Inhaled aviptadil for the possible treatment of COVID-19 in patients at high risk for ARDS: study protocol for a randomized, placebo-controlled, and multicenter trial

Background

Despite the fast establishment of new therapeutic agents in the management of COVID-19 and large-scale vaccination campaigns since the beginning of the SARS-CoV-2 pandemic in early 2020, severe disease courses still represent a threat, especially to patients with risk factors. This indicates the need for alternative strategies to prevent respiratory complications like acute respiratory distress syndrome (ARDS) associated with COVID-19. Aviptadil, a synthetic form of human vasoactive intestinal peptide, might be beneficial for COVID-19 patients at high risk of developing ARDS because of its ability to influence the regulation of exaggerated pro-inflammatory proteins and orchestrate the lung homeostasis. Aviptadil has recently been shown to considerably improve the prognosis of ARDS in COVID-19 when applied intravenously. An inhaled application of aviptadil has the advantages of achieving a higher concentration in the lung tissue, fast onset of activity, avoiding the hepatic first-pass metabolism, and the reduction of adverse effects. The overall objective of this project is to assess the efficacy and safety of inhaled aviptadil in patients hospitalized for COVID-19 at high risk of developing ARDS.

Methods

This multicenter, placebo-controlled, double-blinded, randomized trial with 132 adult patients hospitalized for COVID-19 and at high risk for ARDS (adapted early acute lung injury score ≥ 2 points) is conducted in five public hospitals in Europe. Key exclusion criteria are mechanical ventilation at baseline, need for intensive care at baseline, and severe hemodynamic instability. Patients are randomly allocated to either inhale 67 μg aviptadil or normal saline (three times a day for 10 days), in addition to standard care, stratified by center. The primary endpoint is time from hospitalization to clinical improvement, defined as either hospital discharge, or improvement of at least two levels on the nine-level scale for clinical status suggested by the World Health Organization.

Discussion

Treatment strategies for COVID-19 are still limited. In the context of upcoming new variants of SARS-CoV-2 and possible inefficacy of the available vaccines and antibody therapies, the investigation of alternative therapy options plays a crucial role in decreasing associated mortality and improving prognosis. Due to its unique immunomodulating properties also targeting the SARS-CoV-2 pathways, inhaled aviptadil may have the potential to prevent ARDS in COVID-19.

Trial registration

ClinicalTrials.gov, NCT04536350. Registered 02 September 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06723-w.

Which hospital workers do (not) want the jab? Behavioral correlates of COVID-19 vaccine willingness among employees of Swiss hospitals

In many countries, the current vaccination rates are stagnating, to the extent that vaccine hesitancy—the delay or refusal to take recommended vaccinations—forms a major obstacle to ending the COVID-19 pandemic. This tendency is particularly concerning when observed among healthcare workers who are opinion leaders on medical matters for their patients and peers. Our study surveys 965 employees of two large Swiss hospitals and profiles vaccine-hesitant hospital employees using not only socio-demographic characteristics, but also a comprehensive set of standard behavioral preference measures: (i) Big-5 personality traits, (ii) risk-, time- and social preferences, and (iii) perceived prevailing social norms. Using multinomial probit models and linear probability models, we find that vaccine-hesitant hospital employees are less patient and less likely to perceive vaccination as the prevailing social norm—in addition to replicating previously published socio-demographic results. Our findings are robust to a range of model specifications, as well as individual and situational covariates. Our study thus offers actionable policy implications for tailoring public-health communications to vaccine-hesitant hospital employees.

Wearing a mask-For yourself or for others? Behavioral correlates of mask wearing among COVID-19 frontline workers

Human behavior can have effects on oneself and externalities on others. Mask wearing is such a behavior in the current pandemic. What motivates people to wear face masks in public when mask wearing is voluntary or not enforced? Which benefits should the policy makers rather emphasize in information campaigns-the reduced chances of getting the SARS-CoV-2 virus (benefits for oneself) or the reduced chances of transmitting the virus (benefits for others in the society)? In this paper, we link measured risk preferences and other-regarding preferences to mask wearing habits among 840 surveyed employees of two large Swiss hospitals. We find that the leading mask-wearing motivations change with age: While for older people, mask wearing habits are best explained by their self-regarding risk preferences, younger people are also motivated by other-regarding concerns. Our results are robust to different specifications including linear probability models, probit models and Lasso covariate selection models. Our findings thus allow drawing policy implications for effectively communicating public-health recommendations to frontline workers during the COVID-19 pandemic.

Postoperative Paenibacillus thiaminolyticus Wound Infection, Switzerland

Paenibacillus thiaminolyticus is a nonvirulent organism found in human and ruminant microbiota. However, P. thiaminolyticus can act as an opportunistic pathogen in humans. We describe a case of abdominal wall hematoma secondarily infected by P. thiaminolyticus. Our findings emphasize the risk for unusual Paenibacillus infections in otherwise healthy persons.

Periprosthetic knee infection by Mycobacterium bovis and Candida guilliermondii in the context of a zoonosis: a case report and review of the literature

Introduction

Periprosthetic joint infections are a major challenge for treating physicians. Musculoskeletal infections with Mycobacterium bovis are extremely rare, with an assumed incidence of 0.08–0.1%. Consequently, periprosthetic joint infections with Mycobacterium bovis are even less frequent. Fungal periprosthetic joint infections are very rare. No cases of Candida guilliermondii infection of implanted prostheses are described in the literature.

