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Four infants aged between 8 and 13 months presented between November 2002 and May 2006 with dermatitis of the lower abdomen, perineum or buttocks. All lived in semi-rural properties in the Adelaide Hills and had not travelled outside South Australia. Wandering thread-like serpiginous tracks were evident on examination, consistent with a diagnosis of cutaneous larva migrans. No abnormalities were detected on full blood examination, Strongyloides stercoralis serology or faecal analysis. Treatment with oral albendazole resulted in rapid resolution of symptoms. An epidemiological survey was undertaken which suggested possums or millipedes may have been the source of nematode larvae, the precise nature of which is unclear but could include Parastrongyloides trichosuri and Rhabditis necromena., (© 2010 The Authors. Australasian Journal of Dermatology © 2010 The Australasian College of Dermatologists.)

Androgen deprivation is the mainstay of therapy for progressive prostate cancer. Despite initial and dramatic tumor inhibition, most men eventually fail therapy and die of metastatic castration-resistant (CR) disease. Here, we characterize the profound degree of genomic alteration found in CR tumors using array comparative genomic hybridization (array CGH), gene expression arrays, and fluorescence in situ hybridization (FISH). Bycluster analysis, we show that the similarity of the genomic profiles from primary and metastatic tumors is driven by the patient. Using data adjusted for this similarity, we identify numerous high-frequency alterations in the CR tumors, such as 8p loss and chromosome 7 and 8q gain. By integrating array CGH and expression array data, we reveal genes whose correlated values suggest they are relevant to prostate cancer biology. We find alterations that are significantly associated with the metastases of specific organ sites, and others with CR tumors versus the tumors of patients with localized prostate cancer not treated with androgen deprivation. Within the high-frequency sites of loss in CR metastases, we find an overrepresentation of genes involved in cellular lipid metabolism, including PTEN. Finally, using FISH, we verify the presence of a gene fusion between TMPRSS2 and ERG suggested by chromosome 21 deletions detected by array CGH. We find the fusion in 54% of our CR tumors, and 81% of the fusion-positive tumors contain cells with multiple copies of the fusion. Our investigation lays the foundation for a better understanding of and possible therapeutic targets for CR disease, the poorly responsive and final stage of prostate cancer.

Mucormycosis is a rare opportunistic fungal infection in renal transplant recipients which is associated with exceedingly high mortality when inadequately treated. Risk factors for this infection include diabetes, neutropaenia and immunosuppression. We report a case of pulmonary mucormycosis in a renal allograft recipient with type 2 diabetes and limited pulmonary reserve. The patient was successfully treated with lobectomy and liposomal amphotericin B with preservation of pulmonary and allograft functions. Early recognition of this infection is warranted before dissemination, which carries a poor prognosis.

Pneumocystis jivorecii (formerly known as carinii) pneumonia (PCP) is potentially a life-threatening opportunistic infection after organ transplantation, occurring most frequently in the first 12 months, where the incidence rate is several-fold higher than in later years. PCP typically presents with fever, cough, dyspnoea and hypoxia. In organ transplant recipients, the onset of symptoms is generally more fulminant compared to patients infected with the human immunodeficiency virus. We present a patient who developed PCP five years after a renal transplantation. His presentation was characterised by atypical symptoms and an indolent onset. Previous acute vascular rejection, ongoing maintenance prednisolone usage, cytomegalovirus seropositivity and past tuberculous infection may have predisposed this patient to PCP.

The two main histological types of infiltrating breast cancer, lobular (ILC) and the more common ductal (IDC) carcinoma are morphologically and clinically distinct. To assess the molecular alterations associated with these breast cancer subtypes, we conducted a whole-genome study of 166 archival estrogen receptor (ER)-positive tumors (89 IDC and 77 ILC) using the Affymetrix GeneChip(R) Mapping 10K Array to identify sites of loss of heterozygosity (LOH) that either distinguished, or were shared by, the two phenotypes. We found single nucleotide polymorphisms (SNPs) of high-frequency LOH (>50%) common to both ILC and IDC tumors predominately in 11q, 16q, and 17p. Overall, IDC had a slightly higher frequency of LOH events across the genome than ILC (fractional allelic loss = 0.186 and 0.156). By comparing the average frequency of LOH by chromosomal arm, we found IDC tumors with significantly (P < 0.05) higher frequency of LOH on 3p, 5q, 8p, 9p, 20p, and 20q than ILC tumors. We identified additional chromosomal arms differentiating the subtypes when tumors were stratified by tumor size, mitotic rate, or DNA content. Of 5,754 informative SNPs (>25% informativity), we identified 78 and 466 individual SNPs with a higher frequency of LOH (P < 0.05) in ILC and IDC tumors, respectively. Hierarchical clustering of these 544 SNPs grouped tumors into four major groups based on their patterns of LOH and retention of heterozygosity. LOH in chromosomal arms 8p and 5q was common in higher grade IDC tumors, whereas ILC and low-grade IDC grouped together by virtue of LOH in 16q.

