Genome-based epidemiology and antimicrobial resistance of Neisseria gonorrhoeae in Spain: A prospective multicentre study

BACKGROUND

Whole-genome sequencing (WGS) of Neisseria gonorrhoeae isolates combined with epidemiological and phenotypic data provides better understanding of population dynamics.

AIM

The objective of this study was to investigate the molecular epidemiology of N. gonorrhoeae isolates from three centres in Spain and determine associations of antimicrobial resistance.

METHODS

Genetic characterization was performed in 170 N. gonorrhoeae isolates. WGS was carried out with the HiSeq platform (Illumina). Genome assemblies were submitted to the PubMLST Neisseria database website to determine NG-MAST, MLST and NG-STAR. Antimicrobial resistance genes and point mutations were identified with PubMLST. Phylogenomic comparison was based on whole-genome single nucleotide polymorphism analysis.

RESULTS

Twenty-six MLST, 49 NG-MAST and 41 NG-STAR sequence types were detected, the most prevalent being MLST-ST9363 (27.1%), NG-MAST ST569 (12.4%) and NG-STAR ST193 (14.7%). Phylogenetic analysis identified 13 clusters comprising 69% of the isolates, with two of note: one involved cefixime-resistant isolates from Barcelona presenting a mosaic penA X and belonging to MLST-ST7363 and the other involved azithromycin-resistant isolates from Mallorca that possessed the C2611T mutation in the four 23S rRNA alleles belonging to MLST-ST1901.

CONCLUSION

The population of N. gonorrhoeae is quite heterogeneous in Spain. Our results agree with previous data published in Europe, albeit with some differences in distribution between regions. This study describes the circulation of two gonococcal populations with a specific resistance profile and sequence type in a specific geographic area. WGS is an effective tool for epidemiological surveillance of gonococcal infection and detection of resistance genes.

Prevalencia y determinantes de la infección por virus de papiloma humano en mujeres jóvenes de Guanacaste y Puntarenas, Costa Rica, 2004-2005

OBJETIVO

Estimar la prevalencia e identificar determinantes de la infección por el virus del papiloma humano (VPH) en mujeres jóvenes (18-25 años). Material y métodos. Se analizaron datos de 5 871 mujeres sexualmente activas a quienes se les realizó una entrevista y toma de muestras cervicouterinas para detección de VPH y citología durante la visita de reclutamiento del Ensayo de Vacunación contra VPH16/18 en Costa Rica. Se calculó la prevalencia total para cualquier tipo de VPH y tipos oncogénicos, no oncogénicos y específicos, con intervalos de confianza al 95% (IC95%). Se utilizó regresión logística múltiple paso-a-paso para identificar determinantes asociados con la infección.

RESULTADOS

La prevalencia total de VPH fue 50.0% (IC95% 48.8,51.3) y por tipos oncogénicos fue 33.8% (IC95% 32.6,35.0). El VPH-16 fue el tipo más prevalente (8.3%, IC95% 7.6,9.0). Los determinantes asociados con un alto riesgo de infección prevalente por VPH oncogénicos fueron no estar casada/unión libre, >1 compañero sexual, infección concomitante por Chlamydia trachomatis, y entre aquéllas con un único compañero sexual en su vida, un compañero con antecedente de múltiples compañeras sexuales. Conclusión. Se confirma la asociación de las infecciones por VPH oncogénicos con el comportamiento sexual de la mujer y se destacan los comportamientos del compañero sexual.

Analysis of cervical HPV infections among unvaccinated young adult women to inform vaccine strategies in this age group: the Costa Rica HPV Vaccine Trial

INTRODUCTION

Human papillomavirus (HPV) vaccines protect against incident HPV infections, which cause cervical cancer.

OBJECTIVES

We estimated the prevalence and incidence of HPV infections in young adult women to understand the impact of an HPV vaccination programme in this population.

METHODS

We collected cervical specimens from 6322 unvaccinated women, aged 18-37 years, who participated in the Costa Rica Vaccine Trial and its long-term follow-up. Women were followed for (median) 4.8 years and had (median) 4.0 study visits. Cervical specimens were tested for the presence/absence of 25 HPV genotypes. For each age band, we estimated the percentage of women with 1+ prevalent or 1+ incident HPV infections using generalised estimating equations. We also estimated the prevalence and incidence of HPV as a function of time since first sexual intercourse (FSI).

RESULTS

The model estimated HPV incident infections peaked at 28.0% (95% CI 25.3% to 30.9%) at age 20 years then steadily declined to 11.8% (95% CI 7.6% to 17.8%) at age 37 years. Incident oncogenic HPV infections (HPV16/18/31/33/35/39/45/51/52/56/58/59) peaked and then declined from 20.3% (95% CI 17.9% to 22.9%) to 7.7% (95% CI 4.4% to 13.1%); HPV16/18 declined from 6.4% (95% CI 5.1% to 8.1%) to 1.1% (95% CI 0.33% to 3.6%) and HPV31/33/45/52/58 declined from 11.0% (95% CI 9.3% to 13.1%) to 4.5% (95% CI 2.2% to 8.9%) over the same ages. The percentage of women with 1+ incident HPV of any, oncogenic, non-oncogenic and vaccine-preventable (HPV16/18, HPV31/33/45, HPV31/33/45/52/58, and HPV6/11) types peaked <1 year after FSI and steadily declined with increasing time since FSI (p for trends <0.001). We observed similar patterns for model estimated HPV prevalences.

CONCLUSION

Young adult women may benefit from HPV vaccination if newly acquired vaccine-preventable oncogenic infections lead to cervical precancer and cancer. HPV vaccination targeting this population may provide additional opportunities for primary prevention.

TRIAL REGISTRATION NUMBER

NCT00128661.

P-423 Metabolomic profiles of receptive-phase endometrium in women with different infertility diagnosis

Study question

What is the entire metabolomic profile of receptive-phase human endometrium and does the metabolic composition differ between women with different infertility diagnosis?

Summary answer

Human endometrium contains 925 different metabolites from diverse chemical classes, and the metabolomic signature varies between women with different infertility diagnosis.

What is known already

Different metabolites have been identified in human endometrium, including amino acids, nucleosides/nucleotides, organic acids, lipids, and sugars, with main focus on lipid profiles in endometriosis. Metabolic dysregulation in the uterus has been shown to provoke complex effects in the endometrium, leading to a low rate of embryo implantation and endometriosis. These are the first studies highlighting the importance of metabolites (metabolic routes) in endometrial functions and more research in the field is warranted. Further, the previous studies have focussed on specific metabolite classes, and we lack the knowledge of the whole metabolome composition in human uterus.

