A combined analysis of double-blind studies with risperidone vs. placebo and other antipsychotic agents: factors associated with extrapyramidal symptoms

Combined data from double-blind risperidone studies were used to analyse the severity of extrapyramidal symptoms (EPS) associated with treatment in patients with chronic schizophrenia. Factors associated with maximum EPS severity were increasing risperidone dose (< or = 8 mg/day was similar to placebo), lower baseline EPS scores, and longer duration of psychotic symptoms, particularly in older patients. EPS severity was significantly greater in patients receiving haloperidol or other antipsychotics than in those receiving risperidone (4 to 8 mg/day) or placebo. Antiparkinsonian medications were required by significantly fewer patients treated with risperidone (4 to 8 mg/day) than by patients treated with haloperidol or other antipsychotics. Combined efficacy data showed that 4 to 8 mg/day was also the most efficacious dose range; there was no increase in efficacy with doses over 4 mg/day. Based on these data and post-marketing experience, 4 mg/day is an appropriate initial target dose for most patients with schizophrenia. Higher doses may be appropriate for patients with chronic illness, and lower doses may be appropriate for patients with a first psychotic episode or for elderly patients.

Surveillance of human Yersinia enterocolitica infections in Belgium: 1967-1996

Between 1967 and 1996, > 18,700 strains of Yersinia species, excluding Yersinia pestis, were recovered in Belgium from a variety of gastrointestinal and extraintestinal sites in patients. Full identification and serotyping were performed by the two Belgian reference laboratories. Yersinia enterocolitica serogroup O:3 predominated (79.4% of strains), followed by serogroup O:9 (11.1%). The remaining 9.5% of isolates belonged to serogroups and related species generally considered nonpathogenic. Acute enterocolitis was the most common clinical form of Y. enterocolitica infection, affecting primarily children younger than 5 years of age. Since 1967, there was a steady increase in isolations every year, with 305 cases in 1975 and up to 1,469 in 1986. From 1987 on, there was a clear decrease in the number of reported cases, although the number of participating laboratories and culture techniques remained constant. This significant decrease in the occurrence of Y. enterocolitica infections may be explained by changes in the slaughtering procedures and eating habits of the population.

Antimicrobial resistance and serotypes of Shigella isolates in Kigali, Rwanda (1983 to 1993): increasing frequency of multiple resistance

The serotype distribution and susceptibility to nine antibiotics was determined for 2491 Shigella isolates cultured in the medical laboratory of the Centre Hospitalier de Kigali, Rwanda, during 1983 to 1993. Overall, Shigella flexneri was the most frequent species, ranking before Shigella sonnei, Shigella boydii, and Shigella dysenteriae. However, the relative frequency of the different Shigella spp. showed an important variability over time. S flexneri increased from 40% in 1983 to 68% of the isolates in 1993 whereas S. dysenteriae Type 1 decreased gradually from 30 to 0.5% of the isolates in 1992. After the outbreak of severe civil unrest, which caused the displacement of many people to the capital, a new epidemic of dysentery started in the Kigali area and S. dysenteriae Type 1 accounted again for 24% of the isolates in 1993. In 1983, resistance to tetracycline, streptomycin, and sulfonamides was common among the endemic Shigella spp. Resistance to chloramphenicol was observed in 17% (30/182) of the isolates. Only 10% were resistant to ampicillin and an equal proportion to trimethoprim, whereas 5% of the isolates showed resistance to both products. By 1993, 66% (195/295) of the isolates were resistant to chloramphenicol (for comparison with 1983, p < 0.001), 70% (207/295) to ampicillin (p < 0.001), 67% to trimethoprim (p < 0.001), and 58% had combined resistance to the latter two drugs (p < 0.001). Resistance patterns differed strongly by species, S. flexneri being more frequently resistant than S. sonnei. In 1983, all S. dysenteriae Type 1 isolates were resistant to ampicillin, chloramphenicol, tetracycline, and sulfonamides. Trimethoprim resistance increased from 31% (25/80) in 1983 to 96% (26/27) of the isolates in 1986 (p < 0.001). After the introduction of nalidixic acid as an alternative for trimethoprim-sulfamethoxazole, trimethoprim resistance decreased to 87%, during 1987 to 1992, and subsequently to 68% of the isolates in 1993. However, 20% of the isolates became resistant to nalidixic acid in 1993. Ampicillin and trimethoprim-sulfamethoxazole are no longer useful for the empirical treatment of shigellosis in Rwanda.