Case presentation

An 87-year-old Swiss man with German ethnic origin suffered from symptoms of osteoarthritis of the knee. We present the first described case of periprosthetic joint infection after total knee arthroplasty by both Mycobacterium bovis and Candida guilliermondii in the context of a zoonosis with 14 months of follow-up. The infection was presumed to originate more than 55 years earlier, when these infectious agents were still present in cattle in Switzerland. After diagnosis of the pathogens, our patient was successfully treated with tuberculostatic and mycocide medication, and a two-stage revision knee arthroplasty was performed. The medication was given for 1 year.

The postoperative course was normal and he achieved ambulant musculoskeletal rehabilitation. After 14 months of follow-up no further complication emerged. At all routine consultations, there were no indications for joint inflammation, wound healing was normal, and the range of motion was flexion/extension 110/0/0°.

Conclusions

We found no comparable cases in our literature search. Only a few joint infections by Mycobacterium bovis after intravesical instillation of Bacillus Calmette–Guérin are described. Primary infections without previous Bacillus Calmette–Guérin injection appear to be even less frequent. In cases where mycobacterial infection cannot be ruled out, we recommend cultivating mycobacteria cultures for weeks. In addition, a histological examination of the tissue should be carried out. After diagnosis, the concept of a two-stage reimplantation of total knee arthroplasty with mycostatic therapy for 1 year and antimycotic therapy appears to be effective.

[Not Available]

Zusammenfassung. Wir berichten über einen 58-jährigen Patienten mit seit Monaten bestehender B-Symptomatik, rezidivierenden Fieberschüben begleitet von Kopfschmerzen und erhöhten Entzündungsparametern. In der Erstlinienabklärung ergaben sich keine eindeutigen Hinweise auf eine infektiologische oder rheumatologische Ursache, auffällig war lediglich eine mediastinale und hiläre Lymphadenopathie. Zum Ausschluss eines Malignoms wurde eine PET-CT durchgeführt, in der sich eine FDG-Aufnahme im Bereich der grossen Gefässe zeigte, passend zu einer Riesenzellarteritis. Bei eindeutigem Befund konnte auf einen Temporalarterienbiopsie verzichtet und eine Therapie mit Glukokortikoiden begonnen werden.

[Not Available]

Zusammenfassung. Zusammenfassung: Wir schildern den Fall einer 60-jährigen Süditalienerin mit rezidivierenden Fieberschüben bei erhaltenem Allgemeinzustand. Nach umfangreicher infektiologischer, hämatologischer und rheumatologischer Diagnostik ohne wegweisende Befunde erfolgte unter dem Verdacht auf eine atypische Form des familiären Mittelmeerfiebers aufgrund der ethnischen Herkunft der Patientin eine probatorische Colchicin-Therapie. Der schnell eingetretene, anhaltende Therapieerfolg sichert retrospektiv entsprechend den aktuell gültigen modifizierten Tel-Hashomer-Kriterien die Diagnose.

["Why am I Deaf and my Vision is Blurred?" Thinking of a Horse or a Zebra?]

We present the case of a 66 year old patient with a heterogeneous clinical course over ten months, particularly worsening of vision, hearing and hip pain. She finally died of multi-organ failure. The increased wear of a metal-on-metal hip implant lead to cobalt intoxication. The crucial therapy consists in removing the cobalt source. In the future, physicians need to be aware of this insidious and life-threatening disease possibly affecting thousands of patients after total hip replacement.

[A very slow growing ankle swelling in a healthy male]

We describe the case report of a 66-year-old man with a very slow growing ankle tumour caused by a subcutaneous fungal abscess. Phaeoacremonium inflatipes, a member of the Dematiaceae family, was identified by needle puncture and culture of the non-odorous creamy yellow brown fluid. The fungal pseudocyst was surgically removed in toto and no further fungicidal drug therapy was required. Human infections by dematiaceous fungi causes subcutaneous phaeohyphomycosis, a rare, deep fungal infection of the skin and subcutaneous tissues usually acquired through traumatic skin lesions. In addition, systemic infections are reported, predominantly in immunosuppressed individuals.

Suppression of HBV by tenofovir in HBV/HIV coinfected patients: a systematic review and meta-analysis

BACKGROUND

Hepatitis B coinfection is common in HIV-positive individuals and as antiretroviral therapy has made death due to AIDS less common, hepatitis has become increasingly important. Several drugs are available to treat hepatitis B. The most potent and the one with the lowest risk of resistance appears to be tenofovir (TDF). However there are several questions that remain unanswered regarding the use of TDF, including the proportion of patients that achieves suppression of HBV viral load and over what time, whether suppression is durable and whether prior treatment with other HBV-active drugs such as lamivudine, compromises the efficacy of TDF due to possible selection of resistant HBV strains.

METHODS

A systematic review and meta-analysis following PRISMA guidelines and using multilevel mixed effects logistic regression, stratified by prior and/or concomitant use of lamivudine and/or emtricitabine.