Study design, size, duration

This cross-sectional study included in total 47 women (age= 34.7±3.8 years, BMI= 24.5±4.2 kg/m²) who attended the Reproduction Unit at the University Hospital Granada from March 2019 to April 2021. Women with endometriosis (n = 13), unexplained infertility (n = 10), recurrent implantation failure (RIF) (n = 15) and male factor infertility (n = 9) were included. The study was approved by the Ethics Committee of Investigación Biomédica de Andalucia.

Participants/materials, setting, methods

Endometrial biopsies were collected at the mid-secretory phase (LH + 7) of a natural cycle using Pipelle curette. The complete metabolome from endometrial samples was analysed by Ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy (UPLC-MS/MS). Raw data were extracted, peak-identified and quality control processed using Metabolon’s hardware and software (metabolon.com). Multiple regression models controlling for age and BMI were applied using R software.

Main results and the role of chance

We provide the whole metabolome profile of endometrium, where 925 different metabolites were identified. Among these metabolites, lipid metabolites comprised the largest percentage (44%), where long chain fatty acids such as myristate (14:0), palmitoleate (16:1n7), nonadecanoate (19:0), arachidate (20:0), and dihomo-linolenate (20:3n3 or n6) prevailed. The endometrial metabolomic profiles differed significantly between women with different infertility diagnosis (p &lt;0.05). Overall, the metabolites of the lipid and protein metabolism were less present, while carbohydrates, nucleotides, and xenobiotics were predominant in the uterus of women with unexplained infertility, endometriosis, and RIF when compared to women with male factor infertility. Specifically, the metabolites linoleate (18:2n6), linolenate (18:3n3 or n6), and dihomo-linolenate (20:3n3 or n6) were less abundant in women with indication of dysfunctional endometrium (endometriosis and RIF) (FDR p -value&lt;0.05).

Limitations, reasons for caution

This is the first study presenting the complete metabolome of human endometrium on a limited sample size, which might have been underpowered to detect all differences in metabolite composition between groups.

Wider implications of the findings

This study identifies a metabolomic profiles associated with infertility diagnoses where altered endometrial functions are suspected (RIF and endometriosis). Our study findings could help to understand the molecular background of female infertility and lead to identification of potential molecular biomarkers of endometrial functions involved in embryo implantation and infertility.

Trial registration number

not applicable

HPV16 infection decreases vaccine-induced HPV16 antibody avidity: the CVT trial

The HPV vaccine has shown sustained efficacy and consistent stabilization of antibody levels, even after a single dose. We defined the HPV16-VLP antibody avidity patterns over 11 years among women who received one- or three doses of the bivalent HPV vaccine in the Costa Rica HPV Vaccine Trial. Absolute HPV16 avidity was lower in women who received one compared to three doses, although the patterns were similar (increased in years 2 and 3 and remained stable over the remaining 8 years). HPV16 avidity among women who were HPV16-seropositive women at HPV vaccination, a marker of natural immune response to HPV16 infection, was significantly lower than those of HPV16-seronegative women, a difference that was more pronounced among one-dose recipients. No differences in HPV16 avidity were observed by HPV18 serostatus at vaccination, confirming the specificity of the findings. Importantly, point estimates for vaccine efficacy against incident, six-month persistent HPV16 infections was similar between women who were HPV16 seronegative and seropositive at the time of initial HPV vaccination for both one-dose and three-dose participants. It is therefore likely that this lower avidity level is still sufficient to enable antibody-mediated protection. It is encouraging for long-term HPV-vaccine protection that HPV16 antibody avidity was maintained for over a decade, even after a single dose.

Effect of the topical administration of corticosteroids and tuberculin pre-sensitisation on the diagnosis of tuberculosis in goats

Background

Caprine tuberculosis (TB) is a zoonosis caused by members of the Mycobacterium tuberculosis complex (MTBC). Caprine TB control and eradication programmes have traditionally been based on intradermal tuberculin tests and slaughterhouse surveillance. However, this strategy has limitations in terms of sensitivity and specificity. Different factors may affect the performance of the TB diagnostic tests used in goats and, subsequently, the detection of TB-infected animals. In the present study, the effect of two of the factors that may affect the performance of the techniques used to diagnose TB in goats, the topical administration of corticosteroids and a recent pre-sensitisation with tuberculin, was analysed.

Methods

The animals (n = 151) were distributed into three groups: (1) a group topically treated with corticosteroids 48 h after intradermal tuberculin tests (n = 53); (2) a group pre-sensitised with bovine and avian purified protein derivatives (PPDs) 3 days before the intradermal tuberculin test used for TB diagnosis (n = 48); and (3) a control group (n = 50). All the animals were tested using single and comparative intradermal tuberculin (SIT and CIT, respectively) tests, an interferon-gamma release assay (IGRA) and a P22 ELISA.

Results

The number of SIT test reactors was significantly lower in the group treated with corticosteroids when compared to the pre-sensitised (p < 0.001) and control (p = 0.036) groups. In contrast, pre-sensitisation with bovine and avian PPDs did not cause a significant reduction in the number of SIT and CIT test reactors compared with the control group. In fact, a higher number of reactors was observed after the prior tuberculin injection in the pre-sensitised group (p > 0.05). No significant effect was observed on IGRA and P22 ELISA due to corticosteroids administration. Nevertheless, a previous PPD injection affected the IGRA performance in some groups.

Conclusions

The application of topical corticosteroid 24 h before reading the SIT and CIT tests can reduce the increase in skin fold thickness and subsequently significantly decrease the number of positive reactors. Corticosteroids used can be detected in hair samples. A previous pre-sensitisation with bovine and avian PPDs does not lead to a significant reduction in the number of intradermal tests reactors. These results are valuable in order to improve diagnosis of caprine TB and detect fraudulent activities in the context of eradication programs.

