[Quality criteria for health promotion and primary prevention measures in association with obesity in children and adolescents. A BZgA-coordinated expert consensus]

On behalf of the Federal Ministry of Health, a working group coordinated by the Federal Center for Health Education (BZgA) compiled quality criteria for health promotion and primary prevention measures in association with obesity in children and adolescents that are applicable both to population-wide and to target group-specific measures. The criteria are intended to support the planning of new measures and the conceptual improvement of existing measures. Additional elements are the assessment of programs for financing purposes and the rendering of accounts to funding agencies, as well as the acquisition of further knowledge. The criteria, thus, address not only project developers and providers, but also multipliers who implement measures, as well as funding agencies, who can use the criteria as a basis for assessing the measures. The structure of the quality criteria is geared to the fundamental structure of the Public Health Action Cycle. In addition, resource orientation, participation and, above all, organizational development are important aspects associated with quality that have not been given adequate consideration to date. The quality criteria are applicable to all situation-based and behavioral prevention measures, and also development processes that focus on promoting the health and normal weight development of children and adolescents.

Leukoencephalomalacia and Laminar Neuronal Necrosis Following Smoke Inhalation in a Dog

Acute respiratory and neurologic disease after smoke inhalation are well documented, but human patients may also develop delayed-onset neurologic symptoms associated with leukoencephalomalacia after exposure to smoke or carbon monoxide. In this case, a dog developed progressive neurologic signs 6 days after rescue from an apartment fire. At necropsy 9 days after smoke inhalation, leukoencephalomalacia of the central cerebral white matter was accompanied by laminar necrosis of cerebrocortical neurons. This is the first report of delayed posthypoxic leukoencephalopathy in a nonhuman animal.

How to search and harvest the medical literature: let the citations come to you, and how to proceed when they do

BACKGROUND

There is a virtual avalanche of medical information available to clinicians and researchers. The traditional 'search' can be substantially augmented by proactive 'harvesting.'

AIMS

To describe how to search and harvest the medical literature.

MATERIALS & METHODS

Survey of selected resources available on the internet.

RESULTS

PubMed remains the backbone of the traditional literature search. The availability of automated delivery of electronic tables of contents ('eTOCs'), electronic feeds of targeted search results, and workflow tools allows relevant articles to find the reader. Electronic storage and retrieval tools make it possible to manage this information and make day-to-day clinical and research activities more efficient.

DISCUSSION

Searching and harvesting the medical literature is made easier with the advent of the internet and email. In addition, there are internet resources that screen and filter potential articles of interest. Managing one's electronic library of PDF documents requires attention to appropriately naming files and the use of indexing programs.

CONCLUSION

In addition to readers searching for relevant citations, these citations themselves can be searching for readers. Clinicians and researchers can take advantage of this and efficiently harvest the medical literature with a modest investment of time.

Science journal editors' views on publication ethics: results of an international survey

BACKGROUND

Breaches of publication ethics such as plagiarism, data fabrication and redundant publication are recognised as forms of research misconduct that can undermine the scientific literature. We surveyed journal editors to determine their views about a range of publication ethics issues.

METHODS

Questionnaire sent to 524 editors-in-chief of Wiley-Blackwell science journals asking about the severity and frequency of 16 ethical issues at their journals, their confidence in handling such issues, and their awareness and use of guidelines.

RESULTS

Responses were obtained from 231 editors (44%), of whom 48% edited healthcare journals. The general level of concern about the 16 issues was low, with mean severity scores of <1 (on a scale of 0-3) for all but one. The issue of greatest concern (mean score 1.19) was redundant publication. Most editors felt confident in handling the issues, with <15% feeling "not at all confident" for all but one of the issues (gift authorship, 22% not confident). Most editors believed such problems occurred less than once a year and >20% of the editors stated that 12 of the 16 items never occurred at their journal. However, 13%-47% did not know the frequency of the problems. Awareness and use of guidelines was generally low. Most editors were unaware of all except other journals' instructions.

CONCLUSIONS

Most editors of science journals seem not very concerned about publication ethics and believe that misconduct occurs only rarely in their journals. Many editors are unfamiliar with available guidelines but would welcome more guidance or training.