Disseminated epithelial cells can be isolated from the bone marrow of a far greater fraction of prostate-cancer patients than the fraction of patients who progress to metastatic disease. To provide a better understanding of these cells, we have characterized their genomic alterations. We first present an array comparative genomic hybridization method capable of detecting genomic changes in the small number of disseminated cells (10-20) that can typically be obtained from bone marrow aspirates of prostate-cancer patients. We show multiple regions of copy-number change, including alterations common in prostate cancer, such as 8p loss, 8q gain, and gain encompassing the androgen-receptor gene on Xq, in the disseminated cell pools from 11 metastatic patients. We found fewer and less striking genomic alterations in the 48 pools of disseminated cells from patients with organ-confined disease. However, we identify changes shared by these samples with their corresponding primary tumors and prostate-cancer alterations reported in the literature, evidence that these cells, like those in advanced disease, are disseminated tumor cells (DTC). We also show that DTCs from patients with advanced and localized disease share several abnormalities, including losses containing cell-adhesion genes and alterations reported to associate with progressive disease. These shared alterations might confer the capability to disseminate or establish secondary disease. Overall, the spectrum of genomic deviations is evidence for metastatic capacity in advanced-disease DTCs and for variation in that capacity in DTCs from localized disease. Our analysis lays the foundation for elucidation of the relationship between DTC genomic alterations and progressive prostate cancer.

Scedosporium species are increasingly isolated from immunocompromised and immunocompetent patients. Scedosporium infections are generally resistant to multiple antifungals, and Scedosporium prolificans is particularly resistant to all single antifungal agents currently in use with in vitro testing. We report here a long-term renal transplant recipient who developed isolated S. prolificans septic monoarthritis and probable osteomyelitis. The infection was successfully treated with a combination of voriconazole and terbinafine in addition to joint washout but did not require radical surgery. This combination has been shown to have synergistic in vitro effect, and anecdotal in vivo success has also been reported recently. We also review the clinical presentation, treatment, and outcome of S. prolificans infection in patients with solid organ transplantation.

In this case report, we describe the first instance of septicemia caused by an obligately anaerobic Staphylococcus aureus in a human. A 45-year-old man presented with septicemia, septic arthritis, and multiple pulmonary abscesses, which were caused by an obligately anaerobic S. aureus. The clinical and microbiological features that led to the diagnosis are discussed. Genotyping cannot at present reliably separate S. aureus subsp. aureus from S. aureus subsp. anaerobius, but phenotypic characteristics suggest that the present isolate is a previously undescribed strain of anaerobic Staphylococcus aureus.

This study of infection of southern Australian land snails with Brachylaima cribbi metacercariae has shown that all commonly encountered native and introduced snails are susceptible second intermediate hosts. The range of infected snails is extensive with metacercariae-infected snails being present in all districts across southern Australia. C. virgata has the highest average natural metacercarial infection intensity of 6.1 metacercariae per infected snail. The susceptibility of birds, mammals and reptiles to B. cribbi infection was studied in South Australia by capturing, dissecting and examining the intestinal tract contents of animals which commonly eat land snails as a food source. Indigenous Australian little ravens (Corvus mellori), which are a common scavenger bird, and two other passeriform birds, the black bird (Turdus merula) and the starling (Sturnus vulgaris), which are both introduced European birds, were found to have the highest infection rates of all animals examined. Other birds found infected with B. cribbi were an emu (Dromaius novaehollandiae), chickens (Gallus gallus) and a pigeon (Columba livia). Natural infections were also detected in field mice (Mus domesticus) and shingleback lizards (Tiliqua rugosa) although the intensity of infection was lower than that observed in birds. Susceptibility studies of laboratory mice, rats and ducks showed that mice developed patent infections which persisted for several weeks, rats developed a short-lived infection of three weeks' duration and ducks did not support infection. This study has shown for the first time that a brachylaimid can infect a wide host range of birds, mammals and reptiles in nature.

