Retrospective determination of U and Pu isotopes and atom ratios in lung samples from Vienna, Austria

Uranium and plutonium isotope concentrations as well as ²³⁶U/²³⁸U and ²⁴⁰Pu/²³⁹Pu atom ratios were measured by AMS in human lung samples from the early 1960s. The ²³⁶U concentrations as well as the ²³⁶U/²³⁸U atom ratios show a maximum in 1964, ²³⁹Pu and ²⁴⁰Pu concentrations are increasing continually from 1962 to 1965. ²³⁶U/²³⁸U atom ratios are lower by two orders of magnitude compared to corresponding aerosol data from Vienna, probably due to older ²³⁸U deposited in the lungs, enhanced ²³⁸U concentrations in the city air, and activity partition within different particle sizes. The ²³⁶U/²³⁹Pu atom ratios in lung samples are also lower than expected from the aerosol data, while ²⁴⁰Pu/²³⁹Pu atom ratios lie well within the range typical for nuclear bomb fallout.

SARS-CoV-2 Antibody Prevalence and Population-Based Death Rates, Greater Omdurman, Sudan

In a cross-sectional survey in Omdurman, Sudan, during March–April 2021, we estimated that 54.6% of the population had detectable severe acute respiratory syndrome coronavirus 2 antibodies. Overall population death rates among those >50 years of age increased 74% over the first coronavirus disease pandemic year.

High prevalence of urinary schistosomiasis in a desert population: results from an exploratory study around the Ounianga lakes in Chad

BACKGROUND

Researching a water-borne disease in the middle of the Sahara desert might not seem the most relevant concern. However, nomadic Sahelian pastoralists health concerns regarding their livestock and anecdotal reports about trematode infections of Fasciola spp. and Schistosoma spp. in desert-raised animals justified an exploratory study focusing on the lakes of Ounianga in Northern Chad. The aim was to test whether trematode parasites such as Schistosoma spp. occur in human populations living around the Sahara desert lakes of Ounianga Kebir and Ounianga Serir in northern Chad.

METHODS

The study was carried out in January 2019 and comprised of three components. First, a cross sectional survey based on a random sample drawn from the population to detect infections with S. haematobium and S. mansoni; second, focus group discussions exploring disease priorities, access to health and health seeking behaviour; and third, surveying water contact sites for intermediate host snails. Samples of trematode parasites and snails were confirmed on species level by molecular genetic methods. For parasitological and malacological surveys descriptive statistics were performed. Qualitative data analysis included the full review of all transcripts, followed by a descriptive and explorative thematic analysis.

RESULTS

Among 258 participants, the overall S. haematobium prevalence using urine filtration was 39.2% [95% confidence interval (CI): 33.5-45.1%], with 51.5% of the infected suffering from heavy infection. The intermediate host snail of S. haematobium (Bulinus truncatus) occurred at water contact sites near both study villages, revealing the potential for local transmission. Although a positive S. mansoni point-of-care circulating cathodic antigen (POC-CCA) test result was obtained from 8.6% (95% CI 5.7-12.8%) of the samples, no intermediate host snails of S. mansoni were found, and the relevance of S. mansoni remains uncertain. Qualitative findings underline the importance of morbidity caused by urinary schistosomiasis, and the lack of access to diagnostics and treatment as a major health concern.

CONCLUSIONS

This research revealed a high prevalence of urinary schistosomiasis in the population living around the lakes of Ounianga in the Sahara, a United Nations Educational, Scientific and Cultural Organization (UNESCO) world heritage site in Chad. Despite the high public health importance of the associated morbidity expressed by the population, there is no access to diagnostics and treatment. Further work is needed to develop and test a context-adapted intervention.

One mean to rule them all? The arithmetic mean based egg reduction rate can be misleading when estimating anthelminthic drug efficacy in clinical trials

Animal and human helminth infections are highly prevalent around the world, with only few anthelminthic drugs available. The anthelminthic drug performance is expressed by the cure rate and the egg reduction rate. However, which kind of mean should be used to calculate the egg reduction rate remains a controversial issue. We visualized the distributions of egg counts of different helminth species in 7 randomized controlled trials and asked a panel of experts about their opinion on the egg burden and drug efficacy of two different treatments. Simultaneously, we calculated infection intensities and egg reduction rates using different types of means: arithmetic, geometric, trimmed, winsorized and Hölder means. Finally, we calculated the agreement between expert opinion and the different means. We generated 23 different trial arm pairs, which were judged by 49 experts. Among all investigated means, the arithmetic mean showed poorest performance with only 64% agreement with expert opinion (bootstrap confidence interval [CI]: 60−68). Highest agreement of 94% (CI: 86−96) was reached by the Hölder mean M_0.2, followed by the geometric mean (91%, CI: 85−94). Winsorized and trimmed means showed a rather poor performance (e.g. winsorization with 0.1 cut-off showed 85% agreement, CI: 78−87), but they performed reasonably well after excluding treatment arms with a small number of patients. In clinical trials with moderate sample size, the currently recommended arithmetic mean does not necessarily rank anthelminthic efficacies in the same order as might be obtained from expert evaluation of the same data. Estimates based on the arithmetic mean should always be reported together with an estimate, which is more robust to outliers, e.g. the geometric mean.

