[Recent psychophysical deterioration in the elderly patient: a potentially severe medical emergency. Assessment and attitudes]

An atypical presentation of diseases is common in the elderly patient. Also, a number of conditions in the elderly are commonly associated with deterioration of the functional status, that is, the independence level for daily life activities. This loss of autonomy occasionally calls the physicians attention, masking other symptoms. On the other hand, the high prevalence of social problems in the elderly adds a distorting element to the clinical evaluation of the patient. Four patients with a main complaint of recent physical and psychical deterioration are here reported. The complementary tests were inconclusive and patients were classified as social problems, thus posing the problem of home discharge. All patients were later demonstrated to have potentially severe conditions amenable to hospital admission (hypothyroidism, meningitis, arrhythmia, which prompted the implantation of a pacemaker, and digital intoxication). The recent loss of autonomy should be considered as a potentially severe medical emergency among the elderly. Failure to identify this problem may lead to minimizing the symptoms and overestimating the social problems, thus leading to inappropriate hospital discharges.

ELISA test to detect Chlamydophila pneumoniae IgG

A new ELISA test (Chlamydophila pneumoniae IgG, Vircell, Spain) to detect Chlamydophila pneumoniae IgG was evaluated. The micro-immunofluorescence (MIF) test was used as reference method. Chlamydia trachomatis and Chlamydophila psittaci elementary bodies were also assayed. Two hundred and sixteen sera were included in the study: 66 from patients with peripheral arterial occlusive disease (Panel 1), 68 from adults with pneumonia (Panel 2), 44 from healthy adults (Panel 3) and 38 from patients with a sexuality transmitted disease by C. trachomatis (Panel 4). In Panel 1, 51 sera (77%) had antibody titres between 32 and 128; 4 out of 15 sera with IgG titres < 32 were positive by ELISA test and 2 sera with 32 IgG titres were uncertain by ELISA; the remaining 60 sera were correctly classified, giving a 91% concordance between the techniques. In Panel 2, 55 sera (81%) had IgG titres between 32 and 512; 2 out of 13 sera with IgG titres < 32 were positive by ELISA and 2 sera with 32 titres were uncertain by ELISA; the remaining 64 sera were correctly classified, giving a 97% concordance. In Panel 3, 22 sera (50%) had IgG titres between 32 and 64; only 1 out of 22 sera with IgG titres < 32 was positive by ELISA, giving a 97% concordance between the techniques. In Panel 4, there were 24 (63%) negative, 10 (26%) uncertain and 4 (10%) positive results by ELISA, giving an 86% concordance. The C. pneumoniae ELISA test demonstrated 100% sensitivity and 85% specificity. The IgG ELISA test demonstrated a good concordance with the MIF test without the drawbacks associated with the latter assay. We conclude that the ELISA test could be an alternative to the MIF test.

[Abdominal pain and infection by the varicella-zoster virus following bone marrow transplant]

Infection by the varicella-zoster virus (VZV) is an important cause of morbidity and mortality in patients who have received a bone marrow transplantation (BMT), both autologue and alogenic. Infection is generally produced in the first post-transplant year and, in its disseminated form, it can show itself through abdominal pain that translates the visceral affectation, pain that can precede the appearance of the characteristic cutaneous lesions by days, making diagnosis difficult. The clinical case described belongs to a patient who, 10 months after a bone marrow transplant, showed an infection by varicella-zoster virus, manifested through abdominal pain due to hepatic affectation, with an interval of 2 days between the start of pain and the appearance of cutaneous lesions. The diagnosis and treatment of these patients is discussed.