[Efficacy and safety of probiotics]

Probiotics are bacteria or fungi, which modulate pathogenic growth and invasion of the bowel. The most frequently used are Lactobacillus and Saccharomyces cerevisiae. They are widely used as dietary supplements or for the treatment and prevention of various types of diarrhoea. Probiotics are generally considered as safe, but some cases of invasive infections have been described in different patient populations. This article reviews the literature about the indications and risks of probiotics, especially in immunocompromised patients.

Long-term endurance exercise decreases antiangiogenic endostatin signalling in overweight men aged 50-60 years

BACKGROUND

Endurance training may decrease the risk of coronary artery disease. It has been speculated that these effects may be due to an exercise-induced stimulation of angiogenesis. The underlying mechanisms are not yet clear. Therefore, using ELISA, we investigated the plasma level of vascular endothelial growth factor (VEGF, angiogenic factor) and endostatin (antiangiogenic factor) in a group of untrained men aged 50-60 years with obesity.

METHODS

All men were randomised into a "running" group (training 3 times/week, 60 min each, n = 7), a "cycling" group ( training 3 times/week, 90 min each, n = 7) and a sedentary control group ( n = 7). Both training groups worked at moderate intensity (2-4 mmol/l lactate). The intervention had a duration of 6 months. Before and after this period, blood samples were taken from the participants at rest and they underwent a medical investigation.

RESULTS

Body mass index (BMI), systolic and diastolic blood pressure, and plasma levels of VEGF and endostatin were comparable in all three groups. Endurance training significantly reduced BMI in both exercise groups (mean (SEM) before v after 29.7 (0.7) v 29.1 (0.6) kg/m2 and 31.1 (0.7) v 30.1 (0.9) kg/m2 for the running and cycling groups respectively) but not in the control group (30.0 (1.0) v 30.2 (0.8) kg/m2). Endurance training did not influence VEGF plasma level (before v after 1.3 (0.4) v 1.5 (0.2) ng/ml for the running group; 1.6 (0.3) v 1.5 (0.2) ng/ml for the cycling group; and 2.5 (0.6) v 2.1 (0.7) ng/ml for the control group). Plasma level of endostatin was significantly reduced in both exercise groups (mean (SEM) before v after: 20.9 (1.6 v 17.5 (1.0) ng/ml and 21.3 (1.4 v 18.0 (1.6) ng/ml for the running and cycling groups respectively) but not in controls (19.7 (1.3 v 17.7 (1.1 ng/ml).

CONCLUSIONS

Endurance training may reduce the antiangiogenic mechanisms in men aged 50-60 years by reducing endostatin plasma level and this may subsequently decrease the risk of cardiovascular disease.

No evidence of association between genetic variants of the PDCD1 ligands and SLE

PDCD1, an immunoreceptor involved in peripheral tolerance has previously been shown to be genetically associated with systemic lupus erythematosus (SLE). PDCD1 has two ligands whose genes are located in close proximity on chromosome 9p24. Our attention was drawn to these ligands after finding suggestive linkage to a marker (gata62f03, Z=2.27) located close to their genes in a genome scan of Icelandic families multiplex for SLE. Here, we analyse Swedish trios (N=149) for 23 single nucleotide polymorphisms (SNPs) within the genes of the PDCD1 ligands. Initially, indication of association to eight SNPs was observed, and these SNPs were therefore also analysed in Mexican trios (N=90), as well as independent sets of patients and controls from Sweden (152 patients, 448 controls) and Argentina (288 patients, 288 controls). We do not find support for genetic association to SLE. This is the first genetic study of SLE and the PDCD1 ligands and the lack of association in several cohorts implies that these genes are not major risk factors for SLE.

