Trabeculations of the porcine and human cardiac ventricles are different in number but similar in total volume

An intricate meshwork of trabeculations lines the luminal side of cardiac ventricles. Compaction, a developmental process, is thought to reduce trabeculations by adding them to the neighboring compact wall which is then enlarged. When pig, a plausible cardiac donor for xenotransplantation, is compared to human, the ventricular walls appear to have fewer trabeculations. We hypothesized the trabecular volume is proportionally smaller in pig than in human. Macroscopically, we observed in 16 pig hearts that the ventricular walls harbor few but large trabeculations. Close inspection revealed a high number of tiny trabeculations, a few hundred, within the recesses of the large trabeculations. While tiny, these were still larger than embryonic trabeculations and even when considering their number, the total tally of trabeculations in pig was much fewer than in human. Volumetrics based on high-resolution MRI of additional six pig hearts compared to six human hearts, revealed the left ventricles were not significantly differently trabeculated (21.5 versus 22.8%, respectively), and the porcine right ventricles were only slightly less trabeculated (42.1 vs 49.3%, respectively). We then analyzed volumetrically 10 pig embryonic hearts from gestational day 14-35. The trabecular and compact layer always grew, as did the intertrabecular recesses, in contrast to what compaction predicts. The proportions of the trabecular and compact layers changed substantially, nonetheless, due to differences in their growth rate rather than compaction. In conclusion, processes that affect the trabecular morphology do not necessarily affect the proportion of trabecular-to-compact myocardium and they are then distinct from compaction.

Acute grade IV toxic hepatitis due to the e-cigarette

A 46-year-old woman presented at the emergency department because of acute hepatitis with jaundice. After hepatological work-up including liver biopsy, drug induced liver disease (DILI) was suspected. Patient recovered completely within a few months. One year later she presented again with jaundice due to acute hepatitis. Vaping was the only agent that could be identified as causative agent for DILI. After VAPING cessation, the hepatitis resolved completely. Calculated RUCAM score was 10, making the diagnosis of toxic hepatitis very likely. During follow-up liver tests remained normal. This is the first report of severe DILI secondary to the use of e-cigarettes. In future vaping can be included in the differential diagnosis of DILI.

Clinical Outcomes and Immunotoxicity in People with HIV (PWH) after Definitive Chemoradiation (CRT) for Anal Squamous Cell Carcinoma

PURPOSE/OBJECTIVE(S)

Anal cancer disproportionately affects PWH despite antiretroviral therapy. Data on CRT outcomes are limited. Modern IMRT CRT decreases acute toxicity but may exacerbate immune dysregulation from chronic HIV. Although historical CRT has been associated with prolonged CD4 count suppression, little is known about late immunotoxicity in PWH after contemporary CRT. We report clinical outcomes and long term immunotoxicity.

MATERIALS/METHODS

Single-center retrospective review of all PWH confirmed on chart review with anal squamous cell carcinoma without prior pelvic irradiation treated with definitive IMRT CRT. Patient and CRT factors including HIV suppression (<200 copies/mL), mean CD4 count (cells/µL), and receipt of capecitabine (C) or 5-fluorouracil (F) +/- mitomycin (M) were summarized with n (%) or median (interquartile range). Progression-free and overall survival (PFS; OS) were estimated per Kaplan-Meier with 95% confidence intervals and compared with log-rank tests. Mean CD4 count and CD4:CD8 were compared by HIV suppression status (Welch's t-test); longitudinal changes in median CD4 count and CD4:CD8 were compared between baseline vs. nadir (within 6 months of CRT start) and 1-year follow-up for patients with complete data (Wilcoxon signed-rank test).

RESULTS

A total of 23 PWH were treated between 2010-2022, median age 52, median 16 (13 - 19) years after HIV diagnosis; 4 had unsuppressed HIV; AJCC 8th stage I/II/III/IV 5/5/12/1. Radiation dose was median 54 Gy in 30 fractions over 42 (40 - 44) days. Most had C+M (57%); only 43% had 2×M with either C or F. One had neoadjuvant carboplatin/paclitaxel/pembrolizumab. With 2.9 (1.03 - 3.3) years follow-up, median OS was 6.6 (6.2 - unreached [UR]) years. With 2.2 (0.67 - 2.7) years follow-up, median PFS was UR. OS and PFS were similar regardless of HIV suppression status (both P ≥ 0.09). Overall baseline CD4 count was 458 (226 - 484), and CD4:CD8 was 0.54 (0.2 - 0.7). Nadir CD4 was 100 (59 - 126) and CD4:CD8 was 0.3 (0.2 - 0.4). Baseline and nadir CD4 count and CD4:CD8 were lower if HIV-unsuppressed (each P ≤ 0.04). One year after CRT, CD4 count was 252 (102 - 276), while CD4:CD8 was 0.5 (0.2 - 0.7). For 7 patients with repeated values the change in median from baseline to nadir, 6-, and 12-months post-CRT was -282, -549 (both P = 0.02), -480 (P = 0.9) for CD4 counts, and -0.7, -0.5, -0.4 (each P > 0.5) for CD4:CD8 ratios; none had unsuppressed HIV.