Candida dubliniensis, a new fungal pathogen

There is a high interest in Candida species other than Candida albicans because of the rise and the epidemiological shifts in candidiasis. These emerging Candida species are favored by the increase of immunocompromised patients and the use of new medical practices, and m. Most oropharyngeal candidiasis can be foundare observed in those HIV-infected patients infected with human immunodeficiency virus (HIV). Candida dubliniensis is a recently described opportunistic pathogen that is closely related to C. albicans but differs from it with respect to epidemiology, certain virulence characteristics, and the ability to develop fluconazole resistance in vitro. C. dubliniensis has been linked to oral candidiasis in AIDS patients, although it has recently been associated to invasive disease. C. dubliniensis shares diagnostic characteristics with C. albicans, as germ tube- and chlamydospore-production, and it is generally misclassified as C. albicans by standard diagnostic procedures. Several recent studies have attempted to elucidate useful phenotypic and genotypic characteristics for separating both species. A large variety of methods have been developed with the aim of facilitating rapid and, accurate identification of this species. These have included differential chromogenic isolation platesculture media, direct immunological tests, and enhanced manual and automated biochemical and enzymatic panels. Chromogenic isolation media, as CHROMagar Candida, demonstrate better detection rates than traditional media, and allow the presumptive identification of C. dubliniensis by means of colony color (dark-green colonies). API 20 C AUX system is considered a reference method, but ID 32 C strip, the VITEK Yeast Biochemical Card and the VITEK 2 ID-YST system correctly identify most C. dubliniensis isolates, being the latter the most accurate. Spectroscopic methods, such as Fourier transformed-infrared spectroscopy, offer potential advantages. However, many authors consider that standard methods for differentiation of Candida species are time-consuming, often insensitive and can fail to distinguish C. dubliniensis. To overcome these low sensitivity, poor specificity and intolerable delay,drawbacks, molecular tools have been developed to discriminate C. dubliniensis, and particularly those based on the polymerase chain reaction. But, molecular tools prove difficult and too complex for routine use in the clinical laboratory setting and new developments are necessary. Moreover, an increased resistance to antifungal drugs has been described. Although preliminary studies indicate that most strains of C. dubliniensis are susceptible to antifungal agents, fluconazole-resistant strains have been detected. Furthermore, fluconazole-resistant strains are easily derived in vitro, showing an increased expression of multidrug resistance transporters, as MDR1.

Reduced CpG methylation is associated with transcriptional activation of the bone-specific rat osteocalcin gene in osteoblasts

Chromatin remodeling of the bone-specific rat osteocalcin (OC) gene accompanies the onset and increase in OC expression during osteoblast differentiation. In osseous cells expressing OC, the promoter region contains two nuclease hypersensitive sites that encompass the elements that regulate basal tissue-specific and vitamin D-enhanced OC transcription. Multiple lines of evidence indicate that DNA methylation is involved in maintaining a stable and condensed chromatin organization that represses eukaryotic transcription. Here we report that DNA methylation at the OC gene locus is associated with the condensed chromatin structure found in cells not expressing OC. In addition, we find that reduced CpG methylation of the OC gene accompanies active transcription in ROS 17/2.8 rat osteosarcoma cells. Interestingly, during differentiation of primary diploid rat osteoblasts in culture, as the OC gene becomes increasingly expressed, CpG methylation of the OC promoter is significantly reduced. Inhibition of OC transcription does not occur by a direct mechanism because in vitro methylated OC promoter DNA is still recognized by the key regulators Runx/Cbfa and the vitamin D receptor complex. Furthermore, CpG methylation affects neither basal nor vitamin D-enhanced OC promoter activity in transient expression experiments. Together, our results indicate that DNA methylation may contribute indirectly to OC transcriptional control in osteoblasts by maintaining a highly condensed and repressed chromatin structure.

Multiple sclerosis and human herpesvirus 6

BACKGROUND

A possible but as yet unproven relationship has been proposed between the onset or persistence of multiple sclerosis (MS) symptoms and herpesviruses, including, most recently, human herpesvirus 6 (HHV-6). A study was conducted to investigate the presence of HHV-6 DNA and the synthesis of antibodies against HHV-6, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) in serum and cerebrospinal fluid (CSF) of patients with MS.

MATERIALS AND METHODS

PCR and ELISA were used to detect HHV-6 DNA and specific antibodies against HHV-6, CMV and EBV in 211 samples (139 sera and 72 CSF). There were three groups of samples: group I, paired samples of serum and CSF from 41 MS patients; group II, paired samples of serum and CSF from 31 patients with neurological diseases other than MS (OND); group III, 67 serum samples from 27 different MS patients undergoing serologic follow-up.

RESULTS

No HHV-6 DNA was found in any sample. Group I sera showed elevated anti-HHV-6 IgG and IgA levels. In group II, anti-CMV IgG was detected in one CSF sample and anti-HHV-6 IgM in one serum sample. Group III sera showed high concentrations of anti-HHV-6 IgG, IgA and IgM.