Melanoma cultures show different susceptibility towards E1A-, E1B-19 kDa- and fiber-modified replication-competent adenoviruses

Replicating adenovirus (Ad) vectors with tumour tissue specificity hold great promise for treatment of cancer. We have recently constructed a conditionally replicating Ad5 AdDeltaEP-TETP inducing tumour regression in a xenograft mouse model. For further improvement of this vector, we introduced four genetic modifications and analysed the viral cytotoxicity in a large panel of melanoma cell lines and patient-derived melanoma cells. (1) The antiapoptotic gene E1B-19 kDa (Delta19 mutant) was deleted increasing the cytolytic activity in 18 of 21 melanoma cells. (2) Introduction of the E1A 122-129 deletion (Delta24 mutant), suggested to attenuate viral replication in cell cycle-arrested cells, did not abrogate this activity and increased the cytolytic activity in two of 21 melanoma cells. (3) We inserted an RGD sequence into the fiber to extend viral tropism to alphav integrin-expressing cells, and (4) swapped the fiber with the Ad35 fiber (F35) enhancing the tropism to malignant melanoma cells expressing CD46. The RGD-fiber modification strongly increased cytolysis in all of the 11 CAR-low melanoma cells. The F35 fiber-chimeric vector boosted the cytotoxicity in nine of 11 cells. Our results show that rational engineering additively enhances the cytolytic potential of Ad vectors, a prerequisite for the development of patient-customized viral therapies.

[Integrated Health Care in cardiology]

Integrated Health Care forces rethinking of all partners. Health care providers need to cooperate and have to face an emerging competition among themselves. Health insurance companies are no longer the common enemy, but a business partner on an individual basis. Rethinking has already commenced. The Barmer insurance company has initiated a considerable number of similar contracts with respect to Integrated Health Care in cardiology. One of the first contracts was agreed upon at Recklinghausen (it is reported later in this volume) and a couple of them have been concluded in the Berlin/Brandenburg region (which are also reported in this volume).A special feature is the support for the general disease management programs that have been initiated in light of the new laws beginning in 2000. The Barmer company will enroll some 500,000 patients with coronary artery disease in these programs.

Endothelial Function in the Forearm Circulation of Patients with the Metabolic Syndrome – Effect of Different Lipid-Lowering Regimens

We compared the effect of statin therapy (either alone or combined with ezetimibe) on the inhibition of cholesterol resorption and endothelial function by measuring forearm blood flow in male patients with the metabolic syndrome. Compared to 40 mg atorvastatin alone, combination therapy with 10 mg ezetimibe and 10 mg atorvastatin for 8 weeks resulted in significantly decreased total serum cholesterol and triglycerides levels (n = 14). Endothelium-dependent, acetylcholine-mediated vasodilation was significantly better with combination therapy (p < 0.05). In contrast, endothelium-independent forearm blood flow response to sodium nitroprusside was comparable in both groups. Our data suggest a more effective restoration of endothelial function with the statin/ezetimibe combination compared to statin monotherapy in patients with the metabolic syndrome.

Sonographische Verlaufskontrollen bei palpablen soliden, wahrscheinlich gutartigen Brustläsionen (BI-RADSTMKategorie III)

PURPOSE

To determine whether palpable non-calcified solid breast masses with benign morphology on ultrasound can be classified as probably benign and whether these lesions fulfill the criteria required for BI-RADS (TM) category III.

MATERIALS AND METHODS

This analysis includes 78 patients with 80 palpable non-calcified solid masses that were classified as probably benign at initial sonography. Of 78 patients, 66 had periodic imaging surveillance (2 - 8 years, mean 4.6 years). The remaining 12 patients had a biopsy after initial imaging.

RESULTS

In the 64 patients under surveillance, palpable lesions remained stable at follow-up. In 2 patients lesions increased in size during follow-up and no malignancy was diagnosed at subsequent open biopsy. In 19 of the 66 patients, 29 additional nonpalpable lesions of similar morphology were detected on ultrasound. No malignancy was diagnosed in the 12 patients, who had a biopsy after initial imaging.

CONCLUSION

Our data suggest that palpable non-calcified solid breast masses with benign morphology on ultrasound can be classified as probably benign (BI-RADS (TM) category III). Biopsy can be averted when lesions remain stable at follow-up.

Correlation between BMI, leisure habits and motor abilities in childhood (CHILT-project)

INTRODUCTION

The prevalence of childhood obesity is increasing with its negative medical and psychosocial consequences. This paper examines the association between body mass index (BMI), motor abilities and leisure habits of 668 children within the CHILT (Children's Health InterventionaL Trial) project.