CONCLUSION

Definitive IMRT CRT with guideline-concordant doublet chemotherapy for anal cancer in PWH is effective despite unsuppressed HIV. Treatment leads to prolonged immunological changes that may increase the risk of HIV-related morbidity and mortality. Modifiable treatment-related causes of hematoimmunologic toxicity should be investigated further, and immune surveillance after CRT should be considered to better understand impact on quality of life.

Characteristics of mpox positive, versus mpox negative, and mpox unsuspected clients from the Centre of Sexual Health, Public Health Service of Amsterdam, 20 May to 15 September 2022

BACKGROUND

In May 2022, an outbreak of mpox (monkeypox) in men-who-have-sex-with-men (MSM) emerged and quickly affected over 100 countries. In the early stages of the outbreak, overlap in symptoms with sexually transmitted infections (STI) made triage for mpox testing challenging. More information was needed on whom to screen and the main route of transmission.

OBJECTIVES

We aimed to identify characteristics of mpox cases to further strengthen case definitions. We also compared Cycle threshold (Ct) values of the DNA positive mpox samples as a proxy for viral load by body location.

METHODS

From 20 May 2022 to 15 September 2022, we tested all MSM who presented with malaise, and/or ulcerative lesions, and/or proctitis and/or a papular-vesicular-pustular eruption attending the Centre of Sexual Health in Amsterdam, the Netherlands, for mpox, with a PCR test. In the same period, 6932 MSM mpox unsuspected clients were not tested. We compared those tested positive for mpox with those tested negative and those unsuspected for mpox.

RESULTS

Of the 374 MSM tested, 135 (36%) were positive for mpox. The mpox-positive MSM were older (median age, respectively, 36, 34 and 34 years, p = 0.019) and more often lived with HIV (30% vs. 16% and 7%, p < 0.001). Furthermore, mpox-positive patients more often reported receptive anal sex without a condom, sexualized drug use, more sex partners, and were more often diagnosed with bacterial STI (p < 0.001). Systemic symptoms and anogenital lesions were associated with mpox infection. For mpox-positive patients, anal samples (p = 0.009) and lesional samples (p = 0.006) showed significantly lower median mpox Ct values compared to throat samples.

CONCLUSIONS

Mpox-positive patients more often reported receptive anal sex without a condom, had more sex partners and more often lived with HIV. Our results suggest that in the current mpox outbreak among MSM, sexual transmission is the main route.

Hyperferritinemia and non-HFE hemochromatosis: differential diagnosis and workup

Hyperferritinemia is a common reason for referral to a hepatogastroenterologist. The most frequent causes are not associated with iron overload (e.g. inflammatory diseases, alcohol abuse, metabolic syndrome, etc.). However, hyperferritinemia can also be caused by a genetic variant in one of the iron regulatory genes, called hereditary hemochromatosis, often but not always associated with iron overload. A variation in the human Hemostatic Iron Regulator protein (HFE) gene is the most common genotype, but many other variants have been described. In this paper we discuss two cases of rare hyperferritinemia associated disorders, ferroportin disease and hyperferritinemia-cataract syndrome. We also propose an algorithm for evaluating hyperferritinemia, facilitating a correct diagnosis and preventing potentially unnecessary examinations and therapeutic actions.

Current clinical practice in antibiotic treatment of Staphylococcus aureus bacteraemia: results from a survey in five European countries

OBJECTIVES

To determine clinical practice variation and identify knowledge gaps in antibiotic treatment of Staphylococcus aureus bacteraemia (SAB).

METHODS

A web-based survey with questions addressing antibiotic treatment of SAB was distributed through the ESGAP network among infectious disease specialists, clinical microbiologists and internists in Croatia, France, Greece, the Netherlands and the UK between July 2021 and November 2021.

RESULTS

A total number of 1687 respondents opened the survey link, of whom 677 (40%) answered at least one question. For MSSA and MRSA bacteraemia, 98% and 94% preferred initial monotherapy, respectively. In patients with SAB and non-removable infected prosthetic material, between 80% and 90% would use rifampicin as part of the treatment. For bone and joint infections, 65%-77% of respondents would consider oral step-down therapy, but for endovascular infections only 12%-32% would. Respondents recommended widely varying treatment durations for SAB with different foci of infection. Overall, 48% stated they used 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) to guide antibiotic treatment duration. Persistent bacteraemia was the only risk factor for complicated SAB that would prompt a majority to extend treatment from 2 to 4-6 weeks.

CONCLUSIONS

This survey in five European countries shows considerable clinical practice variation between and within countries in the antibiotic management of SAB, in particular regarding oral step-down therapy, choice of oral antibiotic agents, treatment duration and use of 18F-FDG-PET/CT. Physicians use varying criteria for treatment decisions, as evidence from clinical trials is often lacking. These areas of practice variation could be used to prioritize future studies for further improvement of SAB care.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

[Confusion and abdominal pain after COVID-19 vaccination]

BACKGROUND

Vaccine-induced immune thrombotic trombocytopenia (VITT) is a rare phenomenon, that may present with diffuse and atypical symptoms.