Background: This study was designed to assess the relative efficiency of three different culture media for isolating fungi in patients suspected of having noninvasive fungal sinusitis., Methods: A prospective study was performed of 209 operative samples of sinus "fungal-like" mucin from 134 patients on 171 occasions and processed for microscopy and fungal culture in Sabouraud's dextrose agar, potato dextrose agar, and broth media., Results: Ninety-three (69%) of 134 patients had evidence of fungal infection. Two-thirds of patients had negative microscopy samples yet 56% of these went on to positive cultures. Forty-five percent cultured Aspergillus genus. Discrepancy between the fungi cultured in different media and on different occasions was common. With a single culture medium up to 19% of patients and 15% of samples would have been falsely labeled fungal negative., Conclusion: Increasing the number and type of fungal culture media used increases the number and range of fungal isolates from mucin in patients with the features of fungal sinusitis. Negative specimen microscopy is unreliable. All specimens should be cultured in multiple media and on multiple occasions when fungal sinusitis is suspected.

In this study, we performed high-resolution array comparative genomic hybridization with an array of 4153 bacterial artificial chromosome clones to assess copy number changes in 44 archival breast cancers. The tumors were flow sorted to exclude non-tumor DNA and increase our ability to detect gene copy number changes. In these tumors, losses were more frequent than gains, and gains in 1q and loss in 16q were the most frequent alterations. We compared gene copy number changes in the tumors based on histologic subtype and estrogen receptor (ER) status, i.e., ER-negative infiltrating ductal carcinoma, ER-positive infiltrating ductal carcinoma, and ER-positive infiltrating lobular carcinoma. We observed a consistent association between loss in regions of 5q and ER-negative infiltrating ductal carcinoma, as well as more frequent loss in 4p16, 8p23, 8p21, 10q25, and 17p11.2 in ER-negative infiltrating ductal carcinoma compared with ER-positive infiltrating ductal carcinoma (adjusted P values < or = 0.05). We also observed high-level amplifications in ER-negative infiltrating ductal carcinoma in regions of 8q24 and 17q12 encompassing the c-myc and c-erbB-2 genes and apparent homozygous deletions in 3p21, 5q33, 8p23, 8p21, 9q34, 16q24, and 19q13. ER-positive infiltrating ductal carcinoma showed a higher frequency of gain in 16p13 and loss in 16q21 than ER-negative infiltrating ductal carcinoma. Correlation analysis highlighted regions of change commonly seen together in ER-negative infiltrating ductal carcinoma. ER-positive infiltrating lobular carcinoma differed from ER-positive infiltrating ductal carcinoma in the frequency of gain in 1q and loss in 11q and showed high-level amplifications in 1q32, 8p23, 11q13, and 11q14. These results indicate that array comparative genomic hybridization can identify significant differences in the genomic alterations between subtypes of breast cancer.

Although cutaneous leishmaniasis is occasionally seen in Australia in overseas travellers and migrants, visceral leishmaniasis has been reported rarely and only in people who were immunocompromised. We describe an 18-year-old immunocompetent man who presented with pancytopenia and a 2-week history of fever and lethargy a year after visiting the Greek Islands. Visceral leishmaniasis was diagnosed after a bone marrow biopsy showed protozoa, and the patient responded well to treatment with liposomal amphotericin. To our knowledge, this is the first case of visceral leishmaniasis in an immunocompetent patient in Australia.

The course of infection in C57BL/6J mice re-infected with Brachylaima cribbi was assessed by comparing faecal egg excretion of re-infected mice with age- and sex-matched mice receiving a primary infection only. For both male and female mice there was a significant reduction in the mean number of eggs per gram of faeces at the peak of infection 4 weeks after the challenge infection compared with mice receiving a primary infection only. There was no significant difference in the duration of the infection. This experiment was repeated using age-matched male mice but on this occasion all mice were killed and dissected 4 weeks after the challenge infection and mean eggs per gram of faeces, worm burden and fecundity determined. There was no significant difference in the worm burdens of the re-infected mice compared with age-matched animals receiving a primary infection only. However, there were significant differences in the mean faecal eggs per gram and worm fecundity with the challenge infection group having lower egg counts and reduced fecundity. An enzyme-linked immunosorbent assay using whole worm antigens was developed and used to determine mouse anti-B. cribbi serum antibody levels during the course of infection. Anti-B. cribbi serum antibody absorbance ratios increased six- to sevenfold by 4 weeks after a primary infection beyond which a constant level was maintained. The course of challenge infection in non-obese diabetic severe combined immunodeficient mice showed no significant differences in egg excretion, worm burden or fecundity when primary and challenge infections were compared. These results indicate that the immune response invoked by a previous B. cribbi infection in immunocompetent mice affects fecundity but does not affect the establishment or duration of infection.