METHOD

A total of 668 children (51.0% boys; 49.0% girls) and their parents were questioned on sport and leisure behaviour of the children. The anthropometric data were measured. Motor abilities were determined by a body gross motor development test for children (Köperkoordinationstest für Kinder; KTK) and a 6-min run.

RESULTS

The children were 6.70 +/- 0.42 y old, 122.72 +/- 5.36 cm tall and weighed 24.47 +/- 4.59 kg, the average BMI was 16.17 +/- 2.27 kg/m2. KTK showed an average motor quotient (MQ) of 93.49 +/- 15.01, the 6-min run an average of 835.24 +/- 110.87 m. Both tests were inversely correlated with BMI (KTK and BMI r=-0.164 (P<0.001); 6-min run and BMI r=-0.201 (P<0.001)); the group of overweight/obese children showed poorer results than the normal/underweight ones, even after adjustment for gender and age (in each case P<0.001). Children with the greatest extent of exercise achieve the highest MQ (P=0.035).

SUMMARY

Overweight/obesity is associated with a poorer body gross motor development and endurance performance. On the other hand, an active lifestyle is positively correlated with a better gross motor development in first-grade children. Therefore, to prevent the negative consequences of physical inactivity and overweight/obesity early intervention to support exercise and movement is recommended.

A novel attenuated replication-competent adenovirus for melanoma therapy

To generate a replication-competent adenovirus (Ad) with specificity for melanoma, we constructed a tissue-specific promoter restricting E1A expression to melanoma cells. The combination of four copies of a mouse tyrosinase enhancer element (TE) fused to the human tyrosinase promoter (TP) yielded up to 2000-fold higher luciferase reporter activity in tyrosinase-expressing melanoma cells than in nonmelanoma cells. Insertion of the composite TETP construct upstream of the E1A gene was combined with deleting as far as possible the intertwined endogenous Ad enhancer/promoter (EP). The resulting AdDeltaEP-TETP vector, also deleted for the E3 region, was found to replicate in tyrosinase-positive melanoma cells, such as SK-Mel23 as efficiently as wild-type Ad5, but at a more than 50-fold reduced level in nonmelanoma tumour cells and primary human cells. Injection of AdDeltaEP-TETP into xenotransplanted melanomas, but not into HeLa-derived tumours led to long-lasting tumour regression in nude mice. This AdDeltaEP-TETP virus might be useful for the treatment of accessible lesions in advanced melanoma patients.

Remitting seronegative symmetrical synovitis with pitting oedema: a study of 12 cases

Twelve patients with remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) were analysed. Eight of them had typical RS3PE without underlying disease, and four presented associated neoplasia. The first patients experienced an excellent response to low doses of prednisone, and they all achieved complete and permanent remission. The mean treatment duration was 18 months and the mean follow-up was 4.4 years. During the follow-up, none of these patients relapsed, had fever or general health deterioration, and hand and foot radiographs did not show erosion. One of them developed a panarteritis nodosa 6 years later. Four RS3PE patients had associated neoplasia. Two were with solid malignancies, and the other two presented haematological malignancies. In one of them RS3PE preceded the diagnosis of malignancy. The diagnosis of RS3PE in the other patients was subsequent to cancer. The first patients presented clinical characteristics suggestive of paraneoplastic RS3PE, and they had a poor response to corticosteroid therapy. Two patients died, and the rest of them had a complete response to surgical resection of the tumour or to chemotherapy. In general, idiopathic RS3PE patients do not show either general health deterioration or fever and they do respond to low doses of steroids (10 mg/day). We observed strong contrasts with the results obtained when treating RS3PE patients with associated neoplasia. In patients with RS3PE the presence of systemic symptoms along with resistance to low doses of corticosteroid therapy should alert the physician to the possible presence of malignancy.

Integrated effects of the vasodilating beta-blocker nebivolol on exercise performance, energy metabolism, cardiovascular and neurohormonal parameters in physically active patients with arterial hypertension

OBJECTIVE

The present study was designed to investigate the integrated effects of the beta-1-selective blocker with vasodilator properties, nebivolol, on systemic haemodynamics, neurohormones and energy metabolism as well as oxygen uptake and exercise performance in physically active patients with moderate essential hypertension (EH).