RESULTS

Data was available from 23 studies including 550 HBV/HIV coinfected patients treated with TDF. Follow up was for up to seven years but to ensure sufficient power the data analyses were limited to three years. The overall proportion achieving suppression of HBV replication was 57.4%, 79.0% and 85.6% at one, two and three years, respectively. No effect of prior or concomitant 3TC/FTC was shown. Virological rebound on TDF treatment was rare.

INTERPRETATION

TDF suppresses HBV to undetectable levels in the majority of HBV/HIV coinfected patients with the proportion fully suppressed continuing to increase during continuous treatment. Prior treatment with 3TC/FTC does not compromise efficacy of TDF treatment. The use of combination treatment with 3TC/FTC offers no significant benefit over TDF alone.

Risk perception of travelers to tropical and subtropical countries visiting a swiss travel health center

BACKGROUND

This study assessed the risk perception ratings of travelers pre- and post-travel and in comparison to the ratings by travel health experts. While most surveys on travel health knowledge, attitudes, and practices focus on malaria and vaccine-preventable diseases, noninfectious travel risks were included in this study.

METHODS

Pre- and post-travel perception of nine travel-associated health risks was recorded among 314 travelers to tropical and subtropical destinations. All travelers sought pre-travel health advice at the Travel Clinic of the Swiss Tropical and Public Health Institute in 2008 and 2009. In addition, 18 Swiss travel health experts provided an assessment of the respective risks. A validated visual psychometric measuring instrument was used [pictorial representation of illness and self measure (PRISM)].

RESULTS

Travelers and experts rated most risks similarly, except for accidents and sexually transmitted infections (STIs) which experts rated higher. Compared to other risks, accidents ranked highly in both groups and were the only risk perceived higher after travel. Pre- and post-travel perceptions of all other risks were similar with a tendency to be lower after travel. Travelers perceived mosquitoes to be the highest risk before travel and accidents after travel.

CONCLUSION

Travelers' risk perception appears to be accurate for most risks stated in this study. However, travel health professionals should be aware that some perception patterns among travelers regarding travel-related health risks may be different from professional risk assessment. Important but insufficiently perceived health risks, such as sexual behavior/STIs and accidents, should be considered to be part of any pre-travel health advice package.

Open and hidden agendas of "asymptomatic" patients who request check-up exams

Background

Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking.

Methods

For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS).

Results

All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease.

Conclusions

The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up.

The impact of combination antiretroviral therapy and its interruption on anxiety, stress, depression and quality of life in Thai patients

OBJECTIVE

Investigation on anxiety, stress, depression, and quality of life (QoL) within STACCATO, a randomised trial of two treatment strategies: CD4 guided scheduled treatment interruption (STI) compared to continuous treatment (CT).

PARTICIPANTS

Thai patients with HIV-infection enrolled in the STACCATO trial.

METHODS

Anxiety, depression assessed by the questionnaires Hospital Anxiety and Depression Scale (HADS) and DASS, stress assessed by the Depression Anxiety Stress Scale (DASS), and QoL evaluated by the HIV Medical Outcome Study (MOS-HIV) questionnaires. Answers to questionnaires were evaluated at 4 time-points: baseline, 24 weeks, 48 weeks and at the end of STACCATO.

RESULTS

A total of 251 patients answered the HADS/DASS and 241 answered the MOS-HIV of the 379 Thai patients enrolled into STACCATO (66.2 and 63.6% respectively). At baseline 16.3% and 7.2% of patients reported anxiety and depression using HADS scale. Using the DASS scale, 35.1% reported mild to moderate and 9.6% reported severe anxiety; 8.8% reported mild to moderate and 2.0% reported severe depression; 42.6% reported mild to moderate and 4.8% reported severe stress. We showed a significant improvement of the MHS across time (p=0.001), but no difference between arms (p=0.17). The summarized physical health status score (PHS) did not change during the trial (p=0.15) nor between arm (p=0.45). There was no change of MHS or PHS in the STI arm, taking into account the number of STI cycle (p=0.30 and 0.57) but MHS significant increased across time-points (p=0.007).

CONCLUSION

Antiretroviral therapy improved mental health and QOL, irrespective of the treatment strategy.

[Headaches and aphasia in an immunocompromised patient]

We report the case of a 81-year-old, immunocompromised Patient, admitted to our hospital with new-onset headaches and word-finding difficulties. The MRI of the brain revealed a temporal mass on the left with marginal contrast-enhancement. During the next days Listeria monocytogenes grew in the bloodcultures so that the diagnosis of a brain-abscess caused by Listeria was established. Due to the localisation, surgical drainage of the abscess was not possible, so that a prolonged antibiotic therapy lasting over 4.5 months was initiated. The MRI after therapy demonstrated no abscess persistence. Listeria mostly cause infections in the immunocompromised, elderly, newborn or pregnant host. Next to bacteraemia without a focus, CNS-invasion with meningitis, meningoencephalitis or less frequent abcess-formation (5-10%) is the most important manifestation.