Besides cure rates, egg reduction rates represent an important indicator of anthelminthic drug efficacy in clinical trials. However, there is an ongoing controversy whether the arithmetic or the geometric mean should be used for its calculation. The arithmetic mean is problematic in skewed distributions mainly because the mean is sensitive to outliers, whereas the geometric mean does not correspond to our intuitive interpretation of average reduction. Several studies tried to compare the performance of different means but they relied on assumptions, which favored one approach over another. Despite the ongoing debate, the World Health Organization (WHO) recommends the arithmetic mean to calculate egg reduction rates. To overcome limitations from previous studies, we visualized data from several clinical trials and asked a panel of experts to compare drug efficacy of two different treatments. Afterwards, we estimated efficacy by using different means. Finally, we calculated the raw agreement between expert opinion and the different means. From all investigated methods to calculate efficacy, the arithmetic mean showed the poorest performance in terms of agreement with expert opinion. In anthelminthic human drug trials, which are characterized by small sample size and non-adherence, estimates more robust to outliers should be reported to assess drug efficacy performance.

Off-target effects of tribendimidine, tribendimidine plus ivermectin, tribendimidine plus oxantel-pamoate, and albendazole plus oxantel-pamoate on the human gut microbiota

Soil-transmitted helminths infect 1.5 billion people worldwide. Treatment with anthelminthics is the key intervention but interactions between anthelminthic agents and the gut microbiota have not yet been studied. In this study, the effects of four anthelminthic drugs and combinations (tribendimidine, tribendimidine plus ivermectin, tribendimidine plus oxantel-pamoate, and albendazole plus oxantel-pamoate) on the gut microbiota were assessed. From each hookworm infected adolescent, one stool sample was collected prior to treatment, 24 h post-treatment and 3 weeks post-treatment, and a total of 144 stool samples were analyzed. The gut bacterial composition was analyzed using 16S rRNA gene sequencing. Tribendimidine given alone or together with oxantel-pamoate, and the combination of albendazole and oxantel pamoate were not associated with any major changes in the taxonomic composition of the gut microbiota in this population, at both the short-term post-treatment (24 h) and long-term post-treatment (3 weeks) periods. A high abundance of the bacterial phylum Bacteroidetes was observed following administration of tribendimidine plus ivermectin 24 h after treatment, due predominantly to difference in abundance of the families Prevotellaceae and Candidatus homeothermaceae. This effect is transient and disappears three weeks after treatment. Higher abundance of Bacteroidetes predicts an increase in metabolic pathways involved in the synthesis of B vitamins. This study highlights a strong relationship between tribendimidine and ivermectin administration and the gut microbiota and additional studies assessing the functional aspects as well as potential health-associated outcomes of these interactions are required.

Diagnostic comparison between FECPAKG2 and the Kato-Katz method for analyzing soil-transmitted helminth eggs in stool

BACKGROUND

Over one billion people are infected with soil-transmitted helminths (STH), i.e. Ascaris lumbricoides, hookworm and Trichuris trichiura. For estimating drug efficacy and monitoring anthelminthic drug resistance, accurate diagnostic methods are critical. FECPAKG2 is a new remote-diagnostic tool used in veterinary medicine, which produces an image of the stool sample that can be stored on an internet cloud. We compared for the first time FECPAKG2 with the recommended Kato-Katz method.

METHODOLOGY/PRINCIPAL FINDINGS

Two stool samples were collected from adolescent participants (age 15-18 years) at baseline and 14 to 21 days after treatment in the framework of a randomized clinical trial on Pemba Island, Tanzania. Stool samples were analyzed with different diagnostic efforts: i) one or ii) two Kato-Katz thick smears from the first sample, iii) two Kato-Katz thick smears from two samples and iv) FECPAKG2 from the first sample. Parameters were calculated based on a hierarchical Bayesian egg count model. Complete data for all diagnostic efforts were available from 615 participants at baseline and 231 hookworm-positive participants at follow-up. At baseline FECPAKG2 revealed a sensitivity of 75.6% (72.0-77.7) for detecting A. lumbricoides, 71.5% (67.4-95.3) for hookworm and 65.8% (64.9-66.2) for T. trichiura, which was significantly lower (all p<0.05) than any of the Kato-Katz methods and highly dependent on infection intensity. Despite that the egg counts based on FECPAKG2 were relatively lower compared to Kato-Katz by a ratio of 0.38 (0.32-0.43) for A. lumbricoides, 0.36 (0.33-0.40) for hookworm and 0.08 (0.07-0.09) for T. trichiura, the egg reduction rates (ERR) were correctly estimated with FECPAKG2.

CONCLUSIONS/SIGNIFICANCE

The sensitivity to identify any STH infection was considerably lower for FECPAKG2 compared to Kato-Katz. Following rigorous development, FECPAKG2 might be an interesting tool with unique features for epidemiological and clinical studies.