DESIGN AND METHODS

Eighteen physically active patients with moderate EH were included: age: 46.9 +/- 2.38 years, weight: 83.9 +/- 2.81 kg, blood pressure (BP): 155.8 +/- 3.90/102.5 +/- 1.86 mm Hg, heart rate: 73.6 +/- 2.98 min(-1). After a 14-day wash-out period a bicycle spiroergometry until exhaustion (WHO) was performed followed by a 45-min submaximal exercise test on the 2.5 mmol/l lactate-level 48 h later. Before, during and directly after exercise testing blood samples were taken. An identical protocol was repeated after a 6-week treatment period with 5 mg nebivolol/day.

RESULTS

Nebivolol treatment resulted in a significant (P < 0.01) decrease in systolic and diastolic BP and heart rate at rest and during maximal and submaximal exercise. Maximal physical work performance, blood lactate and rel. oxygen uptake (rel. VO(2)) before and after nebivolol treatment at rest and during maximal and submaximal exercise remained unaltered. Free fatty acid, free glycerol, plasma catecholamines, beta-endorphines and atrial natriuretic peptide (ANP) increased before and after treatment during maximal and submaximal exercise but remained unaltered by nebivolol treatment. In contrast, plasma ANP levels at rest were significantly higher in the presence of nebivolol, endothelin-1 levels were unchanged.

CONCLUSIONS

Nebivolol was effective in the control of BP at rest and during exercise in patients with EH. Furthermore, nebivolol did not negatively affect lipid and carbohydrate metabolism and substrate flow. The explanation for the effects on ANP at rest remain elusive. This pharmacodynamic profile of nebivolol is potentially suitable in physically active patients with EH.

ACE and angiotensinogen gene genotypes and left ventricular mass in athletes

BACKGROUND

Genetic factors may be important in modifying heart size due to long-term athletic training. The significance of polymorphisms of genes of the renin-angiotensin system in myocardial mass in a population of athletes participating in different disciplines is not known.

METHODS

The angiotensin I-converting enzyme gene insertion/deletion (I/D) polymorphism, angiotensinogen gene M235T polymorphism and angiotensin II type 1 receptor gene A1166C polymorphism were determined in 83 male Caucasian endurance athletes and associated with left ventricular mass.

RESULTS

No association with left ventricular mass was found for the polymorphisms of angiotensin I-converting enzyme gene I/D, angiotensinogen gene M235T and angiotensin II type 1 gene A1166C when studied separately. However, combined analysis of the angiotensin I-converting enzyme gene I/D polymorphism and angiotensinogen gene M235T polymorphism genotypes suggested an association with left ventricular mass (g m(-2)) (P = 0.023). Athletes with the angiotensin I-converting enzyme gene DD/angiotensinogen gene TT genotype combination had greater left ventricular mass compared with all other genotype combinations (179.8 +/- 26.1 g m(-2) vs. 145.2 +/- 27.3 g m(-2), P = 0.003).

CONCLUSIONS

These results suggest an association of combined angiotensin I-converting enzyme gene I/D polymorphism genotypes, and angiotensinogen gene M235T polymorphism genotypes with left ventricular hypertrophy due to long-term athletic training. A synergistic effect of angiotensin I-converting enzyme gene DD genotype and angiotensinogen gene TT genotype on left ventricular mass in endurance athletes appears to occur.

[Changes in penile blood flow during cycling--how does one prevent a decreased perfusion?]

BACKGROUND AND OBJECTIVES

An increased incidence of erectile dysfunction has been observed in cycling enthusiasts. Compression of the perineal region during cycling seems to cause decreased penile perfusion. The resulting hypoxaemia in the corpus cavernosum is associated with penile fibrosis, which leads in the long run to erectile dysfunction. This study set out to determine if cycling can cause changes in penile perfusion and, if so, what precautions can be taken to avoid any associated health hazards, including whether various saddle forms and designs might influence penile blood flow. COHORTS AND METHODS: In 100 healthy athletic men (aged 36 +/- 6.2 years) transcutaneous penile oxygen pressure (tpO (2)) at the glans penis was measured during cycling in different positions and with different types of saddle, using a modified Clark oxygen electrode.