Rationale and design of a double-blind randomized non-inferiority clinical trial to evaluate one or two doses of vaccine against human papillomavirus including an epidemiologic survey to estimate vaccine efficacy: The Costa Rica ESCUDDO trial

HPV vaccination of adolescent girls is the most effective measure to prevent cervical cancer. The World Health Organization recommends that adolescent girls receive two doses of vaccine but only a small proportion of girls from regions with the highest disease burden are vaccinated because of cost and logistical considerations. Our Costa Rica HPV Vaccine trial suggested that one dose of the bivalent HPV vaccine provides robust and lasting protection against persistent HPV infections for over a decade. Data from a post-licensure trial of the quadrivalent vaccine in India also suggested that a single dose may be effective in reducing cervical cancer risk. To formally compare one versus two doses of the bivalent and nonavalent HPV vaccines, we implemented a large, randomized, double-blind trial to investigate the non-inferiority of one compared to two vaccine doses in the prevention of new HPV16/18 infections that persist 6 or more months. Bivalent and nonavalent vaccines will be evaluated separately. The trial enrolled and randomized (1:1:1:1 to 1- and 2-dose arms of the bivalent and nonavalent vaccines) 20,330 girls 12 to 16 years old residing in Costa Rica. Trial participants are followed every 6 months for up to 5 years. We also aim to estimate vaccine efficacy by comparing the rates of 6 month persistent infection in unvaccinated women with the rates in the follow-up visits of trial participants. We included one survey of unvaccinated women at the start of the study (N = 4452) and will include another survey concomitant with follow up visits of trial participants at year 4.5 (planned N = 3000). Survey participants attend two visits 6 months appart. Herein, we present the rationale, design, and enrolled study population of the ESCUDDO trial. ClinicalTrials.gov Identifier: NCT03180034.

Reproducibility, Temporal Variability, and Concordance of Serum and Fecal Bile Acids and Short Chain Fatty Acids in a Population-Based Study

BACKGROUND

Bile acid (BA) and short chain fatty acid (SCFA) production is affected by diet and microbial metabolism. These metabolites may play important roles in human carcinogenesis.

METHODS

We used a fully quantitative targeted LC-MS/MS system to measure serum and fecal BA and SCFA concentrations in 136 Costa Rican adults at study baseline and 6-months. We randomly selected 50 participants and measured their baseline samples in duplicate. Our objective was to evaluate: Technical reproducibility; 6-month temporal variability; and concordance between sample type collected from the same individual at approximately the same time.

RESULTS

Technical reproducibility was excellent, with intraclass correlation coefficients (ICC) ≥0.83 for all BAs except serum tauroursodeoxycholic acid (ICC = 0.72) and fecal glycolithocholic acid (ICC = 0.66) and ICCs ≥0.81 for all SCFAs except serum 2-methylbutyric acid (ICC = 0.56) and serum isobutyric acid (ICC = 0.64). Temporal variability ICCs were generally low, but several BAs (i.e., deoxycholic, glycoursodeoxycholic, lithocholic, taurocholic, and tauroursodeoxycholic acid) and SCFAs (i.e., 2-methylbutyric, butyric, propionic, and valeric acid) had 6-month ICCs ≥0.44. The highest degree of concordance was observed for secondary and tertiary BAs.

CONCLUSIONS

Serum and fecal BAs and SCFAs were reproducibly measured. However, 6-month ICCs were generally low, indicating that serial biospecimen collections would increase statistical power in etiologic studies. The low concordance for most serum and fecal metabolites suggests that consideration should be paid to treating these as proxies.

IMPACT

Our findings will inform the design and interpretation of future human studies on associations of BAs, SCFAs, and potentially other microbial metabolites, with disease risk.

Tuberculosis caused by Mycobacterium caprae in a camel (Camelus dromedarius)

BACKGROUND

Animal tuberculosis (TB) is distributed worldwide and has a wide range of wild and domestic reservoirs. Few studies concerning TB in camelids have been published in the last decade, particularly as regards Old World Camelids (OWC), but the increase in reports of TB outbreaks in these species in recent years suggests a high susceptibility to the infection.

CASE PRESENTATION

We studied a dromedary camel (Camelus dromedarius) herd (n = 24) in which a Mycobacterium caprae infection was detected. The TB infection was confirmed in one animal at necropsy through the detection of TB lesions, mainly in the abdominal organs, and the subsequent isolation of M. caprae (SB0157 spoligotype). The whole herd was additionally tested using cellular and humoral based diagnostic techniques. The intradermal tuberculin test results were compared with those obtained using P22 ELISA for the detection of specific antibodies against the M. tuberculosis complex. The TB infected animal was a positive reactor to both the intradermal tuberculin tests and P22 ELISA, while the others were negative to all the diagnostic tests.

CONCLUSION

The present study found M. caprae infection in OWC. This is the first report of M. caprae infection in an OWC not living in a zoo. Since the animal was born in the herd and fed with goat's milk, this practice was suspected to be the potential source of TB infection, which was not confirmed in the other animals present in the herd. Moreover, our results highlight that the intradermal tuberculin test and the P22 ELISA could be valuable tools for the diagnosis of TB in OWC.

Cervical determinants of anal HPV infection and high-grade anal lesions in women: a collaborative pooled analysis

BACKGROUND

Cervical cancer screening might contribute to the prevention of anal cancer in women. We aimed to investigate if routine cervical cancer screening results-namely high-risk human papillomavirus (HPV) infection and cytohistopathology-predict anal HPV16 infection, anal high-grade squamous intraepithelial lesions (HSIL) and, hence, anal cancer.

METHODS

We did a systematic review of MEDLINE, Embase, and the Cochrane library for studies of cervical determinants of anal HPV and HSIL published up to Aug 31, 2018. We centrally reanalysed individual-level data from 13 427 women with paired cervical and anal samples from 36 studies. We compared anal high-risk HPV prevalence by HIV status, cervical high-risk HPV, cervical cytohistopathology, age, and their combinations, using prevalence ratios (PR) and 95% CIs. Among 3255 women with anal cytohistopathology results, PRs were similarly calculated for all anal HSIL and HPV16-positive anal HSIL.

FINDINGS

Cervical and anal HPV infections were highly correlated. In HIV-negative women, anal HPV16 prevalence was 41% (447/1097) in cervical HPV16-positive versus 2% (214/8663) in cervical HPV16-negative women (PR 16·5, 95% CI 14·2-19·2, p<0·0001); these values were 46% (125/273) versus 11% (272/2588) in HIV-positive women (4·4, 3·7-5·3, p<0·0001). Anal HPV16 was also associated with cervical cytohistopathology, with a prevalence of 44% [101/228] for cervical cancer in HIV-negative women (PR vs normal cytology 14·1, 11·1-17·9, p<0·0001). Anal HSIL was associated with cervical high-risk HPV, both in HIV-negative women (from 2% [11/527] in cervical high-risk HPV-negative women up to 24% [33/138] in cervical HPV16-positive women; PR 12·9, 95% CI 6·7-24·8, p<0·0001) and HIV-positive women (from 8% [84/1094] to 17% [31/186]; 2·3, 1·6-3·4, p<0·0001). Anal HSIL was also associated with cervical cytohistopathology, both in HIV-negative women (from 1% [5/498] in normal cytology up to 22% [59/273] in cervical HSIL; PR 23·1, 9·4-57·0, p<0·0001) and HIV-positive women (from 7% [105/1421] to 25% [25/101]; 3·6, 2·5-5·3, p<0·0001). Prevalence of HPV16-positive anal HSIL was 23-25% in cervical HPV16-positive women older than 45 years (5/20 in HIV-negative women, 12/52 in HIV-positive women).