Management of acute steroid-resistant rejection after liver transplantation

Prior to the FK506 era, OKT3 was primarily used for treatment of steroid-resistant rejection. Initially FK506 has been used as a last treatment of refractory acute or chronic rejection. We provide strong evidence that the use of FK506 is more successful if rescue therapy is performed early instead of using it as the last resort. Between September 1988 and March 1995 a total of 600 liver transplantations were performed in 550 patients. Of these 550 patients, 426 received primarily cyclosporine A (CsA)-based immunosuppression. Of the 426 CsA patients, 70 (16.4%) required either FK506 (51.4%), or OKT3 rescue therapy (27.1%), or a combination of the two drugs (21.5%). The latter group of patients received first OKT3 and then FK506 rescue when OKT3 therapy failed. Treatment was initiated simultaneously (within 1 week) in 11 patients, and 4 patients received FK506 rescue later during the course of rejection. The highest success rates (88.9%) were observed in patients given FK506 rescue therapy. Retransplantation was necessary more often in patients receiving OKT3 than in those with FK506 rescue therapy (15.8% versus 5.5%, respectively). Retransplantation and death due to chronic rejection increased with the need for additional FK506 rescue therapy after OKT3 failure. This increase was most pronounced in patients receiving FK506 during the late course of rejection, reaching a failure rate of 75.0% (50. 0% of deaths were due to chronic rejection). The lowest incidence of cytomegalovirus infection and of infectious, neurologic, and renal complications was observed in the FK506 rescue group. We conclude that early FK506 rescue therapy may be the treatment of choice for acute steroid-resistant rejection.

Hepatitis C: indication for anti-viral therapy?

Hepatitis C infection is a frequent indication for liver transplantation. In general, recurrent graft hepatitis is assumed to be mild, but may be the cause of lethal postoperative complications in a small patient population. Out of 500 transplants in 458 patients, 123 patients were transplanted due to hepatitis C infection (26.7%) between September 1988 and April 1994. Cumulative 1- to 6-year patient survival was similar for patients transplanted due to hepatitis C (87.0%) and those transplanted for other indications (86.0%). In patients with hepatitis C virus (HCV), death, in 50% of the cases, was related to HCV recurrence and chronic rejection. Four patients (25.0%) died because of severe infection and multiple organ failure syndrome unrelated to HCV recurrence and chronic rejection. The incidence of retransplantation was similar in HCV (9.8%) and other patients (8.4%). In HCV patients, 6 of 12 retransplantations (50.0%) were performed due to HCV recurrence and chronic rejection. Of 123 HCV patients, 45 experienced histologically proven recurrent graft hepatitis between 2 weeks and 5.5 years after transplantation. The incidence of acute rejection was similar in both groups. The incidence of steroid-resistant rejection was, however, higher in HCV patients (29.3%) than in those transplanted for other indications (14.5%; P < or = 0.05). Furthermore, there was a significant association between acute rejection and the development of recurrent graft hepatitis. In conclusion, patients with hepatitis C may be transplanted with as good patient and graft survival rates as patients transplanted for other indications. However, the combination of recurrent graft hepatitis and chronic rejection remains the most limiting factor for some of these patients, which strengthens the necessity for a specific anti-viral therapy.

Mycobacterial infection after liver transplantation

Tuberculosis occurred in 5 (1.2%) of 462 liver transplant recipients. De novo infection was assumed in 4 patients and a recurrent infection in 1. The clinical courses varied, from asymptomatic open lung tuberculosis to disseminated disease with cerebral tuberculoma and convulsions. Four patients survived with anti-tuberculous triple-drug therapy. Very few cases of tuberculosis after liver transplantation have been reported (4 patients in the medical literature and 5 patients in this paper). However, the incidence, course of infection, and outcome seem to be similar to those of tuberculosis in renal transplant recipients, approximately 150 cases of which are known.