CASE DESCRIPTION

We present a case of 63 years old female patient with abdominal pain, confusion and tromboctytopenia. CT scan shows sinustrombosis and trombosis of the vena renalis. The diagnosis VITT was confirmed by a positive HIT test. After initiating treatment with immunoglobulines and a non-heparinoid anticoagulans, symptoms improved and platelet count increased.

CONCLUSION

This case illustrates that awareness in case of atypical symptoms and a history of vaccination is important to recognize this phenomenon.

Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data

Background

We previously developed proxy indicators (PIs) that can be used to estimate the appropriateness of medications used for infectious diseases (in particular antibiotics) in primary care, based on routine reimbursement data that do not include clinical indications.

Objectives

To: (i) select the PIs that are relevant for children and estimate current appropriateness of medications used for infectious diseases by French paediatricians and its variability while using these PIs; (ii) assess the clinimetric properties of these PIs using a large regional reimbursement database; and (iii) compare performance scores for each PI between paediatricians and GPs in the paediatric population.

Methods

For all individuals living in north-eastern France, a cross-sectional observational study was performed analysing National Health Insurance data (available at prescriber and patient levels) regarding antibiotics prescribed by their paediatricians in 2017. We measured performance scores of the PIs, and we tested their clinimetric properties, i.e. measurability, applicability and room for improvement.

Results

We included 116 paediatricians who prescribed a total of 44 146 antibiotic treatments in 2017. For all four selected PIs (seasonal variation of total antibiotic use, amoxicillin/second-line antibiotics ratio, co-prescription of anti-inflammatory drugs and antibiotics), we found large variations between paediatricians. Regarding clinimetric properties, all PIs were measurable and applicable, and showed high improvement potential. Performance scores did not differ between these 116 paediatricians and 3087 GPs.

Conclusions

This set of four proxy indicators might be used to estimate appropriateness of prescribing in children in an automated way within antibiotic stewardship programmes.

EBV : not your Everyday Benign Virus

BACKGROUND

Epstein-Barr virus infection is common, with seroprevalence of 90% in adults. Clinical presentation of primary EBV infection can be variable and atypical. It is often subclinical or can result in infectious mononucleosis. Clinical course is mostly benign, but in rare cases serious short- and long-term complications may occur.

CASE PRESENTATION

We present a case of a 19-year-old woman who was admitted to the hospital with general malaise, fever, dyspnea, icterus, vomiting and diarrhea, with acute left upper quadrant pain. She was diagnosed with acute EBV-infection with hepatitis, splenomegaly and spontaneous splenic rupture.

CONCLUSIONS

Spontaneous splenic rupture is an uncommon, but potentially fatal complication of infectious mononucleosis. In a patient with suspicion of EBV infection and abdominal pain, we should always be aware of the possibility of spontaneous splenic rupture and emphasis should be put on appropriate counseling.

Atypical and fulminant presentations of pneumococcal infections: A case series in a tertiary intensive care unit

With the introduction of conjugate pneumococcal vaccines, changes in causative serotypes and clinical presentations of Streptococcus pneumoniae infections are occurring. During the 2017-2018 winter, an unusual number of patients with a severe manifestation of pneumococcal disease was admitted to a tertiary care intensive care unit (ICU) in the Netherlands. We describe some of the cases in depth. Given our observed change in infecting serotypes and extreme clinical manifestations of pneumococcal disease, a systematic clinical registry of pneumococcal infections in the ICU may be a valuable addition to pneumococcal disease surveillance.

Human resources required for antimicrobial stewardship teams: a Dutch consensus report

SCOPE

Antimicrobial stewardship teams are responsible for implementing antimicrobial stewardship programmes (ASP). However, in many countries, lack of funding challenges this obligation. A consensus procedure was performed to investigate which structural activities need to be performed by Dutch stewardship teams and how much time (and thus full-time equivalent (FTE) labor) is needed to perform these activities.

METHODS

In 2015, an electronic survey, based on a nonsystematic literature search and interviews with seven experienced stewardship teams, was sent to 21 stewardship teams that performed an ASP. This was followed by a semistructured face-to-face consensus meeting. Fourteen stewardship teams completed the survey (18% of Dutch acute-care hospitals), and 13 participated in the consensus meeting.

RECOMMENDATIONS

The hours needed each year are dependent on hospital size and number of stewardship objectives monitored. If all activities are performed at a minimal base (one stewardship objective; minimal staffing standard), time investment was estimated to be 1393 to 2680 hours annually in the early phase, corresponding with 0.87 (300 beds) to 1.68 FTE (1200 beds), with a further increase to minimally 1.25 to 3.18 FTE in the following years with three stewardship objectives monitored (optimal staffing standards during the first few years of implementing an ASP). This consensus on required human resources provides a directive for structural financial support of stewardship teams in the Dutch context. Some stewardship activities (and related time investments) might be specific to the Dutch context and hospital setting. To develop standards for other settings, our methodology could be applied.

What is antimicrobial stewardship?

BACKGROUND

The use of the term 'antimicrobial stewardship' has grown exponentially in recent years, typically referring to programmes and interventions that aim to optimize antimicrobial use. Although antimicrobial stewardship originated within human healthcare, it is increasingly applied in broader contexts including animal health and One Health. As the use of the term 'antimicrobial stewardship' becomes more common, it is important to consider what antimicrobial stewardship is, as well as what it is not.