INTERPRETATION

HPV-based cervical cancer screening programmes might help to stratify anal cancer risk, irrespective of HIV status. For targeted secondary anal cancer prevention in high-risk groups, HIV-negative women with cervical HPV16, especially those older than 45 years, have a similar anal cancer risk profile to that of HIV-positive women.

FUNDING

International Agency for Research on Cancer.

Specificity of serological test for detection of tuberculosis in cattle, goats, sheep and pigs under different epidemiological situations

BACKGROUND

Serum antibody detection has potential as a complementary diagnostic tool in animal tuberculosis (TB) control, particularly in multi-host systems. The objective of the present study was to assess the specificity (Sp) of an enzyme-linked immunosorbent assay (ELISA) based on the new multiprotein complex P22 for the detection of specific antibodies against the Mycobacterium tuberculosis complex (MTC) in the four most relevant domestic animals acting as MTC hosts: cattle, goat, sheep and pig. We used sera from an officially TB-free (OTF) country, Norway, and from a non-OTF one, Spain. The samples included sera from goats that had been vaccinated against M. avium subsp. paratuberculosis (MAP) and sheep from a herd in which Corynebacterium pseudotuberculosis had been isolated.

RESULTS

In cattle, the Sp ranged from 92.5 (IC95% 90.7-94) to 99.4% (IC95% 98.3-99.8) depending on the cut-off used and the origin of the samples (Spain or Norway). Sp in cattle (cut-off point 100) was significantly higher (P < 0.05) for Norwegian samples. By contrast, Sp in goats was consistently low at the 100 cut-off [30.9 (CI95%23.4-39.5)-78% (CI95% 68.9-85)]. A higher cut-off of 150 improved Sp in Norwegian goats [97% (CI95% 91.6-99)], but still yielded a poor Sp of 56.1% (CI95% 47.3-64.6) in Spanish goats. In Norway at the 100 cut-off the Sp was 58.3 (CI95% 42.2-72.9) and 90.6% (CI95% 81-95.6) in MAP vaccinated and non-vaccinated goats, respectively, indicating interference due to MAP vaccination. Sp in sheep was between 94.4 (CI95% 91.7-96.3) and 100% (CI95% 96.3-100) depending on the cut-off and country, and no diagnostic interference due to infection with C. pseudotuberculosis was recorded. Sp in pigs was 100%, regardless the cut-off point applied, and no significant differences were observed between pigs from Norway and from Spain.

CONCLUSIONS

Due to its excellent Sp in pigs and acceptable Sp in cattle and sheep, this ELISA may constitute a suitable option for TB screening at herd level, particularly in OTF-countries.

A new test to detect antibodies against Mycobacterium tuberculosis complex in red deer serum

Red deer (Cervus elaphus) farming is a growing economic activity worldwide. However, the capacity of this species to act as reservoir of animal tuberculosis (TB) poses a threat to other wildlife and to livestock. Diagnostic assay accuracy in this species is therefore highly relevant for prevention and control measures. Our aim was to evaluate the diagnostic performance of the protein complex P22, obtained from Mycobacterium bovis derived purified protein derivative (bPPD), as a candidate antigen for the detection of antibodies against Mycobacterium tuberculosis complex (MTC). We assessed the performance of this new antigen in indirect enzyme-linked immunosorbent assays (ELISA) in TB-positive and TB-negative red deer, in comparison with a bPPD-based ELISA. The P22 ELISA achieved a higher specificity (Sp) and similar sensitivity (Se) in comparison with the bPPD ELISA at all the cut-off points considered. The P22 ELISA yielded optimal Sp (99.02%; 95% confidence intervals [CI_95%]: 96.5-99.8) and appropriate Se (70.1%; CI_95%: 63.6-76) at the selected cut-off point of 100%. These results suggest that P22 can be used as an alternative antigen in the immunodiagnosis of animal TB through the use of an ELISA-type detection of antibodies against MTC in red deer, thus contributing to the diagnosis of animal TB in this species as a measure for further disease prevention and control programs.

Evaluation of the Mycobacterium tuberculosis SO2 vaccine using a natural tuberculosis infection model in goats

The development of new vaccines against animal tuberculosis (TB) is a priority for improving the control and eradication of this disease, particularly in those species not subjected to compulsory eradication programmes. In this study, the protection conferred by the Mycobacterium tuberculosis SO₂ experimental vaccine was evaluated using a natural infection model in goats. Twenty-six goats were distributed in three groups: (1) 10 goats served as a control group; (2) six goats were subcutaneously vaccinated with BCG; and (3) 10 goats were subcutaneously vaccinated with SO₂. Four months after vaccination, all groups were merged with goats infected with Mycobacterium bovis or Mycobacterium caprae, and tested over a 40 week period using a tuberculin intradermal test and an interferon-γ assay for mycobacterial reactivity. The severity of lesions was determined at post-mortem examination and the bacterial load in tissues were evaluated by culture. The two vaccinated groups had significantly lower lesion and bacterial culture scores than the control group (P<0.05); at the end of the study, the SO₂ vaccinated goats had the lowest lesion and culture scores. These results suggest that the SO₂ vaccine provides some protection against TB infection acquired from natural exposure.

Is targeted removal a suitable means for tuberculosis control in wild boar?

We assessed the suitability of targeted removal as a means for tuberculosis (TB) control on an intensely managed Eurasian wild boar (Sus scrofa) hunting estate. The 60km² large study area included one capture (treatment) site, one control site, and one release site. Each site was fenced. In the summers of 2012, 2013 and 2014, 929 wild boar were live-captured on the treatment site. All wild boar were micro-chipped and tested using an animal side lateral flow test immediately after capture in order to detect antibodies to the Mycobacterium tuberculosis complex (MTC). The wild boar were released according to their TB status: Seropositive individuals onto the release site (hunted after summer), and seronegative individuals back onto the treatment site. The annual summer seroprevalence of antibodies to the MTC declined significantly in live-captured wild boar piglets from the treatment site, from 44% in 2012 to 27% in 2013 (a reduction of 39%). However, no significant further reduction was recorded in 2014, during the third capture season. Fall-winter MTC infection prevalence was calculated on the basis of the culture results obtained for hunter-harvested wild boar. No significant changes between hunting seasons were recorded on either the treatment site or the control site, and prevalence trends over time were similar on both sites. The fall-winter MTC infection prevalence on the release site increased significantly from 40% in 2011-2012 to 64% in 2012-2013 and 2013-2014 (60% increase). Recaptures indicated a persistently high infection pressure. This experiment, the first attempt to control TB in wild boar through targeted removal, failed to reduce TB prevalence when compared to the control site. However, it generated valuable knowledge on infection pressure and on the consequences of translocating TB-infected wild boar.