CONCLUSION

Given the clinical implications of the presence of antibodies against HHV-6 in MS patients, a viral reactivation cannot be excluded as an environmental factor.

Metabolic changes in Brycon cephalus (Teleostei, Characidae) during post-feeding and fasting

Metabolic changes during the transition from post-feeding to fasting were studied in Brycon cephalus, an omnivorous teleost from the Amazon Basin in Brazil. Body weight and somatic indices (liver and digestive tract), glycogen and glucose content in liver and muscle, as well as plasma glucose, free fatty acids (FFA), insulin and glucagon levels of B. cephalus, were measured at 0, 12, 24, 48, 72, 120, 168 and 336 h after the last feeding. At time 0 h (the moment of food administration, 09.00 h) plasma levels of insulin and glucagon were already high, and relatively high values were maintained until 24 h post-feeding. Glycemia was 6.42+/-0.82 mM immediately after food ingestion and 7.53+/-1.12 mM at 12 h. Simultaneously, a postprandial replenishment of liver and muscle glycogen reserves was observed. Subsequently, a sharp decrease of plasma insulin occurred, from 7.19+/-0.83 ng/ml at 24 h of fasting to 5.27+/-0.58 ng/ml at 48 h. This decrease coincided with the drop in liver glucose and liver glycogen, which reached the lowest value at 72 h of fasting (328.56+/-192.13 and 70.33+/-14.13 micromol/g, respectively). Liver glucose increased after 120 h and reached a peak 168 h post-feeding, which suggests that hepatic gluconeogenesis is occurring. Plasma FFA levels were low after 120 and 168 h and increased again at 336 h of fasting. During the transition from post-feeding to fast condition in B. cephalus, the balance between circulating insulin and glucagon quickly adjust its metabolism to the ingestion or deprivation of food.

An evaluation of a polyantigenic ELISA to detect Epstein-Barr virus reactivation

The diagnostic reliability of the Enzygnost EBV test (DadeBehring, Germany) for the detection of IgG and IgA antibodies in the diagnosis of Epstein-Barr virus (EBV) recurrent disease was investigated. Of 81 serum samples examined there were fourteen asymptomatic patients without EBV infection, 46 with past EBV infection, and 21 patients with EBV reactivation. The Enzygnost EBV test was based on an enzyme-linked immunosorbent assay with a pool of viral antigens. The reliability of IgG at >650 IU/ml, and IgA for the diagnosis of reactivation or chronic persistent EBV infection gave 100% sensitivity, 83.3% and 98.3% specificity, respectively. The data indicated that the appearance of EBV IgA was associated with EBV reactivation together with clinical manifestations.

Interaction of the 1alpha,25-dihydroxyvitamin D3 receptor at the distal promoter region of the bone-specific osteocalcin gene requires nucleosomal remodelling

1alpha,25-Dihydroxyvitamin D3-mediated transcriptional control of the bone-specific osteocalcin (OC) gene requires the integration of regulatory signals at the vitamin D-responsive element (VDRE) and flanking tissue-specific sequences. The 1alpha,25-dihydroxyvitamin D3 receptor (VDR) is a member of the nuclear receptor superfamily and forms a heterodimeric complex with the receptor for 9-cis retinoic acid (RXR) that binds to the VDRE sequence. We have demonstrated previously that changes in chromatin structure at the VDRE region of the rat OC gene promoter accompany transcriptional enhancement in vivo, suggesting a requirement for chromatin remodelling. Here we show that the VDRE in the distal region of the OC gene promoter is refractory to binding of the VDR-RXR complex when organized in a nucleosomal context. Addition of the ligand 1alpha,25-dihydroxyvitamin D3 or the presence of other transcription factors, such as YY1 and Runx/Cbfa (core-binding factor alpha), which also bind to sequences partially overlapping or near the VDRE, is not sufficient to render the VDRE accessible. Thus the VDR-RXR, unlike other steroid receptors, such as glucocorticoid receptor, progesterone receptor and thyroid receptor, is unable to bind its target sequence within a nucleosomal context. Taken together these results demonstrate that nucleosomal remodelling is required for in vivo occupancy of binding sites in the distal region of the OC gene promoter by the regulatory factors responsible for 1alpha,25-dihydroxyvitamin D3-dependent enhancement of transcription.