Fungal infections in liver transplant recipients

A retrospective analysis of 462 consecutive orthotopic liver transplantations was undertaken to evaluate incidence, risk factors, clinical course, and outcome of fungal infections. Infections involving Aspergillus (6 cases), Candida (5 cases), Mucor (1 case), and Cryptococcus (1 case) were observed in 2.8% (13/462) of our patients. Twelve of the 13 episodes developed during the first 2 postoperative months. None of the potential risk factors for fungal infections described by other authors (i.e., age, rejection treatment, dialysis, mechanical ventilation, graft failure, long operation time, second transplant, serious non-fungal infection) correlated significantly with the episodes in our patients. However, in patients who exhibited three or more of these potential risk factors the incidence of fungal infections was elevated (P < 0.001). Six of seven exogenous infections (Aspergillus, Mucor) began before July 1991 when our department moved from Charlottenburg to Wedding, thus indicating that the incidence of these infections is highly influenced by exposure (P = 0.01). Exposure prophylaxis should therefore by meticulously followed, particularly when severely compromised patients are involved, in order to prevent exogenous infections (i.e., Aspergillus/Mucor). Infections involving such patients are combined with a very high mortality (57%). We observed Candida infection as a pathological overgrowth of physiological oropharynx flora into the esophagus and/or trachea in five patients. In each case treatment led to full recovery.

Xenogeneic ex vivo hemoperfusion of rhesus monkey livers with human blood

This model of completely isolated ex vivo hemoperfused RM livers reflects immunologic effects of donor organs and the humoral blood components of the recipient. The reaction between the isolated organ and recirculating blood allows us to concentrate on effects and products liberated under such a selected but limited situation. The slight influence of used materials on the monitored parameters in the circuit is of no importance. The massive release of TNF alpha, IL-1 beta, IL-6, IFN gamma, and 6kPGF1 alpha between 15 and 60 minutes after reperfusion was the specific result of xenoperfusion. IL-2 increases after 60 minutes. Soluble human IL-2R seems to be eliminated from the perfusate by the RM liver to about 50% of initial values. It increases again sharply beyond 180 minutes now originating from the RM liver. During the whole perfusion time, soluble HLA-I antigen and the detected adhesion molecules decrease to 50% of their initial values.

Comparison of quadruple immunosuppression after liver transplantation with ATG or IL-2 receptor antibody

Treatment with monoclonal IL-2 receptor antibodies has been successfully used for immunosuppressive induction therapy following organ transplantation in the recent past. The present study was conducted to compare for the first time a cyclosporine-based quadruple immunosuppressive regimen including a monoclonal IL-2 receptor antibody or ATG as induction therapy after orthotopic liver transplantation. In two groups of 33 patients each, postoperative survival, graft biopsies, liver function enzymes, and the clinical courses after OLT were evaluated. Our results indicate that monoclonal IL-2 receptor antibody therapy as part of a quadruple immunosuppressive regimen is better tolerated and is at least as effective as ATG in prevention of allograft rejection following OLT. Furthermore, our data indicate that a slightly better liver function in general and a lower incidence of rejection reactions necessitating treatment could be observed in the group of patients treated with the monoclonal IL-2 receptor antibody. This study provides evidence that monoclonal IL-2 receptor antibody therapy may be a useful tool for the immunosuppressive induction therapy following clinical orthotopic liver transplantation.

Widespread occurrence of multiple drug-resistant Salmonella typhi in India

Sixteen multiple drug resistant strains of Salmonella typhi belonging to Vi-phage types E1 (14) and O (2) and isolated in Southeast India in 1991 were characterized. All strains were resistant to chloramphenicol and the majority to trimethoprim and ampicillin. In all strains these resistances were encoded by plasmids of the H1 incompatibility group with molecular weights ranging from 110 to 120 megadaltons. Physicians in European countries should be aware that treatment may fail if patients with typhoid fever who have recently returned from the Indian sub-continent are given first-line treatment with chloramphenicol, trimethoprim or ampicillin. With the possible exception of young children, ciprofloxacin is currently the best choice for treatment of such patients.

Measuring quantity and frequency of drinking in a general population survey: a comparison of five indices

This article compares five indices of alcohol consumption in a general population survey conducted in 1985 in the Netherlands. Self-reports of consumption were obtained with a prospective diary, a retrospective 7-day recall method, and three summary measures, such as a quantity-frequency index. The coverage of sales data appeared highest for the diary (67%), which suggests a higher validity. Special attention was given to comparisons of quantity and frequency of drinking between the diary, on the one hand, and the weekly recall and summary measures, on the other. It was found that underreporting, relative to the diary reports, was generally higher in the frequency than in the quantity domain. This result, together with the finding from longitudinal studies that intraindividual variation is also higher for drinking frequency, leads to the conclusion that forgetting is a potent source of undercoverage in surveys and to the hypothesis that large differences in overall drinking pattern between populations (e.g., in regularity of drinking) may account for the large differences in coverage rates of sales data. Furthermore, the subjectively assessed probability of drinking by means of a "usual" frequency question appeared a poor predictor of (diary) drinking frequency for respondents reporting a low or moderate frequency. For subjects claiming a high "usual" drinking frequency, a reasonable correspondence between diary and summary measures was found. This mitigates the fear often expressed that heavy drinkers particularly underreport their consumption.