Brachylaima cribbi is a terrestrial trematode of birds and mammals with helicid and hygromiid land snails reported as first and second intermediate hosts. However, reports describing the first intermediate host range of B. cribbi have been limited to those snail species present in a small number of geographical locations in South Australia. The natural first intermediate host range, distribution and prevalence of B. cribbi in land snails in southern Australia were determined. A total of 6,432 introduced and native land snails were collected from eight geographical districts across 3,000 km of southern Australia and examined microscopically for B. cribbi sporocysts. Four introduced European snails, Theba pisana, Cernuella virgata, Cochlicella acuta and Cochlicella barbara were natural first intermediate hosts. Sporocyst-infected snails were detected in all districts from Victoria to the west coast of South Australia, a distance of over 1,300 km. Natural sporocyst infection was not observed in introduced European snails Microxeromagna armillata and Helix aspersa or in native Australian land snails Succinea australis and Strangesta gawleri. Egg feeding experiments in the laboratory with B. cribbi confirmed the susceptibility of those species of snails found to be natural first intermediate hosts. Of those species not found to be infected in nature, only M. armillata could be infected in the laboratory. Although this study has shown that five different species of European land snails are suitable first intermediate hosts for B. cribbi there are as yet no reports of B. cribbi from these snails in Europe or from other countries where they have been introduced. Further investigations are needed in Europe to clarify the origins of this parasite.

During a nine-day period, five patients in a 14-bed intensive care unit (ICU) were shown to have seroconverted with a four-fold or greater rise in serum antibody titre to Legionella longbeachae serogroup 1. A further two patients were observed to have high titres consistent with previous exposure but earlier serum samples were not available for comparison. No patients had antibody responses to Legionella pneumophila serogroups 1 and 2. L. longbeachae was not cultured from respiratory secretions from patients or from the environment within the unit. Legionella anisa was recovered from one cooling tower on the ninth floor of the tower block. The ICU is located on the first floor of the same tower and receives external air from two vents, one on the eastern and the other on the western aspect. All patients with serological evidence of L. longbeachae infection were concomitantly infected with multiresistant Staphylococcus aureus, and were located in bays on the eastern side of the unit. A large pigeon nest was discovered within 1-2 m of the eastern vent. Following removal of the birds' nest, no further cases were seen on routine screening of all patients within the unit over the next eight weeks. Alternatively, seroconversion may have been related to demolition of the adjacent nine-storey nurses home. This was begun one month before the first case was diagnosed and was completed four months later. The periodic northerly winds could have carried legionellae from the demolition site directly over the block housing the ICU and may have concentrated them near the eastern air vent. All patients had pneumonia, which was probably multifactorial in origin. There is some uncertainty whether the serological responses seen were an epiphenomenon or were truly indicative of infection with L. longbeachae., (Copyright 2002 The Hospital Infection Society)

Brachylaima cribbi is a recently described species of terrestrial trematode that infects mammals and birds with helicid land snails as its first and second intermediate hosts. The adult worm is 2.5-6.0 mm long by 0.5-0.8 mm wide being a long slender cylindrical worm with oral and ventral suckers in the anterior quarter and genital pore in the posterior quarter. Scanning electron microscopy shows that there is a dense covering of tegumental spines at the anterior end which diminishes towards the posterior extremities of the worm. Development of spines was observed in juvenile and mature adult worms. In young worms 1-3 weeks post infection (wpi) spines appear as buds with a serrated edge each having 1-4 spikes per spine. As the worm ages the spines broaden and by 5 wpi the number of spikes per spine increases to an average of 8.1. The serial development of oral sucker papillae in the cercaria, metacercaria and adult worm was observed with the finding of an elongated papilla with a bifurcated tip on the cercaria becoming a shorter and thicker elongated papilla with a large central stoma on the metacercaria. In the adult worm, this papilla becomes dome-shaped with a small central stoma. For some of these papillae a cilium could be seen extended from the central stoma. Other life-cycle stages illustrated were the hatched egg with an extruded egg membrane minus an operculum and a portion of the branched sporocyst dissected from the digestive gland of the land snail Theba pisana showing a terminal birth pore. Scanning electron microscopy morphological features of the adult worm observed for the first time in a Brachylaima were the unarmed cirrus extended from the genital pore with released sperm present and the Laurer's canal opening visible in tegumental folds on the dorsal surface approximately 300 microm posterior to the genital pore.