Survey of blindness and visual impairment in Bioko, Equatorial Guinea

AIMS

This study was designed to estimate the prevalence of blindness and its main aetiologies in Bioko, an onchocerciasis endemic zone of Equatorial Guinea.

METHODS

Random sampling was applied, proportionally to population distribution into urban or rural areas. All the subjects underwent a basic eye examination by trained nurses. In the presence of any ocular affection or a visual acuity of less than 0.3, the subject was visited by the ophthalmologist. This visit included direct and indirect ophthalmoscopy, anterior segment examination with a slit lamp, and intraocular pressure recording. Blindness and visual impairment were defined by using the WHO criteria.

RESULTS

3218 subjects were screened, with a mean age of 34.1 (SD 21.6) years, ranging from 1 month to 102 years (median 34 years). The overall prevalence of blindness was 3.2% (95% CI: 2.6% to 3.9%). Unilateral blindness was present in 4.2%. Visual impairment was diagnosed in 200 patients (6.8%). More than 20% of the acuities inferior to 0.7 improved when explored with a pinhole. The main causes of blindness were cataracts (61.3%); macular affection (25.3%), optic atrophy (16%), and glaucoma (13.3%). Ocular onchocerciasis was detected in 12 cases (0.4%).

CONCLUSION

Ocular onchocerciasis was very uncommon in an area of high endemicity. Results also pointed at the lack of basic ophthalmologist eye care and optician resources in the island.

Cytoplasm of sea urchin unfertilized eggs contains a nucleosome remodeling activity

After fertilization the sea urchin sperm nucleus transforms into the male pronucleus which later fuses with the female pronucleus re-establishing the diploid genome of the embryo. This process requires remodeling of the sperm chromatin structure including the replacement of the sperm histones by maternally derived cleavage stage histone variants. In recent years, a group of protein complexes that promote chromatin-remodeling in an ATP-dependent manner have been described. To gain understanding into the molecular mechanisms operating during sea urchin male pronuclei formation, we analyzed whether chromatin-remodeling activity was present in unfertilized eggs as well as during early embryogenesis. We report that in the sea urchin Tetrapygus niger, protein extracts from the cytoplasm but not from the nucleus, of unfertilized eggs exhibit ATP-dependent nucleosome remodeling activity. This cytosolic activity was not found at early stages of sea urchin embryogenesis. In addition, by using polyclonal antibodies in Western blot analyses, we found that an ISWI-related protein is primarily localized in the cytoplasm of the sea urchin eggs. Interestingly, SWI2/SNF2-related proteins were not detected neither in the nucleus nor in the cytoplasm of unfertilized eggs. During embryogenesis, as transcriptional activity is increased an ISWI-related protein is found principally in the nuclear fraction. Together, our results indicate that the cytoplasm in sea urchin eggs contains an ATP-dependent chromatin-remodeling activity, which may include ISWI as a catalytic subunit.

Analysis and localization of epileptic events using wavelet packets

This article compares results obtained in previous studies using time-frequency representations (Wigner-Ville, Choi-Williams and Parametric) and the wavelet transform with those obtained with wavelet packet functions to show new findings about their quality in the analysis of ECoG recordings in human intractable epilepsy: data from 21 patients have been analyzed and processed with four types of wavelet functions, including Orthogonal, Biorthogonal and Non-Orthogonal basis. These functions were compared in order to test their quality to represent spikes in the ECoG. The energy based on the wavelet coefficients to different scales was also calculated. The best results were found with the biorthogonal-6.8 wavelet on 5-7 scales, which gave 0.92 sensitivity, but with a high percentage of false positives; this representation was highly correlated with spike events on time and duration. To improve these results we have studied the wavelet packet coefficients energy. We found that reconstruction wavelet packet coefficients at 4 and 9 nodes contain significant information to characterize the spike event. These nodes' reconstruction coefficients were multiplied and this product was highly correlated with spikes events on time and duration. With this procedure we improved the sensitivity up to 0.96 with the same biorthogonal-6.8 wavelet at four levels. With this technique we do not sacrifice computation time: 896 samples are processed at only 0.16 s, so that it is possible to show the spike scattering path on line, because 896 samples (7 s)/16 channels are processed at 3.13 s.