RESULTS

The penile blood supply decreased significantly during cycling in a seated position. Cycling in a standing or reclining position (on a reclining bicycle) did not lead to any decrease in penile blood flow. Saddle width was the most important factor for ensuring adequate penile perfusion while cycling in a seated position.

CONCLUSION

This study demonstrates that changing from a seated to a standing position during cycling leads to a significant increase in penile perfusion. Therefore we suggest frequent changes from a seated to a standing position during cycling. Additionally we suggest taking sufficient breaks during prolonged and vigorous bike tours, in order to avoid any possible health hazards. Another, not yet widespread, alternative for avoiding a reduction in penile blood flow is cycling on a reclining bicycle.

[Preventing coronary heart disease by physical activity. How much exercise is necessary?]

The value of general measures, in particular physical exercise, for the prevention of cardiac disease has been unequivocally demonstrated. Meta-analyses done to investigate the preventive character of exercise have shown that the coronary risk of physically active persons is lower by a factor of 2 to 3. This reduction in risk is independent of the presence of other risk factors, and is not due to the better health awareness of those who are physically active. However, the amount or intensity of such training actually required remains uncertain. A number of studies report a protective effect only for intensive physical effort, while others claim a risk reduction independent of training intensity. In the last resort, however, any form of exercise is better than none at all, when it comes to lowering the coronary risk. Not only endurance sports, but also other types of sport, such as tennis, or daily activities, can be recommended.

Similarity and robustness of PET and SPECT binding parameters for benzodiazepine receptors

The single photon emission computed tomography (SPECT) radiotracer [123I]iomazenil is used to assess benzodiazepine receptor binding parameters. These measurements are relative indices of benzodiazepine receptor concentration (B'max). To evaluate the ability of such indices in accurately accessing the B'max the authors compared them with absolute values of B'max, measured using positron emission tomography (PET). The authors performed SPECT, PET, and magnetic resonance imaging (MRI) studies on a group composed of seven subjects. For SPECT studies, the authors administered a single injection of [123I]iomazenil and estimated the total and specific distribution volumes (DV(T SPECT), DV(S SPECT)) and the binding potential (BP) using unconstrained (BP(SPECT)) and constrained (BP(C SPECT)) compartmental models. For PET studies, the authors used a multiinjection approach with [11C]flumazenil and unlabeled flumazenil to estimate absolute values of receptor concentration, B'max, and some other binding parameters. The authors studied the correlation of different binding parameters with B'max. To study the robustness of the binding parameter measurements at the pixel level, the authors applied a wavelet-based filter to improve signal-to-noise ratio of time-concentration curves, and the calculated kinetic parameters were used to build up parametric images. For PET data, the B'max and the DV(PET) were highly correlated (r = 0.988). This confirms that it is possible to use the DV(PET) to access benzodiazepine receptor density. For SPECT data, the correlation between DV(SPECT) estimated using a two- and three-compartment model was also high (r = 0.999). The DV(T SPECT) and BP(C SPECT) parameters estimated with a constrained three-compartment model or the DV(T''SPECT) parameter estimated with a two-compartment model were also highly correlated to the B'max parameter estimated with PET. Finally, the robustness of the binding parameters allowed the authors to build pixel-by-pixel parametric images using SPECT data.

Systemic lupus erythematosus: mortality and survival in Argentina. A multicenter study

OBJECTIVE

To analyze the factors associated with mortality, survival and causes of death in patients with systemic lupus erythematosus (SLE) in Argentina.

PATIENTS AND METHOD

A series of 366 patients with SLE (45 men and 321 women), mean age 29 y (range 11-70 y) and mean disease duration 6 y, was evaluated from 1990 to 1998. A total of 57 clinical, serological and therapeutic variables were studied.

RESULTS

Five- and 10-year survival was 91% and 85% respectively. Forty four patients died (12%): 54% due to sepsis and 32% due to active SLE. Mortality risk factors included heart involvement CRR 3.82), hyperlipidemia (RR 2.72), renal damage (RR 2. 62), infections (RR 2.44), lung disease (RR 2.20) and myositis (RR 2. 07). High-dose prednisone (RR 3.4) or cyclophosphamide (RR 9.19) treatments increased the risk of sepsis (P=0.003) as a cause of death. However, corticosteroids, antimalarial agents and accumulated cyclophosphamide doses proved to be protective factors in overall mortality figures (RR <1).