AIMS

To review the emergence and evolution of the term 'antimicrobial stewardship'.

SOURCES

We searched and reviewed existing literature and official documents, which mostly focused on antibiotics. We contacted the authors of the first publications that mentioned antimicrobial stewardship.

CONTENT

We describe the historical background behind how antimicrobial stewardship came into use in clinical settings. We discuss challenges emerging from the varied descriptions of antimicrobial stewardship in the literature, including an over-emphasis on individual prescriptions, an under-emphasis on the societal implications of antimicrobial use, and language translation problems.

IMPLICATIONS

To help address these challenges, we suggest viewing antimicrobial stewardship as a strategy, a coherent set of actions which promote using antimicrobials responsibly. We stress the continuous need for 'responsible use' to be defined and translated into context-specific and time-specific actions. Furthermore, we present examples of actions that can be undertaken within antimicrobial stewardship across human and animal health.

232 ADDITION OF VERY LOW AMOUNTS OF SERUM (ESTRUS COW SERUM) IMPROVES IN VITRO EMBRYO PRODUCTION IN DAIRY CATTLE

Improving the efficiency of the in vitro production (IVP) process is very important because it results in more embryos to be used in breeding programs or as commercial service. At CRV, a culture medium consisting of SOF with amino acids and BSA is used. In the past, richer culture media were used with 10% fetal calf serum combined with BRL cell co-culture. Although the efficiency of the IVP process of these media was good, these rather high serum concentrations were quite often related to large offspring syndrome (LOS). The switch to a culture system without serum resulted in a significant reduction in LOS but also in a reduction of embryo yield. The aim of the present study was to investigate the effect of adding low amounts of serum to the culture medium on efficiency of embryo production. Immature cumulus-oocyte complexes (COC) were recovered from ovaries 6 to 8 h upon slaughter. The COC were matured in vitro in TCM199/FCS/LH/FSH supplemented with cysteamine (0.1 mM). Subsequently, matured oocytes were fertilised with frozen-thawed gradient-separated semen and further cultured for 7 days in SOFaaBSA. The SOF medium contained either 0 (control), 0.1, 0.5, or 1.0% oestrus cow serum (ECS). Embryos development was scored at Day 7. Three replicates were performed and results were analysed by chi-square analyses. The results clearly show that adding ECS significantly improved embryo production (Table 1). Interestingly, already very low amounts (0.1%) of serum gave a significant increase in embryo percentage. In conclusion, addition of very low amounts of ECS (0.1%) is beneficial for embryo production, resulting in significantly higher embryo production (from 19 to 27%). In a subsequent field trial with OPU-derived embryos, the effect of addition of 0.1% ECS on birth weight (LOS) of the calves has to be investigated. Table 1.Percentage of blastocysts at Day 7 after culture in SOF medium with different amounts of serum

240 OVUM-PICK UP IN HOLSTEIN-FRIESIAN COWS AT 9 TO 10 MONTHS OF AGE

Rate of genetic gain can be improved by increasing selection intensity, increasing selection accuracy, creating a higher amount of variation, or shortening the generation interval. A reduction in the generation interval can be realised by collecting embryos from animals at a young age. At CRV it is currently routine practice to start embryo collection (by flushing) at 12 to 15 months of age. The aim of this study was to investigate if the collection of embryos at a younger age by means of ovum pickup (OPU) is beneficial for our breeding program. Healthy 9- to 10-month-old Holstein-Friesian animals were selected at young age based on their maturity, (i.e. OPU could be performed by normal standard procedure/equipment). Animals were not stimulated with hormones. Oocytes were collected by OPU once every week during a period of ~8 weeks. Collected oocytes were matured, fertilized, and cultured for 7 days in SOF culture medium according to standard procedures (Merton et al. 2002). Embryo development was scored at Day 7. Results were analysed by Student's t-test. On average 11.7 oocytes were collected from animals as young as 9 months of age. However, embryo development of the oocytes from young animals was only 0.4 embryo per session at Day 7 (3% embryo development). When only the results of the first OPU session were taken into account, 18.2 oocytes and 0.8 embryo could be collected per animal per session. Whether an animal was observed in oestrus before the first OPU session affected results. Animals that had shown clear signs of oestrus before the first OPU session produced significantly more embryos than animals that did not (Table 1). It is concluded that OPU is possible on animals at 9 to 10 months of age but only when animals have been in oestrus before the first OPU session. Best results were obtained for the first OPU session. Table 1.Effect of first oestrus before OPU on embryo production

The impact of HIV/HCV co-infection on health care utilization and disability: results of the ACTG Longitudinal Linked Randomized Trials (ALLRT) Cohort