Carer perspective on treatment, comorbidities and diagnosis of Paediatric ADHD in France

Objectives

To examine treatment, comorbidity status and diagnosis among the French sample of the Caregiver Perspective of Pediatric ADHD (CAPPA) survey.

Methods

Carers in 10 EU countries, including France, completed an Internet survey regarding ADHD diagnosis, treatment and comorbidities. Descriptive statistics were calculated for categorical [n (%)] and continuous variables [mean, standard deviation (SD), median, range].

Results

EU carers representing 3688 children/adolescents (6–17 years) with ADHD completed the survey; 486 were from France (median age 10 years, 84% male). Most (77%) French children/adolescents were currently receiving pharmacological treatment(s): 74% stimulant, 15% non-stimulant and 22% antipsychotic. Across countries, stimulant use ranged from 60% (Italy) to 93% (Germany/Netherlands), non-stimulant use from 1% (Germany) to 18% (Sweden) and antipsychotic use from 8% (Germany) to 46% (Italy). Many French children/adolescents received behaviour therapy (BT) after ADHD diagnosis (59%). Among those receiving BT, 52% began prior to starting medication. BT was often discontinued within 6 months (44%) or 6–12 (30%) months. 52% of carers reported ≥ 1 comorbidity; they reported the highest rates of conduct (24%), sleep (11%), eating (6%) and motor-coordination (6%) disorders, and the second-highest rates of anxiety (22%), learning difficulties (15%), oppositional defiant disorder (5%), bipolar disorder (4%) and epilepsy (2%). Time to diagnosis from first doctor's visit averaged 7 months (SD 11, median 3). 81% received a specialist referral. French carers reported the highest perceived difficulty (‘great deal’/’a lot’ of difficulty) obtaining a diagnosis (43%) and a specialist referral (53%).

Conclusions

This sample of French children/adolescents with ADHD had higher non-stimulant and antipsychotic use than most other countries and higher reports of certain comorbid conditions. Carers perceived greater difficulty in obtaining a diagnosis and seeing a specialist, although time to diagnosis was lower compared with a number of other countries.

Effects of dietary restriction combined with different exercise programs or physical activity recommendations on blood lipids in overweight adults

BACKGROUND AND AIM

Many exercise studies, although generally showing the beneficial effects of supervised aerobic, resistance or combined exercise on blood lipids, have sometimes reached equivocal conclusions. The aim of this study is to evaluate the impact of different programs that combined exercise and dietary restriction on blood lipids versus a clinical practice intervention for weight loss, in overweight adults.

METHODS

For this study 66 subjects participated in a supervised 22 weeks training program, composed of three sessions per week and they were randomized in three groups: strength training (S; n = 19), endurance training (E; n = 25), a combination of E and S (SE; n = 22). Eighteen subjects served as physical activity group (PA) that followed a clinical intervention consisted of physical activity recommendations. All groups followed the same dietary treatment, and blood samples were obtained for lipids measurements, at the beginning and end of the study.

RESULTS

Lipid profile improved in all groups. No significant differences for baseline and post-training values were observed between groups. In general, SE and PA decreased low-density lipoprotein cholesterol (LDL-C) values (p < 0.01). S decreased triglyceride levels (p < 0.01) and E, SE, and PA decreased total cholesterol levels (p < 0.05, p < 0.01 and p < 0.01, respectively).

CONCLUSIONS

These results suggest that an intervention program of supervised exercise combined with diet restriction did not achieved further improvements in blood lipid profile than diet restriction and physical activity recommendations, in overweight adults. (Clinical Trials gov number: NCT01116856).

Atrial Fibrillation and Stroke Risk After Coronary Artery Bypass Grafting Surgery

Background: The present multicentre study was aimed at determining the effect of preoperative atrial fibrillation (preop-AF) as stroke risk factor in coronary artery bypass graft surgery (CABG) during the perioperative period. Methods: Patients undergoing isolated CABG surgery were enrolled from 21 Spanish centers. Baseline variables related with perioperative stroke risk were recorded and analysed. The Northern New England Cardiovascular Disease Study Group (NNECVDSG) stroke risk schema was used to stratify stroke risk and compare predicted vs observed neurologic outcomes in this study. Results: 26347 patients were enrolled in the study. Prevalence of preop-AF was 4.2%, and was associated significantly with major cardiovascular comorbidities. The stroke rate was 1.38% (365 strokes), and it was slightly higher for patients with preop-AF vs non preop-AF, 1.82% vs 1.36%, p = 0.2. NNECVDSG schema showed good predictive ability calculating the area under the receiver operating characteristic curve (c-statistic 0.696; 95% CI 0.668 to 0.723). To investigate the associations of baseline preoperative variables with perioperative CABG-stroke a logistic regression model was performed. Preop-AF impact on perioperative stroke was lower that other variables. Preop-AF did not show an adverse impact in the quartiles groups according to NNECVDSG Stroke Risk Index. Conclusion: Risk of perioperative stroke in isolated CABG surgery patients is not significantly increased by preop-AF.

Evaluation of two cocktails containing ESAT-6, CFP-10 and Rv-3615c in the intradermal test and the interferon-γ assay for diagnosis of bovine tuberculosis

The intradermal tuberculin tests and the interferon-gamma (IFN-γ) assay are the principal tests used worldwide for the ante-mortem diagnosis of bovine tuberculosis. The conventional reagent currently in use in these tests is purified protein derivative (PPD) tuberculin obtained from Mycobacterium bovis culture. The components of PPD are poorly characterized and difficult to standardize. To overcome this issue, antigens specific to the Mycobacterium tuberculosis complex are being studied. Here we have assessed the biological potency of ESAT-6, CFP-10 and Rv-3615c presented as peptide or recombinant protein cocktails in comparison with the standard bovine PPD used routinely in Spanish eradication campaigns. The study was performed in cattle (n=23) from a herd with natural M. bovis infection. Animals were simultaneously injected with PPD and the peptide and protein cocktails. The percentages of cattle reacting positively to single intradermal test were 60.9% (bovine PPD), 47.8% (peptide cocktail) and 60.9% (protein cocktail), with no significant difference between the actual skin fold thickness increases (p>0.05). The IFN-γ assay detected 60.9% of animals when stimulation was performed with bovine PPD, but decreased to 52.2% when stimulation was performed with the peptide cocktail and to 47.8% when stimulation was performed with the protein cocktail. However, no significant differences were found between IFN-γ responder frequencies (p>0.05). These results show a potential use of these defined reagents for in vivo tuberculosis diagnosis.