The C57BL/6J strain of Mus musculus is susceptible to the terrestrial trematode Brachylaima cribbi. The duration of infection in these mice is generally 9-12 weeks with a peak excretion of eggs at 4 weeks post-infection (wpi). The effects of age and sex on the course of infection were investigated by comparing infections in male and female mice aged 8 or 28 weeks at the time of infection. There were no significant differences in the susceptibility of the adolescent mice of either sex or older male mice. However, older, mature female mice were significantly more resistant to B. cribbi infection than older mature males and adolescent females with reduced worm burden, fecundity and egg fertility. In comparison with young males, all three parameters were again reduced but this was only significant statistically for reduced egg fertility. It is likely that mature female sex hormones influence resistance to B. cribbi infection. The susceptibility of immunodeficient NOD SCID mice was evaluated and compared with C57BL/6J mice. NOD SCID mice were susceptible to B. cribbi infection with the infection persisting with a relatively unchanged worm burden for the life of the mouse with the longest surviving mice being 31 wpi. The life-span of B. cribbi is therefore at least 31 weeks. There were no significant differences in egg excretion, worm burden or fecundity among NOD SCID mice at 4, 8 or 18 wpi. As the infection progressed in NOD SCID mice, the location of worms in the small intestine moved from the anterior third in the early stages of the infection to the mid- to posterior intestine in the later stages. Comparison of the infection in NOD SCID mice with C57BL/6J mice indicates that the expulsion of worms in the latter is mediated by an immune response.

The flash vacuum pyrolysis (FVP) of 1,2-bis(2-bromophenyl)-4,9-dibromocorannulene leads to a new C(32)H(12) buckybowl.

Susceptibility to infection with Brachylaima cribbi was studied in eight strains of inbred mice (AKR, C3H/HeJ, CBA/CaH, BALB/c, DBA/2J, SJL/J, A/J, C57BL/6J) and Swiss albino outbred mice by quantifying faecal egg excretion over the period of the infection. Preliminary experiments indicated that a combination of filtration/sedimentation/diethyl ether sedimentation was the most sensitive and reliable technique for quantification of eggs in faeces. Mice were infected with 13-15 wild-type B. cribbi metacercariae from naturally infected Cernuella virgata and in a second experiment with human-derived B. cribbi from laboratory-reared Helix aspersa. In both experiments C57BL/6J mice were the most susceptible having the highest egg excretion levels and the longest duration of infection. Worm burdens were assessed at 12 wpi for the wild-type and at 9 wpi for the human-derived infections, when the majority of mice were no longer excreting eggs. The numbers of worms recovered from the small intestine were few and there were no significant differences among the inbred or outbred groups of mice. We have found that C57BL/6J mice were the most susceptible to Brachylaima cribbi infection as assessed by excretion of eggs and provide a suitable model for a laboratory life-cycle.

Aims: To determine whether there has been a change in the patterns of susceptibility to various antibiotics of our isolates of Helicobacter pylori over a 5-year period from 1996 to 2000., Methods: Five hundred and fourteen isolates of H. pylori grown from gastric biopsies were tested for susceptibility to amoxycillin, clarithromycin, metronidazole and tetracycline. The usage of macrolide antibiotics in Australia was examined by calculating the numbers of prescriptions issued under the Australian pharmaceutical benefits scheme between 1992 and 2000., Results: There were no changes in susceptibility of H. pylori to amoxycillin and tetracycline and there was a slight decline in resistance to metronidazole. In contrast, there was a stepwise 4-fold increase from 3.8 to 15.7% in the number of isolates resistant to clarithromycin and a similar increase in the mean minimum inhibitory concentration of clarithromycin during the 5-year period of observation. There was no change in overall macrolide consumption in Australia over this and the preceding 3 years. However, the pattern changed, with erythromycin usage being halved and being replaced by roxithromycin and clarithromycin., Conclusions: Resistance of H. pylori to clarithromycin is increasing, possibly as a consequence of increased usage of roxithromycin and clarithromycin. More patients are likely to fail to respond to empirical therapy and will need microbiological investigation.