HIV/hepatitis C virus (HCV) co-infection places a growing burden on the HIV/AIDS care delivery system. Evidence-based estimates of health services utilization among HIV/HCV co-infected patients can inform efficient planning. We analyzed data from the ACTG Longitudinal Linked Randomized Trials (ALLRT) cohort to estimate resource utilization and disability among HIV/HCV co-infected patients and compare them to rates seen in HIV mono-infected patients. The analysis included HIV-infected subjects enrolled in the ALLRT cohort between 2000 and 2007 who had at least one CD4 count measured and completed at least one resource utilization data collection form (N = 3143). Primary outcomes included the relative risk of hospital nights, emergency department (ED) visits, and disability days for HIV/HCV co-infected vs HIV mono-infected subjects. When controlling for age, sex, race, history of AIDS-defining events, current CD4 count and current HIV RNA, the relative risk of hospitalization, ED visits, and disability days for subjects with HIV/HCV co-infection compared to those with HIV mono-infection were 1.8 (95% CI: 1.3-2.5), 1.7 (95% CI: 1.4-2.1), and 1.6 (95% CI: 1.3-1.9) respectively. Programs serving HIV/HCV co-infected patients can expect approximately 70% higher rates of utilization than expected from a similar cohort of HIV mono-infected patients.

Treatment of cirrhotic ascites

Cirrhosis is the most common cause of ascites and accounts for almost 85% of all cases. It is the most common complication of cirrhosis, after development of ascites only 50% of patients will survive for 2 to 5 years. Successful treatment is dependent on accurate diagnosis of the cause of ascites. Because sodium and water retention is the basic abnormality leading to ascites formation, restriction of sodium intake and enhancing sodium excretion is the mainstay of the treatment of ascites. Patients with cirrhosis and ascites must limit sodium intake to 2 gram per day. Enhancement of sodium excretion can be accomplished by usage of oral diuretics. The recommended initial dose is spironolactone 100-200 mg/d and furosemide 20-40 mg/d. usual maximum doses are 400 mg/d of spironolactone and 160 mg/d of furosemide. The recommended weight loss in patients without peripheral edema is 300 to 500 g/d. There is no limit to the daily weight loss of patients who have edema. About 90% of patients respond well to medical therapy for ascites. Refractory ascites is defined as fluid overload that is unresponsive to sodium restricted diet and high dose diuretic treatment (diuretic resistant) or when there is an inability to reach maximal dose of diuretics because of adverse effects (diuretic-intractable). It has a poor prognosis. Treatment options for patients with refractory ascites are serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS) or peritoneovenous shunt and liver transplantation. TIPS should be considered in patients who repeatedly fail large-volume paracentesis and have relatively preserved liver functions. Liver transplantation is the only modality that is associated with improved survival.

Clinical indicators: development and applications

Clinical indicators give an indication of the quality of the patient care delivered. They must comply with highquality standards and should be constructed in a careful and transparent manner. Indicators must be relevant to the important aspects of quality of care. There should be adequate research evidence that the recommendations from which they are derived are related to clinical effectiveness, safety and efficiency. They should measure the quality in a valid and reliable manner with little inter- and intra-observer variability so that they are suitable for comparisons between professionals, practices, and institutions. Indicators are selected from research data with consideration for optimal patient care (preferably an evidence-based guideline), supplemented by expert opinion. In the selection procedure, the feasibility, such as their measurability and improvability, is important beside validity and reliability. A clinical indicator should be defined exactly and expressed as a quotient. After a try-out, the measurements and reporting should follow. The report contains an in-depth analysis of causal and contributing factors associated with the measured results. A description of the clinical circumstances and a correction for case mix should be included to allow for a justified interpretation. The indicators must be part of an improvement strategy, for which comparison feedback is often used. We give examples of indicator development and applications in oncology, diabetes care, and the use of antibiotics for treating pneumonia. We explain how comparison with reference data can be used to construct improvement programmes.

A new molecular mechanism for severe myoclonic epilepsy of infancy: Exonic deletions in SCN1A

We examined cases of severe myoclonic epilepsy of infancy (SMEI) for exon deletions or duplications within the sodium channel SCN1A gene by multiplex ligation-dependent probe amplification. Two of 13 patients (15%) who fulfilled the strict clinical definition of SMEI but without SCN1A coding or splicing mutations had exonic deletions of SCN1A.

Increase in diagnosed asthma but not in symptoms in the European Community Respiratory Health Survey

BACKGROUND

Information on the epidemiology of asthma in relation to age is limited and hampered by reporting error. To determine the change in the prevalence of asthma with age in young adults we analysed longitudinal data from the European Community Respiratory Health Survey.

METHODS

A self-administered questionnaire was completed by 11 168 randomly selected subjects in 14 countries in 1991-3 when they were aged 20-44 years and 5-11 years later from 1998 to 2003. Generalised estimating equations were used to estimate net change in wheeze, nocturnal tightness in chest, shortness of breath, coughing, asthma attacks in the last 12 months, current medication, "diagnosed" asthma, and nasal allergies.

RESULTS

Expressed as change in status per 10 years of follow up, subjects reporting asthma attacks in the previous 12 months increased by 0.8% of the population (95% CI 0.2 to 1.4) and asthma medication by 2.1% (95% CI 1.6 to 2.6), while no statistically significant net change was found in reported symptoms. Reported nasal allergies increased, especially in the youngest age group.

CONCLUSIONS

As this cohort of young adults has aged, there has been an increase in the proportion treated for asthma but not in the proportion of those reporting symptoms suggestive of asthma. Either increased use of effective treatments has led to decreased morbidity among asthmatic subjects or those with mild disease have become more likely to label themselves as asthmatic.