Treatment of proteinuria with lercanidipine associated with reninangiotensin axis-blocking drugs

Aim. Most calcium antagonists do not seem to reduce microalbuminuria or proteinuria. We have tried to assess the antiproteinuric effect of a calcium channel blocker, lercanidipine, in patients previously treated with ACE inhibitors or angiotensin receptor blockers.Design and methods. The study included 68 proteinuric (>500 mg/day) patients (age 63,1±12,9 years, 69,1 % males and 30,9 % females). All patients were receiving ACE inhibitors (51,4 %) or angiotensin II receptor blockers (48,6 %) therapy but had higher blood pressure (BP) than recommended for proteinuric patients (<130/80 mm Hg). Patients were clinically evaluated one, three, and six months after starting treatment with lercanidipine (20 mg/day). Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment. Creatinine clearance was measured using 24 h urine collection.Results. BP significantly decreased from 152±15/86±11 mm Hg to 135±12/77±10 mm Hg at six months of follow-up (p<0,001). After six months of treatment, the percentage of normalized patients (BP <130/80 mm Hg) was 42,5 %, and the proportion of patients whose BP was below 140/90 mm Hg was 58,8 %. Plasmatic creatinine did not change nor did creatinine clearance. Plasmatic cholesterol also decreased from 210±48 to 192±34 mg/dL (p<0,001), as did plasma triglycerides (from 151±77 to 134±72 mg/dL,p=0,022). Basal proteinuria was 1,63±1,34 g/day; it was significantly (p<0,001) reduced by 23 % at the first month, 37 % at three months, and 33 % at the last visit.

Conclusion. Lercanidipine at 20 mg dose, associated with renin-angiotensin axis-blocking drugs, showed a high antihypertensive and antiproteinuric effect. This antiproteinuric effect seems to be dose-dependent as compared with previous reports and proportionally higher than blood pressure reduction.

Treatment of proteinuria with lercanidipine associated with renin-angiotensin axis-blocking drugs

OBJECTIVE

Most calcium antagonists do not seem to reduce microalbuminuria or proteinuria. We have tried to assess the antiproteinuric effect of a calcium channel blocker, lercanidipine, in patients previously treated with ACE inhibitors or angiotensin receptor blockers.

DESIGN AND METHODS

The study included 68 proteinuric (> 500 mg/day) patients (age 63.1 +/- 12.9 years, 69.1% males and 30.9 females). All patients were receiving ACE inhibitors (51.4%) or angiotensin II receptor blockers (48.6%) therapy but had higher blood pressure than recommended for proteinuric patients (<130/80 mmHg). Patients were clinically evaluated one, three, and six months after starting treatment with lercanidipine (20 mg/day). Samples for urine and blood examination were taken during the examination. When needed, a third drug was added to treatment. Creatinine clearance was measured using 24 h urine collection.

RESULTS

BP significantly decreases from 152 +/- 15/86 +/- 11 mmHg to 135 +/- 12/77 +/- 10 mmHg at six months of follow-up (p < 0.001). After six months of treatment, the percentage of normalized patients (BP < 130/80 mmHg) was 42.5%, and the proportion of patients whose BP was below 140/90 mmHg was 58.8%. Plasmatic creatinine did not change nor did creatinine clearance. Plasmatic cholesterol also decreased from 210 +/- 48 to 192 +/- 34 mg/dL (p < 0.001), as did plasma triglycerides (from 151 +/- 77 to 134 +/- 72 mg/dL, p = 0.022). Basal proteinuria was 1.63 +/- 1.34 g/day; it was significantly (p < 0.001) reduced by 23% at the first month, 37% at three months, and 33% at the last visit.

CONCLUSIONS

Lercanidipine at 20 mg dose, associated to renin-angiotensin axis-blocking drugs, showed a high antihypertensive and antiproteinuric effect. This antiproteinuric effect seems to be dose-dependent as compared with previous reports and proportionally higher than blood pressure reduction.

Experimental infection of Eurasian wild boar with Mycobacterium avium subsp. avium

The Eurasian wild boar (Sus scrofa) is increasingly relevant as a host for several pathogenic mycobacteria. We aimed to characterize the first experimental Mycobacterium avium subsp. avium (MAA) infection in wild boar in order to describe the lesions and the immune response as compared to uninfected controls. Twelve 1-4-month-old wild boar piglets were housed in class III bio-containment facilities. Four concentrations of MAA suspension were used: 10, 10(2) and 10(4) mycobacteria (2 animals each, oropharyngeal route) and 2.5 x 10(6) mycobacteria (2 animals each by the oropharyngeal and nasal routes). No clinical signs were observed and pathology evidenced a low pathogenicity of this MAA strain for this particular host. Bacteriological and pathological evidence of successful infection after experimental inoculation was found for the group challenged with 2.5 x 10(6) mycobacteria. These four wild boar showed a positive IFN-gamma response to the avian PPD and the real-time RT-PCR data revealed that three genes, complement component C3, IFN-gamma and RANTES, were significantly down regulated in infected animals. These results were similar to those found in naturally and experimentally M. bovis-infected wild boar and may constitute biomarkers of mycobacterial infection in this species.