Efficacy of recommended drugs against soil transmitted helminths: systematic review and network meta-analysis

Objective To evaluate efficacies of anthelmintic drugs against soil transmitted helminths in terms of cure rates and egg reduction rates.Design Systematic review and network meta-analysis.Data Sources PubMed, ISI Web of Science, Embase, ScienceDirect, the Cochrane Central Register of Clinical Trials, and the World Health Organization library database from 1960 until 31 December 2016.Study selection Randomised controlled trials evaluating the efficacy of a single dose regimen of albendazole, mebendazole, levamisole, and pyrantel pamoate against Ascaris lumbricoides, hookworm (Necator americanus and Ancylostoma duodenale) and Trichuris trichiura. The primary outcomes included cure rates analysed by network meta-analysis with mixed logistic regression models and egg reduction rates with mixed linear models.Results 55 and 46 randomised controlled trials were included in the analysis of cure rates and egg reduction rates, respectively. All drugs were highly efficacious against A lumbricoides Albendazole showed the highest efficacy against hookworm infections with a cure rate of 79.5% (95% confidence interval 71.5% to 85.6%) and an egg reduction rate of 89.6% (81.9% to 97.3%). All drugs had low efficacy against T trichiura, with mebendazole showing the highest cure rate of 42.1% (25.9% to 60.2%) and egg reduction rate of 66.0% (54.6% to 77.3%). Estimates for the years 1995 and 2015 showed significant reductions in efficacy of albendazole against T trichiura: by 2015 the egg reduction rates fell from 72.6% (53.7% to 91.5%) to 43.4% (23.5% to 63.3%; P=0.049) and the cure rates fell from 38.6% (26.2% to 52.7%) to 16.4 (7.7% to 31.3%; P=0.027).Conclusions All four currently recommended drugs show limitations in their efficacy profile. While only albendazole showed good efficacy against hookworm infection, all drugs had low efficacy against T trichiura The decrease in efficacy of albendazole against T trichiura over the past two decades is of concern. The findings indicate the need for strengthening efforts to develop new drug treatments, with a particular focus on drugs against T trichiura.

Efficacy and safety of tribendimidine, tribendimidine plus ivermectin, tribendimidine plus oxantel pamoate, and albendazole plus oxantel pamoate against hookworm and concomitant soil-transmitted helminth infections in Tanzania and Côte d'Ivoire: a randomised, controlled, single-blinded, non-inferiority trial

BACKGROUND

Preventive chemotherapy is the current strategy to control soil-transmitted helminth infections (caused by Ascaris lumbricoides, hookworm, and Trichuris trichiura). But, to improve efficacy and avoid emerging resistance, new drugs are warranted. Tribendimidine has shown good anthelmintic efficacy and is therefore a frontrunner for monotherapy and combination chemotherapy.

METHODS

We did a randomised, controlled, single-blinded, non-inferiority trial on Pemba Island, Tanzania, and in Côte d'Ivoire. We recruited adolescents aged 15-18 years from four primary schools on Pemba, and school attendees and non-schoolers from two districts in Côte d'Ivoire. Only hookworm-positive participants were randomly assigned (1:1:1:1) to single, oral doses of tribendimidine 400 mg plus placebo (tribendimidine monotherapy), tribendimidine 400 mg plus ivermectin 200 μg/kg, tribendimidine 400 mg plus oxantel pamoate 25 mg/kg, or albendazole 400 mg plus oxantel pamoate 25 mg/kg. Randomisation was done via a computer-generated list in block sizes of four or eight. Participants were asked to provide two stool samples on 2 consecutive days at baseline and again 14-21 days at follow-up. The primary outcome was the difference in egg-reduction rates (ERRs; ie, the geometric mean reduction) in hookworm egg counts between treatment groups, measured by the Kato-Katz technique. Differences in coadministrated treatment groups were assessed for non-inferiority with a margin of -3% to albendazole plus oxantel pamoate based on the available-case population, analysed by intention to treat. Safety was assessed 3 h and 24 h after treatment. This study is registered with ISRCTN (number 14373201).

FINDINGS

Between July 26, and Dec 23, 2016, we treated 636 hookworm-positive participants, and outcome data were available for 601 participants (151 assigned to tribendimidine monotherapy, 154 to tribendimidine plus ivermectin, 148 to tribendimidine plus oxantel pamoate, and 148 to albendazole plus oxantel pamoate). Tribendimidine plus ivermectin was non-inferior to albendazole plus oxantel pamoate (ERRs 99·5% [95% CI 99·2-99·7] vs 96·0% [93·9-97·4]; difference 3·52 percentage points [2·05-5·65]). Likewise, tribendimidine plus oxantel pamoate was non-inferior to albendazole plus oxantel pamoate (ERRs 96·5% [95% CI 94·9 to 97·6] vs 96·0% [93·9 to 97·4]; difference 0·48 percentage points [-1·61 to 2·88]). 3 h after treatment, headache (n=50 [8%]) and vertigo (n=37 [6%]) were the most widely reported symptoms; 24 h after treatment, 50 (8%) patients reported vertigo and 41 (7%) reported headache. Mainly mild adverse events were reported with peak numbers (n=111 [18%]) at 24 h after treatment. Three participants had moderate adverse events 3 h after treatment: two (<1%) had vertigo and one (<1%) had headache, and two had moderate adverse events 24 h after treatment: one (<1%) had vomiting and one (<1%) had vomiting plus diarrhoea.