Quadruple immunosuppression including a new IL-2-receptor antibody and the incidence of infections after liver transplantation

Immunosuppression is a primary concern after orthotopic liver transplantation (OLT). On the one hand, the graft is at jeopardy through acute or chronic rejection, and on the other, immunosuppression and antirejection therapy increase the risk of infectious complications. Effective immunosuppression therefore should prevent rejections without leading to a high rate of infections, bearing in mind the fact that infections and infection-related complications are the most frequent causes of early death after liver transplantation. With more specific immunosuppression the infectious complications can potentially be minimized. Antithymocyte globulin (ATG) and the first monoclonal antibody OKT3 immunosuppression are non-specific. The replacement of these antibodies in a quadruple immunosuppressive regimen with the new monoclonal IL-2R antibody BT 563 probably reduces the early infection rate. We report on our first experience with BT 563. The incidence of infection was compared with a historical control group with ATG.

Pott's tuberculous spondylitis in Belgium 1990

A 23-year-old man is described with tuberculous spondylitis and paravertebral abscedation (Pott's disease). This is one of the rare cases of Pott's disease in a patient coming from industrialised Belgium, not belonging to one of the known risk groups such as intravenous drug users, immunodeficients or immigrants from southern countries. The epidemiology, differential diagnosis, complications and therapy are briefly discussed.

Extracorporeal lung assist with heparin-coated systems

Extracorporeal lung assist (ELA) has been recommended for the treatment of ARDS if conventional therapy fails. However, the need for nearly complete anticoagulation is a major risk factor for hemorrhagic complications. We describe our experience with 13 ARDS patients treated with ELA using heparin-coated systems (Carmeda). Maintaining partial thromboplastin time and activated clotting time within or close to the normal range, even major surgery (20 thoracotomies and 2 laparotomies) could be performed without undue bleeding complications related to anticoagulation during extracorporeal support. Eight of the 13 patients survived. The use of heparin-coated systems allows prolonged ELA with nearly physiological coagulation function, permitting major surgical intervention. It enhances the safety margin of extracorporeal gas exchange and may ultimately extend its indications.

Human Salmonella and Shigella infections in Moroni, the capital of Great Comoro Island (1987-1988)

Over a period of two years 98 cultures of Salmonella and 17 cultures of Shigella were isolated at the El Maarouf Hospital, Moroni, capital of the Comoros. Almost half of the isolates were from children under 5 years. Salmonella belonged to a limited range of serotypes, S. typhi dominating in adults and S. enteritidis in children, often with bacteraemia. Antibiotic resistance was virtually absent in Salmonella and without clinical significance in Shigella. The high isolation rate of S. enteritidis and the rarity of antibiotic resistance are commented.

[Generalized lymphangiomatosis. 25-year follow-up of a case of lymphangiomatosis]

Lymphangiomatosis is a rare systemic lymphatic malformation with intra- and extraosseous lesions. The etiology is poorly understood. Presented is the case of a patient with a generalized lymphangiomatosis manifested by cystic formations in many bones and a large cavernous lymph sac behind her sternum. Clinical, diagnostic, prognostic and therapeutic aspects are reviewed. The condition of the patient remained without complications for more than 25 years, except for two episodes of rather severe respiratory infections.

Weekly recall and dairy estimates of alcohol consumption in a general population survey

Diary and weekly recall measures of alcohol consumption in a representative sample (N = 399) of the Dutch population are compared. The weekly recall method consisted of a personal interview with questions about actual alcohol consumption on the previous 7 days. The diary consisted of 14 daily self-reports of consumption and followed the interview. The diary method yields estimates of consumption that are on average 22% higher than those based on weekly recall measures, reducing total undercoverage by about 11%. The difference between the two methods cannot be attributed to a variation of consumption over weeks but seems to stem from a difference in accuracy of recall. There was an increase in glasses underreported at the upper levels of consumption, but underreporting did not seem to be of a nonlinear nature. Considering the large individual variation in consumption over weeks, the ranking of individuals according to their self-reports is relatively stable across method.