TE-AFLP: combining rapidity and robustness in DNA fingerprinting

A new type of fingerprinting technique is presented, based on amplified fragment length polymorphism (AFLP). Rather than two endonucleases as in AFLP, we propose the use of three enzymes, hence the method is called three endonuclease (TE)-AFLP. Genomic DNA is digested and two sets of adapters are selectively ligated onto the restriction fragments in a single reaction volume. No adapters complementary to the ends generated by a frequent cutter are added. Due to the addition of a third endonuclease, the TE-AFLP method provides a high discriminatory power and a reduction in the number of bands. The latter makes it especially suitable for the analysis of complex genomes. TE-AFLP fingerprints are suitable for detection by automatic fluorescent sequencers and are obtained in less than half the time and at reduced costs compared to a typical AFLP. The reliability of this method was investigated by determining the influence of varying digestion, ligation and PCR components on the fingerprint. Moreover, cross-experiments to study inheritance of loci were performed with a primitive insect and with tomato strains. The features of TE-AFLP are discussed in comparison with conventional AFLP.

Preliminary guidelines for the evaluation and management of dyslipidemia in adults infected with human immunodeficiency virus and receiving antiretroviral therapy: Recommendations of the Adult AIDS Clinical Trial Group Cardiovascular Disease Focus Group

Dyslipidemia is a prevalent condition that affects patients infected with human immunodeficiency virus (HIV) who are receiving antiretroviral therapy. These preliminary recommendations summarize the current understanding in this area and propose guidelines for management. Existing guidelines for the management of dyslipidemia in the general population formed the general basis for our recommendations. Data on the prevalence and treatment of dyslipidemia of HIV-infected patients, implications of treatment-related dyslipidemia in other chronically ill populations, and pharmacokinetic profiles for the available hypolipidemic agents in non-HIV populations were considered. Although the implications of dyslipidemia in this population are not fully known, the frequency, type, and magnitude of lipid alterations in HIV-infected people are expected to result in increased cardiovascular morbidity. We propose that these patients undergo evaluation and treatment on the basis of existing guidelines for dyslipidemia, with the caveat that avoidance of interactions with antiretroviral agents is paramount.

The Dutch 'Folic Acid Campaign'--have the goals been achieved?

Periconceptional folic acid use considerably reduces the risk of neural tube defects. The aim of this study was to measure the effect of the national and the local 'Folic Acid Campaign' on periconceptional folic acid use. Before (1995 survey) and 1 year after the campaign (1996 survey), the awareness and use of folic acid was measured among pregnant women in four regions of the Netherlands. To this end, pregnant women who visited the midwife, general practitioner or obstetrician for the first or second prenatal visit were asked to complete a questionnaire. The results showed that use of folic acid for any period around conception increased from 25.1% in 1995 to 53.5% in 1996. Appropriate use (4 weeks before until 8 weeks after conception) increased from 4.8% in 1995 to 21.0% in 1996. No additional effect of the local Folic Acid Campaign was found (adjusted odds ratio= 1.0; 95% confidence interval = 0.7, 1.4). It was possible to conclude that folic acid use at the recommended time increased considerably as a result of the national and the local Folic Acid Campaign, but the target (use in 46% of women wishing to conceive) was not achieved. New health education programmes are needed to increase further its use at the appropriate times.

Overexpression of Arabidopsis thaliana SKP1 homologues in yeast inactivates the Mig1 repressor by destabilising the F-box protein Grr1

The timed destruction of cell cycle regulatory proteins is of key importance in controlling cell cycle progression in eukaryotes. Recently, Skp1 from yeast (Saccharomyces cerevisiae) was shown to play an important role in the ubiquitin-mediated proteolysis of these proteins via the Skp1-Cdc53-F-box (SCF) pathway. Here we describe the fortuitous cloning of cDNAs for two Skp1 homologues from the plant Arabidopsis thaliana on account of their ability to activate reporter gene expression in yeast directed by the cyt-1 element from the promoter of the Agrobacterium tumefaciens T-cyt gene, which is essential for expression of the gene in plants. This element is strikingly similar in sequence to the binding site for the yeast Migl protein, a transcriptional repressor of genes involved in the utilisation of carbohydrates other than glucose. We report that Mig1 protein binds to the cyt-1 element with similar specificity as a previously described plant nuclear protein factor, and that the cyt-1 element is a target for an unknown yeast transcriptional activator when Mig1 itself is inactivated. Interestingly, our data further indicate that A. thaliana Skp1 inactivates Mig1 by destabilising the yeast F-box protein Grr1, which is required for cyclin degradation and is thus involved in control of the cell cycle, and for glucose-regulated gene repression. Our results suggest that the plant counterpart of yeast Skp1 is probably also instrumental in ubiquitin-mediated proteolysis of specific proteins via an SCF-like pathway.