INTERPRETATION

Tribendimidine in combination with either ivermectin or oxantel pamoate had a similar, non-inferior efficacy profile as albendazole plus oxantel pamoate, hence tribendimidine will be a useful addition to the depleted anthelmintic drug armamentarium.

FUNDING

Swiss National Science Foundation.

Unexpected low soil-transmitted helminth prevalence in the Butha-Buthe district in Lesotho, results from a cross-sectional survey

BACKGROUND

Soil-transmitted helminth (STH) infections with Ascaris lumbricoides, hookworm and Trichuris trichiura affect large parts of the world's population. For the implementation of national STH control programs, e.g. preventive chemotherapy (treatment with albendazole and mebendazole), the spatial distribution and prevalence of STH infections must be known. However, for Lesotho only little data were available and the STH distribution remains largely unknown.

METHODS

In early 2016, a cross-sectional parasitological STH survey was conducted including six different primary schools in the Butha-Buthe district of Lesotho. In each school stool samples were collected from 50 children (age 8-14 years) and analysed with a duplicate Kato-Katz thick smear for the presence of A. lumbricoides, hookworm and T. trichiura.

RESULTS

A total of 301 children provided a stool sample. All children were negative for A. lumbricoides and T. trichiura. Only two children from one primary school showed a light hookworm infection.

CONCLUSION

Our data indicate a low prevalence of STH infections in the Butha-Buthe district of Lesotho. Additional parasitological surveys on the prevalence and the spatial distributions of STH infections across the entire country of Lesotho are needed.

Efficacy and reinfection with soil-transmitted helminths 18-weeks post-treatment with albendazole-ivermectin, albendazole-mebendazole, albendazole-oxantel pamoate and mebendazole

Background

Preventive chemotherapy with albendazole or mebendazole is the current strategy to control soil-transmitted helminth (STH) infections (i.e. Ascaris lumbricoides, hookworm and Trichuris trichiura). STH reinfections, in particular A. lumbricoides and T. trichiura occur rapidly after treatment with the standard drugs. However, their low efficacy against T. trichiura, made an accurate assessment of reinfection patterns impossible.

Methods

In 2013 a randomised controlled trial was conducted on Pemba Island, Tanzania. School-aged children diagnosed positive for T. trichiura, were randomly allocated to (i) albendazole-ivermectin; (ii) albendazole-mebendazole; (iii) albendazole-oxantel pamoate; or (iv) mebendazole. Here we report the efficacy [cure rates (CR) and egg-reduction rates (ERR)], reinfection rates and new infections determined 18 weeks post-treatment.

Results

For a total of 405 children complete baseline and follow-up data were available. Similar to the efficacy determined after 3 weeks, 18 weeks after treatment albendazole-oxantel pamoate showed a significantly higher efficacy against T. trichiura (CR: 54.0 %, 95 % CI: 43.7–64.0; ERR: 98.6 %, 95 % CI: 97.8–99.2) compared to the other treatment arms. Children treated with albendazole-oxantel pamoate or albendazole-ivermectin had fewer moderate infections compared to children treated with albendazole. The reinfection rates 18 weeks post-treatment among all treatment arms were 37.2 % for T. trichiura (95 % CI: 28.3–46.8), 34.6 % for A. lumbricoides (95 % CI: 27.3–42.3) and 25.0 % for hookworms (95 % CI: 15.5–36.6).

Conclusion

The moderate reinfection rates with STHs 18 weeks post-treatment support the concept of regular anthelminthic treatment in highly endemic settings. Combination chemotherapy might achieve decreased morbidity in children since in the albendazole plus oxantel pamoate and albendazole plus ivermectin treatment arms only few moderate T. trichiura infections remained. Further trials should investigate the long term efficacy of albendazole-oxantel pamoate (i.e. 6 and 12 month post-treatment) and after several rounds of treatment in order to develop recommendations for appropriate control approaches for STH infections.

Trial registration

Current Controlled Trials ISRCTN80245406

Electronic supplementary material

The online version of this article (doi:10.1186/s13071-016-1406-8) contains supplementary material, which is available to authorized users.

Efficacy and safety of oxantel pamoate in school-aged children infected with Trichuris trichiura on Pemba Island, Tanzania: a parallel, randomised, controlled, dose-ranging study

BACKGROUND

Commonly used drugs for preventive chemotherapy against soil-transmitted helminths (ie, albendazole and mebendazole) show low efficacy against Trichuris trichiura. Recent studies with oxantel pamoate revealed good cure rates and high egg-reduction rates against T trichiura. We aimed to assess the nature of the dose-response relation to determine the optimum dose.

