Non-primary CMV infection not always innocent. A case-report and literature review

OBJECTIVES

Cytomegalovirus (CMV) is the most common infectious cause of congenital malformations. CMV infections are frequently symptomatic in case of a primary infection during pregnancy. Generally, maternal immunity protects the newborn against a symptomatic course of the CMV infection.

METHODS

We present clinical information and medical images of a neonate with non-primary congenital CMV infection.

RESULTS

We report the case of a severe congenital infection in a newborn clinically presenting with diffuse petechia, facial dysmorphisms, respiratory distress, hepatomegaly and hypotonia. The girl was born to a mother with CMV immunity. Blood results demonstrated thrombocytopenia and elevated transaminases. Brain MRI revealed ventricular dilatation and germinolytic cysts, compatible with CMV infection. Auditory brain stem response testing was abnormal. CMV culture of saliva was positive. This led to the diagnosis of a severe congenital CMV infection due to a non-primary maternal infection. Antiviral treatment with valganciclovir was initiated immediately and continued for 6 months.

CONCLUSION

Our case illustrates that, even when the mother was demonstrated CMV immune, congenital CMV infection is still an important differential diagnostic consideration in neonates presenting with congenital cerebral abnormalities, thrombocytopenia and/or hearing loss.

ABBREVIATIONS

ABR: auditory brainstem responses; CMV: Cytomegalovirus; CPAP: Continuous Positive Airway Pressure; CRP: C-Reactive Protein; dBnHL: Decibel Above Normal Adult Hearing Level; IV: intravenously; MRI: Magnetic Resonance Imaging; SGA: Small for Gestational Age; SNHL: Sensorineural Hearing Loss.

Process evaluation of care scale up for hypertension in diabetes in Belgium, Slovenia and Cambodia

Background

Effective integrated care interventions for hypertension (HT) and type 2 diabetes (T2D) exist and need to be scaled-up. The ‘SCale-Up diaBetes and hYpertension care' SCUBY project aims to facilitate scale-up of integrated care for HT and T2D through the implementation of contextualised scale-up roadmaps in Cambodia, Slovenia and Belgium and co-creation in policy dialogues. We herewith describe the plan for the process and scale-up evaluation of the SCUBY project, including the development, adoption and implementation of the roadmaps. The specific goals of the process evaluation are to (i) analyse how the reality of scale-up adheres to the developed roadmaps and (ii) assess how the different contexts can influence the implementation process of the scale-up strategies.

Methods

A comprehensive framework was developed to include context, process, scale-up and impact evaluation that is embedded in implementation and political theory. A diverse range of mostly qualitative tools - including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping - will be used to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. Key implementation outcomes include acceptability, feasibility relevance, adaptation, adoption and cost of roadmap activities. The role of context is relevant, and barriers and facilitators to scale-up will be continuously assessed.

Conclusions

The SCUBY project presents a comprehensive framework to guide the evaluation of scale-up of complex interventions. We describe three contextualised roadmaps, for Belgium, Slovenia and Cambodia, each adopting their own (horizontal/diversification/vertical) scale-up strategy(ies) as a basis to monitor adaptations through a co-creation process. This study protocol will be a guide for other scale-up interventions making use of knowledge translation and co-creation activities.

Key messages

Process evaluation is needed to keep track of complex interventions including scale up. The SCUBY project developed an evaluation plan to comprehensively monitor the scale-up of HT and T2D care.

A policy analysis of the chronic care policies in Belgium

Introduction

Chronic diseases form the largest burden of disease in European countries. Redesign of health systems towards chronic integrated care is needed, with more collaboration between first and second line, between medical and social services and support to prevention and self-management. What are the levers for change in such health systems? This study addresses this knowledge gap, through a policy analysis of barriers and facilitators for change towards chronic integrated care.

Methods

26 central level stakeholders were selected, based upon their influence in regulation and policy, financing, health care provision and community representation. Semi-structured face-to-face interviews were held covering assessment of past and current policies and implementation, barriers and opportunities for change.

Results

Reforms have taken place, such as the stimulation of local initiatives for chronic integrated care projects and the set-up of local care councils. Most stakeholders assessed the current Belgium's implementation of integrated care as low, despite a growing awareness for the need for change. A context factor often mentioned to constrain implementation was a state reform which led to a partial decentralization, fragmentation of decision power and a division of healthcare competences between federal and federated levels. Other barriers were the current financing system, the lack of investments in new models of care and the vested interests of providers.