[Early gastric cancer--or not]

A 46-year old female patient presented with non-specific epigastric discomfort that had been present for 6 months. Endoscopic work-up showed a small gastric polyp and biopsy samples revealed adenocarcinoma. There was no evidence of metastatic disease or penetration of the muscle layer on endosonography, rating the tumor as early gastric cancer. Endoscopic submucosal dissection was unsuccessful due to bleeding complications and the patient was treated with subtotal gastrectomy. Surprisingly, the final histological diagnosis revealed a highly differentiated neuroendocrine tumor and the initial diagnosis had to be revised.

[Hyperprolactinemia in a man's world]

A 60-years old patient was admitted for mamillary pain for several weeks, without galactorrhea. Erectile dysfunction had been present for several years but diminished libido had developed only recently. Ultrasonography of the mamillary gland was not definite for gynecomastia but repeated serum prolactin concentrations were elevated 5-fold the upper limit of normal. Furthermore serum level of testosterone was decreased and levels of luteinizing hormone and follicle-stimulation hormone were within normal range. Magnetic resonance imaging (MRI) of the pituitary gland could not identify a tumoral mass. In review of the laboratory features and the absence of a tumoral mass on MRI, idiopathic hyperprolactinemia was diagnosed and therapy with a dopamine-agonist was started.

Trends in imported malaria to Basel, Switzerland

BACKGROUND

Due to persistent international travel and immigration trends, imported malaria remains to be of clinical and public health importance in nonendemic countries. The aim of this study was to investigate trends in imported malaria over a period of more than three decades.

METHODS

We assessed travel history, demographic characteristics, and clinical course with special regard to malaria diagnosis and intensive care unit (ICU) admission of patients diagnosed with malaria. The sample comprised 109 patients with the diagnosis of malaria according to the International Statistical Classification of Diseases and Related Health Problems (ICD)-coding system (versions 9 and 10) at the University Hospital and at a teaching hospital in Basel between January 1994 and June 2004. Changes in clinical management and outcomes were compared with previous studies at the same institutions dating back to the 1970s.

RESULTS

The most common reason for travel was to visit friends and relatives in the country of origin (37%), and most infections were acquired in Africa (82%), with Plasmodium falciparum malaria the most frequently found parasite (84%). The mean time between first symptoms and the diagnosis of malaria was 4 days (range 0.5-31 d). Delay in diagnosis occurred in 14% of cases, and 37% of hospitalized patients were referred to the ICU. In 22% of referred cases, high parasitemia (>2%) according to internal criteria was a reason for referral. The course of disease remained mild in the great majority (90%) of patients, and none of the patients died.

CONCLUSIONS

Prompt and specific diagnosis of malaria could be improved. Malaria-associated mortality was reduced over time. As ICU referral showed to be inappropriately high in relation to a moderate clinical course of several admitted patients, criteria for ICU admission should be reevaluated. The trend toward malaria in patients originating from endemic areas suggests that preventive travel advice should specifically address these patients.

[Antiviral treatment of influenza in humans]

Antiviral agents are the most effective treatment option for influenza. Two classes of drugs are available, the adamantanes and the neuraminidase inhibitors. Neuraminidase inhibitors were a major breakthrough in the treatment options for influenza and were licensed in the year 2000. They have an excellent safety profile and effectively reduce viral shedding, symptoms, duration of illness, secondary complications, hospitalizations and consumption of antibiotics. Patients have also shown a more rapid return to everyday activities. The therapeutic efficacy is highly dependent on the time between the onset of symptoms and the starting of therapy. Very early initiation is primordial to have a maximal effect. Neuraminidase inhibitors are also effective in primary and secondary prophylaxis during epidemic influenza. They are a key point in the pandemic preparedness. Resistance to neuraminidase inhibitors does occur but has not become an extensive problem so far.

[Tuberculous lymphadenitis]

We report a case of a 49-year-old woman from the Philippines, who has been living for many years in Switzerland, with chronic unilateral swelling of the cervical lymphnodes. After the serological exclusion of several microorganisms, a fine needle aspiration was performed without conclusive result. However, patient history and a strongly positive PPD skin test were highly suspicious for tuberculous lymphadenitis, which was finally confirmed by lymphnode biopsy on histopathological and cultural workup. Therefore tuberculostatic treatment was initiated for 6 months.

[Update on tuberculosis: interferon-gamma assays]

Until recently, skin testing with purified protein derivative of tuberculin was the only practical way of detecting latent tuberculosis infection (LTBI). However, the tuberculin skin test (TST) is subject to considerable variations and other limitations. PPD is a mixture of more than 200 mycobacterial antigens also present in nontuberculous mycobacteria and in the Bacille Calmette-Guérin (BCG) vaccine strains. Therefore false-positive testing results were common. Recently, peripheral blood-derived T-cell interferon-gamma responses to M.tuberculosis-specific antigens have been investigated for the management of tuberculosis. The results suggest that interferon-gamma assays may have advantages over the TST, in terms of higher specificity, better correlation with exposure to M.tuberculosis, and less cross-reactivity due to BCG vaccination and non-tuberculous mycobacterial infection. Furthermore, the interferon-gamma assays are less subject to reader bias and error and can be accomplished after a single patient visit. However, there is inadequate evidence on the value of interferon-gamma assays in the management of immunocompromised individuals for whom an alternative assay to the TST would be of great value.