METHODS

We did a parallel, randomised, placebo-controlled, single-blind trial with oxantel pamoate in school-aged children (aged 6-14 years) infected with T trichiura on Pemba Island, Tanzania. Children were asked to provide two stool samples and children positive for T trichiura were eligible to participate in the trial. Children were excluded if they suffered from any systematic illness. Children were randomly assigned to six different oxantel pamoate doses (5-30 mg/kg) or a placebo. Randomisation was stratified by baseline infection intensity using random block sizes of seven and 14. The primary endpoints were cure rates and egg-reduction rates against T trichiura, both analysed by available case. Drug safety was assessed 2 h and 24 h after treatment. The trial is registered at www.isrctn.com, number ISRCTN86603231.

FINDINGS

Between Oct 14, and Nov 28, 2014, we enrolled 480 participants and randomly assigned 350 children to the different oxantel pamoate doses or the placebo. 5 mg/kg oxantel pamoate was the minimum effective dose (10 of 46 children cured [cure rate 22%, 95% CI 11-36]; egg-reduction rate 85·0%, 64·5-92·9). An increased probability of being cured and reduced egg counts with escalating doses was recorded. At 25 mg/kg oxantel pamoate 27 of 45 children were cured (cure rate 60%, 95% CI 44-65) with an egg-reduction rate of 97·5% (94·4-98·9), and at 30 mg/kg 27 of 46 children were cured (59%, 43-73) with an egg-reduction rate of 98·8% (96·8-99·6). Oxantel pamoate was well tolerated across all treatment groups; only mild adverse events were reported by the participants 2 h (27 [10%]) and 24 h (12 [4%]) after treatment.

INTERPRETATION

Our dose-finding study revealed an excellent tolerability profile of oxantel pamoate in children infected with T trichiura. An optimum therapeutic dose range of 15-30 mg/kg oxantel pamoate was defined. With a weight independent dose of 500 mg oxantel pamoate 95% of children aged 7-14 years in sub-Saharan Africa would receive doses of 11·7-32·0 mg/kg. Future research should include studies with oxantel pamoate in younger children and on different continents with the ultimate goal to be able to add oxantel pamoate to soil-transmitted helminth control programmes.

FUNDING

Swiss National Science Foundation.

The spatial and seasonal distribution of Bulinus truncatus, Bulinus forskalii and Biomphalaria pfeifferi, the intermediate host snails of schistosomiasis, in N'Djamena, Chad

There is a paucity of epidemiological and malacological data pertaining to schistosomiasis in Chad. In view of a recently articulated elimination agenda, a deeper understanding of the spatio-temporal distribution of schistosomiasis intermediate host snails is pivotal. We conducted cross-sectional malacological surveys during the dry season (April/May 2013) and after the short rainy season (October 2013) in N'Djamena, the capital of Chad. Snails were identified at the genus and species level using morphological keys and molecular DNA barcoding approaches. Those belonging to Bulinus and Biomphalaria were examined for cercarial shedding. Snail habitats were characterised and their predictive potential for the presence of schistosomiasis intermediate host snails explored. Seasonal patterns were studied using geographical information system and kriging in order to interpolate snail abundance data to make predictions at non-sampled locations across N'Djamena. Overall, 413 Bulinus truncatus, 369 Bulinus forskalii and 108 Biomphalaria pfeifferi snails were collected and subjected to cercarial shedding. During the dry season, one Bu. truncatus of 119 snails collected shed Schistosoma spp. cercariae (0.84%), while S. mansoni was shed by one of 108 Bi. pfeifferi snails (0.93%). None of the snails collected after the rainy season shed Schistosoma spp. cercariae. The abundance of Bu. truncatus and Bu. forskalii showed an inverse U-shape relationship with the square term of conductivity, i.e. low abundance at the lowest and highest levels of conductivity and high abundance at intermediate levels. Bi. pfeifferi showed a negative, linear association with pH in the dry seasons. It is planned to link these intermediate host snail data to infection data in human populations with the goal to draw a predictive risk map that can be utilised for control and elimination of schistosomiasis in N'Djamena.

Enabling guidelines for computer-based decision support--process and tools

Many guideline only implicitly or vaguely define the process of health care delivery. However, an explicit model of the medical tasks comprising this process is needed before active decision support at the patient encounter can take place. We propose to use a structured, but semi-formal representation as intermediate step in the process of enacting a guideline. This allows for the application independent representation of the content of a guideline enabled for decision support. The process and the tools of the methodology have been applied to enable guidelines from the field of Diabetes mellitus.