Multiple gastric biopsies were taken from 288 patients in Port Lincoln, South Australia. One biopsy was used for a CLOtest and the other three were transported to a central laboratory in Adelaide in physiological saline, Portagerm pylori transport medium or after culture on a chocolate agar plate which was placed in a Biobag. Helicobacter pylori was isolated from 18.3% of patients. There was a 95.7% concordance between culture results and the CLOtest result. Recovery rates after transport on chocolate agar, Portagerm pylori and in saline were 90.2, 90.2 and 84.3%, respectively.

The life-cycle of Brachylaima cribbi n. sp. was established in the laboratory. Asymmetrical brachylaimid eggs, measuring 26-32 microm (29.1 microm) long and 16 -17.5 microm (16.6 microm) wide, were recovered from human faeces and fed to the helicid land snail Theba pisana as the first intermediate host. Sporocysts and cercariae were recovered from the T. pisana eight weeks after infection. The cercariae were used to infect the helicid land snails Cernuella virgata and Helix aspersa as second intermediate hosts. Metacercariae were recovered from the kidneys of these snails and used to infect mice. Adults of Brachylaima cribbi n. sp. were recovered from the small intestine of the mice. The differential features of B. cribbi n. sp. are the specificity for helicid snails as first and second intermediate hosts; characteristic ventral sucker and body cercarial chaetotaxy; and a long slender adult worm with equal size suckers in the first quarter of the worm, the ventral sucker occupying 41% of the body width, the uterus extending anterior to the ventral sucker and the vitelline follicles falling short of the posterior margin of the ventral sucker. No other known Brachylaima species exhibits all of these features. B. cribbi n. sp. is the first brachylaimid known to have infected humans and is probably of European origin, as the intermediate host snails were all introduced into Australia from Europe.

We have reviewed our experience of long-term antibiotic suppressive therapy in patients who underwent repair of an abdominal aortic aneurysm (AAA) and developed proven or strongly suspected infection of a graft. Five patients with abdominal aortic repair complicated by proven or suspected graft infections were treated with continuing antibiotic suppressive therapy based on microbiology culture reports. Two patients developed infection of an established graft, two patients had a graft inserted into an infected area and one patient was thought to be at high risk of developing infection of a recently placed graft. All patients had severe co-existent medical problems and were considered too ill to tolerate further definitive surgery. Response to therapy was monitored by absence of symptoms, fever, inflammatory markers and survival. All patients are alive with a median survival of 32 months, the longest having survived for 6 years. In selected patients with abdominal aortic graft infections, indefinite antibiotic suppressive therapy may be an acceptable alternative to further surgery.

A gram-positive bacillus was isolated repeatedly from blood taken through the lumina of a central venous catheter of a patient with multiple myeloma who developed febrile neutropenia following chemotherapy. The bacterium was identified by the API CORYNE system as 'Corynebacterium aquaticum'. Gene analysis targeting the 16S rRNA indicated that the organism had a 99.5% identity with Aureobacterium liquefaciens although there were two phenotypic characteristics at variance with the description of this species. Problems remain with the routine identification of 'C. aquaticum' and Aureobacterium species. The few clinical reports on patients infected with 'C. aquaticum' and A. liquefaciens indicate that these are rare infections often associated with immunocompromise.

Ten commercial transport swabs were evaluated for their ability to preserve bacteria for 24 and 48 hours. Microorganisms included ATCC strains of Gram-positive and Gram-negative aerobes and anaerobes. There was a wide variation in performance. Swabs using Amies plus charcoal medium or Stuart's medium had better recovery rates than those using Amies medium alone. The nature of the tips of the swabs had little influence. Performance was not correlated with cost of the swabs. These data will assist institutions to make cost-effective decisions when purchasing bacteriological transport systems.