[Therapy-refractory arterial hypertension in a young patient]

We report on a 41-year-old patient admitted for refractory arterial hypertension that had developed after a curative chemotherapy regimen due to seminoma stadium IIb four years ago. After exclusion of secondary forms of arterial hypertension (actually unsuccessfully treated with 5 different antihypertensive drugs) we performed a controlled medication intake-trial in our outpatient clinic. 90 minutes after taking the pills the patient complained of dizziness and perspiration while hypotension and bradycardia were measured simultaneously. Due to the difficult psychosocial situation (conflicts with the insurance and in the family, financial problems) and the suspected narcisstic personality disorder the issue of the proven malcompliance was not openly discussed in order to preserve the patient-doctor alliance. The antihypertensive regimen was then reduced to a double regimen. In the second part of the article the most common reasons for refractory arterial hypertension, especially the problem of treatment malcompliance, are summarized.

[Urticaria and parasites: case report and general view over the most common pathogens of chronic urticaria]

Chronic urticaria is a disease with numerous aetiologies. In case of blood hypereosinophilia a parasitosis is probable an should be mentioned. Infections with echinococcus and helminths can cause IgE mediated release of histamine. Different cytokines are involved and lead to chronic urticaria as well. There are only a few case repoorts about chronic urticaria caused by amoebiasis. The transmission of amoebas is faeco oral and the pathogen can be detected with stool examinations or with testing of antigens or molecular methods. This case showed a remission of chronic urticaria after treatment of the amboebiasis with metronidazole and paromomycine. Therfore a direct causal connection of the amoebiasis and chronic urticaria can be assumed.

Is phosphorus recovery from waste water feasible?

Phosphorus (P) recovery from waste water must become a predominant goal of all countries to face the limited resources of this essential nutrient. The induced crystallisation of calcium phosphates straight from the waste water phase applying tobermorite-rich calcium silicate hydrate compounds (CSH) from the construction industry as the trigger material has proved to be a suitable method. Laboratory and semi-technical scale experiments were carried out in fixed bed, stirred reactor and expanded bed mode. P-loads of the crystallisation substrates of up to 13 wt-% total P (P-tot) (30 wt-% P2O5) were achieved. Recycling options of the generated products, both as substitute for phosphate rock in the phosphate industry and as a new fertiliser in agriculture, were demonstrated. Indicative operating and investment costs were estimated for conversion of conventional waste water treatment plants (WWTP) designed for nutrient removal and P-precipitation with iron and aluminium reagents to the proposed new crystallisation technology for simultaneous P-removal and P-recovery.

Hearing loss after discontinuing secondary prophylaxis for cryptococcal meningitis: relapse or immune reconstitution?

Relapse and immune reconstitution syndrome are difficult to distinguish in HIV-infected patients treated with antiretroviral therapy (ART). We report on a 26-year-old HIV-infected male (CDC C3) with hearing loss on the right side 2 months after discontinuing secondary prophylaxis for cryptococcal meningitis. CD4 cell counts had increased from 32/microl to stable counts > 200/microl for the preceding 6 months on ART but HIV replication was not fully suppressed (7,000 copies/ml). Magnetic resonance imaging identified lesions at the origin of the right cranial nerve VIII. Lumbar puncture revealed monocytic pleocytosis, slightly increased protein, but normal glucose and lactate levels, negative microbiological studies. Fluconazole was restarted and a new ART regimen was started in order to fully suppress HIV replication. Clinical and radiological signs were reversible during follow-up, and secondary prophylaxis was stopped after 6 months without adverse events. We review 26 published cases of cryptococcal infections with immune reconstitution syndrome and highlight the distinguishing features.

[Patient from Cameroon with recurrent, transient, itching swelling of arms and legs]

Wir berichten über eine 36-jährige, aus Kamerun stammende Patientin mit rezidivierenden, transienten Schwellungen an den Extremitäten verbunden mit starkem Juckreiz. Zudem Augensymtome mit zeitweiligem Gefühl, «als ob ein Wurm ihr Auge durchquere». Die weitere Diagnostik ergab ein Eosinophilie und die Filarienserologie war positiv, sodass die Verdachtsdiagnose einer Loiasis mit rezidivierenden Kalabarschwellungen bestätigt werden konnte. Der Mikrofilariennachweis im Blut und Urin gelang nicht, was wir auf die geringe Mikrofilariendichte zurückführten. Unter einer Einmaldosis Ivermectin (43 × 3 mg) war die Patientin in der Folge beschwerdefrei. Die Loiasis kommt vorwiegend im tropischen Regenwald Zentral- und Westafrikas vor und gehört zu den Filariosen. Die Übertragung erfolgt durch die tagaktive Chrysopsfliege. Die Krankheit verursacht meist keine erntshaften Schäden, führt jedoch in endemischen Gebieten zu chronischen Beschwerden. Eine medikamentöse Therapie ist mit Diethylcarbamazine, Ivermectin oder auch Albendazol möglich. Prävention erfolgt durch schützende helle Kleidung, Anwendung von Insektensprays und allenfalls präventive Therapie mit Diethylcarbamazine oder Ivermectin.