Reliability of nurses' neurological assessments in the cardiothoracic surgical intensive care unit

BACKGROUND: Alterations in mental status are common among patients in the cardiothoracic surgical intensive care unit. Changes in mental status can be caused by metabolic factors, medications, or brain injury. In this setting, reliable, serial neurological evaluations are critical for assessing the effectiveness of treatment and the need for additional studies. OBJECTIVES: To estimate the reliability of the Rancho Los Amigos Cognitive Scale and the newly developed Neurologic Intensive Care Evaluation as measures of cognitive function in the cardiothoracic surgical intensive care unit. METHODS: Nurses used 1 of the 2 scales as part of routine neurological assessments of patients in the cardiothoracic surgical intensive care unit. For each test, scores of different observers were correlated and a reliability estimate formed. RESULTS: Interrater reliability was high for both evaluations (Rancho scale, 0.91; Neurologic Intensive Care Evaluation, 0.94). Correlations between the scores of different pairs of observers were also high (mean rho values, 0.84 for the Rancho scale and 0.77 for the Neurologic Intensive Care Evaluation). CONCLUSIONS: Both scales are reliable indicators of the neurological state of patients in the cardiothoracic surgical intensive care unit. These scales measure different, although limited, aspects of cognitive function. Each test was simple to administer and did not take more time than the standard nursing neurological examination. Most of the variability in scoring was related to the different degrees of stimulation used by examiners when assessing patients, not to differences in the interpretation of patients' responses.

Reliability of nurses' neurological assessments in the cardiothoracic surgical intensive care unit

BACKGROUND

Alterations in mental status are common among patients in the cardiothoracic surgical intensive care unit. Changes in mental status can be caused by metabolic factors, medications, or brain injury. In this setting, reliable, serial neurological evaluations are critical for assessing the effectiveness of treatment and the need for additional studies.

OBJECTIVES

To estimate the reliability of the Rancho Los Amigos Cognitive Scale and the newly developed Neurologic Intensive Care Evaluation as measures of cognitive function in the cardiothoracic surgical intensive care unit.

METHODS

Nurses used 1 of the 2 scales as part of routine neurological assessments of patients in the cardiothoracic surgical intensive care unit. For each test, scores of different observers were correlated and a reliability estimate formed.

RESULTS

Interrater reliability was high for both evaluations (Rancho scale, 0.91; Neurologic Intensive Care Evaluation, 0.94). Correlations between the scores of different pairs of observers were also high (mean rho values, 0.84 for the Rancho scale and 0.77 for the Neurologic Intensive Care Evaluation).

CONCLUSIONS

Both scales are reliable indicators of the neurological state of patients in the cardiothoracic surgical intensive care unit. These scales measure different, although limited, aspects of cognitive function. Each test was simple to administer and did not take more time than the standard nursing neurological examination. Most of the variability in scoring was related to the different degrees of stimulation used by examiners when assessing patients, not to differences in the interpretation of patients' responses.

The AMOR study: a randomized, double-blinded trial of omeprazole versus ranitidine together with amoxycillin and metronidazole for eradication of Helicobacter pylori

BACKGROUND

Besides antibiotics, additionally effective acid inhibition is necessary for the eradication of Helicobacter pylori.

OBJECTIVE

To assess the significance of acid suppression and, in particular, treatment with proton pump inhibitors (PPIs) compared with H2 receptor antagonists (H2 RAs). The primary target parameter for the study was H. pylori eradication. In addition, the ulcer healing rate, speed of pain reduction, score for gastritis in the antrum and gastric body, and rate of side effects were recorded.

DESIGN

Randomized, double-blinded, multicentre study.

PARTICIPANTS

A total of 456 patients between the ages of 18 and 80 years with H. pylori-positive duodenal ulcers were included in the study.

METHODS

Using a randomization list, patients were assigned either to a treatment group receiving omeprazole 40 mg once daily, amoxycillin 750 mg three times a day, and metronidazole 500 mg three times a day (OAM), or to a group receiving ranitidine 300 mg once daily, amoxycillin 750 mg three times a day, and metronidazole 500 mg three times a day (RAM). The treatment period was 7 days in both groups. Long-term acid-suppressant treatment was not given.

RESULTS

The eradication rate was 87.1% (169/194, intention to treat [ITT]) in the OAM group and 77% (137/ 178, ITT) in the RAM group. The difference of 10.1% (95% CI 2.5-18%) is statistically significant (P= 0.0104). The ulcer healing rate was 93.3% in the OAM group (181/194, ITT) and 92.1% in the RAM group (164/178, ITT, NS). With regard to the speed and intensity of pain reduction, the OAM group was superior to the RAM group. In patients in whom H. pylori eradication was successful, the reduction in the antral and gastric body gastritis score was significantly greater than in patients without eradication. In the OAM group, 39.1% of the patients (n = 90) reported one or more side effects, compared with 44.7% (n = 101) in the RAM group (P= 1.5449, NS).

CONCLUSION

Omeprazole (40 mg once daily in the morning) is significantly more effective than ranitidine (300 mg once daily in the morning) with respect to H. pylori eradication when used together with amoxycillin (750 mg three times a day) and metronidazole (500 mg three times a day) for a 7-day treatment period.

Electronic Healthcare Records: an essential part of Health Telematics Applications

A healthcare record should ideally be a repository of data, describing a person’s health and how it is being supported; and not, as it is now, describing a person’s diseases and treatment only. The healthcare record is the basis for monitoring and decisions. Therefore it should be open and available to all authorized health professionals and to the patient. To make this easier is one of the major advantages of electronic healthcare records (EHCR). The computer-based patient record could make major contributions to improving the healthcare system. This is the motivation to initiatives, projects and routine implementations of electronic patient records. The European Union and national initiatives have put major efforts into the support of this main field of medical information processing.