Discussion

This analysis shows that chronic care reform in Belgium is constrained by partial decentralization of primary health care, and by the financing system and vested interests. It points to the need for coordination of health policy making and implementation. Disentangling the levels of decision-making and the financial leverage at these levels gives insights for change and change management, for the Belgium health system and other countries with a strong decentralized system.

Key messages

The current Belgium’s implementation of integrated care was assessed as low, due to different contexts factors such as division of health care competencies between different governmental levels. In a country as Belgium with a strong decentralized health care system coordination of health policy making and implementation is key in order to scale up integrated care for chronic diseases.

Psychiatry Trainees' Attitudes, Knowledge, and Training in Addiction Psychiatry-A European Survey

Background: Although psychoactive substance use disorders (PSUDs) are a domain of mental health, addiction psychiatry is only formally recognized as a subspecialty in a few European countries, and there is no standardized training curriculum. Methods: A 76-item questionnaire was developed and disseminated through an online anonymous data-collecting system and hand-to-hand amongst psychiatric trainees from the 47 European countries of the Council of Europe plus Israel and Belarus. Results: 1,049/1,118 psychiatric trainees from 30 European countries completed the questionnaire. Fifty-nine-point nine percent of trainees stated to have training in addictions. Amongst the trainees who described having training in addictions, 43% documented a not well-structured training and 37% an unsatisfactory training, mainly due to poor acquired knowledge. Overall, 97% of trainees stated that addiction represents a core curriculum for their training. Overall, general adult psychiatric trainees reported a better knowledge in addictions, compared to trainees in child and adolescent psychiatry. Conclusion: Despite a growing spread of PSUDs in European countries, addiction psychiatry is a relatively poorly trained field within psychiatry training programs. Further research should investigate reasons for poor training and timings of the educational activities to optimize experiential education training in addiction psychiatry.

Quench, Normal Zone Propagation Velocity, and the Development of an Active Protection Scheme for a Conduction Cooled, R&W, MgB2 MRI Coil Segment

The development of coils that can survive a quench is crucial for demonstrating the viability of MgB₂-based main magnet coils used in MRI systems. Here we have studied the performance and quench properties of a large (outer diameter: 901 mm; winding pack: 44 mm thick × 50.6 mm high) conduction-cooled, react-and-wind (R&W), MgB₂ superconducting coil. Minimum quench energy (MQE) values were measured at several coil operating currents (I _op ), and distinguished from the minimum energy needed to generate a normal zone (MGE). During these measurements, normal zone propagation velocities (NZPV) were also determined using multiple voltage taps placed around the heater zone. The conduction cooled coil obtained a critical current (I _c ) of 186 A at 15 K. As the operating currents (I _op ) varied from 80 A to 175 A, MQE ranged from 152 J to 10 J, and NZPV increased from 1.3 to 5.5 cm/s. Two kinds of heater were involved in this study: (1) a localized heater ("test heater") used to initiate the quench, and (2) a larger "protection heater" used to protect the coil by distributing the normal zone after a quench was detected. The protection heater was placed on the outside surface of the coil winding. The test heater was also placed on the outside surface of the coil at a small opening made in the protection heater. As part of this work, we also developed and tested an active protection scheme for the coil. Such active protection schemes are of great interest for MgB₂-based MRIs because they permit exploitation of the relatively large MQE values of MgB₂ to enable the use of higher J _e values which in turn lead to competitive MgB₂ MRI designs. Finally, the ability to use a quench detection voltage to fire a protection heater as part of an active protection scheme was also demonstrated.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium

Key messages

Innovative strategies are needed to scale up integrated chronic care for non-communicable diseases. The SCUBY project develops, implements and assesses roadmaps for the scale-up of an integrated chronic care package for hypertension and diabetes.