Gastric biopsy specimens were taken from 737 patients undergoing upper gastrointestinal endoscopy and assessed for Helicobacter pylori infection. The diagnostic utilities of H. pylori culture (733 patients), detection of urease production (724 patients) and histopathological examination (469 patients) were compared. Since each of these techniques may fail to diagnose patients infected with H. pylori, an attempt was made to estimate the true rate of infection using a mathematical approach that combined the results of culture, histopathology and urease testing; 34% of the 733 patients were thought to be infected. Using this figure as a benchmark, the sensitivity, specificity, positive predictive value and negative predictive value of H. pylori culture were 73.2%, 100%, 100% and 86.3%, respectively, compared with 58.7%, 100%, 100% and 89.6%, respectively for urease production and 77.0%, 100%, 100% and 82.4%, respectively for histopathology. Thus, histopathological examination was the single most reliable test. A combination of histopathological examination and H. pylori culture diagnosed 99.5% of patients that were estimated to be truly infected. The minimum inhibitory concentrations of a number of antibiotics were measured for 135 isolates of H. pylori. All isolates were susceptible to amoxycillin and tetracycline whereas 5.2% were resistant to clarithromycin and 60% were resistant to metronidazole.

A 78-year-old woman presented with an 18-month history of intermittent diarrhoea. Examination of her stools revealed brachylaimid eggs, which were present in three separate specimens over a week. After treatment with praziquantel a degenerate adult Brachylaima species was recovered from her faeces. She lived in a rural area of South Australia and ate vegetables grown in her own garden which had been infested with helicid snails. In south Australia these introduced European helicid snails are commonly infected with brachylaimid intermediate larval stages and are considered to be the source of the human infection.

The prognostic significance of delayed therapy in Legionnaires' disease is poorly defined. Thirty-nine consecutive serologically confirmed cases of Legionnaires' disease were reviewed to examine whether an association exists between delayed therapy and prognosis. Clinical and laboratory factors predictive of mortality were also sought. Thirty-one cases (79%) were classified as having severe pneumonia at diagnosis. Thirty-six patients (92%) had community-acquired infection, and three patients (8%) had nosocomial disease. Ten patients died, resulting in a crude mortality rate of 26%. At the first assessment, variables noted for pneumonia associated with death were low diastolic blood pressure (p < 0.02), low serum albumin concentration (p < 0.04), and increased number of days from onset of pneumonia to hospitalisation (prodrome) (p < 0.02). However, multiple logistic regression analysis revealed that the prodrome was the only variable noted at diagnosis that achieved significance (p = 0.024). Mortality also correlated with both delay in the initiation of erythromycin therapy following admission (p < 0.001) and the total delay in starting erythromycin therapy (p < 0.001). It is therefore recommended that erythromycin be included early in the empiric therapy of severe community-acquired pneumonia.

A total of 14,272 urine specimens were examined over one year to determine the validity of direct antimicrobial agent susceptibility testing against ampicillin, amoxicillin-clavulanic acid, cephalothin, gentamicin, norfloxacin, and trimethoprim. A comparison between direct and standardized disk diffusion tests was made for a total of 1,106 urine specimens containing > or = 10(5) organisms per ml in pure culture. There were 5,821 individual organism-antimicrobial agent challenges compared for the two testing methods, and there was complete agreement of susceptibility category in 5,492 comparisons (94.3%). Initially, discordant results were reduced from 5.7 to 2.1% when the intermediate category was considered susceptible. Intralaboratory variation was assessed by testing another 453 organisms by the standard National Committee for Clinical Laboratory Standards (NCCLS) method on two consecutive days; there was complete agreement in 96.1% of comparisons. When results of direct and standardized testing were simply classified as susceptible or resistant, there was 1.1% discordance. When simple same-day tests were used together with predictable patterns of susceptibility and resistance, 536 (48.5%) of 1,106 isolates could be identified satisfactorily to the genus or species level. For laboratory reporting purposes, the direct method is equivalent to the standard method when the urine being tested is infected with > or = 10(5) organisms of a single type per ml. The presence or absence of preexisting antimicrobial agents in urine did not appreciably influence the results. This procedure allows the earlier reporting of susceptibility results and facilitates less expensive identification of many organisms. Costs and benefits need to be determined in each institution.

Fortunately, Australia does not have many of the parasitic worm infections, such as filariasis, onchocerciasis and dracunculiasis, that are important on a global scale. Nevertheless, several medically important parasitic worms are endemic in Australia. Intestinal nematodes occur mostly in the tropical north although threadworm is ubiquitous. Hydatid disease and tapeworm infections occur especially in sheep and cattle farming regions.