[Transient complete atrioventricular block following a nonpenetrating chest trauma]

Cardiac contusion may cause disorders of impulse formation and propagation in the specific conduction system. Transient complete atrioventricular block following a nonpenetrating chest trauma is a rare complication.We describe the case of a patient who presented a transient complete atrioventricular block, and later a transient right bundle branch block and a left anterior hemiblock, following a nonpenetrating chest trauma due to a car accident. The difficulty for diagnosing myocardial contusion is pointed out, and the usefulness of the electrophysiological study for detecting baseline conduction system disorders is discussed.

Antibiotic susceptibility of bacterial strains isolated from patients with community-acquired urinary tract infections

Isolates from urine samples obtained during 1999 were identified and their susceptibility to antimicrobial agents studied along with any production of extended-spectrum beta-lactamases (ESBL) by Escherichia coli and Klebsiella pneumoniae. A total of 13774 samples were analysed using an automatic system for the detection of bacterial ATP (Coral, USA). Of these samples, 49% were reported to be positive and uncontaminated; bacteria most frequently isolated were E. coli (47%), Proteus mirabilis (7%), Enterococcus faecalis (6%) and K. pneumoniae (5%). The susceptibility studies showed 37% E. coli strains resistant to amoxycillin+clavulanate 33% to cotrimoxazole and 22% to ciprofloxacin. Seven strains of E. coli produced ESBL. Thirteen per cent of strains were resistant to cefuroxime but only (1%) to fosfomycin. Resistance to nitrofurantoin in K. pneumoniae was 38%. P. mirabilis showed 52% resistance to cotrimoxazole and 13% Staphylococcus aureus, were methicillin-resistant. E. faecalis did not show any special resistance to normal medication. Fosfomycin continued to show high activity against Gram-negative bacilli. However, enterococci, some species of staphylococci and yeasts were difficult to treat empirically. ESBL were detected in the isolates of E. coli and there were some methicillin-resistant strains of S. aureus.

Chlamydia pneumoniae DNA in the arterial wall of patients with peripheral vascular disease

BACKGROUND

Chlamydia pneumoniae is a human respiratory pathogen that has recently been related to the genesis of symptomatic atherosclerosis. C. pneumoniae has been studied more widely in relation to coronary atherosclerosis than to peripheral arterial occlusive disease (PAOD). The present study aimed to retrospectively analyze the presence of C. pneumoniae DNA in patients with PAOD.

MATERIALS AND METHODS

A seminested PCR method was applied on 85 samples from 71 patients with PAOD secondary to surgical treatment. The control group comprised 50 patients with chronic superficial venous insufficiency who required varicose resection surgery.

RESULTS

The number of patients, number of samples studied and percentage of patients found to be positive in the PCR study were 17, 18 and 59%, respectively, for arteries of the lower extremities; 15, 16 and 60% for aneurysm of the abdominal aorta; 22, 23 and 73% for carotid stenosis and 17, 18 and 65% for aortic stenosis. C. pneumoniae DNA was found in six external pudendal arteries (12%) of the control group, significantly lower than the incidence in the patient group (p < 0.0001).

CONCLUSION

A causal relationship between chronic C. pneumoniae infection and PAOD cannot be ruled out. On the contrary, the high incidence of C. pneumoniae DNA detected in our patients suggests that C. pneumoniae infection may play some role in the pathogenesis of peripheral vascular disease.

NMR solution structure of murine CCL20/MIP-3alpha, a chemokine that specifically chemoattracts immature dendritic cells and lymphocytes through its highly specific interaction with the beta-chemokine receptor CCR6

CCL20/MIP-3alpha is a beta-chemokine expressed in the thymus, skin, and intestinal epithelial cells that exclusively binds and activates the CCR6 receptor in both mice and humans. The strict receptor binding specificity of CCL20 is exceptional; other chemokines and their receptors bind promiscuously with multiple partners. Toward determining the structural basis for the selective receptor specificity of CCL20, we have determined its three-dimensional structure by 1H NMR spectroscopy. CCL20 exhibits the same monomeric structure previously described for other chemokines: a three-stranded beta-sheet and an overlying alpha-helix. The CCL20 receptor selectivity could arise from the rigid conformation of the N-terminal DCCL motif as well as the groove between the N-loop and the beta2-beta3 hairpin, which is significantly narrower in CCL20 than in other chemokines. Similar structural features are seen in human beta-defensin 2, a small nonchemokine polypeptide reported to selectively bind and activate CCR6, which stresses their importance for the specific binding of both CCL20 and beta-defensin 2 to CCR6. CCL20's structure will be useful to design tools aimed to modulate its important biological functions.