Electronic Healthcare Records: an essential part of Health Telematics Applications

A healthcare record should ideally be a repository of data, describing a person's health and how it is being supported; and not, as it is now, describing a person's diseases and treatment only. The healthcare record is the basis for monitoring and decisions. Therefore it should be open and available to all authorized health professionals and to the patient. To make this easier is one of the major advantages of electronic healthcare records (EHCR). The computer-based patient record could make major contributions to improving the healthcare system. This is the motivation to initiatives, projects and routine implementations of electronic patient records. The European Union and national initiatives have put major efforts into the support of this main field of medical information processing.

Increased activity of 16-membered lactone ring macrolides against erythromycin-resistant Streptococcus pyogenes and Streptococcus pneumoniae: characterization of South African isolates

The susceptibility of 40 erythromycin-resistant isolates of Streptococcus pyogenes and 40 multiply-resistant isolates of Streptococcus pneumoniae to six macrolide antibiotics, representing 14-, 15- and 16-membered lactone ring structures, was tested. The genetic basis for macrolide resistance in the strains was also determined. Both erm and mef determinants were encountered in the 36 S. pneumoniae isolates tested, but only mef in the five S. pyogenes isolates tested. All isolates showed cross-resistance among the 14-membered macrolides erythromycin, clarithromycin and roxithromycin and the 15-membered macrolide, azithromycin. However, the erythromycin-resistant S. pyogenes isolates retained full susceptibility to spiramycin and josamycin (16-membered agents). These latter two antibiotics were also more active than the other macrolides against erythromycin-resistant S. pneumoniae isolates, especially josamycin which was 8-64 times more active than erythromycin; spiramycin was only two to eight times more active than erythromycin.

Transport characteristics of peptidomimetics. Effect of the pyrrolinone bioisostere on transport across Caco-2 cell monolayers

PURPOSE

To compare the permeation characteristics of amide bond-containing HIV-1 protease inhibitors and their pyrrolinone-containing counterparts across Caco-2 cell monolayers, a model of the intestinal mucosa.

METHODS

Transepithelial transport and cellular uptake of three pairs of amide bond-containing and pyrrolinone-based peptidomimetics were assessed in the presence and absence of cyclosporin A using the Caco-2 cell culture model. The potential of the peptidomimetics to interact with biological membranes was estimated by IAM chromatography.

RESULTS

In the absence of cyclosporin A, apical (AP) to basolateral (BL) flux of all compounds studied was less than the flux determined in the opposite direction (i.e., BL-to-AP). The ratio of the apparent permeability coefficients (Papp) calculated for the BL-to-AP and AP-to-BL transport (P(BL-->AP)/P(AP-->BL)) varied between 1.7 and 36.2. When individual pairs were ompared, P(BL-->AP)/P(AP-BL) ratios of the pyrrolinone-containing compounds were 1.5 to 11.5 times greater than those determined for the amide bond-containing analogs. Addition of 25 microM cyclosporin A to the transport buffer reduced the P(BL-->AP)/P(AP-->BL) ratios for all protease inhibitors to a value close to unity. Under these conditions, the amide bond-containing peptidomimetics were at least 1.6 to 2.8 times more able to permeate Caco-2 cell monolayers than were the pyrrolinone-containing compounds. The intrinsic uptake characteristics into Caco-2 cells determined in the presence of 25 microM cyclosporin A were slightly greater for the amide bond-containing protease inhibitors than for the pyrrolinone-containing analogs. These uptake results are consistent with the transepithelial transport results determined across this in vitro model of the intestinal mucosa.

CONCLUSIONS

The amide bond-containing and pyrrolinone-based peptidomimetics are substrates for apically polarized efflux systems present in Caco-2 cell monolayers. The intrinsic permeabilities of the amide bond-containing protease inhibitors are slightly greater than the intrinsic permeabilities of the pyrrolinone-based analogs through Caco-2 cell monolayers.

A formal model of diabetological terminology and its application for data entry

This paper summarises the developmental activities for an electronic patient record system in diabetology based on GALEN technologies. It focusses on the modelling of primarily terminological medical knowledge of this subspecialty and describes its application for predictive data entry.