Suitability of the Charm HVS and a microbiological multiplate system for detection of residues in raw milk at EU maximum residue levels

In this paper we assessed the suitability of the Charm HVS and a newly developed microbiological multiplate system as post-screening tests to confirm the presence of residues in raw milk at or near the maximum permissible residue level (MRL). The multiplate system is composed of Bacillus stearothermophilus var. calidolactis plate at pH 8.0 for detection of beta-lactam antibiotics and tylosin, Bacillus cereus plate at pH 6.0 for detection of tetracyclines, Micrococcus luteus plate at pH 8.0 for detection of macrolides, Bacillus subtilis BGA plate at pH 8.0 for detection of aminoglycosides, trimethoprim-containing plate seeded with B. subtilis BGA at pH 7.0 for detection of sulphonamides, Escherichia coli plate at pH 6.0 for detection of quinolone and polymyxin, and Staphylococcus epidermidis plate at pH 6.0 for detection of novobiocin. For each test plate an action level is proposed in such a way that residues can be detected in raw bulk tank milk at levels near or below the established EU MRLs of beta-lactam antibiotics, tetracyclines, aminoglycosides, macrolides, sulphonamides, colistin, and quinolones. The Charm HVS test used to confirm the presence of tetracycline and macrolide residues gave false-positive results near the EU MRLs. The multiplate system gave valid results. Based on data for raw bulk tank milk samples and the proposed action level for each test plate for suspected samples, we demonstrated that the multiplate system is a reliable post-screening method that can be performed easily and cheaply in microbiological laboratories.

Peak expiratory flow variability, bronchial responsiveness, and susceptibility to ambient air pollution in adults

Bronchial hyperresponsiveness (BHR) and peak expiratory flow (PEF) variability are associated expressions of airway lability, yet probably reflect different underlying pathophysiologic mechanisms. We investigated whether both measures can be used interchangeably to identify subjects who are susceptible to ambient air pollution. Data on BHR (>= 20% fall in FEV1), PEF variability (ampl%mean PEF > 5% on any day during an 8-d period with low air pollution levels) and diary data on upper and lower respiratory symptoms, cough, and phlegm were collected in 189 subjects (48-73 yr). The acute effects (lag0) of particulate matter with a diameter less than 10 micrometers (PM10), black smoke, SO2 and NO2 on the prevalence of symptoms were estimated with logistic regression. In subjects with airway lability, both when expressed as PEF variability (69%) and BHR (28%), the prevalence of symptoms increased significantly with increasing levels of air pollution, especially in those with the greater PEF variability (n = 55, 29%). We found no such consistent positive associations in adults without airway lability. PEF variability, and to a smaller extent BHR, can be used to identify adults who are susceptible to air pollution. Though odds ratios were rather low (ranging from 1.13 to 1.41), the impact on public health can be substantial because it applies to large populations.

Testing of raw milk for tetracycline residues

A newly improved Bacillus calidolactis tube diffusion test and two postscreening test systems--a receptor assay (Charm HVS; Charm Sciences, Inc., Malden, MA) and a newly developed Bacillus cereus ATCC 11778 mycoides test system--were evaluated for the detection and identification of tetracycline residues using 973 samples of bulk milk taken at random in The Netherlands. All milk samples were assayed with the B. calidolactis tube and the receptor test. The milk samples testing as suspect or positive with one or both of the test systems were analyzed with HPLC (limit of detection, 10 ng/ml) and the recently developed B. cereus test system. The B. calidolactis tube diffusion test detected tetracycline residues > 45 ng/ml in milk. With the B. cereus test plate, residues of oxytetracycline and tetracycline of > 30 ng/ml milk were detected; for chlortetracycline and doxycycline, the detection limit was 10 ng/ml. Raw milk exhibiting inhibition diameters of < 20 mm on the B. cereus test plate fulfilled the European Union criterion for maximum residue level for tetracyclines of < 100 ng/ml (including their 4-epimer derivatives). The detection limits of the receptor assay depended on the type of milk used. The scintillation counts that were obtained for control samples of bulk milk were considerably lower than for the milks obtained from Charm Sciences, Inc. or processed using UHT pasteurization. One of 973 milk samples was suspect for tetracycline residues by means of the B. calidolactis tube test as well as by the receptor assay; 8 other samples were also considered to be positive using the receptor assay alone. The presence of tetracycline residues could not be proved for these 9 samples (residue concentration, < 10 ng/ml) with HPLC. We concluded that the receptor assay was not reliable to detect tetracycline residues in raw milk at < 150 ng/ml. The B. cereus test plate was determined to be an inexpensive, reliable alternative for the receptor assay for detection of tetracycline residues.

Time-series analysis of air pollution and cause-specific mortality

Ten large European cities provided data on daily air pollution as well as mortality from respiratory and cardiovascular mortality. We used Poisson autoregressive models that controlled for trend, season, influenza epidemics, and meteorologic influences to assess the short-term effects of air pollution at each city. We then compared and pooled the city-specific results in a meta-analysis. The pooled relative risks of daily deaths from cardiovascular conditions were 1.02 [95% confidence interval (CI) = 1.01-1.04] for a 50 microg/m3 increment in the concentration of black smoke and 1.04 (95% CI = 1.01-1.06) for an increase in sulfur dioxide levels in western European cities. For respiratory diseases, these figures were 1.04 (95% CI = 1.02-1.07) and 1.05 (95% CI = 1.03-1.07), respectively. These associations were not found in the five central European cities. Eight-hour averages of ozone were also moderately associated with daily mortality in western European cities (relative risk = 1.02; 95% CI = 1.00-1.03 for cardiovascular conditions and relative risk = 1.06; 95% CI = 1.02-1.10 for respiratory conditions). Nitrogen dioxide did not show consistent relations with daily mortality. These results are similar to previously published data and add credence to the causal interpretation of these associations at levels of air pollution close to or lower than current European standards.