Receptors for insulin-like growth factor-I (IGF-I) predominate over insulin receptors in skeletal muscle throughout the life cycle of brown trout, Salmo trutta

Insulin and IGF-I binding has been studied in brown trout (Salmo trutta) wheat germ agglutinin semipurified receptors from embryos (organogenesis), larvae (yolk sac), juveniles (2.98 +/- 0.21 g bw) and adults (111.6 +/- 6.92 and 522 +/- 53 g bw). Embryos and larvae were sampled at 5 and 12 weeks after fertilization (December 1999 and February 2000) and juvenile and adults were taken simultaneously (July 1999) and under the same feeding conditions to minimize potential nutritional and seasonal effects. Insulin receptor number was maximal at 12 weeks (144 fmol/mg glycoprotein) and progressively decreased in subsequent samplings. No alterations in affinity were detected (K(d) range, 0.21-0.32 nM) and changes in number of receptor paralleled changes in total specific binding. IGF-I receptor number was highest at 5 weeks (1044 fmol/mg) and was significantly higher than values for insulin in all samplings. The affinity of IGF-I receptor did not change (K(d) range, 0.11-0.18 nM) but was consistently higher than that for the insulin receptor. A more rapid decrease of IGF-I binding and receptor number was found with age. However, the ratio of insulin/IGF-I binding established in 12-week-old larvae (0.18 +/- 0.01) was thereafter maintained at very similar values in juveniles and adults (0.15-0.17). Tyrosine kinase activity (TKA) for insulin receptors ranged between 136 and 183% and there were no significant changes with age. For the IGF-I receptor, TKA ranged from 174 to 281% and was significantly higher in 5-week-old larvae coincident with the highest levels of receptor number and declined gradually in parallel with binding levels. In conclusion, the greater abundance of IGF-I receptors during embryonic and larval development is maintained throughout juvenile and adult stages. This would suggest a key role for IGF-I in the growth and metabolism of trout muscle.

[Descriptive analysis of patients admitted to hospital for acute cerebrovascular disease]

INTRODUCTION

Acute cerebrovascular disease (ACVA) makes up a high proportion of the neurological patients admitted to hospital, but we do not know the exact figures in our setting. We consider that it would be useful if the use of health-care resources for attending these patients was to be evaluated and studied by the neurologists who direct them.

OBJECTIVE

To analyze a predetermined series of variables related to strokes in our setting. Patients and methods. We made a descriptive analysis by means of a questionnaire, recording variables related to the admission to the neurology department of patients with probable ACVA, at 100 days and with further evaluation 6 months later.

RESULTS

We recorded 107 cases with ACVA confirmed in 101 of 104 patients with averages of: 70.54 years, average admission 13.53 days and intrahospital mortality 5.8%. The most common neurological findings were paralysis and speech disorder. The proportion of ischaemic stroke as compared with haemorrhagic stroke was 87.5% to 12.5%. The prevalence of usual risk factors was: arterial hypertension, diabetes and cardiopathy. The percentage of patients given rehabilitation treatment during their admission was 41.34%. A proportion, 37.2%, of the patients were referred to Hospital San Rafael for convalescence and treatment. The average time before evaluation by a neurologist was 30.23 hours. Eleven of 86 patients who answered a weekly questionnaire died (12.8%) and 54/86 had no rehabilitation treatment during the week (62.8%).

CONCLUSIONS

We found no differences in the epidemiological characteristics as compared with other studies. The excessive lapse of time before attending the emergency department was striking, as was the delay in receiving neurological attention since there was no emergency neurologist available and fewer haemorrhagic strokes since there was no neurosurgical service available. There was little use of salicylates as a platelet anti-aggregrant agent on discharge from hospital, little rehabilitation treatment six months after the stroke, and twice as much mortality as when the patients were in hospital. We consider that a more detailed and extensive analysis would be fully justified in our setting, preferably with more people interested in the early and late treatment of ACVA taking part and prolonged follow-up of these patients.