Xeroderma pigmentosum – Fakten und Perspektiven

Die Nukleotid-Exzisions-Reparatur (NER) ist für die Beseitigung von ultraviolett (UV) -induzierten DNA-Schäden und damit zur Vermeidung von Hautkrebs essenziell. Menschen mit einem genetischen Defekt in der NER, Xeroderma pigmentosum (XP) -Patienten, sind äußerst sonnenempfindlich. Sie entwickeln bereits in den ersten Lebensjahren Zeichen der vorzeitigen Hautalterung mit einem deutlich erhöhten Risiko zur Entwicklung von UV-induzierten kutanen Karzinomen. DNA-Reparaturdefektsyndrome werden vorrangig in der Klinik diagnostiziert und auf molekularer Ebene bestätigt. Für die seltene, rezessiv vererbte Erkrankung XP steht zum jetzigen Zeitpunkt leider noch keine kausale Therapie zur Verfügung, weshalb eine frühe Diagnosestellung umso bedeutsamer ist. Durch frühzeitige sowie konsequente UV-protektive Maßnahmen und eine regelmäßige Überprüfung der Haut im Zuge der Hautkrebsfrüherkennung werden sowohl die Prognose als auch Krankheitsverlauf maßgeblich verbessert.

Molekulare Mechanismen der kutanen Photokarzinogenese: ein Update

UV-Strahlung gilt als primäre Ursache der Photokarzinogenese und trägt somit zur Entwicklung von kutanen Hautkrebsentitäten wie Plattenepithelkarzinom, Basalzellkarzinom und Melanom bei. Durch UV-Strahlung entstehen einerseits typische DNA-Photoprodukte und andererseits indirekte DNA-Schäden durch reaktive Sauerstoffspezies. UV-bedingte DNA-Schäden werden durch die Nukleotid-Exzisions-Reparatur behoben, die somit der Bildung von Mutationen und der Hautkrebsentwicklung entgegenwirkt. Durch Mutationen werden Tumorsuppressorgene inaktiviert und wachstumsfördernde Signalwege aktiviert, die die normale Zellzyklusprogression stören. Abhängig von der jeweilig zugrunde liegenden Hautkrebsentität, sind bestimmte Gene häufiger betroffen als andere. Basalzellkarzinome weisen häufig Patched- oder Smoothened-Mutationen auf, die den Sonic hedgehog-Signalweg beeinflussen. Plattenepithelkarzinome zeigen vermehrt TP53-Mutationen. Weitere Mutationen umfassen den epidermalen Wachstumsfaktorrezeptor, RAS, FYN und CDKN2A. In Melanomen konnten vor allem UV-induzierte Mutationen in TP53 und CDKN2A nachgewiesen werden. Zudem tragen UV-induzierte Entzündungsprozesse zur Photokarzinogenese bei. Neuere Studien konnten einen Einfluss von Zitrusfruchtkonsum, Alkoholkonsum, Hormonersatztherapien und oralen Kontrazeptiva auf die Photokarzinogenese feststellen. Präventive Maßnahmen gegen UV-bedingte Karzinogenese beinhalten den adäquaten Gebrauch von Sonnenschutz und regelmäßige Hautkrebsvorsorgeuntersuchungen.

First Measurement of Electron Neutrino Appearance in NOvA

We report results from the first search for ν_{μ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Parallel transmit excitation at 1.5 T based on the minimization of a driving function for device heating

PURPOSE

To provide a rapid method to reduce the radiofrequency (RF) E-field coupling and consequent heating in long conductors in an interventional MRI (iMRI) setup.

METHODS

A driving function for device heating (W) was defined as the integration of the E-field along the direction of the wire and calculated through a quasistatic approximation. Based on this function, the phases of four independently controlled transmit channels were dynamically changed in a 1.5 T MRI scanner. During the different excitation configurations, the RF induced heating in a nitinol wire immersed in a saline phantom was measured by fiber-optic temperature sensing. Additionally, a minimization of W as a function of phase and amplitude values of the different channels and constrained by the homogeneity of the RF excitation field (B1) over a region of interest was proposed and its results tested on the benchtop. To analyze the validity of the proposed method, using a model of the array and phantom setup tested in the scanner, RF fields and SAR maps were calculated through finite-difference time-domain (FDTD) simulations. In addition to phantom experiments, RF induced heating of an active guidewire inserted in a swine was also evaluated.

RESULTS

In the phantom experiment, heating at the tip of the device was reduced by 92% when replacing the body coil by an optimized parallel transmit excitation with same nominal flip angle. In the benchtop, up to 90% heating reduction was measured when implementing the constrained minimization algorithm with the additional degree of freedom given by independent amplitude control. The computation of the optimum phase and amplitude values was executed in just 12 s using a standard CPU. The results of the FDTD simulations showed similar trend of the local SAR at the tip of the wire and measured temperature as well as to a quadratic function of W, confirming the validity of the quasistatic approach for the presented problem at 64 MHz. Imaging and heating reduction of the guidewire were successfully performed in vivo with the proposed hardware and phase control.