Are there three types of horizontal cell in the human retina?

Golgi-impregnated horizontal cells (HCs) as viewed in whole mount human retinas have been studied by light microscopic (LM) techniques. Impregnated HCs have been drawn by camera lucida and by the Eutectics neuron tracing method to provide quantitative data on dendritic tree sizes, dendritic tree shapes, and dendritic terminals for statistical treatment and cluster analysis. In addition, fractal analyses of HC dendritic branching patterns have been performed. Three significantly different HCs can be classified on both subjective and objective morphological criteria in central and peripheral human retina. In the fovea all HCs are so small that it is difficult to achieve a clear separation of the subtypes, although they can be distinguished by the experienced observer. HI types are the classic HCs of Polyak (The Retina, Chicago: University of Chicago Press, 1941) with distinct dendritic terminal clusters going to cones and a fan-shaped axon terminal consisting of large numbers of rod-destined terminals. HII cells have profusely branched, overlapping dendrites, with poorly defined terminals going to cones and a short curled axon bearing small terminals also going to cones. The HIII types exhibit larger diameter, more asymmetrically shaped dendritic trees and 30% more dendritic terminal clusters than HI cells at any location on the retina. Many HIII cells appear to emit a process from the cell body in the inner nuclear layer (INL) that descends into the outer strata of the inner plexiform layer (IPL). The axon of the HIII cell may end in a loosely organized, sprawling arborization. Fractal dimensions of the horizontal cells also show significant differences between the three groups. HII cells exhibit the highest fractal dimension followed by HI and HIII cells with lower and lowest fractal dimensions, respectively. The fractal dimension of HII cells of rhesus monkey, as determined from drawings by other authors in other publications, are the same as HII cells of human retina.

The association of frequent headaches with personality and life events

The associations between personality traits, life events and frequent headaches were studied in a sample of 5766 adult subjects between 20 and 65 years of age from the general population. Subjects with at least weekly headaches had more life events and higher inadequacy, social inadequacy, rigidity and injuredness than subjects with less frequent headaches. These relationships were not observed in subjects of 50 years of age and older, with the exception of the association with inadequacy. From the traits measured, inadequacy had the highest odds ratios for frequent headaches and showed a modest interaction with the presence of a life event. These findings are in agreement with Sarason's interactional model.

Influence of apo E polymorphism on the response to simvastatin treatment in patients with heterozygous familial hypercholesterolemia

In a group of 120 patients with heterozygous familial hypercholesterolemia (FH) the influence of the apolipoprotein E (apoE) polymorphism on pre-treatment plasma lipid levels and on the response to treatment with simvastatin was studied. The apoE phenotype distribution did not differ significantly between the FH group and a sample group of the Dutch population. Differences in pre-treatment lipid levels were not related to the apoE polymorphism in this FH population. After 12 weeks use of a daily dose of 40 mg simvastatin, the plasma total cholesterol, low density lipoprotein (LDL)-cholesterol and plasma triglyceride levels were reduced on average by 33%, 38% and 19%, respectively. At the same time high density lipoprotein (HDL)-cholesterol concentration increased on average by 7%. In the combined FH patient group (males and females) a considerable interindividual variation in response to simvastatin was observed, but was not related to the apoE polymorphism. However, considering males and females separately, we found that female FH patients with the apoE3E3 phenotype responded better on simvastatin treatment with respect to LDL-cholesterol than male FH patients with the apoE3E3 phenotype.

Cardiovascular effects of two xanthines and the relation to adenosine antagonism

We hypothesize that the hemodynamic effects of xanthine derivatives depend on their ability to antagonize the vasodilating effects of endogenous adenosine. In a randomized, double-blind, and placebo-controlled study of 10 normotensive volunteers caffeine, a xanthine with in vitro adenosine antagonistic properties, increased mean arterial pressure by 5.6 +/- 0.9 mm Hg and lowered heart rate by 5.3 +/- 1.1 beats/min. After administration of enprofylline, a xanthine without adenosine antagonism, forearm vascular resistance decreased by 5.6 +/- 3.4 IU, heart rate increased by 10.6 +/- 2.6 beats/min, and plasma adrenaline, plasma noradrenaline, and renin activity increased by 178 +/- 86%, 14 +/- 8%, and 36 +/- 13%, respectively. Adenosine infusion alone induced a dose-related increase in pulse pressure and heart rate, and it increased plasma adrenaline and noradrenaline by 186 +/- 77% and 132 +/- 55%, respectively. This response to adenosine was reduced by pretreatment with caffeine but not enprofyline. Thus opposite circulatory responses to caffeine and enprofylline occurred, with signs of vasoconstriction and vasodilation, respectively. In addition, caffeine, but not enprofylline, reduced the cardiovascular response to exogenous adenosine.