Death of neurons in the neonatal rodent and primate globus pallidus occurs by a mechanism of apoptosis

We have examined the developing rat, mouse and marmoset globus pallidus for evidence of cells dying by a process of "naturally occurring" or programmed cell death. We have demonstrated that cells in the developing mammalian globus pallidus die by a process of apoptosis and that by day 7 after birth many of the apoptotic cells possess a neuronal phenotype. Light microscopic and ultrastructural evidence of apoptotic cell death included cell shrinkage, blebbing of the extracellular membrane and condensation of the nuclear chromatin. Additionally we used an in situ nick translation method to assess the integrity of the DNA within the dying cells. This revealed that cells with the morphological characteristics of apoptosis also possessed fragmented DNA typical of cells undergoing Type 1 programmed or apoptotic cell death. The lack of lysosomal enzyme activity within the dying cells and the frequent observations of phagocytosis by neighbouring cells also suggest that the form of programmed cell death is apoptosis and not Type 2 autophagic degeneration. We found no evidence for cells dying by Type 3 non-lysosomal degeneration since all dying cells examined under the electron microscope possessed intact intracellular organelles and cell membranes. We developed a sensitive silver stain which detected balls of condensed chromatin within the apoptotic cells. This enabled identification of apoptotic cells in the developing globus pallidus at low magnification and so allowed us to map the numbers and distribution of dying cells with time. The incidence of apoptotic cells in the neonatal globus pallidus was greatest at birth and then declined such that few cells were detected at one week and none was seen in the adult rat. Although the loss of large numbers of cells in the developing nervous system is a well documented phenomenon, there are only a limited number of reports of the mechanism by which neuronal cells die, and few of these are in the developing mammalian brain. There are at least four different morphological categories of neuronal cell death which are discriminated on morphological and biochemical criteria. Our analysis suggests that apoptotic or Type 1 cell death is the major form of programmed cell death occurring in the mammalian globus pallidus in the first week of life. This report also describes the use of two methods for the ready identification of apoptotic cells at the light microscope level. Because these methods are suitable for use on tissue sections they provide a means to assess the incidence of apoptotic cell death, in parallel with other analyses of the expression of gene products which control cell fate.

[Necrosis of the tongue in temporal arteritis. Case report]

Because of the rich blood supply ischemic necrosis of the tongue is extremely rare. But if it happens though, the reason is most often due to temporal arteritis. It predominantly occurs in elderly women, like in our case. The correct diagnosis should be established as soon as possible because high-dose cortisone therapy both relieves the patient's complaints and prevents life-threatening complications.

[Modern aspects of contraception]

As the ideal contraceptive has not been found after a quarter century of global contraception research, this is an attempt to assess the advantages and drawbacks of the so-called "safe" methods of contraception currently in use. The most persuasive arguments in favour of oral contraceptives which other reversible methods cannot claim are their unsurpassed safety as well as the simplicity of their application. The disadvantage of potential damages through the perennial intake of hormones can be minimized with the low dosages of modern compounds. Recommendations are made concerning the controlled use of the various kinds of ovulation-inhibitors. Likewise, the use of ovulation-inhibitors with adolescents, at the end of reproductive age, and with women afflicted with diabetes mellitus are discussed. Advantages and drawbacks of contraception through the exclusive use of progestagen are briefly stated. Despite good applicability in single cases, intrauterine contraception should rather be viewed as a second choice only. Yet the standard problems, such as menstrual disturbances, increased tendency toward inflammations and individual incompatibility remain unsolved. Moreover, the rate of failure of 3% is ten times as high as with the ovulation-inhibitors. In their instructions some producers recommend too short a period of placement of the device in the uterus. Most IUD's can stay in place for a longer period of time. Repeated references to the possible complications of the use of IUD's with nulliparous women are made. As an emergency method to prevent a pregnancy after intercourse without contraceptives a hormonal method as well as the post-coital insertion of an IUD are discussed. After completed family planning the definitive sterilization presents itself as the ideal method of contraception, either through tubal sterilization in case of the woman, or vasectomy in case of the man. Rates of complications, failure rates, and chances of reversibility of both methods are specified.

[Formation and transport of ozone and other photochemical oxidants]

Photochemical oxidants (O3, PAN, HCHO) are the typical pollutants in photochemical Smog. They can be formed as the result of the sunlight induced oxidation of precursor pollutants emitted into the atmosphere (NOx, CxHy). Other important precursor substances and reactive intermediates are compounds of the organic hydroxyl group (-O-H, for instance the methoxy radical CH3O), hydroxyl radical .OH, hydroperoxy radical HO2, and singlet oxygen O. For the production of photochemical oxidants in smog, especially ozone, NOx primarily act as catalysator. But CxHy serve as "combustibles". The quantities of the several formed photooxidants are mainly dependent on intensity and duration of daily sunshine, temperature, oxidant concentrations at the beginning of a build-up period, and on emission rates and concentrations of primary pollutants (NO, CxHy). Maximum mixing ratios of secondary pollutants often occur at certain distances downwind of primary pollutant sources, dependent on meteorological conditions (wind velocity, rel. humidity, etc.) and on rate constants for oxidant formation cycles. During the period of July 5 to 11, 1984, for instance, 6 kilometers SW from Zürich we found maximum ground-level mixing ratios of about 150 ppbv ozone, 4 ppbv PAN and 9 ppbv formaldehyde, that is 5 (ozone) to 10 (PAN) times above the supposed oxidant concentrations of unpolluted continental air. The increase in ozone in the late morning and early afternoon is accompanied by an increase in PAN and HCHO and by a decrease in NOx. This shows that in this case HCHO originates from photochemical reactions rather than being emitted directly to the atmosphere from vehicles.(ABSTRACT TRUNCATED AT 250 WORDS)