[Salmonella bacteremia and generalized cryptococcosis, a double indicator of African AIDS]

A male Rwandese adult with proven A.I.D.S. died from generalized cryptococcosis six months after episodes of recurrent fever with isolation of Salmonella enteritidis from the blood culture. The authors discuss the frequent and precocious appearance of Salmonella septicaemia in patients with A.I.D.S. They propose the inclusion of nontyphoidal Salmonella bacteraemia in the provisional W.H.O. case definition of adult A.I.D.S. in countries with limited diagnostic resources.

Unusual in vivo rearrangements of the Y-chromosome in two males

In the present paper two male patients with dic Y-chromosomes are reported with special attention to the identical and peculiar Y-chromosome rearrangements. Different cell types with variable morphology of the rearranged Y-chromosomes were found in both patients.

Comparison of norfloxacin and nalidixic acid for treatment of dysentery caused by Shigella dysenteriae type 1 in adults

A severe epidemic of dysentery began late in 1979 in northeast Zaire and spread to Rwanda, Burundi, and Tanzania. The epidemic strain is a multiply resistant Shigella dysenteriae type 1, which acquired resistance against trimethoprim and more recently against nalidixic acid in the course of the epidemic. A comparative open trial in Rwandan adults with Shiga dysentery involved 18 patients treated with norfloxacin at 400 mg twice daily and 12 patients treated with nalidixic acid at 1 g three times daily for 5 days. All isolates showed in vitro susceptibility to both drugs. Though norfloxacin eliminated Shigella organisms from stools more rapidly than nalidixic acid, its clinical superiority did not reach the level of significance. Norfloxacin is a promising drug and is more effective than nalidixic acid in the treatment of multiresistant shigellosis.

Significance of Clostridium difficile and its cytotoxin in children

Stools of 147 children belonging to different age groups were examined for the presence of Clostridium difficile, its cytotoxin and other enteric pathogens. None of the 31 full-term neonates, 5 (16%) of the 32 premature neonates, 27 (46%) of the 59 infants and 1 (4%) of the 25 older children excreted C. difficile in their stools. Faecal cytotoxin was only detected in four infants (7%). There was no correlation with diarrhoea, previous antibiotic therapy, type of diet, or the concomitant presence of other intestinal pathogens. We conclude that colonisation of the intestine by C. difficile is probably acquired from environmental sources and that it cannot be regarded as a significant cause of diarrhoea in children.

Plasmid characterization of drug-resistant Shigella dysenteriae 1 from an epidemic in Central Africa

A widespread epidemic of severe dysentery in Zaire and neighbouring Central African countries was caused by a multiply drug-resistant strain of Shigella dysenteriae 1. Early isolations were resistant to ampicillin, chloramphenicol, streptomycin, sulphonamides and tetracyclines (R-type = ACSSuT). Later in the epidemic strains resistant to trimethoprim (Tm) became prevalent and a few strains resistant to kanamycin (K) or nalidixic acid were also isolated. All resistances except nalidixic acid were encoded by plasmids of incompatibility groups X (ACT) or I1 (ACSSuTTm) and the epidemic strain also carried an SSu plasmid and a number of cryptic plasmids. The Inc X plasmid from this epidemic is the same as that in Sh. dysenteriae 1 strains isolated in Somalia in 1976 whereas the epidemic strains from the Shiga outbreaks in Central America, 1969 to 1971, and Sri Lanka, 1979, carried plasmids of group B. This epidemic demonstrates that when a multiresistant strain includes resistance to trimethoprim, nalidixic acid is a suitable alternative therapeutic agent.

Human Edwardsiellosis traced to ornamental fish

Protracted diarrhea in a 2-month-old Belgian infant was associated with Edwardsiella tarda as the only potential pathogen. The same organism was isolated from a tropical aquarium fish in the home of the patient. The enteropathogenic role of E. tarda and the role of fish as a reservoir of infection are reviewed. Additional observations, volunteer studies, and careful prospective surveys in tropical countries will be needed to produce firm evidence of the enteropathogenic potential of E. tarda.