First data on Eurasian wild boar response to oral immunization with BCG and challenge with a Mycobacterium bovis field strain

The Eurasian wild boar (Sus scrofa) is considered a reservoir for bovine tuberculosis (bTB) caused by Mycobacterium bovis and closely related members of the Mycobacterium tuberculosis complex in south-central Spain. The vaccination of wildlife with BCG offers an alternative to culling and to movement restriction for the control of bTB among wildlife reservoirs. In this study, we hypothesized that oral BCG immunization of wild boar would affect the expression of immunoregulatory genes and confer protection against M. bovis. Three groups were used to describe the infection, pathological findings and gene expression profiles in wild boar: BCG-vaccinated and M. bovis-challenged (vaccinated challenged group; N=6), non-vaccinated and M. bovis-challenged (non-vaccinated challenged group; N=4), and non-vaccinated and mock-infected (control group; N=2) animals. M. bovis was isolated from 50% (3/6) and 75% (3/4) of vaccinated challenged and non-vaccinated challenged animals, respectively. All four wild boar from the non-vaccinated challenged group developed bTB-compatible lesions 114 days after challenge. In contrast, only 50% of vaccinated challenged wild boar developed lesions. The PBMC mRNA levels of IL4, RANTES, C3, IFN-gamma and methylmalonyl-CoA mutase (MUT) were analyzed at several days post-vaccination (dpi). When vaccinated challenged animals were compared to controls, all five genes were significantly upregulated at the time of M. bovis infection at 186dpi but IFN-gamma levels were also upregulated at 11 and 46dpi. The C3 and MUT mRNA levels were higher at 46dpi, and 11 and 186dpi, respectively, in vaccinated protected wild boar when compared to non-vaccinated challenged animals. At the end of the experiment (300dpi), the mRNA levels of selected genes were lower in non-vaccinated challenged animals when compared to control wild boar. Exposing wild boar to a dose of 10(4)cfu of M. bovis by the oropharyngeal route is an adequate protocol to produce an infection model in this species. Our results suggested that oral BCG immunization of wild boar results in the upregulation of immunoregulatory genes that may be associated with protective response to M. bovis infection in this species. More studies on vaccine efficacy, delivery, and safety will be needed to confirm if oral vaccination with BCG could be used in bTB control programs for reducing M. bovis infection and clinical disease in wild boar.

Long-term antiproteinuric effect of dual renin-angiotensin system blockade

We evaluated the long-term changes on overt proteinuria induced by dual blockade of the renin-angiotensin system (RAS). Dual blockade was produced by adding an angiotensin II receptor blocker (ARB) to treatment with maximal recommended doses of an angiotensin converting enzyme (ACE) inhibitor in proteinuric patients. A total of 28 patients (19 men and 9 women) with proteinuria higher than 1 g/24 h were enrolled in this trial of treatment with the ARB candesartan (from 4 up to 32 mg daily) added to existing treatment with an ACE inhibitor. At 6, 12, 24, and 36 months, we evaluated proteinuria in 24-h urinary collections, office blood pressure (BP), plasmatic creatinine (Cr), serum potassium (K), and 24 h urine collection creatinine clearance (CrC). During monoblockade of the RAS by ACE inhibitor treatment, albuminuria was 2.94 +/- 1.92 mg/24 h; BP was 137/76 mmHg; K+ was 4.8 +/- 0.5 mmol/l, Cr was 1.76 +/- 0.67 mg/dL, and CrC was 62 +/- 31.9 mL/min. After 6 months, dual blockade of the RAS albuminuria was 2.18 +/- 2.29 mg/24 h (P < 0.01 vs. baseline) and BP was 133/75 mmHg (not significant). At 36 months, albuminuria was 2.21 +/- 2.20 mg/24 h (P < 0.05 vs. baseline); BP was 133/73 mmHg (not significant). CrC was not changed along the follow up. A small increment of Cr was detected at 24 months (2.11 +/- 1.06 mg/mL, P < 0.05). The antiproteinuric effect of dual renin-angiotensin system blockade combining candesartan and ACE inhibitors remain after 36 months without losing its initial effect. Blood pressure changes seem not to explain this long-term antiproteinuric effect.

[Chronic ethanol feeding induces oxidative stress in the rat retina: treatment with the antioxidant ebselen]

PURPOSE

To assess the involvement of biochemical and functional changes to the retina after chronic ethanol intake in adult rats, and the capacity of the antioxidant ebselen to prevent these changes.

METHODS

Male Sprague-Dawley rats were used in the study. They were fed an ethanol-containing liquid diet, whereas a control group was given an ethanol-free isocaloric diet. After six weeks of experiment, the eyes were extracted and homogenized without the lens, and markers of oxidative stress were assayed, i.e., glutathione (GSH) and malondialdehyde (MDA) as an intracellular antioxidant and a lipid peroxidation product, respectively. Moreover, retinal function was assessed by electroretinogram (ERG).

RESULTS

The retinal MDA concentration was significantly increased in the ethanol-fed animals compared to controls, whereas the GSH content was significantly reduced in the ethanol-fed group compared to controls. Ethanol also induced a decrease in ERG b-wave amplitude. Ebselen treatment restored the MDA and GSH concentrations and ERG b-wave amplitude to control values.

CONCLUSION

These results indicate that chronic alcohol consumption alone and without the influence of nutritional factors alters the retinal redox status as well as its function (ERG). Further studies are required to better understand the protective mechanism of ebselen in this experimental model of chronic alcoholism.

Polymorphisms in gyrA and gyrB genes among Mycobacterium avium subsp. paratuberculosis type I, II, and III isolates

The analysis of the gyrA and gyrB genes of a panel of Mycobacterium avium subsp. paratuberculosis isolates from types I, II, and III detected type-specific single nucleotide polymorphisms. Based on these results, we developed a PCR and restriction enzyme analysis to discriminate type I and III isolates. The application of this technique would be the unique strategy to characterize these strains when there is not enough bacterial growth to perform pulsed-field gel electrophoresis and IS900 restriction fragment length polymorphism.

Molecular epidemiology of Types I/III strains of Mycobacterium avium subspecies paratuberculosis isolated from goats and cattle

Molecular characterization of Mycobacterium avium subsp. paratuberculosis (M. a. paratuberculosis) isolates classifies them into three groups: cattle or Type II, sheep or Type I, and intermediate or Type III. To avoid problems associated with characterization of extremely slow growth strains, PCR-based techniques that divide the M. a. paratuberculosis strains in two main groups (cattle or Type II, and sheep or Types I/III) can be performed. The objectives of this study were to characterize the M. a. paratuberculosis isolates identified by different PCR-based tests (IS1311-PCR and restriction endonuclease analysis, PCR test based on a DNA sequence difference, and a PCR aimed at three Type I-specific loci), and to determine the clinical and epidemiological implications of Types I/III M. a. paratuberculosis strains in livestock. One hundred and fifty-eight M. a. paratuberculosis strains from domestic ruminants were analyzed. One hundred and six M. a. paratuberculosis isolates (61 from goats and 45 from cattle) were classified as Type II strains; and 52 (29 from cows, 20 from goats, and three from sheep) were included in the Types I/III. The Types I/III M. a. paratuberculosis strains were associated to Spanish native breeds. The majority of these animals had not been in direct or indirect contact with sheep flocks infected with M. a. paratuberculosis. This fact should be taken into account when implementing paratuberculosis control programs.