CONCLUSIONS

The main risk factors of death in SLE were heart involvement, hyperlipidemia and renal damage. Treatment with steroids, antimalarial agents and cyclophosphamide improved survival. High-dose corticosteroids and cyclophosphamide were associated with sepsis as a cause of death.

Evaluation of the SOFA score: a single-center experience of a medical intensive care unit in 303 consecutive patients with predominantly cardiovascular disorders. Sequential Organ Failure Assessment

OBJECTIVE

To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score, the total maximum SOFA (TMS) score, and a derived variable, the deltaSOFA (TMS score minus total SOFA score on day 1) in medical, cardiovascular patients as a means for describing the incidence and severity of organ dysfunction and the prognostic value regarding outcome.

DESIGN

Prospective, clinical study.

SETTING

Medical intensive care unit in a university hospital.

PATIENTS

A total of 303 consecutive patients were included (216 men, 87 women; mean age 62 +/- 12.6 years; SAPS II 26.2 +/- 12.7). They were evaluated 24 h after admission and thereafter every 24 h until ICU discharge or death between November 1997 and March 1998. Readmissions and patients with an ICU stay shorter than 12 h were excluded.

MAIN OUTCOME MEASURE

Survival status at hospital discharge, incidence of organ dysfunction/failure.

INTERVENTIONS

Collection of clinical and demographic data and raw data for the computation of the SOFA score every 24 h until ICU discharge.

MEASUREMENTS AND MAIN RESULTS

Length of ICU stay was 3.7 +/- 4.7 days. ICU mortality was 8.3% and hospital mortality 14.5%. Nonsurvivors had a higher total SOFA score on day 1 (5.9 +/- 3.7 vs. 1.9 +/- 2.3, p < 0.001) and thereafter until day 8. High SOFA scores for any organ system and increasing number of organ failures (SOFA score > or = 3) were associated with increased mortality. Cardiovascular and neurological systems (day 1) were related to outcome and cardiovascular and respiratory systems, and admission from another ICU to length of ICU stay. TMS score was higher in nonsurvivors (1.76 +/- 2.55 vs. 0.58 +/- 1.39, p < 0.01), and deltaSOFA/total SOFA on day 1 was independently related to outcome. The area under the receiver-operating characteristic curve was 0.86 for TMS, 0.82 for SOFA on day 1, and 0.77 for SAPS II.

CONCLUSIONS

The SOFA, TMS, and deltaSOFA scores provide the clinician with important information on degree and progression of organ dysfunction in medical, cardiovascular patients. On day 1 both SOFA score and TMS score had a better prognostic value than SAPS II score. The model is closely related to outcome and identifies patients who are at increased risk for prolonged ICU stay.

Increased carriage of trimethoprim/sulfamethoxazole-resistant Streptococcus pneumoniae in Malawian children after treatment for malaria with sulfadoxine/pyrimethamine

Treatment of malaria with sulfadoxine/pyrimethamine and of presumed bacterial infections with trimethoprim/sulfamethoxazole (cotrimoxazole) was assessed to see if either increases the carriage of cotrimoxazole-resistant Streptococcus pneumoniae in Malawian children. Children <5 years old treated with sulfadoxine/pyrimethamine, cotrimoxazole, or no antimicrobial agent were enrolled in a prospective observational study. Nasopharyngeal swabs were taken before treatment and 1 and 4 weeks later. Pneumococci were tested for antibiotic susceptibility by broth microdilution. In sulfadoxine/pyrimethamine-treated children, the proportion colonized with cotrimoxazole-nonsusceptible pneumococci increased from 38.1% at the initial visit to 44.1% at the 4-week follow-up visit (P=.048). For cotrimoxazole-treated children, the proportion colonized with cotrimoxazole-nonsusceptible pneumococci increased from 41.5% at the initial visit to 52% at the 1-week follow-up visit (P=.0017) and returned to 41.7% at the 4-week follow-up. Expanding use of sulfadoxine/pyrimethamine to treat chloroquine-resistant malaria may have implications for national pneumonia programs in developing countries where cotrimoxazole is widely used.