CONCLUSIONS

Phantom and in vivo data demonstrated that additional degrees of freedom in a parallel transmission system can be used to control RF induced heating in long conductors. A novel constrained optimization approach to reduce device heating was also presented that can be run in just few seconds and therefore could be added to an iMRI protocol to improve RF safety.

Efficacy of vaccination against Actinobacillus pleuropneumoniae in two Belgian farrow-to-finish pig herds with a history of chronic pleurisy

The efficacy of an Actinobacillus pleuropneumoniae subunit vaccine based on ApxIA, ApxIIA, ApxIIIA and OMP-2 (Porcilis App, MSD) was investigated in two farrow-to-finish pig herds (A and B) affected by chronic pleurisy. In total, 1161 pigs were included. At three weeks of age, the pigs were randomly allocated to non-vaccinated control (NV; n=580) and vaccinated (V; n=581) groups. At 6 and 10 weeks of age, pigs were injected with Porcilis-APP (V group) or adjuvant (NV group). At slaughter (26 weeks), pleurisy and pneumonia lesions were assessed. All pigs were weighed individually at 6 and 26 weeks of age, and average daily weight gain (ADG; g/pig/day) was calculated. Mortality and days of additional treatment (DAT) were registered during the whole experiment. Data were analysed using binary logistic regression or analysis of variance for proportions or continuous variables, respectively. The prevalence of pleurisy and pneumonia was (NV-A=19.3, V-A=7.9, (P=0.000); NV-B=17.9, V-B=0.7, (P=0.000)) and (NV-A=42.4, V-A=21.2, (P=0.000); NV-B=46.7, V-B=19.0, (P=0.000)), respectively. The ADG was NV-A=632±157, V-A=647±91, (P=0.162); NV-B=660±115, V-B=670±82, (P=0.232). The mortality during the experiment was NV-A=5.7, V-A=1.8, (P=0.015); NV-B=2.3, V-B=1.0, (P=0.170) per cent. The DAT was: NV-A=15.04±1.41, V-A=14.95±0.67, (P=0.010); NV-B=21.68±2.43, V-B=16.99±0.62, (P=0.000). The present study showed a significant reduction of the prevalence of pleurisy and pneumonia, and antimicrobial use in V pigs from both herds, and in mortality in V pigs from one herd.

Determination des metabolites monoester de butylbenzyl-phthalate (bbp) par gcms dans les urines de personnes exposees: analysis of the monoester metabolites of butylbenzyl phthalate by gc-ms in urine of exposed workers

A method of analysis was developed to determine free and glucuronated monobutyl phthalate (BuP) and monobenzyl phthalate (BeP) in urine for the assessment of exposure of man to butylbenzyl phthalate (BBP) in the workplace and in the environment. This method has also been applied in pharmacokinetic studies in experimental animals and the determination in urine of exposed workers. Urine samples are first subjected to enzymatic hydrolysis with ß-glucuronidase to enable the measurement of the total amount of monophthalates excreted. A fraction of the hydrolysate is used for further analysis. Monohexyl phthalate is added as an internal standard and the hydrolysed urine extracted with a n-hexane/ dichloromethane mixture after acidification and saturation with salt. The organic fractions are washed, dehydrated and evaporated. The residue is methylated by means of diazomethane dissolved in diethylether, evaporated and further purified by extraction into n-hexane from an alkaline buffer. The organic fractions are evaporated and the residue redissolved in acetonitrile for analysis by ion trap GC-MS equipped with a 50 m apolar WCOT capillary column. TIC mass chromatograms are recorded from which SIM chromatograms can be derived electronically. The m/z values used are 91, 149, and 163 which provide a sufficient sensitive response and which are specific enough to pick up the methylated monophthalates under investigation. The quantitative limit of detection (LOQ) is 60 μg/L for BuP and BeP when using the Magnum ion Trap detector and 3 μg/L when using the Polaris Q in the splitless mode. The calibration curve in urine is linear from 120 μg/L to 50,000 μg/L with a coefficient of variation of less than 10 % . In case of the Polaris Q linearity started from 10 μg/L. The recovery of the method is monitored by the response signal of the internal standard in the ion chromatogram. In the event of insufficient recovery the analysis is repeated. Variations in recovery are compensated by the internal standard of which the molecular structure is very similar to the ones of the monophthalates under investigation.