The entire 1766 bases of the 18S rRNA gene of Strongyloides stercoralis have been sequenced. The gene has a 38% G+C content. Although it is similar in length to the 18S rRNA gene of Caenorhabditis elegans, the only other completely sequenced nematode 18S rRNA gene, it is only 69% identical. Closely related helminths will need to be sequenced in order to delineate sequences specific for the diagnosis of strongyloidiasis.

A case of corneal ulceration due to infection with Nocardia asteroides is described. Microbiological examination of corneal scrapings permitted accurate diagnosis and suggested appropriate therapy. Nineteen other cases that have been described in the world literature are reviewed.

The protein composition of Strongyloides stercoralis infective larvae and adult worms solubilized sequentially in water, sodium deoxycholate and sodium dodecyl sulphate (SDS) and their excretory/secretory products were analysed by one- and two-dimensional SDS-polyacrylamide electrophoresis. These extracts were demonstrated to be complex mixtures containing many proteins, some of which were common and others which were stage-specific. Western blot analysis of these antigens with infected human sera showed most sero-reactivity against larval antigens, whilst normal human sera were unreactive. These data identify immunogenic antigens which may be available for detection in an antigen assay.

A survey was undertaken of all of the consultant staff members of Perth's major teaching hospitals together with all the fellows of The Royal Australian College of General Practitioners in Western Australia in order to define their views on the issues of informed consent, compulsion in relation to surgery, and confidentiality in a particular circumstance, when testing for infection with the human immunodeficiency virus (HIV). Of the 701 individuals surveyed, 548 (78.2%) responded. Of these, 74.3% considered that it was not always necessary to gain informed consent, 22.0% believed that it was always necessary to do so, while 2.3% were undecided. General practitioners (38.4%) were more likely to think it necessary to obtain consent than were hospital consultants (19.0%), but otherwise the field of specialty had little effect on opinion. Of the respondents, 39.0% believed that testing before elective surgery is mandatory for all patients, while 53.0% considered that it should be compulsory in high-risk groups. Similar views were held about compulsory HIV antibody testing after emergency surgery. Similar responses were obtained from all specialty groups. When asked about whether they would tell a sexual partner of a patient's HIV status when the patient refused, 10.5% of doctors stated they would never advise the partner, 24.7% of doctors would on some occasions, 41.0% of doctors would tell a partner, and 23.8% always were undecided. Many individuals commented that they failed to see why HIV infection was being treated differently from other serious diseases. We have found that the majority opinion of the most senior members of the medical profession is that specific, informed consent should not always be required, that there is great support for compulsory testing, and that confidentiality may be broken under certain circumstances. These views must be recognized by administrators and legislators when framing measures to control this infection.

When dogs were immunized with soluble extract of adult Ancylostoma ceylanicum antigen, they were partially resistant to challenge infection in this model of human hookworm infection. Two immunizing doses, each of 1 mg protein suspended in Freund's complete adjuvant, were administered to one group of animals 1 and 3 weeks prior to infection with 5000 larvae. When compared with control dogs given the same infective dose, fecal egg excretion and intestinal adult worm burden in the immunized animals were reduced by 59 and 74%, respectively. Infection had no significant effect on hemoglobin concentrations, mean red cell volumes, total white cell counts, platelet levels, or spontaneous and phytohemagglutinin-induced lymphocyte transformations in both control and immunized animals. Both groups developed an eosinophilia, and lymphocytes from the immunized dogs responded transiently to stimulation with both larval and adult worm antigens. Specific IgM antibodies were transitory in both groups of dogs following infection. IgG antibodies developed significantly 2 weeks after infection in the immunized group; however, they did not appear until 4 weeks after infection in the control group. Both groups developed IgA antibodies 1 week after infection. They were maintained in the control dogs, in contrast to the levels in immunized animals which subsided rapidly 4 weeks after infection. Therefore, when animals are injected with soluble adult worm antigen prior to infection, specific protective immunity is acquired.

Most helminth parasites of man are unable to replicate within the human host. Thus, the worm burden of an infected person (on which the pathology largely depends - see Box 1) is a function of the number of infective forms to which the person is exposed. But for some species of helminths, the ability to replicate in man has a marked effect on the course and duration of infection, and for the pathogenesis of disease. In this review, David Grove discusses the mechanisms by which such replication may occur, and considers how this ability affects our approach to therapy and control.