial meningitis and re-iterates some of the points made in an earlier edition regarding the use (and abuse) of CT scanning prior to lumbar puncture. For a change we have no case reports this time, although Dr Macdonald’s audit of the innovative review clinic in the Emergency Assessment Area of Heartlands hospital provides a worthy substitute. Submission of similar articles in future would be most welcome. Once again, a reminder that multiple choice questions are for self assessment and ‘personal’ CPD only; I hope you will find this edition helpful in your clinical practice.

Diagnostic potential of tetramer-based monitoring of cytomegalovirus-specific cd8 + t lymphocytes in allogeneic stem cell transplantation

Cytomegalovirus (CMV) infection remains a significant problem in allogeneic stem cell transplant (SCT) recipients despite the availability of effective antiviral drugs. This problem concerns patients which are unable to mount an effective T-lymphocyte response against CMV. Therefore, the development and use of tetramer technology to enumerate CMV-specific T cells will be valuable to identify these patients as early as possible. Here, we review clinical studies in which CMV-specific CD8 + T cells have been monitored in allogeneic SCT recipients using tetramers in the context of similar studies that are based on functional assays of CMV-specific T cells. The results thus far warrant the further development of tetramer technology as a diagnostic tool to monitor CMV-specific T cells in SCT recipients and other groups of immunocompromised patients threatened by CMV.