[Talc granulomatosis in poly-toxicomania with i.v. drug abuse]

Wir berichten über einen 48-jährigen Patienten mit einer Polytoxikomanie in der Vorgeschichte, der wegen Husten und intermittierend pleuritischen Schmerzen abgeklärt wurde. Bei mikronodulärem Verschattungsmuster in der CT-Thorax-Untersuchung Durchführung einer Bronchoskopie mit BAL und Biopsie. Histologisch Diagnosestellung einer Talkgranulomatose. Im Verlauf war der Patient wenig symptomatisch, sodass keine Therapie notwendig wurde. Bei der Talkgranulomatose handelt es sich um eine seltene Erkrankung, die vorwiegend bei Drogenabhängigen vorkommt und klinisch ein sehr breites Spektrum zeigt (asymptomatische bis fulminante Verläufe). Bei symptomatischen Patienten initial meist Anstrengungsdyspnoe und Husten. Differentialdiagnostisch müssen opportunistische Infektionen, atypische Pneumonien, aber auch Neoplasien in Betracht gezogen werden, sodass eine Bronchoskopie mit BAL und Biopsie notwendig ist. Wichtigste Therapiemassnahme ist das Sistieren des Drogenkonsums, obschon auch dann progrediente Fälle vorkommen. Ansonsten gibt es keine etablierte Therapie. Gewisse Erfolge mit Kortikosteroiden wurden beschrieben, doch fehlen randomisierte kontrollierte Studien.

CD4-guided scheduled treatment interruptions compared with continuous therapy for patients infected with HIV-1: results of the Staccato randomised trial

BACKGROUND

Stopping antiretroviral therapy in patients with HIV-1 infection can reduce costs and side-effects, but carries the risk of increased immune suppression and emergence of resistance.

METHODS

430 patients with CD4-positive T-lymphocyte (CD4) counts greater than 350 cells per muL, and viral load less than 50 copies per mL were randomised to continued therapy (n=146) or scheduled treatment interruptions (n=284). Median time on randomised treatment was 21.9 months (range 16.4-25.3). Primary endpoints were proportion of patients with viral load less than 50 copies per mL at the end of the trial, and amount of drugs used. Analysis was intention-to-treat. This study is registered at ClinicalTrials.gov with the identifier NCT00113126.

FINDINGS

Drug savings in the scheduled treatment interruption group, compared with continuous treatment, amounted to 61.5%. 257 of 284 (90.5%) patients in the scheduled treatment interruption group reached a viral load less than 50 copies per mL, compared with 134 of 146 (91.8%) in the continued treatment group (difference 1.3%, 95% CI-4.3 to 6.9, p=0.90). No AIDS-defining events occurred. Diarrhoea and neuropathy were more frequent with continuous treatment; candidiasis was more frequent with scheduled treatment interruption. Ten patients (2.3%) had resistance mutations, with no significant differences between groups.

INTERPRETATION

Drug savings with scheduled treatment interruption were substantial, and no evidence of increased treatment resistance emerged. Treatment-related adverse events were more frequent with continuous treatment, but low CD4 counts and minor manifestations of HIV infection were more frequent with scheduled treatment interruption.

Immunological recovery and antiretroviral therapy in HIV-1 infection

Potent antiretroviral therapy has dramatically improved the prognosis of patients infected with HIV-1. Primary and secondary prophylaxis against Pneumocystis carinii, Mycobacterium avium, cytomegalovirus, and other pathogens can be discontinued safely once CD4 cell counts have increased beyond pathogen-specific thresholds. Approximately one-third of individuals receiving antiretroviral therapy will not reach CD4 cell counts above 500 cells per muL after 5 years despite continuous suppression of plasma HIV-1 RNA. Whether this failure represents a risk factor for the long-term incidence of opportunistic diseases--eg, tuberculosis or malignancies--remains uncertain. We describe the time course of CD4 cell concentrations in patients whose plasma HIV-1 RNA is durably suppressed by antiretroviral therapy, in patients with incomplete suppression of plasma HIV-1 RNA, and during treatment interruptions. In addition, immune reconstitution disease, an inflammatory syndrome associated with immunological recovery occurring days to weeks after the start of antiretroviral therapy, is briefly described.

[Icteric course of Epstein-Barr virus infection]

Wir berichten über eine 37-jährige Patientin mit Ikterus, erhöhten Leber- und Cholestaseparametern und Exanthem. Als Ursache fand sich eine Epstein-Barr-Virus-Infektion, die bei Erwachsenen seltener das klassische Bild des Pfeiffer'schen Drüsenfiebers (Angina tonsillaris/Pharyngitis, Lymphknotenschwellung, Fieber) aufweist. Häufig stehen bei Erwachsenen Fieber, Hepatomegalie und Ikterus im Vordergrund. Die Therapie ist symptomatisch, die Prognose der Erkrankung ist gut.