[Nightmares in patients with Alzheimer's disease caused by donepezil. Therapeutic effect depends on the time of intake]

Dementia of the Alzheimer type (DAT) has been linked to losses of cholinergic function in the brain. The acetylcholinesterase inhibitors donepezil, rivastigmine and galantamine improve cognitive performance in manifest dementia. These substances, however, also influence the quality of sleep, and particularly the quality and amount of dreams. We therefore investigated the influence of the time point of donepezil intake on the occurrence of nightmares. We observed a clear-cut relationship between the occurrence of nightmares and an evening dose of donepezil in eight patients with DAT. None of these patients reported nightmares when donepezil was taken in the morning. We suggest that the activation of the visual association cortex during REM sleep is enhanced by donepezil, a mechanism most likely facilitating the development of nightmares in patients with DAT.

Release of inflammatory mediators in irradiated cell salvage blood and their biological consequences in human beings following transfusion

BACKGROUND AND OBJECTIVE

Irradiation of intraoperative cell salvage blood has recently been used to inactivate tumour cells before retransfusion, during cancer surgery. No information is available about a potential inflammatory response of the recipient to the retransfusion of irradiated intraoperative cell salvage blood. This pilot study was conducted to investigate the possible release of the pro-inflammatory mediators, tumour necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), eotaxin and monocyte chemo-attractant protein-1 (MCP-1), in the serum of recipients by intraoperative retransfusion of irradiated intraoperative cell salvage blood.

METHODS

Nine patients undergoing gynaecological cancer surgery were included in this study. Intraoperative cell salvage blood was irradiated with 50 Gy and retransfused to the patient. Serum and intraoperative cell salvage blood concentrations of TNF-alpha, IL-1beta, eotaxin and MCP-1 were repeatedly analysed before and after retransfusion, respectively before and after irradiation.

RESULTS

Traces of mediators were detected in intraoperative cell salvage blood but no increase due to irradiation was observed. Following transfusion of intraoperative cell salvage blood, minute quantities (all < 30 pg mL(-1) of mediators were detected in the serum of patients. However, there was no significant upregulation compared to serum values before retransfusion.

CONCLUSIONS

These results provide evidence that retransfusion of irradiated intraoperative cell salvage blood might represent a blood-saving strategy in cancer surgery without an immunological inflammatory response as shown by a lack of upregulation of inflammatory mediators.

Molecular brain imaging and the neurobiology and genetics of schizophrenia

It has been hypothesized that schizophrenia is related to dysfunction in temporolimbic-prefrontal neuronal networks, which is acquired early in an individual's development. After puberty, relatively reduced prefrontal control of striatal dopaminergic neurotransmission may lead to unmodulated striatal dopamine (DA) activity, and the positive symptoms of acute psychosis. Brain imaging studies support the notion of prefrontal dysfunction in schizophrenia and correlated upregulation of presynaptic striatal DA activity. Recent molecular brain imaging studies have combined genetic assessments with a multimodal neuroimaging approach to further refine our understanding of the pathophysiologic architecture of the disorder. We review the literature on functional brain imaging in schizophrenia and discuss genotype effects on core psychotic symptoms. A promising research strategy is the identification of genetic and environmental factors that contribute to intermediate phenotypes such as working memory deficits in schizophrenia. Molecular brain imaging can help to unravel the complex interactions between genes and environment and its association with neuronal network dysfunction in schizophrenia.

[Self-esteem in Mexican pediatric patients on peritoneal dialysis and kidney transplantation]

It has been reported in literature that self-esteem increases in patients who pass from continuous ambulatory peritoneal dialysis to renal transplantation. However, our clinical observations in the Department of Nephrology of Hospital Infantil de México Federico Gómez indicate otherwise. Therefore, we carried out this research on 60 patients, children and adolescents, male and female between the ages from 8 to 15 years old, and we applied them the Coopersmith self-esteem questionnaire, which has been validated in mexican population. These findings indicate that the social environment continuous ambulatory peritoneal dialysis patients feel more adapted than patients in renal transplant (p = 0.05). However it was also observed that these patients tried to show a better image on their situation through compensatory mechanisms (defense p = 0.03). It was concluded that it would be necessary to follow the adaptation of the transplanted patients, in order to help them achieve complete rehabilitation.

[German-speaking memory clinics: state of the art and practical recommendations]

The 7th annual meeting of the memory clinics of Germany, Switzerland and Austria in March 2002 in Göttingen, Germany was an optimal opportunity to make an inventory about the state of the art in diagnostic and therapy of dementia and mild cognitive impairment in German-speaking memory clinics. Several problems were discussed including difficulties in 1) diagnosis of patients with aphasia or foreign patients, 2) handling of demented patients without a caregiver, 3) psychological support for patients, who have been diagnosed in a very early stage, 4) misunderstandings between general practitioners, neurologists and psychiatrists in private practice on the one hand and the memory clinics on the other hand, 5) recommendations for prevention of dementia, 6) recommendations concerning dementia and car driving and 7) questions of genetic counselling. The following paper is a summary of the results of a workshop in Göttingen and gives practical recommendations based on the experiences of the memory clinics.

Reproducibility of sequential head-up tilt testing in patients with recent syncope, normal ECG and no structural heart disease

AIMS

To assess the reproducibility of the response to sequential head-up tilt tests.

METHODS AND RESULTS

A head-up tilt test was performed early after syncope in 127 patients with a normal ECG and no structural heart disease. Patients with a positive response (82 patients) were randomized to two (1 week and 2 weeks later) or one (2 weeks later) additional head-up tilt tests, and patients with a negative response (45 patients) were randomized to a second head-up tilt test 1 or 2 weeks after the first. The reproducibility of a positive response in the second head-up tilt test was 80% after 1 week and 53% after 2 weeks (P<0.01). Only 53% of the patients with a positive response to a first and second head-up tilt test had a positive response to a third (P=0.01). Intra-individual variation in the time to a positive response was wide. The reproducibility of the cardioinhibitory responses was very poor. Reproducibility of a negative response was 80%.

CONCLUSIONS

In patients with recent syncope, the rate of positive responses decreases with sequential head-up tilt tests. Furthermore, the time to a positive response in different head-up tilt tests shows important intra-individual variations, and the reproducibility of the cardioinhibitory responses is very poor. In contrast, the reproducibility of the negative responses is high.