von Willebrand's disease (vWD) is the commonest inherited bleeding disorder in man with an estimated incidence of 1 per thousand of the population. Acquired von Willebrand's disease (AvWD) is rare with less than 70 cases reported. AvWD is usually associated with autoimmune or clonal proliferation disorders and whilst the precise mechanism of acquired deficiency of von Willebrand factor (vWF) is poorly understood, the most likely candidate mechanism(s) are; antibodies inactivate or form a complex with immunologic or functional sites on vWF, or vWF multimers are selectively absorbed by malignant cells. Unlike hereditary vWD, the acquired form of the disease can be exceedingly difficult to manage. We report 4 cases of AvWD diagnosed at our centre over the past 3 yr. There was no evidence of a previous personal or family history of bleeding in any of the patients and AvWD was confirmed by laboratory testing. All 4 patients had a recognised primary medical condition known to be associated with AvWD (Waldenstrom's Macroglobulinaemia in 2 patients, hypothyroidism in 1 patient and monoclonal gammopathy of unknown significance (MGUS) in 1 patient). The acquired haemostatic defect corrected following treatment of the primary condition in 3 patients with the other patient requiring on demand von Willebrand Factor replacement to control spontaneous and surgery induced bleeding.

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"In-situ" Teicoplanin for central venous catheter infection.

Infection of central venous catheters (CVC) is a relatively common occurrence in immunocompromised patients, management of which has included I.V. antibiotics +/- removal of catheter. We have previously demonstrated that intracatheter administration of Amikacin empirically, successfully eradicated all bacterial infections except those due to S. epidermidis. A study was subsequently undertaken to treat gram positive cocci infections of CVC with intracatheter Teicoplanin. Eleven patients attending a single institution with documented gram positive cocci infection of CVC over a one year period were included in the study. Teicoplanin was instilled with heparinised saline once daily into the infected lumen of the CVC and allowed to remain for 24 hours. Treatment was continued for 48 hours after negative cultures were reported. Teicoplanin was successful in eradicating infection in 100% of cases. Mean duration of treatment was six days (range 4-9 days). Four patients subsequently developed a further infection, a mean of 13 weeks from first infection, only one of which was due to the same organism and this was successfully treated by a further course of Teicoplanin. No side effects were reported and catheter life was prolonged a mean of 132 days after completion of treatment. The use of Teicoplanin in this way for treatment of gram positive cocci infection of CVC is highly effective; once daily administration of antibiotic enables treatment to be given on an outpatient basis, thereby minimising hospital admission.

Adolescent↗

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Predicting loneliness in the hospitalized elderly: what are the risk factors?

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Evolution of the echinoderm Hox gene cluster.

Extant echinoderms are members of an ancient and highly derived deuterostome phylum. The composition and arrangement of their Hox gene clusters are consequently of interest not only from the perspective of evolution of development, but also in terms of metazoan phylogeny and body plan evolution. Over the last decade numerous workers have reported partial Hox gene sequences from a variety of echinoderms. In this paper we used a combined methods approach to analyze phylogenetic relationships between 68 echinoderm Hox homeodomain fragments, from species of five extant classes--two asteroids, one crinoid, one ophiuroid, one holothuroid, and three echinoids. This analysis strengthens Mito and Endo's (2000) proposition that the ancestral echinoderm's Hox gene cluster contained at least eleven genes, including at least four posterior paralogous group genes. However, representatives of all paralogous groups are not known from all echinoderm classes. In particular, these data suggest that echinoids may have lost a posterior group Hox gene subsequent to the divergence of the echinoderm classes. Evolution of the highly derived echinoderm body plan may have been accompanied by class-specific duplication, diversification and loss of Hox genes.

Amino Acid Sequence↗

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Screening for cervical abnormalities in women with anogenital warts in an STD clinic: an inappropriate use of colposcopy.

An audit of the use of colposcopy in women with anogenital warts was performed. Fifty women attending a clinic for sexually transmitted diseases in a District General Hospital with anogenital warts were examined by cervical cytology and colposcopy for cervical infection by human papillomavirus (HPV) or epithelial abnormality indicating cervical intraepithelial neoplasia (CIN) or both. Collated results showed a high prevalence of both conditions in these 50 women; 20 (40%) had evidence of cervical infection by HPV and 11 (22%) epithelial abnormalities consistent with CIN 1 or 2. However, neither CIN 3 nor invasive disease was detected. Colposcopy in this setting was shown to be a specific but insensitive tool and its role in the routine management of women with anogenital warts at our institution is not warranted.

Adolescent↗

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Geriatric depression: a survey of nurses' knowledge and assessment practices.

A sample of 149 registered nurses were surveyed to determine their knowledge of the symptoms of depression in the elderly and their assessment practices. Respondents were able to identify not only the traditionally associated symptoms but also two other behaviors, irritability and blaming others, which are not usually designated by other health care providers as associated with geriatric depression. These additional observations may reflect nurses' providing extensive physical as well as verbal care over much longer time periods for patients in inpatient and home settings than do other professionals. Recent findings in nursing research support the presence of these other behaviors as symptoms of depression. An additional finding revealed that nurses were not assessing their patients for depression even though they had a knowledge base of the symptoms.

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