Phosphorus removal and recovery from wastewater by tobermorite-seeded crystallisation of calcium phosphate

Investigations were focused on the development of a technology for phosphorus (P) recovery straight from wastewater. Facing the finiteness of the natural resources of this essential nutrient, the declared goal must be the sustainable use of available phosphorus sinks such as wastewater treatment plants (WWTP) for the generation of P rock substitutes. A feasible method for simultaneous elimination and recovery of phosphorus from wastewater proved to be the P-RoC process - the phosphorus recovery from wastewater by induced crystallisation of calcium phosphate, applying tobermorite-rich waste compounds of the construction industry. The experiments were performed in fixed bed-, stirred- and expanded bed reactors in laboratory--as well as in pilot-scale experiments. The efficiency and longevity of the P-RoC process was determined by the supply of Ca ions and the initial P concentration. Total P (P-tot) contents in the generated crystallisation products of up to 13% P-tot (30% P2O5) were achieved. Mineralogical investigations proved the formation of a hydroxy-apatite-(HAP)-like coating onto the seed material's surface. Reuse options for the generated crystallisation products, such as substitute for phosphate rock or as new fertiliser, were assessed.

[Souvenirs from vacation. Rocky Mountain spotted fever]

Eine 37-jährige Patientin stellt sich nach der Rückkehr von einer Rundreise durch Nordamerika mit einem Status febrilis seit zehn Tagen und einem makulösem extremitätenbetontem Exanthem seit einem Tag vor. Bei suggestiver Klinik und Besuch der Rocky Mountains wird ein Rocky Mountain spotted fever diagnostiziert. Die Serologie für Rickettsia conorii, die mit Rickettsia rickettsii kreuzreagiert, war positiv und bestätigte die klinische Diagnose. Allerdings konnte der beweisende vierfache Titeranstieg, möglicherweise wegen spät abgenommener ersten Serologie, nicht nachgewiesen werden. Nach zweiwöchiger antibiotischer Therapie mit Doxycycline waren Status febrilis und Exanthem regredient.

Der Wurm in der Lunge

Die Lunge kann bei einer Vielzahl von Helminthiasen beteiligt sein. Sie ist entweder das Habitat der Würmer oder die pulmonalen Symptome sind Folge der Passage von Helminthenlarven während deren Reife- und Migrationsprozess im menschlichen Organismus. Entsprechend vielfältig und unspezifisch können bei einer pulmonalen Helminthiase die klinischen Symptome sein. Die klassische Trias von respiratorischen Symptomen, Eosinophilie im peripheren Blut und Infiltrate im Thorax-Röntgenbild ist nur eine der vielen möglichen Manifestationen. Es gibt kaum pathognomonische Zeichen, die sich spezifisch einer Helminthiase zuordnen lassen. Bei klinischem Verdacht kann mit einer detaillierten Anamnese das in Frage kommende Erregerspektrum eingegrenzt werden. Die Diagnose einer Helminthiase erfolgt entweder durch direkten Erregernachweis oder indirekt mit serologischen Methoden.

Meta-analysis: accuracy of rapid tests for malaria in travelers returning from endemic areas

BACKGROUND

Microscopic diagnosis of malaria is unreliable outside specialized centers. Rapid tests have become available in recent years, but their accuracy has not been assessed systematically.

PURPOSE

To determine the accuracy of rapid diagnostic tests for ruling out malaria in nonimmune travelers returning from malaria-endemic areas.

DATA SOURCES

The authors searched MEDLINE, EMBASE, CAB Health, and CINAHL (1988 to September 2004); hand-searched conference proceedings; checked reference lists; and contacted experts and manufacturers.

STUDY SELECTION

Diagnostic accuracy studies in nonimmune individuals with suspected malaria were included if they compared rapid tests with expert microscopic examination or polymerase chain reaction tests.

DATA EXTRACTION

Data on study and patient characteristics and results were extracted in duplicate. The main outcome was the likelihood ratio for a negative test result (negative likelihood ratio) for Plasmodium falciparum malaria. Likelihood ratios were combined by using random-effects meta-analysis, stratified by the antigen targeted (histidine-rich protein-2 [HRP-2] or parasite lactate dehydrogenase [LDH]) and by test generation. Nomograms of post-test probabilities were constructed.

DATA SYNTHESIS

The authors included 21 studies and 5747 individuals. For P. falciparum, HRP-2-based tests were more accurate than parasite LDH-based tests: Negative likelihood ratios were 0.08 and 0.13, respectively (P = 0.019 for difference). Three-band HRP-2 tests had similar negative likelihood ratios but higher positive likelihood ratios compared with 2-band tests (34.7 vs. 98.5; P = 0.003). For P. vivax, negative likelihood ratios tended to be closer to 1.0 for HRP-2-based tests than for parasite LDH-based tests (0.24 vs. 0.13; P = 0.22), but analyses were based on a few heterogeneous studies. Negative likelihood ratios for the diagnosis of P. malariae or P. ovale were close to 1.0 for both types of tests. In febrile travelers returning from sub-Saharan Africa, the typical probability of P. falciparum malaria is estimated at 1.1% (95% CI, 0.6% to 1.9%) after a negative 3-band HRP-2 test result and 97% (CI, 92% to 99%) after a positive test result.

LIMITATIONS

Few studies evaluated 3-band HRP-2 tests. The evidence is also limited for species other than P. falciparum because of the few available studies and their more heterogeneous results. Further studies are needed to determine whether the use of rapid diagnostic tests improves outcomes in returning travelers with suspected malaria.

CONCLUSIONS

Rapid malaria tests may be a useful diagnostic adjunct to microscopy in centers without major expertise in tropical medicine. Initial decisions on treatment initiation and choice of antimalarial drugs can be based on travel history and post-test probabilities after rapid testing. Expert microscopy is still required for species identification and confirmation.

[The treatment of urinary tract infections--an update]

Wie bei vielen Infektionskrankheiten ist auch bei den Harnwegsinfektionen die optimale Dauer der Antibiotikatherapie nicht abschliessend geklärt. Zum Thema wurde eine Vielzahl klinischer Studien von unterschiedlicher Qualität publiziert. Die unterdessen vorliegende Evidenz belegt, dass bei einem unkomplizierten Harnwegsinfekt eine drei- (bis sieben)-tägige Therapie optimal ist. Liegt ein komplizierter Harnwegsinfekt vor, scheint eine vierzehntägige Therapie bisher am besten zu sein. Als Antibiotika der Wahl haben sich Cotrimoxazol und Chinolone erwiesen. Sie weisen im Vergleich zu b-Lactam-Antibiotika eine höhere Eradiaktionsrate und eine geringere Rezidivrate auf.

Phosphate elimination and recovery from wastewater by active filtration using crushed gas concrete

Laboratory long-term upstream fixed-bed experiments were carried out to investigate the efficiency of phosphorus elimination with the effluent of a biological sewage treatment plant using crushed gas concrete. The development of the pH-value in the column outflow as well as the reaction kinetics was investigated. Furthermore, the phosphorus yield was balanced for phosphorus recovery and the calcium phosphate compounds generated were specified by mineralogical analysis methods. These activities were followed by a study with respect to the suitability of the material as raw material for the phosphate industry.

Meta-analysis of randomized controlled trials of simplified versus continued protease inhibitor-based antiretroviral therapy in HIV-1-infected patients

OBJECTIVE

To evaluate the efficacy and safety of simplified maintenance therapy (SMT) compared with continued protease inhibitor (PI) therapy.

DESIGN

Meta-analysis of nine randomized controlled trials in which 833 patients were switched to SMT (abacavir, efavirenz or nevirapine) and 616 continued PI, assessing virologic failure (primary outcome), discontinuation of therapy for reasons other than virologic failure, CD4 cell count, total plasma cholesterol and triglycerides.

RESULTS

The risk ratio for virologic failure for SMT compared to continued PI was 1.06 [95% confidence interval (CI) 0.58-1.92; test for homogeneity P = 0.01] for SMT, 2.56, (95% CI, 1.17-5.64) for abacavir, 0.83 (95% CI, 0.36-1.91) for efavirenz and 0.54 (95% CI, 0.29-1.02) for nevirapine. The risk ratio for premature discontinuation of therapy with SMT was 0.61 (95% CI, 0.48-0.77; test for homogeneity P < 0.10). The difference in absolute mean cholesterol for SMT compared to continued PI was -0.15 mmol/l, (95% CI, -0.40 to 0.09; test for homogeneity P < 0.01) for SMT, -0.51 mmol/l (95% CI, -0.70 to -0.33) for abacavir, 0.22 mmol/l (95% CI, 0 to 0.43) for efavirenz and -0.19 mmol/l (95% CI, -0.48 to 0.09) for nevirapine.

CONCLUSIONS

Current evidence suggests that SMT with abacavir rather than continued PI increases the risk of virologic failure, this increased risk may be confined to patients with prior mono or dual therapy with reverse transcriptase inhibitors. There is not enough evidence on whether SMT with efavirenz and nevirapine influences the risk of virologic failure. SMT with any of the three drugs reduces the risk of discontinuation of therapy, and SMT with abacavir reduces plasma cholesterol.

[32-year-old refugee from Angola with pulmonary coin lesion. Tuberculoma, pulmonary tuberculosis]

Anhand einer Fallbeschreibung werden die verschiedenen Abklärungsschritte bei einem neu entdeckten pulmonalen Rundherd bzw. multiplen Lungenrundherden besprochen. Schwerpunktmässig wird im Kommentar die Diagnostik bei unklaren pulmonalen Rundherden/multiplen Lungenrundherden mit Abwägung zwischen «wait and see» versus invasives Vorgehen eingegangen.

[53-year-old patient with over 38 degrees C fever over 3 weeks and generalized exanthema]

Anhand einer Fallbeschreibung werden epidemiologische, diagnostische und therapeutische Aspekte der Zytomegalievirusinfektion besprochen. Schwerpunktmässig werden im Kommentar die Diagnostik bzw. Abklärungsschritte bei «Fever of unknown origin» (FUO) beleuchtet. Im Weiteren wird die Abschätzung des Zeitfensters, in der eine Infektion durch EBV-, CMV- oder Toxoplasmose erfolgte, anhand der Avidität erklärt.

[Lymphadenopathy]

Lymphadenopathy is a very common problem that affects patients of all ages. Differential diagnosis is extensive, in general lymph nodes that have been present for longer than 1 month and measure more than 1 x 1 cm should be considered for further examinations, including laboratory testing and biopsy for histological and microbiological examinations.